RU2643332C2 - Method for prevention of keloidal and hypertrophic scars in case of laparotomy wounds closure - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method for prevention of keloid and hypertrophic scars formation in the laparotomic wounds closure includes botulinum toxin administration to the left and right external oblique abdominal muscles, K-wires conduction in the sheaths of the abdominal rectus muscles, wires traction to align the edges of the wound defect with subsequent fixation of the wound defect edges by sutures and local intradermal botulinum toxin introduction to the postoperative wound area.

EFFECT: invention allows to reduce muscle traction, which makes a significant contribution to lateral retraction, which ensures formation of a thin linear scar and a high cosmetic effect.

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Description

The invention relates to medicine, namely to general surgery, aesthetic surgery, traumatology, and can be used to ensure favorable healing of extensive wounds of the anterior abdominal wall with the formation of a functional and aesthetic optimal scar.

A special problem of surgery is wounds after laparotomy, which for various reasons (event, laparostomy, etc.) turned into purulent, then granulating wounds of the anterior abdominal wall. Their feature is the impact on the wound edges of the traction of the oblique and transverse muscles of the abdomen from the midline, the contraction of these muscles (the so-called “lateral retraction”), which prevents the closure of the wound defect (1).

To close soft tissue wounds, methods using a full-layer or split skin flap are used. More advantageous in cosmetic and functional terms are methods that use a full-layer skin flap. A full-layer skin flap can be free, that is, transplanted onto the recipient bed using microvascular anastomoses, which requires microsurgical technique, lengthy operations, and at the same time there is a high risk of thrombosis of intravascular microanastomoses. It is possible to move a full-layer flap “on the leg” from distant parts of the body, which, however, is also accompanied by a high risk of thrombosis and suppuration, and if it fails, another full-layer wound occurs in the donor site. The safest and technically simplest way to close a wound is with a full-layer skin flap by stretching the tissues surrounding the wound. In this case, stretching can be carried out both “from the inside” (endodermotension) by placing a special expander under the skin near the wound area, injecting liquid into it and thereby obtaining a reserve of skin integument, and externally (exodermotension) - by pulling on stitches, needles or knitting needles through the tissue near the wound area. The skin obtained in this way corresponds in its biophysical parameters to the missing skin of the wound defect, if it fails - suppuration or marginal necrosis - there is no significant increase in the area of the defect. However, the method has a known drawback: in conditions of tissue deficiency, comparison of the edges of the wound under conditions of tissue distension leads to the formation of a rough, wide scar.

Closest to the claimed solution to this problem is the "Method of treatment and prevention of the development of hypertrophic and keloid scars" (2). Authors transdermally administer collagenase, while intradermally administer lidase in therapeutic doses. The course of treatment is 10-15 daily procedures. The method provides increased permeability of the intercellular matrix for collagenase and helps to prevent the development of hypertrophic and keloid scars.

The disadvantages of this method include the following. The introduction of chemotherapeutic agents in order to prevent the formation of hypertrophic scars, which is effective in the absence of pronounced tension of the wound edges, is insufficient in conditions of prolonged, dosed tissue stretching, which leads to dynamic stress at the wound edges, aimed at their divergence. Therefore, generally accepted methods for administering drugs (including enzymes, 5-fluorouracil, steroids, etc.) are not able to provide adequate healing of the skin wound, which ultimately leads to stretching and hypertrophy of the regenerate.

The objective of the proposed method is to enable plastic defects in soft tissues in the midline of the abdomen with a full-layer flap by stretching the tissues surrounding the wound to match its edges while preventing the formation of a hypertrophic scar.

The essence of the proposed method for connecting the edges of the wound under tension and the divergence of its edges is illustrated by drawings, which show a diagram of the method before comparing the edges of the wound (Fig. 1) and after comparing the edges of the wound (Fig. 2), where 1 is a laparotomy wound, 2 are spokes Kirchner conducted in the vagina of the rectus abdominis muscle, 3 - projection of the external oblique muscle of the abdomen, 4 - points of introduction of botulinum toxin, 5 - sutures, fixing needles, 6 - skin sutures.

The inventive method is as follows. In the projection of the external oblique muscle of the abdomen 3, under the control of ultrasound, botulinum toxin is injected through 4-6 points of injection 4 at a distance of about 2 cm from each other intramuscularly into the external oblique muscle on each side. Three days after the introduction of botulinum toxin after mobilization of the edges of the laparotomy wound, 1 Kirschner spokes 2 pierce the skin of the wound edge, draw the spokes inside the vagina of the rectus abdominis muscles, and bring the spokes through the skin to the anterior abdominal wall. Sutures 5 through all layers seize the Kirchner spokes and draw the edges of the wound defect closer by traction for the spokes. Rapprochement of the edges of the wound is carried out dosed, focusing on the clinical signs of tissue ischemia or instrumental indicators. After comparing the edges of the wound and the application of skin sutures, 6 botulinum toxin is administered intradermally with a step of 2 cm at a distance of 1 cm from the edge of the wound along the entire forming scar.

The technical result of the claimed invention is to reduce muscle traction, which makes a significant contribution to lateral retraction, matching wound edges and ensuring the formation of a thin linear scar.

The specified technical result is achieved by the fact that the method includes the introduction of botulinum toxin into the left and right external oblique muscles of the abdomen or into the cellular spaces between the external and internal oblique muscles of the abdomen, conducting Kirschner spokes in the rectus sheaths, traction for the spokes, until the edges of the wound defect are compared and local intradermal injection of botulinum toxin into the area of the postoperative wound.

Distinctive techniques of the proposed method are that when planning closure of a wound of the anterior abdominal wall in order to counteract the forces of lateral retraction, a significant role in which is played by the traction of the external oblique muscle of the abdomen, botulinum toxin is introduced into the specified muscle (possibly under ultrasound control). As with any drug treatment, for patients who have not received prior botulinum toxin therapy, the minimum effective dose should be used as the initial dose. The dose administered at each point should not be more than 20 units. In each external oblique muscle, no more than 100 IU of the drug is administered. The total dose of the drug during the first procedure should not exceed 200 units. The action of the drug develops on the 2-7th day after the procedure and lasts 3-6 months. 3 days after the introduction of botulinum toxin (that is, after the onset of its action), Kirschner spokes are inserted inside the vagina of the rectus abdominis muscles and begin craving for the spokes. Using traction for these spokes, the edges of the laparotomy wound are brought together and, after matching, they are fixed with sutures. The introduction of botulinum toxin and its action provides relaxation of the external oblique muscles, increasing their length, and thus reduces the effect of tensile forces on the resulting scar. Kirchner spokes are removed after 10-12 days, by this time the action of botulinum toxin develops, sufficient to reduce muscle traction, which makes a significant contribution to lateral retraction, to compare the edges of the wound and to ensure the formation of a thin linear scar.

Clinical example. Patient I., 62 years old - condition after relaparotomy for purulent peritonitis. Kirschner spokes were carried out in the vaginas of the rectus abdominis muscles, traction was performed for the spokes. According to dynamometry, when comparing the edges of the laparotomy wound, the force was 64 N. Further approach was suspended due to an increase in intra-abdominal pressure. After insertion of botulinum toxin into the left and right external oblique muscles of the abdomen after 24 hours, the force in approaching the aponeurotic edges of the wound was 46 N, the edges of the wound were matched and sutured, no complications were noted. After 2 months, a thin linear scar formed.

The analysis of patent and medical literature showed that the proposed method contains features that distinguish it not only from the prototype, but also from other options for connecting the edges of laparotomy wounds. These differences allow us to conclude that the claimed technical solution meets the criteria of the invention of "novelty."

A comparative analysis of the proposed method and prototype shows that the claimed method differs from the known one in that for the prevention of the formation of keloid and hypertrophic scars when closing laparotomic wounds, the drug is administered not locally acting on the processes of reparative regeneration, but a substance that provides muscle relaxation in two zones (levels, layers ) abdominal wall. By placing the spokes in the sheaths of the rectus muscles, traction behind them and fixing the sutures of the edges of the laparotomy wound, two biomechanical zones are created:

1. The zone of tissue stretching - laterally from the knitting needles, in which, to reduce the tensile forces (lateral retraction), botulinum toxin is injected into the muscle layer - into the external oblique muscles of the abdomen.

2. The rest zone (fixation) - medially relative to the Kirschner spokes, in which they achieve rapprochement and stable matching of the edges of the wound along the entire cut line without tension. To ensure the formation of a thin linear scar, botulinum toxin is injected medially from the spokes - intradermally into the region of the edges of the wound defect.

The inventive method provides a high cosmetic effect - by reducing muscle traction, which makes a significant contribution to lateral retraction, matching wound edges and ensuring the formation of a thin linear scar.

The method comprising the claimed invention is intended for use in healthcare. This method can be used in surgery and traumatology. The possibility of its implementation is confirmed by the available techniques and means described in the application, therefore, the proposed technical solution meets the criteria of the invention "industrial applicability".

Literature

1. Guzoeva L.A. The choice of a program of staged reoperations in severe forms of widespread peritonitis: dis. ... cand. honey. Sciences: 14.01.17 / Guzoeva Leyla Akhmetovna. - Moscow, 2014 .-- 181 p.

2. Zinatullin P.M., Gilmanov A.Zh., Hunafin C.H., Simonova E.S. A method for the treatment and prevention of the development of hypertrophic and keloid scars. Patent No. 2220741 C2, IPC 7 A61K 38/43, A61P 17/02. Application 2002105074/14, 02.26.2002. Published January 10, 2004.

Claims (1)

A method for preventing the formation of keloid and hypertrophic scars when closing laparotomic wounds, including the introduction of botulinum toxin into the left and right external oblique abdominal muscles, conducting Kirschner spokes in the rectus sheaths of the rectus muscles, traction for the spokes to compare the edges of the wound defect with subsequent fixation of the edges of the wound defect with sutures and local intradermal injection of botulinum toxin into the area of the postoperative wound.

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