RU2736688C1 - Surgical management method of chronic inflammation of epithelial coccygeal passage - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to coloproctology, and can be used for surgical management of chronic inflammation of epithelial coccygeal passage complicated by secondary fistulas of gluteus sacrococcygeal region in patients with high standing of buttocks. Skin and subcutaneous fat is dissected by two semi-oval incisions within healthy tissues and 2–3 cm above and below primary opening of stroke with capturing secondary fistulous passages without opening of their lumen. Pathological focus within the healthy tissues is excised so that in its middle part the depth of excision is maximum, in the upper and lower edges of the incision - minimal, in the form of a navicular wound. In the upper and lower corners of the wound in the perpendicular direction, additional incisions are made on the gluteal region on the side of the lesion with length equal to 1/3 of the buttock height plus the width from the middle line to the edge of the wound. At this length skin with subcutaneous fat is mobilized, subcutaneous fat is not wedge-shaped. Wound is closed by a skin flap with a shifted flap from the bottom to the top: the subcutaneous fat is sutured on 2/3 of the wound with a double absorbable suture. Nasal sutures are fastened. Then ends of the first and second threads on both sides are intracutaneously grasped wound edges, which are reduced and fixed to the bottom of the partially closed wound by binding ends of each thread, obtaining two nodular intracutaneous sutures at distance of 1.5 cm from each other, followed by repetition depending on the length of the wound. Additional incisions of the postoperative wound are closed with intracutaneous suture.

EFFECT: method provides reducing the length of the operation and reducing the length of the postoperative recovery by excising the primary opening of the stroke with capturing secondary fistulous passages without exposing their lumen.

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Description

The technical field to which the invention relates

The invention relates to medicine, namely to coloproctology, in particular, to a method for the surgical treatment of chronic inflammation of the epithelial coccygeal duct and can be used in the surgical treatment of the epithelial coccygeal duct complicated by secondary fistulas of the gluteal-sacrococcygeal region in patients with high buttocks standing.

State of the art

A known method of suturing a wound after excision, including the imposition of parallel sutures with the capture of the wound at a distance of 2 cm from each other, followed by their tightening and tying simultaneously the ends of each pair of parallel sutures on one and the other side of the wound until its edges are in full contact (see US Pat. RU No. 2305499, IPC А61В 17/00, publ. 09.10.2007, bulletin No. 25).

The disadvantage of this method is long-term postoperative recovery.

There is a known method of surgical treatment of purulent inflammation of the epithelial coccygeal passage (ECC), which consists in the fact that to clarify the length and prevalence of ECC, it is probed, then through the primary or fistulous openings of the ECC, it is stained with 1% alcohol solution of brilliant green using a special needle, the skin and subcutaneous tissue are dissected with two semi-oval incisions (leaf-like) with an indent from the intergluteal fold by 0.5-1.0 cm and 2-3 cm above and below the primary opening of the passage with the capture of the secondary fistulous passage without opening their lumen, excised without damage to the periosteum, the pathological focus within the healthy tissues in such a way that in its middle part the depth of excision is maximum, in the upper and lower edges of the incision - minimum, while the wound has a scaphoid shape, careful hemostasis is carried out, wound debridement with 1% aqueous solution of chlorhexidine bigluconate, then in the upper and lower corners of the wound, perpendicular to it and along the elastic fibers, additional incisions are made in both gluteal regions. Their length is equal to the height of the standing of the buttocks + the width of the wound from the midline to its edge.

For this length, the skin with subcutaneous tissue is mobilized, the subcutaneous fat is excised in a wedge-shaped manner from both sides, and the mobilized flap is lowered without tension and sutured to the bottom of the wound. Wounds in the area of additional incisions on the buttocks are sutured with blind interrupted sutures (see Vorobyov, GI Basics of Coloproctology / GI Vorobyov. - M .: Medical Information Agency. - 2006. - 432 p.).

The disadvantage of this method is the ability to cut through the seams and discharge the edges of the wound from its bottom.

A known method of surgical treatment of secondary fistulas, infiltrates with open wound management, including staining the fistulas with methylene blue, then a grooved probe is introduced into the outer opening of one of them, advanced to the center to the outer opening of the epithelial passage itself, over this probe, the skin with subcutaneous tissue is cut, so the upper wall of the purulent passage is opened up, then in the same way the remaining fistulous passages are dissected along the probe, the resulting superficial wound along the fistulous passages is scraped out with a Volkman spoon and treated with 1% iodanate solution, then the resulting irregularly shaped wound is tamponed with narrow ribbons with water-soluble ointment (see Rivkin V.L.Guide to Coloproctology / V.L. Rivkin, A.S. Bronstein, S.N. Fine./M .: Medpraktika. - 2001. - 300 p.).

The disadvantage of this method is the complexity and invasiveness of the operation, the possibility of postoperative complications: hematomas.

The closest in technical essence and the achieved positive effect and adopted by the authors as a prototype is a method of surgical treatment of purulent inflammation of the epithelial coccygeal passage, including preoperative sanitation, excision of purulent fistulas and infiltrates of the inflammation focus with curly skin incisions, hemostasis and suturing of the edges of the skin to the bottom of the formed excision cavity with sutures , made with a ligature with a step along the edge of the cavity, while the ends of the ligatures are tied with knots along the edges of the skin, the latter are brought down to the middle of the bottom of the cavity to form an open cavity of the bottom of the length of the excision, while the excision of purulent fistulas and infiltrates of the inflammation focus is performed in a single array by two arcuate skin incisions along intergluteal fold, and after hemostasis, the edges of the skin are sutured with the capture of the sacral fascia by monofilament atraumatic non-absorbable synthetic ligatures, while each suture is performed by sequentially passing the needle through the edge of the skin and subcutaneous fat th tissue of one of the walls of the excision cavity with the exit of the needle with a ligature into the cavity, then the sacral fascia and subcutaneous fatty tissue through the edge of the skin of the opposite wall, after which the ends of the ligatures of two adjacent sutures protruding at the edges of the cavity are tied on each side in pairs with nodes, which the edges of the skin with subcutaneous adipose tissue are brought down to the middle of the cavity and pressed against the sacral fascia to form an open channel along the excision cavity for the outflow of exudate.

In the method, hemostasis is performed by vascular coagulation.

In the method, before the operation, the boundaries of the focus of purulent inflammation of the epithelial coccygeal passage are determined by contrasting the color of purulent-fistulous infiltrates, along which the focus of purulent inflammation is excised.

In the method, contrasting the color of purulent-fistulous infiltrates is performed with a solution containing 1% brilliant green and 3% hydrogen peroxide in a 1: 1 ratio.

In the method, before the operation, an ultrasound examination of the focus of purulent inflammation of the epithelial coccygeal passage is performed (see US Pat. RU No. 2400156, IPC А61В 17/00, publ. 09/27/2010, bull. 27).

The disadvantages of this method are: the possibility of cutting the seams and the separation of the edges of the wound from its bottom; necrosis of the skin edges; the danger of suppuration in the area of the mobilized edges.

Disclosure of invention

The objective of the present invention is to develop a method for the surgical treatment of chronic inflammation of the epithelial coccygeal passage, complicated by secondary fistulas of the gluteal-sacrococcygeal region in patients with a high standing of the buttocks, located 2-3 cm to the sides of the intergluteal fold, with a pronounced infiltrative and inflammatory process in the adjacent him tissues, which has a simplification and a decrease in the time of the method of carrying out the operation by means of a one-step operation to completely remove the focus of purulent inflammation and shorten the duration of postoperative recovery.

The technical result that can be obtained with the help of the present invention comes down to simplifying and reducing the time of the method of performing the operation and reducing the duration of postoperative recovery.

The technical result is achieved using a method of surgical treatment of chronic inflammation of the epithelial coccygeal passage, complicated by secondary fistulas of the gluteo-sacrococcygeal region in patients with high standing of the buttocks, including preoperative sanitation of the fistulas, excision of the epithelial coccygeal passage, purulent fistulas, infiltrates and wound closure, while the skin and subcutaneous tissue are dissected with two semi-oval incisions within healthy tissues and 2-3 cm above and below the primary opening of the passage with the capture of secondary fistulous passages without opening their lumen, while the pathological focus within healthy tissues is excised in such a way that in the middle parts, the depth of excision is maximum, in the upper and lower edges of the incision - minimum, in the form of a scaphoid wound, in the upper and lower corners of the wound in the perpendicular direction, additional incisions are made on the gluteal regions on the side of the lesion with a length equal to 1/3 of the height of the buttocks, plus width from the average line to the edge of the wound, the skin with subcutaneous tissue is mobilized for this length, the subcutaneous fatty tissue is not excised in a wedge-shaped manner, the wound is sutured with skin grafting with a displaced flap from the bottom up: the subcutaneous tissue is stitched 2/3 of the depth of the wound with a double absorbable suture, knot sutures are tied , then the ends of the first and second threads on both sides intradermally capture the edges of the wound, which are brought down and fixed to the bottom of the partially sutured wound by tying the ends of each thread, receiving two interrupted intradermal sutures at a distance of 1.5 cm from each other, with subsequent repetition depending on from the length of the wound, additional incisions of the postoperative wound are sutured with an intradermal suture.

The essence of the proposed method for the surgical treatment of chronic inflammation of the epithelial coccygeal passage (ECH) is as follows.

The method of surgical treatment of chronic inflammation of the epithelial coccygeal passage, complicated by secondary fistulas of the gluteal-sacrococcygeal region in patients with a high standing of the buttocks, located 2-3 cm to the sides of the intergluteal fold, with a pronounced infiltrative and inflammatory process in the tissues adjacent to them, is carried out in the following way. Pre-operative sanitation of fistulas, excision of the epithelial coccygeal passage, purulent fistulas and infiltrates with subsequent suturing of the wound, the skin and subcutaneous tissue are dissected with two semi-oval incisions within healthy tissues and 2-3 cm above and below the primary opening of the passage with the capture of secondary fistulous passages without opening their lumen, while excising the pathological focus within healthy tissues in such a way that in its middle part the depth of excision is maximum, in the upper and lower edges of the incision - minimum, in the form of a scaphoid wound, in the upper and lower corners of the wound in the perpendicular direction additional incisions on the gluteal areas on the side of the lesion with a length equal to 1/3 of the height of the standing of the buttocks plus the width from the midline to the edge of the wound, for this length the skin with subcutaneous tissue is mobilized, subcutaneous fatty tissue is not excised in a wedge-shaped manner, the wound is sutured with skin grafting with a displaced flap bottom to top: flashing subcutaneous tissue is taken to 2/3 of the depth of the wound with a double absorbable suture, knotted sutures are tied, then the ends of the first and second sutures on both sides intradermally capture the edges of the wound, which are brought down and fixed to the bottom of the partially sutured wound by tying the ends of each thread, obtaining two interrupted intradermal suture at a distance of 1.5 cm from each other, followed by repetition depending on the length of the wound, additional incisions of the postoperative wound are sutured with an intradermal suture.

Brief description of drawings and other materials

FIG. 1 shows a method for the surgical treatment of chronic inflammation of the epithelial coccygeal passage, excision of ECC, purulent fistulas and infiltrates.

FIG. 2 - the same, wound after excision of pathological tissues.

FIG. 3 - the same, additional cuts for the gluteal regions with mobilization of the skin and subcutaneous tissue.

FIG. 4 - the same, the first row of seams.

FIG. 5 - the same, the second row of seams.

FIG. 6 - the same, formed intergluteal fold.

Fig. 7 is the same view of a sutured wound.

Implementation of the invention

Examples of a specific implementation of the method for the surgical treatment of chronic inflammation of the epithelial coccygeal passage.

Example 1. Examination of patients with ECC included in the study in the amount of 140 people, which includes, in addition to collecting subjective and objective data, the use of special research methods: examination, palpation and study of the parameters of the gluteal-sacrococcygeal region; identification of primary and secondary openings of the fistulous passages, their remoteness from the intergluteal fold and the anus; digital examination of the rectum; probing and staining of fistulous passages with an antiseptic from the group of dyes - 1% alcoholic solution of brilliant green. Some patients, if indicated, undergo an X-ray examination of the sacrum and coccyx, fistulography.

Operation is a method of surgical treatment of chronic inflammation of the ECH complicated by secondary fistulas of the gluteal-sacrococcygeal region in patients with a high standing of the buttocks, located 2-3 cm to the sides of the intergluteal fold, with a pronounced infiltrative and inflammatory process in the tissues adjacent to them.

Operation technique. The surgical field is carefully processed. To clarify the extent and prevalence of ECH, it is probed. Through the primary or fistulous holes of the EKH, it is stained with 1% alcohol solution of brilliant green using a special needle. The skin and subcutaneous tissue are dissected, for example, with a radio wave knife (Surgitron) with two semi-oval incisions (of the sheet-like type) with an indent from the intergluteal fold by 0.5-1.0 cm and 2-3 cm above and below the primary opening of the course with the capture of secondary fistulous passages without opening their lumen. The pathological focus within healthy tissues is excised without damaging the periosteum in such a way that the depth of the excision is maximum in its middle part, and minimum in the upper and lower edges of the incision. The wound has a scaphoid shape. Control of hemostasis. Wound sanitation with 3% hydrogen peroxide solution, ozonized saline solution at a concentration of 2.5 mg / l. In the upper and lower corners of the wound, perpendicular to it and along the elastic fibers, additional incisions are made in both gluteal regions. Their length is equal to the height of the configuration of the buttocks + the width of the wound from the midline to its edge. For this length, the skin with subcutaneous tissue is mobilized, the subcutaneous fat is not excised in a wedge-shaped manner. Suturing of the resulting wound from the bottom up is carried out as follows: double synthetic absorbable thread along the course of the wound is sewn through its bottom; on both sides, the subcutaneous tissue is stitched to 2/3 of the depth of the wound with the corresponding thread in the U-shaped suture type; knot sutures are tied on different walls of the wound with the knot shifted in opposite directions; then the ends of each thread on both sides intradermally capture the edges of the wound, which are brought down and fixed to the bottom of the partially sutured wound by tying the ends of each thread. This manipulation, depending on the length of the wound, is repeated 2-4 times, which makes it possible to form an intergluteal fold and a path in the form of a narrow strip up to 0.5 cm wide, providing an adequate outflow of the wound discharge.

Examples of a specific implementation, a method of surgical treatment of purulent inflammation of the epithelial coccygeal passage in a clinical setting, which was tested on 140 patients.

The control group included 140 (52.4%) patients with epithelial coccygeal passage who were hospitalized in the coloproctology department of the MBUZ "2nd City Clinical Hospital" of Stavropol in the period from 2018 to 2019. Of these, 21 (15.0%) patients were without clinical manifestations, 31 (22.1%) were in remission and 88 (62.9%) were in the stage of chronic inflammation.

In the preoperative period, the fistula is sanitized with antiseptic solutions; a few hours before the surgical intervention, the surgical field is shaved. Bowel preparation is performed with cleansing enemas. The choice of anesthesia is carried out individually for each patient: in 34 (24.3%) patients - local infiltration anesthesia; in 83 (59.3%) - spinal anesthesia; in 23 (16.4%) - intravenous anesthesia, of which 7 (2.6%) - in combination with local anesthesia.

A radical surgical approach in patients with ECC included excision within healthy tissues, both the tract itself and the fistulous tracts. Closing the formed defect is carried out in different ways: 1. blind suture of the wound; 2. stitching the edges of the wound to its bottom; 3. skin grafting with a displaced flap. Clinical example 2. Patient A., 23 years old, was admitted to the coloproctology department of the 2nd city clinical hospital with complaints of the presence of a fistula in the left buttock and periodic scanty discharge of pus from it. Sick for about 4 months, when pain appeared in the sacrococcygeal region, which then acquired a twitching character, swelling, hyperemia appeared, the temperature rose to 38.5 ° C. He did not seek medical help.

After 4 days, an abscess spontaneously opened in the coccyx area, followed by the formation of a fistula. On external examination of the intergluteal fold: 3.4 cm from the anus, the primary opening of the EKH, 5 cm - the opening of the fistulous passage with scant purulent discharge. Probing established a connection between the fistulous tract and the primary opening of the EKH, confirmed by a test with a dye (2% alcohol solution of brilliant green together + 3% hydrogen peroxide solution). In the course of the fistula, infiltration of subcutaneous fat, moderate pain is determined. In the study of the topographic and anatomical parameters of the gluteal-sacrococcygeal region, a high standing of the buttocks was established. Acetylator activity - 6.9%. A complex preoperative preparation was carried out: sanitation of the fistulous passage with 3% hydrogen peroxide solution and 0.5% alcohol solution of chlorhexidine, followed by treatment with medium-frequency ultrasound No. 3 under spinal anesthesia with one block with skin and subcutaneous tissue within healthy tissues, ECC and fistula were excised, skin edges of the wound brought down and sewn to its bottom. The postoperative period was smooth, on the 8th day the stitches were removed, on the 9th day the patient was discharged. Examined after 1.5 years. There is no relapse or discomfort in the sacrococcygeal region. Healthy.

The study of the terms of stay in the hospital of patients with ECC was carried out depending on the clinical form of the disease and the nature of the performed surgical intervention. Patients with ECH in the stage of chronic inflammation were inpatient treatment on average 12.3 ± 0.27 bed-days, remission - 9.4 ± 0.35 bed-days, without inflammation - 7.6 ± 0.19 bed-days.

The proposed invention has the following advantages in comparison with the prototype and other known technical solutions:

- simplifying and reducing the time of the method of conducting the operation;

- reduction in the duration of postoperative recovery.

Claims (1)

A method of surgical treatment of chronic inflammation of the epithelial coccygeal passage, complicated by secondary fistulas of the gluteo-sacrococcygeal region in patients with high standing of the buttocks, including preoperative sanitation of the fistulas, excision of the epithelial coccygeal passage, purulent fistulas, infiltrates and wound closure, characterized in that the skin and subcutaneous cellulose is dissected with two semi-oval cuts within healthy tissues and 2-3 cm above and below the primary opening of the passage with the capture of secondary fistulous passages without opening their lumen, while the pathological focus is excised within healthy tissues in such a way that in its middle part the depth of excision maximum, in the upper and lower edges of the incision - minimal, in the form of a scaphoid wound, in the upper and lower corners of the wound in the perpendicular direction, additional incisions are made on the gluteal regions on the affected side with a length equal to 1/3 of the height of the buttocks standing plus the width from the midline to the edges of the wound, on this Inu, the skin with subcutaneous tissue is mobilized, the subcutaneous fat is not excised in a wedge-shaped manner, the wound is sutured with a skin grafting with a displaced flap from the bottom up: the subcutaneous tissue is stitched 2/3 of the depth of the wound with a double absorbable thread, interrupted sutures are tied, then the ends of the first and second threads both sides intradermally capture the edges of the wound, which are brought down and fixed to the bottom of the partially sutured wound by tying the ends of each thread, receiving two interrupted intradermal sutures at a distance of 1.5 cm from each other, with subsequent repetition depending on the length of the wound, additional incisions of the postoperative wound sutured with an intradermal suture.

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