RU2531541C1 - Method for prevention of postoperative inguinal wound abscess - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method refers to medicine, namely to surgery. A cavity of the lesser pelvis is washed with antiseptic solutions through two perforated tubes. One tube is placed in the pelviorectal space in the more proximal direction from the levators. The second tube is inserted into subcutaneous fat in the more distal direction from the levators. The perineal wound chamber is washed with the antiseptic solution in a single fraction amount of 50-60 ml. That is followed with washing successfully through one of the tube ends with the second end hermetically closed. The wound hydraulic compression of the antiseptic is generated. A clamped end of the tube is opened, and the antiseptic is released. The residual content is completely aspirated. The wounds are flow-through washed daily once a day compression-free starting from the 3^rd-4^th up to 9^th-10^th day.

EFFECT: method for prolonged aspiration-flow drainage with antiseptic compression prevents the developing of pyoinflammatory processes in the perineal wound, thereby providing the primary-tension wound healing.

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Description

The present invention relates to medicine, namely to surgery, and can be used to prevent the development of purulent-inflammatory processes in the perineal wound.

One of the main classical surgical approaches for surgical treatment of anterior rectocele, rectovaginal fistula, and anal sphincter insufficiency is transperineal (1, 2, 3, 4, 5, 7, 10). According to many authors, thanks to him, having separated the rectovaginal septum, it is possible to adequately mobilize the front portions of the “levators”, to corrugate the front wall of the rectum, if necessary, perform posterior colporaphy, sew the “levators”, after which some surgeons strengthen them with various explants (2, 3 , 4, 10).

Compliance with the rules of asepsis and antiseptics, improving surgical and therapeutic methods for the prevention and treatment of wound infections, significantly reduce the number of postoperative purulent-septic complications from perineal wounds. However, their level, according to various authors, continues to remain in the range of 2-10% (4, 7, 9, 10). This problem is of particular importance in elderly and patients suffering from diabetes mellitus, obesity, and impaired immunity, since wound healing in this category of patients proceeds more slowly and has prerequisites for the more frequent occurrence of purulent-inflammatory processes.

Currently, various methods for the prevention of suppuration of perineal wounds are known. S. Holdin suggested leaving the wound open, healing by secondary intention under dressings with hydrophilic ointments. This method of treating wounds virtually eliminates their suppuration, but the risk of secondary infection remains high (9). Long conservative treatment is required in an inpatient or outpatient setting, which makes patients uncomfortable, inconvenient and causes additional psychological trauma.

Removable drainage sutures, proposed by N. Kosinets, ensure the outflow of wound exudate only from the area of the perineal wound in the subcutaneous tissue located distal to the “levators” (4). While the area of the perineal wound proximal to the "levators" (pelvic rectal space) remains undrained. And the use of threads impregnated with antibiotics has an antimicrobial effect only near their location, which may not be sufficient during the manifestation of inflammation.

Revitsky V.P. et al. (2005) propose to drain with small one-lumen tubular drainage supplemented with a corrugated polyethylene complex in the form of a three-petal fan. This type of drainage may not ensure complete removal of all contents from the wound cavity, there is a high risk of obstruction of the drainage tube, patient mobility is limited, there is an additional wound at the site of the fan drainage installation, its design complexity, and subcutaneous tissue is not drained.

For the closest analogue, a method has been adopted that provides perineal wound drainage using the intracavitary microirrigation aspiration-washing system used in patients after colon cancer proctologic operations (6). The authors use a system of two single-lumen drainages introduced into the small pelvis through separate punctures 3-4 cm to the left and right of the anus and installed nearby (in the type of double-lumen drainage) in the pelvic cavity. Several times a day, the pelvic cavity is washed with antiseptic solutions through one drainage, followed by passive or active removal of wound contents through the second drainage. On average, drainages are in the pelvic cavity for 3-4 days, after which they are removed. Skin sutures from the perineal wound (after abdominal-perineal extirpation of the rectum) are removed on the 10-12th day. Thanks to this method, the number of purulent complications was reduced to 6-12%. The disadvantages of this method is the incomplete leaching of wound detritus; complexity, cumbersome design with frequent flushing (3-4 times a day for 500 ml of antiseptic), which does not allow patients to proceed with early activation. There remains an undrained subcutaneous tissue zone between the vagina and rectum distal to the “levators”.

Objectives - to reduce the number of suppurations of postoperative perineal wounds during the elimination of the anterior rectocele, rectovaginal fistula, insufficiency of the anal sphincter.

The essence of the invention is that after stitching the front portions of the "levators" in the wound cross-set two flowing perforated drainage. One in the frontal plane proximal to the “levators” into the pelvic rectal space (Fig. 1 - flowing drainage in the pelvicorectal space), and the second in the sagittal plane distal to the “levators” into the subcutaneous tissue (Fig. 2 - flowing drainage in the subcutaneous tissue).

The novelty in the application is that, starting from the first postoperative day, once per day, with daily dressings, the perineal wound cavities are washed fractionally with 50-60 ml of antiseptic solution, alternately through one of the ends of each tube with a tightly closed second end, creating intra-hydraulic antiseptic hydraulic compression , then the clamped second end of the tube is opened and the entire antiseptic is released from the wound, then the contents remaining in the drainage tube and in the wound are completely aspirated, after which from 3-4 and 9-10 days from the day of surgery and continued once daily washing wounds instantaneous manner without hydraulic compression element.

The method is as follows. Fragments of tubes from the standard system for intravenous infusion are used as drains, on which 3-4 oval-shaped holes 3 × 5 mm in size, necessarily located in the drained cavity, are cut in a checkerboard pattern. The ends of the drainage located in the pelvic rectal cavity are brought out to the skin 4-5 cm outward from the edge of the anus on both sides and fixed to the skin with separate interrupted sutures with a monofilament thread. Drainage in the subcutaneous tissue, located in the sagittal plane, is strengthened as follows. One end of it is brought out through the vestibule of the vagina and fixed with a separate nodal catgut suture of size 0-2. And the other end is brought out 3-4 cm to the left or right of the edge of the anus and is also fixed to the skin with a separate interrupted suture with a monofilament thread (Fig. 3 - general view of the perineum with the drainage tubes brought out).

Further, the outer ends of the drainage tubes are bent and hermetically sealed with plugs, for which we use sterile caps from injection needles of disposable syringes. The final stage of the operation is performed - sanitation of the perineal wound with antiseptics (0.02% aqueous solution of chlorhexidine or 2-3% boric acid solution), suturing of the skin part of the perineal wound in the longitudinal direction with separate monofilament sutures along Donati, and the wound site at the site of the removed excess of the anterior mucosa walls of the anal canal with nodal catgut sutures. The wound is closed with an aseptic napkin impregnated with iodine derivatives (iodopyrone, iodonate, etc.). On top of which the outer ends of the drainage tubes are laid, fixed on the wound with an adhesive cotton-gauze dressing.

Subsequently, the drainage is washed during the first 9-10 postoperative days, every day, once, starting from any randomly selected drainage, an antiseptic is injected into the wound through one end of the tube (0.02% chlorhexidine aqueous solution or 2-3% boric acid solution) 50-60 ml each, which penetrates through the perforations into the wound cavity. In this case, the first 2-3 postoperative days, the second end of the drainage tube is clamped, preventing the solution from leaking out immediately, while creating an intra-hydraulic hydraulic compression factor for the antiseptic, due to which complete reorganization and washing out of the substrate from all the “pockets” and cracks of the wound cavity. Then, the blocked second end of the drainage is opened, allowing the antiseptic solution with wound contents to leak. Further, the secret remaining in the wound and in the drainage tube is completely aspirated with the same syringe. Caps-caps are put on the bent ends of the tube and the edges of the tube are laid under the bandage. Then, from 3-4 postoperative days to 9-10 days (drainage removal period), the second end of the tube is left open and the wound is washed in a flow-through manner without an hydraulic compression element. Drainage is removed on the 9-10 postoperative day.

Technical result

- Thanks to the proposed method of prolonged suction-flow drainage with compression of an antiseptic in the perineal wound, in all observed cases, the wound is healed by primary intention.

- The method was tested on 37 patients. Local suppuration occurred only once due to a technical error.

- The lack of complex structures and devices that ensure the operation of other types of microirrigation systems, our method does not prevent the early activation of patients.

The method was tested on coloproctological patients of the Regional Clinical Hospital No. 1 of Krasnodar, operated on for anterior rectocele 2-3 degrees in 2008-2012. All patients - women are divided into two comparable groups: the main and control. The main group - 37 people, the control - 40. The average age in the main group was 55.3 years; in the control - 54.7 years. Patients were included in the study by continuous selection. After a standard examination, preoperative preparation, all patients underwent anterior levator plastic with excision of the excess mucosa of the anterior wall of the anal canal. In the control group, the perineal wound was sutured tightly, and in the main group with perforated drainage inserted into the wound for subsequent prolonged flow-aspiration washing, with the condition of intra-wound "hydraulic compression" of the antiseptic in the first 2-3 days.

Results. In the control group, suppuration of the perineal wound occurred in 6 (15%) patients in the period from 3 to 9 days (p <0.05). To all these patients the wounds were divorced. In five patients, the foci of suppuration was located superficially in the subcutaneous tissue, in one in the pelvic rectal space. Wound healing in these patients later occurred by secondary intention.

In the main group of observations, consisting of 37 people, local suppuration of subcutaneous tissue occurred in one patient (2.7%) (p <0.05). In the analysis of this case, it turned out that the washing technology was impaired, the hydraulic compression element of the antiseptic was not used, as a result, all wound discharge from the contaminated wound was not properly washed, which consistently contributed to the appearance of clinically significant suppuration. In the remaining patients of the main group, all wounds healed by primary intention. Flowing drainage from wounds was removed on 9-10 postoperative days. Skin sutures were removed on the 11-12th day from the day of surgery.

Example: Patient S., 58 years old, medical history No. 1234, was admitted to the coloproctology department of the Regional Clinical Hospital No. 1 of Krasnodar on 10.10.12 with a diagnosis of anterior rectocele of 3 degrees. The next day, 11/10/12, anterior levator plastic surgery was performed with excision of the excess mucosa of the anterior wall of the anal canal.

Operation: Under the MCA after processing the surgical field, the labia majora is hemmed to the skin on both sides. Anus divulsion produced. The rectovaginal septum is split in an acute and blunt way to a depth of 7-8 cm under the control of a finger inserted into the rectum. Highlighted "levators" on both sides. Then the wall of the rectum is corrugated in the transverse direction by several separate interrupted sutures with Biosyn 3-0 thread. After that, the front portions of the “levators” are sequentially sewn from each other from a depth in the distal direction by two rows of separate interrupted sutures with a PGA-0 thread. Two perforated perforated drainages are cross-wound in the wound. One in the pelvic rectal space, the other in the subcutaneous tissue. The skin part of the perineal wound is sutured with separate interrupted sutures with a monofilament thread according to Donati. The resulting excess mucosa of the anterior wall of the anal canal is excised. The wound in its place is sutured with interrupted catgut sutures. Control for hemostasis. Treatment with iodopyrone. Ointment swabs in the vagina and in the rectum. The ends of the drainage tubes are bent and hermetically sealed with cap caps and placed under an aseptic dressing.

Subsequently, every day, starting from the first postoperative day, once per day, the perineal wound was washed with 50-60 ml of a solution of 3% boric acid through the drains through the drains, moreover, in the first 3 days after the operation with hydraulic compression of the antiseptic. During this period, the discharge from the wound was sacred, 8-10 ml each. By the fifth postoperative day, the wound secret became serous. The amount of it daily gradually decreased by 1-2 ml. Starting from the fourth postoperative day, the washing was continued with the suction-flow method without the “hydraulic compression” element, and, having completed the washing, the drainage tubes were aspirated, completely removing the exudate residues, and closed with cap caps. On the 10th postoperative day, the drainage discharge ceased. Drainage removed. The patient was discharged from the clinic with recovery on the 10th day after the operation. Skin sutures from the perineal wound were removed on the 12th postoperative day in the clinic at the place of residence. Healing by first intention.

LITERATURE

1. Hakobyan A.S. et al. Surgical treatment of patients with anal sphincter insufficiency due to postpartum injury // Materials of the III All-Russian Congress of Coloproctologists. - Belgorod, 2011 .-- p.21.

2. Dryga A.V. Improving the diagnosis and surgical treatment of rectocele in women. Abstract. dis ... doctor honey. sciences. - Chelyabinsk. - 2008 .-- 46 p.

3. Zakharchenko A.A., Sukhorukov A.M., Shtoppel A.E. and other Prevention of postoperative purulent-inflammatory complications in colorectal surgery // Actual problems of coloproctology / Abstract. Doc. IV conf. coloproctologists. Irkutsk, 1999 .-- S.459-460.

4. Kosinets N.B. New approaches to the restoration of the anatomical structures of the rectovaginal septum with rectocele. Dis ... cand. honey. sciences. - Krasnodar. - 2005 .-- 159 p.

5. Muravyov K.A. A differentiated approach to the surgical treatment of rectovaginal fistula. Abstract. dis ... cand. honey. sciences. - M. - 2002. - 15 p.

6. Fedorov V.D., Vorobev G.I., Rivkin V.L. Clinical surgical coloproctology, M. - 1994, S. 217, 229-231.

7. Hvorov V.V. Comparative evaluation of methods for restoration of the rectovaginal septum and perineum in the treatment of rectocele. Abstract. dis ... cand. honey. sciences. - M. - 2007. - 18 p.

8. Holdin S.A. Neoplasms of the rectum and sigmoid colon. - M. - 1977, p. 237.

9. Heriot AG, Skull A, Kumar D. Functional and physiological outcome following transanal repair of rectocele. Br J Surg. - 2004. - Oct; 91 (10): 1340-4.

10. Leventoglu S, Mentes BB, Akin M et al. Transperineal rectocele repair with polyglycolic acid mesh: a case series. Dis Colon Rectum. - 2007. - Dec; 50 (12): 2085-92.

Claims (1)

A method for the prevention of suppuration of postoperative perineal wounds, including washing the pelvic cavity with antiseptic solutions through two cross-placed perforated tubes, one of which is installed in the pelvic rectal space proximal to the levators, the other in the subcutaneous tissue distal to the levators, with the ends of the tubes leading outward through the patient’s counter-aperture formed on the skin characterized in that, starting from the first postoperative day, once, with daily dressings, fractionally produced they wash the perineal wound cavities with 50-60 ml of antiseptic solution, alternately through one of the ends of each tube with a hermetically sealed second end, creating intra-hydraulic hydraulic compression of the antiseptic, then the clamped second end of the tube is opened and the entire antiseptic is opened and released, then the remainder in the drainage is completely aspirated the contents of the tube and the wound, after which from 3-4 to 9-10 days from the day of the operation, the wound is also washed once daily with a flow-through method without an hydraulic compression element.

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