RU2691321C1 - Method of closure of laparotomic wound in treatment of eventration - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgery and can be used for closure of laparotomic wound in eventrations on tubes made of polyvinylchloride. 5 mm trocar is formed by symmetric channels that permeate skin, subcutaneous fat, anterior sheet of rectus aponeurosis, rectus muscle, posterior leaf in oblique tangential direction to wound so that it appeared in pre-peritoneal tissue and does not touch peritoneum. Then formed channels are formed by means of Kocher clamp tubes made of polyvinyl chloride, which are tightened and fixed with a thread.

EFFECT: method enables avoiding recurrences.

1 cl, 1 ex, 6 dwg

Description

The invention relates to medicine, namely to abdominal surgery, and can be used in the surgical treatment of eventration.

Despite the high level of development of minimally invasive technologies, open operations on the abdominal organs are widely used in our time. The number of postoperative complications requiring re-intervention also does not decrease [1]. Operations performed through the median laparotomic access are accompanied by the development of postoperative complications in 6-20% of cases, while the share of infectious diseases is 80%. One of the most frequent complications is eventration. They occur in 0.5-2.35% of patients, with a high frequency of recurrent events - 12.5% [2,3]. An important principle of suturing a laparotomy wound is to perform plastics without tensioning the tissues, taking into account the uniform load on the suture, since non-observance of these rules leads to the eruption of the seams, increases the microcirculation disturbance in the tissues, violates their trophism, which aggravates dystrophic processes and contributes to the occurrence of postoperative hernias of the anterior abdominal wall [4,5,6]. Despite knowledge of these principles, one of the main problems in surgery is the choice of a method for suturing a laparotomy wound, since at the moment there is no consensus on this choice. In the treatment of subcutaneous eventration and eventration into a "purulent" wound, conservative tactics predominate, and only with true eventration, all surgeons recommend surgical treatment. Currently, there is no strict differentiated approach to the choice of treatment method for various types of eventration. All of the above indicates an unsolved overall problem of surgical prevention and treatment of eventration.

Currently, the main methods of treatment of postoperative wounds of the anterior abdominal wall are ways of closing wounds after rehabilitation by imposing various types of nodal and continuous sutures.

There are various ways of suturing an aponeurosis: nodal, mattress, U- and U-shaped, front and rear U-shaped, single and double-row, cushioned, Girard-Sika stitches with duplicate aponeurosis, continuous - furrier, mattress [7].

For the prevention of postoperative events and hernias of the white line of the abdomen, many surgeons prefer a simple knotted suture, which is simple in technique, better matches the edges of the aponeurosis and allows you to measure the degree of force of tightening the node. At high risk of development of eventration, a method of suturing the median laparotomy wound according to Smead - Jones is used, which consists in suturing the wound with a single deep suture with the capture of the fascia edges [8]. In order to prevent eventration after laparotomy, a through deep suture is used to close the wound through all layers with the obligatory gripping of the anterior and posterior vaginal sheets of the rectus abdominis to firmly consolidate the edges of the sutured aponeurosis with a wide area of tissue contact [9]. It is known layer-by-layer suturing of a laparotomic wound, according to which the peritoneum is sutured separately (with catgut), aponeurosis, and skin separately [10]. Bodrov A.A. developed a method of suturing the median laparotomic wounds with the imposition of intermittent blanket stitch. This method, as well as certain types of continuous (uninterrupted) suture can reduce the trauma of stitched fabrics, increase the reliability of their connection and thereby reduce the risk of wound complications [11]. For suturing aponeurosis, a continuous suture is currently preferred [12].

As a prototype, we chose a method of wound closure by continuous removable monofilament (BCM) suture [13]. The seam is performed as follows. To perform this method, use monofilament nylon thread with a diameter of 0.4 mm. In order to achieve a tightness of the wound, a peritoneum and muscles are placed on the BMR-suture, starting from the internal angle of the wound. Puncture-punctured with a ligature needle is made against each other with respect to the edges of the wound in the form of a U-shaped continuous suture. The edges of the aponeurosis of the external oblique muscle with the help of a double thread are connected with a BCM-suture, which is applied in such a way that when the threads are tightened, one edge of the aponeurosis falls on the other in the form of duplicatory. On the subcutaneous fatty tissue impose BSM-stitches, making symmetrical vkoly-pokoly needle with a ligature. Needle injection points on one side should be located exactly opposite the needle exit points on the opposite side. The skin is connected with an intradermal BMS-suture.

The known suture has drawbacks: this suture cannot be placed on the median laparotomic wound, the operation time increases, the anatomical comparison of the tissues of the anterior abdominal wall is lacking.

Adverse listed factors are the cause of the development of purulent complications and events.

Technical result: to improve the indicators of treatment of patients with eventration (to avoid relapses, to achieve complete wound healing, to avoid repeated suppurations).

The modeling method is as follows: Stepping back 2 cm from the wound edge in the top-down direction with a scalpel, make notches on the skin 4-5 mm long every 4 centimeters, first on one side, and then similar symmetrical skin incisions on the opposite side (Figure 1). Prepare the required number of polyvinyl chloride (PVC) tubes with a diameter of 4 mm and a length of 15 cm. Then, a 5 mm trocar forms a channel that pierces the skin (1), subcutaneous tissue (2), the front piece of the aponeurosis of the rectus muscle, the rectus muscle (3), the back leaf . Immediately reaching the posterior leaflet, the trocar is pulled out in an oblique tangential direction to the wound so that it is in the preperitoneal tissue (4) and does not touch the peritoneum (5) (Fig. 2). Take the end of the tube with your hand and bring it to the wound. Then, a Kocher clamp is inserted into the formed channel, the end of the supplied pipe is grabbed and taken out. Similarly, form a channel on the opposite side and the second end of the PVC tube is carried out on the skin. The free ends of the tubes are gripped in the clamp. The manipulation is repeated until the entire wound is taken on a PVC tube (Fig. 3). Next, the assistant takes the ends of the tubes and tightens the edges of the wound before matching, fixing the ends of the tubes with the Mikulich clamp (Fig. 4). Immediately under the clamp, the tubes are tied with a braided thread (Fig. 5). The number of stitches on polyvinyl chloride tubes can be variable depending on the length of the laparotomy wound, the thickness of the abdominal wall, the severity of the inflammatory process in the wound. Between the seams obtained, Donati rare seams are imposed with the aim of a possible subsequent revision of the wound. In order to prevent skin necrosis, gauze napkins are placed under tubular seams (Fig. 6). Donati seams and tubes are recommended to be removed on the 10th day.

Thus, the proposed method of suturing a laparotomy wound can improve the treatment of patients with eventration.

Clinical example. Patient A., 63 years old, was admitted on an emergency basis with a clinical picture of mesenteric vessel thrombosis. The patient received a mid-median laparotomy, resection of the small intestine. Suturing a laparotomy wound through all layers of nylon threads. In the history of the patient bronchial asthma, moderate. On the 3rd day after the operation, the patient had full eventration when coughing. An emergency procedure was performed - suturing a laparotomy wound on PVC tubes as follows: Stepping back 2 cm from the wound edge in the downward direction with a scalpel, made notches on the skin 4-5 mm long every 4 centimeters (only 4 notches), first on one side and then similar symmetrical skin incisions on the opposite side. Four PVC tubes were prepared with a diameter of 4 mm and a length of 15 cm. Then, a 5 mm trocar formed a channel that pierced the skin, subcutaneous tissue, anterior leaflet of the aponeurosis of the rectus muscle, rectus muscle, and the posterior leaflet. Immediately reaching the back of the leaflet, the trocar was poked out in an oblique tangential direction to the wound so that it was in the preperitoneal tissue and did not touch the peritoneum. Then, a Kocher clamp was inserted into the formed channel, the end of the tube was seized and brought out. Similarly, the second end of the PVC tube was held on the skin from the opposite side. The free ends of the tubes captured in the clip. Similar manipulations are performed with the remaining tubes. Further, the assistant, pulling the ends of the tubes, tightens the edges of the wound before matching, fixing them with Mikulich clamp right there. Immediately under the clamp tube connected with braided thread. Between the seams obtained Donati rare seams with the aim of possible subsequent revision of the wound. In order to prevent skin necrosis, gauze napkins are placed under tubular seams. The postoperative period was uneventful. On the second day after the operation, the patient got out of bed. Daily dressings were performed. PVC tubes removed on the 10th day. The stitches were removed on the 10th day. The wound healed by first intention. The patient is examined in a month. No complaints.

Bibliography

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13. A method of suturing a laparotomy wound. Garaev V.N. and others. Patent for invention RU 2261665 01/27/2004.

Claims (1)

Method of suturing a laparotomic wound at events on polyvinyl chloride tubes, characterized in that 5 mm trocar form symmetric channels piercing the skin, subcutaneous tissue, anterior leaf of the aponeurosis of the rectus muscle, rectus muscle, posterior leaf in the oblique tangential direction to the wound so that it appears in the pre-abdominal tissue and not touched the peritoneum, then polyvinylchloride tubes are held into the formed channels with the Kocher clamp, which are tightened and fixed with thread.

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