RU2734048C1 - Method for treating extensive head wounds - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to plastic surgery, combustiology, traumatology, and can be used in patients with posttraumatic wounds, deep burns and their consequences on extensive head wounds. Oscillating saw is applied at 1–1.5 cm to cross-cut at right angle per one depth to a bleeding layer. Osteonecretomia is performed with a chisel per one depth within a viable lower cortical plate. Performing the free skin autoplasty with the transplant without perforation with thickness of 0.7–1 mm: on the skull bone and on the wounds of the soft tissues of the head with a transplant; donor sites are covered with perforated skin autografts with thickness of 0.2–0.3 mm and covered with HitoPran wound coating. At the end of the operation, the auditory passages are plastered, the eye slits are closed and a vacuum dressing is applied, leaving the mouth and nasal passages open.

EFFECT: method provides restoring integrity of skin on extensive wounds of head with exposure of skull bones, good functional and cosmetic results of surgical treatment of facial wounds due to use of grafts, wound coating HitoPran and vacuum dressing.

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Description

The proposed invention relates to medicine, namely to plastic surgery, combustiology, traumatology, and can be used in patients with post-traumatic wounds, deep burns and their consequences on extensive head wounds.

The problem of burns and extensive wounds of the head to this day remains one of the most urgent and complex in modern medicine. First of all, this is due to the significant spread of burns among the population, in connection with which, without exaggeration, it can be called a modern traumatic epidemic of densely populated cities and industrialized countries of the world. (A.V. Vorobiev, S.P. Peretyagin, S.A. Bukhalov et al., 2008). According to the World Health Organization, burns rank second - third among other types of injuries. Every year in Russia, an average of 420 thousand victims seek medical help for burns, of which 120 thousand are hospitalized in specialized burns, surgical and trauma departments of medical institutions. (A.A. Alekseev et al. 2008). Burns and head injuries occupy a special place among all localizations, because are quite common. With deep burns and head injuries, extensive wound defects of the scalp are often formed.

An analogue of the proposed invention, we adopted a method of applying a vacuum dressing using Kerlix gauze, a bag for Suprasorb CNP EasyDress vacuum systems from Lohmann & Rauscher and Suprasorb F film described by S. B. Bogdanov, A.L. Kovalenko, A.S. Dikarev and D.N. Marchenko (Patent No. 2651057 dated 18.04.2018). The operation begins after standard preparation. After performing dilatation tracheotomy, staging a gastric tube, tamponade of the nose and oral cavity, performing blepharorrhaphy, surgical preparation of the wound, followed by hemostasis and autoplasty. An antiseptic bandage is applied. Then the head is tightly bandaged in 3-4 rounds using Kerlix AMD gauze from Lohmann & Rauscher. After applying the headbands, a special sterile bag for Suprasorb CNP EasyDress vacuum systems from Lohmann & Rauscher is put on. Suprasorb CNP EasyDress for vacuum is fixed to healthy skin using Suprasorb F incisal film, then a vacuum is connected and a constant negative pressure of 90-110 mmHg is injected. The first dressing is carried out for 2-3 days, the vacuum system is removed, wet-drying aseptic dressings are applied. The engraftment of autodermotranspantates, as a rule, occurs on the 5-7th day.

The disadvantages of this method include:

1. The need to perform tracheostomy for the patient.

2. The need to perform blepharorrhaphy.

3. Finding the patient before the first dressing on mechanical ventilation.

Another analogue of the alleged invention adopted the method of osteonecrotomy on flat surfaces of bones described by P.M. Zinatullin, S.N. Khunafin, S.S. Kuvatov and N.D. Kuvatova (Patent No. 2209606 from 04.05.2001) This method of treating wound defects of the skull sphod with exposure of bone structures, includes osteonecrotomy in order to stimulate granulation growth: a patient with a circular-rotating cutter (diameter 40 mm, thickness 1-2 mm) with a Kolokoltsev dermatome with a rotation speed of 400 rpm, longitudinal and transverse cuts of the bone surface are made, with a pattern in a cell of 8 × 15 mm until blood drops appear. In the future, ointment dressings are applied and after the growth of granulation tissue, delayed autodermoplasty is performed on the granulating wound, followed by the application of pressing wet-drying dressings.

The disadvantages of this method include:

1. The need to perform delayed autodermoplasty with the growth of granulations in 2-3 months.

2. Long-term treatment with the development of infection in the wound.

3. Execution of cuts at different depths and possible exposure of the dura mater.

4. Uneven application of pressure when applying dressings with a simple medical bandage.

5. Application of uncontrolled pressure on the head.

6. Possibility of the formation of hematomas under the grafts when applying dressings after plastic surgery.

7. Possibility of slipping of the bandages when the patient moves his head. Tasks:

- improve the restoration of the skin on extensive head wounds;

- reduce the time of treatment;

- to improve and facilitate the dressing technique;

- create conditions for engraftment of free skin autograft on the bone;

- to provide uniform dense pressure on the graft during autodermoplasty on the scalp;

- to improve the functional and cosmetic results of surgical treatment of wounds of various etiology on the scalp.

The essence of the invention, including standard treatment of the operating field, surgical treatment of wounds, osteonecrectomy, free skin autoplasty with grafts with and without perforation, the application of a vacuum dressing, is the following: with an oscillating saw, mutually intersecting at right angles cuts are applied to one depth through 1-1, 5 cm to the bleeding layer, osteonecrectomy is performed with a chisel to the same depth, free skin autoplasty is performed on the skull bone and soft tissue wounds in the projection of hair growth with grafts with perforation, and on the remaining soft tissue wounds of the head along the border of hair growth - without perforation 0 , 7-1 mm., On donor sites taken with a thickness of 0.7-1 mm. dermal autoplasty with perforation 0.2-0.3 mm thick is performed. with the closure of the wounds with a wound covering "HitoPran", at the end of the operation, the ear canals are tamponed, the eye slits are closed and a vacuum bandage is applied, leaving the mouth and nasal passages open.

EFFECT: this technique allows for one operation in the first days after injury to restore the integrity of the skin on extensive head wounds with exposure of the skull bones; to achieve good functional and cosmetic results of surgical treatment of facial wounds due to plastic surgery with grafts 0.7-1 mm thick; to improve cosmetic results at donor sites due to the use of the HitoPran wound dressing, which covers the areas of perforated autografts. The vacuum bandage ensures a tight contact of the skin autografts with the bottom of the wound, which in turn minimizes the likelihood of migration of autografts, as well as the appearance of hematomas under the autografts, which can slow down their engraftment. Thanks to the vacuum dressing, the patient can take any position in bed, with the ability to lie on the wound without fear of displacement of the dressings.

The implementation of the method for treating extensive head wounds is performed as follows. In the operating room, after standard processing of the operating field, surgical treatment of wounds is performed: a bordering incision is made with a scalpel on the border of healthy skin and granulation tissue of facial wounds, the altered edges of the wound bed are economically excised, and areas of necrotic tissue are tangentially excised to viable layers. Hemostasis is performed with an electrocoagulator and pressure bandages. Then, in the area of dry osteonecrosis with an oscillating saw, mutually intersecting at right angles cuts are applied to one depth every 1-1.5 cm to the bleeding layer, osteonecrectomy is carried out with a chisel to one depth within the viable lower cortical plate. In accordance with the clear marking of the wound defect with preserved soft tissues of the face and skull, the DE-100 electrodermatome is used to collect split thick skin autografts (thickness 0.7 - 1.0 mm). Electrodermatome DE-60 is used to collect split skin autografts, 0.2-0.3 mm thick. Donor beds in the area of thick autograft collection are covered with perforated skin autografts (thickness 0.2 - 0.3 mm, perforation index 1: 4), a wound covering "HitoPran" is applied over the skin grafting performed. On the prepared, surgically treated head wounds, transplantation of skin autografts (thickness 0.7 - 1.0 mm) is performed. The edges of the skin autografts with the edges of the wound defect are stitched with an upholstered continuous suture with a joint-to-joint matching. On the defect of the bones of the base of the skull and on the projection of hair growth, plastic is performed with perforated skin autografts (thickness 0.2-0.3 mm) (perforation index 1: 2), which are fixed to the edges of the wound with interrupted sutures. Then, mesh atraumatic dressings, a sponge from a vacuum system and a film are applied to the wound. Connect a vacuum apparatus and set the pressure parameters (110 mm Hg). The first bandaging is performed 4-6 days after the operation. The vacuum bandage is removed, the zones of the skin grafting performed are sanitized. Full adaptation of autoplasty and epithelization of donor sites is observed 10-14 days after surgery.

Using this method, in a clinical setting, 2 patients with post-traumatic wounds of the scalp and deep burns of the same localization were operated.

Example 1. Patient P., 35 years old was admitted to the burn department. GBUZ-NII KKB No. 1 named after prof. S.V. Ochapovsky from the adjacent trauma department on July 18, 2019 with a diagnosis of Concomitant injury. Extensive post-traumatic head wound 1000 cm ² (Fig. 1). The operation was performed 3 days after the injury, after stabilization of the general condition. After the standard treatment of the operating field, the patient underwent surgical treatment of wounds: a bordering incision was made with a scalpel at the border of healthy skin and granulation tissue of facial wounds, the changed edges of the wound bed were economically excised, and areas of necrotic tissue were tangentially excised to viable layers. Hemostasis was performed with an electrocoagulator and pressure bandages. Then, in the area of dry osteonecrosis with an oscillating saw, mutually intersecting at right angles cuts were applied to one depth every 1-1.5 cm (Fig. 2) to the bleeding layer, with a chisel (Fig. 3), osteonecrectomy was performed at one depth within the viable lower cortical plate (Fig. 4-5). In accordance with a clear marking of the wound defect with a DE-100 electrodermatome, three split thick skin autografts, 0.8 mm thick, were taken. Electrodermatome DE-60 was used to collect six split skin autografts, 0.3 mm thick. Donor beds, in the area of thick autograft collection, were covered with perforated skin autografts (thickness 0.3 mm, perforation index 1: 4) (Fig. 6), a wound covering "HitoPran" was applied over the performed skin grafting. On the prepared surgically treated head wounds, transplantation of skin autografts, 0.8 mm thick, was performed. The edges of the skin autografts with the edges of the wound defect were sutured with a continuous upholstery suture with a joint-to-joint matching (Fig. 7). On the defect of the skull bones and in the projection of hair growth, plastic surgery was performed with perforated skin autografts (thickness 0.3 mm, perforation index 1: 2), which were fixed to the edges of the wound with interrupted sutures (Fig. 8). Then, mesh atraumatic dressings, a sponge from a vacuum system and a film were applied to the wound. We connected a vacuum apparatus and set the pressure parameters - 110 mm. Hg (fig. 9). 5 days after the operation, the vacuum bandage was removed, the zones of the skin grafting performed were sanitized. On the 8th day, the next dressing was performed. On the 12th day, the next dressing was performed with the removal of the dressings on the epithelialized donor wounds. On the 14th day, the last dressing was performed, and complete engraftment of skin grafts was observed (Fig. 10).

Example 2. Patient K., 41 years old, was admitted to the burn department. GBUZ-NII KKB No. 1 named after prof. S.V. Ochapovsky from the adjacent trauma department on 03/10/2019 with a diagnosis of a contact burn of the head 700 cm ² . After standard treatment of the operating field, the patient underwent surgical treatment of wounds: a bordering incision was made with a scalpel at the border of healthy skin and granulation tissue of facial wounds, the altered edges of the wound bed were economically excised, and areas of necrotic tissue were tangentially excised to viable layers. Hemostasis was performed with an electrocoagulator and pressure bandages. Then, in the area of dry osteonecrosis with an oscillating saw, mutually intersecting at right angles cuts were applied to one depth every 1-1.5 cm to the bleeding layer, an osteonecrectomy was performed with a chisel at one depth within the viable lower cortical plate. In accordance with a clear marking of the wound defect with preserved soft tissues of the face and skull, two split thick skin autografts, 0.7 mm thick, were taken with the DE-100 electrodermatome. The DE-60 electrodermatome was used to collect four split skin autografts, 0.4 mm thick. Donor beds, in the area of thick autograft collection, were covered with perforated skin autografts (thickness 0.4 mm, perforation index 1: 4), a wound covering "HitoPran" was applied over the performed skin grafting. Transplantation of skin autografts, 0.7 mm thick, was performed on the prepared surgically treated head wounds. The edges of the skin autografts with the edges of the wound defect were sutured with an upholstered continuous suture with a joint-to-joint matching. Perforated skin autografts (thickness 0.4 mm, perforation index 1: 2) were placed on the defect of the bones of the cranial vault, which were fixed to the edges of the wound with interrupted sutures. Then, mesh atraumatic dressings, a sponge from a vacuum system and a film were applied to the wound. We connected a vacuum apparatus and set the pressure parameters of 110 mm. Hg 5 days after the operation, the vacuum bandage was removed, the zones of the skin grafting performed were sanitized. On the 9th day, the next change of dressings was performed. On the 11th day, bandaging was performed with the removal of bandages on the epithelialized donor wounds. On the 14th day, the last dressing was performed. Complete engraftment of skin grafts was observed.

Claims (1)

A method of treating extensive head wounds, including treatment of the operating field, surgical treatment of wounds, osteonecrectomy, free skin autoplasty with perforated and non-perforated grafts, applying a vacuum bandage, characterized in that with an oscillating saw every 1-1.5 cm, mutually intersecting at right angles cuts to one depth to the bleeding layer, perform osteonecrectomy with a chisel to one depth within the viable lower cortical plate, perform free skin autoplasty with a graft without perforation 0.7-1 mm thick: on the skull bone and on the wounds of the soft tissues of the head with a graft; donor sites are covered with perforated skin autografts 0.2-0.3 mm thick and closed with HitoPran wound dressing, at the end of the operation, the auditory canals are tamponed, the eye slits are closed and a vacuum bandage is applied, leaving the mouth and nasal passages open.

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