RU2776214C1 - Method for determining the viability of a suture strip of skin after mastectomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery, oncology. The oxygen index is calculated as the ratio of hemoglobin saturation of arterial blood of the suture strip of skin after mastectomy to the systemic saturation of arterial blood of the finger. Additionally, the viability index is calculated as the ratio of the blood pressure index of the medial and lateral suture strips of the skin to the systemic blood pressure index. When the values ​​of the obtained indices are 0.5 or higher, the suture strip of skin is considered viable.

EFFECT: method is informative, provides objective and reliable information about the state of the stitched skin edges in the area of ​​suturing, allows you to prevent the failure of the seams and necrosis of the skin edges after mastectomy.

1 cl, 4 tbl, 2 ex

Description

The invention relates to medicine, namely to breast cancer surgery. A known method of preventing the insolvency of the sutures of the interintestinal anastomosis after resection of the intestine, proposed by Ramazanov M.R., Aliev E.A., Magomedov A.M., Nesterov M.I., Bakhmudov A.S. in 2019 (Method for determining the viability of the suture strip of the intestine Ramazanov M.R., Aliev E.A., Magomedov A.M., Nesterov M.I., Bakhmudov A.S. // patent RU 2687650, pub. 15.05.2019 Bull . fourteen).

Prototype

The prototype of the proposed method is a method for determining the viability of the suture band of the intestine, proposed by Ramazanov M.R., Aliev E.A., Magomedov A.M., Nesterov M.I., Bakhmudov A.S. (2019), which is as follows.

After preparing the suture band of the intestine of the interintestinal anastomosis, the oxygen saturation of arterial blood hemoglobin in the finger of the hand is determined, and the oxygen viability index of the distal and proximal parts of the suture band of the intestine is calculated as the ratio of the hemoglobin oxygen saturation index of the arterial blood of the distal and proximal parts of the suture bands to the oxygen saturation index of arterial hemoglobin blood in the finger of the hand, and if the ratio in the distal and proximal parts of the suture bands is higher or equal to one, the suture band of the intestine is considered viable.

Criticism of the prototype

The method for determining the viability of the suture strip of the intestine, proposed by Ramazanov M.R., Aliev E.A., Magomedov A.M., Nesterov M.I., Bakhmudov A.S. (2019) has the following disadvantages.

1. In the suture strip of the intestine after ligation of the rectus vessels, only the oxygen saturation of arterial blood hemoglobin is determined, and blood pressure was not measured.

2. After determining the oxygen saturation of hemoglobin in arterial blood in an experiment out of 34 dogs, 9 (9.65%) sutures of the interintestinal anastomosis were found to fail (Vlasov A.P. Intestinal suture in conditions of impaired blood supply. - Bulletin of Surgery. - 1992. - No. 5 . - S. 138-143).

3. Arterial hemoglobin oxygen saturation values may be low when the hemoglobin in the body is low. Therefore, it is necessary to measure the blood pressure in the suture strip of the stitched tissues.

4. Blood pressure in the suture strip of the skin after mastectomy is lower compared to the suture strip of the intestine.

5. Indicators of blood pressure and oxygen saturation of arterial blood hemoglobin in the suture strip of skin, which is sutured after mastectomy, have not been published in print. They are presented by us for the first time in this proposed invention.

Purpose of the invention

The purpose of the proposed invention is to develop a method for determining the viability of a suture strip of skin after mastectomy in order to prevent the failure of skin sutures and necrosis of the skin margins after suturing the wound.

The essence of the invention

In an experiment on 20 dogs, a mastectomy was performed. Of these, 5 dogs were included in the comparison group, and 15 in the main group. The main laboratory tests are presented in Table 1. In the projection of the suture strip of skin after mastectomy, blood pressure and hemoglobin saturation of arterial blood decrease due to the fact that blood does not enter the sutured skin edges due to vascular ligation during skin mobilization after mastectomy. To obtain objective results, the oxygen index is calculated as the ratio of the hemoglobin oxygen saturation of the arterial blood of the suture strip to the oxygen saturation of hemoglobin of the arterial blood on the finger of the dog's front paw, and the viability of the skin is determined as the ratio of blood pressure in the skin and to blood pressure in femoral artery (systemic pressure) of a dog after exposure.

The essence of the method is as follows. After mastectomy under anesthesia, suture strips of skin edges are prepared under transillumination control to suture the wound. Lateral and medial suture bands are modeled by ligation of skin vessels and mobilization of skin margins. Oxygen saturation of arterial blood hemoglobin is determined using the apparatus proposed by us in the suture strips of the skin edges after mastectomy and shaving the skin on the front paw of a dog (Nesterov M.I., Ramazanov M.R., Magomedov A.M., Aliev E.A., Abdurakhmanova Z. M. Patent "Apparatus for the study of vessels of hollow organs during surgical operations during surgical operations" RU 2581266 C2 dated 08.20.2016. Bull. No. 23).

In experimental studies in dogs, 3 zones of blood pressure and oxygen saturation of hemoglobin in arterial blood were revealed in the suture strip of mobilized skin:

A - zone of normal blood pressure and oxygen saturation of hemoglobin in arterial blood;

B - zone of low blood pressure and saturation of arterial blood hemoglobin with oxygen;

C is the critical zone of blood pressure and arterial hemoglobin oxygen saturation.

In 15 dogs of the main group in the zone ("A") of normal blood pressure and oxygen saturation of arterial blood hemoglobin (Table 2), blood pressure was 75.4±1.2/46±1 mm. rt. Art. at a systemic pressure of 120.2±1.8/75.5±1.5 mm. rt. Art., and arterial hemoglobin oxygen saturation was 85±1.2% of the medial suture band and systemic blood oxygen saturation in the projection of the paw after shaving was 92±1%. In zone "B" of low blood pressure and saturation, blood pressure was 56±0.5/45.2±0.4 mm. rt. Art. at a systemic pressure of 120.2±1.8/75.5±1.5 mm. rt. Art., and oxygen saturation of arterial blood hemoglobin in the medial suture strip was 48±0.8% with the same systemic oxygen saturation of arterial blood hemoglobin in the front paw projection. In the critical zone "C", the blood pressure was 20±0.4/20±0.4 mm. rt st. at the same systemic pressure, and arterial hemoglobin oxygen saturation was 17±0.6%. The ratio of hemoglobin oxygen saturation of the arterial blood of the suture strip of the skin after mastectomy to the systemic saturation of arterial blood in the front paw of the dog is called the oxygen index of the viability of the suture strip of the skin after mastectomy. The calculated index must be equal to 0.5 or greater than 0.5. The oxygen index in the medial suture strip in the projection of the zone ("A") was found to be 0.9, and in the projection of the zone (B) - 0.5 (48:92=0.5) (Table 2). The oxygen index in zone "C" was 0.2, which is lower than the index of 0.5 in zone "B". Also, the skin viability index in zone "C" was 0.2 (20 mm Hg: 120 mm Hg = 0.2). The skin viability index in zone "B" was 0.5, and in zone "A" it was 0.6, which is higher than the index of 0.5 (Table 2).

Similar blood pressure and arterial hemoglobin oxygen saturation were also found in the lateral suture strip of the skin after mastectomy.

The skin edges were connected after mastectomy in 15 dogs of the main group using interrupted sutures with a skin viability index and an oxygen index of 0.5 (Table 3). There were no complications in the postoperative period. All dogs were slaughtered 14 days, 20 days, 1 month, 2 and 3 months after surgery by overdose of anesthetics. Histological examination of the suture strips of the skin sutures were well-founded and necrosis of the skin margins was not detected.

In 5 dogs of the comparison group, the critical zone of the suture strip of skin was modeled by remote mobilization of the skin edges after mastectomy and the wound was sutured at low non-viable rates (17±0.5% and 16±0.5%) of arterial blood hemoglobin saturation and blood pressure (20± 0.4/20±0.4 and 19.8±1/19.8±1 mm Hg) in sutured skin margins at a systemic pressure of 120.2±1.8/75.5±1.5 mm. rt. Art. in the femoral artery and saturation (92±1%) of arterial hemoglobin in the forepaw of the dog. In the medial skin suture after mastectomy, the oxygen index was 0.2 (17:92=0.2), and in the lateral skin suture was also 0.2 (16:92=0.2). The skin viability index was also 0.2 (Table 4). In the postoperative period, necrosis of the sutured skin edges of the wound was found in all 5 dogs, and the sutures were not consistent on days 6-7. Histological examination revealed necrosis of suture skin strips in all 5 dogs. Examples of specific implementation of the method.

Example #1.

Journal of Experimental Research 1. A mastectomy was performed on a white dog weighing 15 kg under general anesthesia and the skin edges were mobilized to suture the wound. Prepared suture strips of skin. The blood pressure in the skin was determined, which was equal to 56/45.2 mm. rt. Art. at a systemic pressure of 120/75 mm Hg, and oxygen saturation of hemoglobin in arterial blood was 48% in the medial suture strip of the skin, and 47% in the lateral suture strip of the skin. In the projection of the forepaw, oxygen saturation of arterial blood was found to be 92%. The postoperative wound was sutured by interrupted sutures on the edges of the skin. The oxygen index in the medial skin suture was 0.5, and in the lateral skin suture was also 0.5. The skin viability index was also 0.5 (56:120=0.5). In the postoperative period, cefotaxime 0.1 mg per 1 kg of body weight, dissolved in physiological saline, was administered intramuscularly 2 times daily for 5-6 days. For pain relief in the postoperative period, 0.5 ml of a 50% solution of analgin and 0.5 ml of a 1% solution of diphenhydramine were administered intramuscularly twice a day. 50 ml of 5% glucose solution was injected under the skin for the purpose of parenteral nutrition.

There were no complications after the operation. The dog recovered.

Example #2.

We give example No. 2 from the Journal of Experimental Research No. 2.

A mastectomy was performed on a black dog weighing 16 kg under general anesthesia and the skin margins were mobilized. Sutured skin strips were prepared for suturing the postoperative wound and oxygen saturation of arterial blood hemoglobin in the area of the proposed sutures was studied. In the medial suture strip of the skin, oxygen saturation of arterial blood hemoglobin was 48% and lateral - 48%, while oxygen saturation of arterial blood hemoglobin in the forepaw was 92%. The oxygen index of the skin margins in the suturing zone was 0.5. The blood pressure in the medial suture strip of the skin was 57 mm Hg. at a systemic pressure of 121/80 mm Hg, and in the lateral suture strip of the skin, the blood pressure was 58 mm Hg. with the same systemic blood pressure. The viability index of the suture bands was 0.5.

In the postoperative period daily for 5-6 days was administered a solution of analgin 50% - 0.5 ml/m and 0.5 ml of a 1% solution of Diphenhydramine 2 times a day. Cefotaxime 0.1 mg per 1 kg of body weight was also injected intramuscularly 2 times a day. The dog recovered after the operation. There were no complications.

Features of the invention, distinguishing from the prototype.

According to the prototype, after preparing the suture strip of the intestine, oxygen saturation of arterial blood hemoglobin in the intestinal wall is examined before the formation of an interintestinal anastomosis.

According to the proposed method, the blood pressure in the suture strip of the skin after mastectomy and the systemic blood pressure are additionally determined, and then the viability index is calculated as the ratio of the blood pressure index of the suture strip of the skin to the systemic blood pressure index, and if the ratio is higher or equal to 0.5, the suture strip is considered skin after mastectomy viable.

The positive effect of the application of the invention.

1. According to the proposed method, not only the oxygen index but also the skin vitality index is calculated in the form of ratios of the blood pressure indicators of the suture strip of the skin to the systemic pressure indicator, since in the projection of the mobilized skin edges, the hemoglobin saturation indicators of arterial blood and blood pressure decrease due to the fact that that blood does not enter the skin edges of the wound due to ligation of vessels during skin mobilization during mastectomy, although systemic pressure does not change.

2. After applying the oxygen index and the viability index of the skin suture strip during mastectomy, there was no failure of the sutures applied to the skin after suturing the wound and there was no skin necrosis in 15 experimental animals of the main group.

3. The proposed method is informative, provides objective and reliable information about the state of the stitched skin edges in the area of suturing after mastectomy, allows you to prevent necrosis of the skin edges and failure of the skin sutures.

In the clinic, oncomammologists use the following clinical methods for assessing skin viability to determine the viability of the skin before suturing the wound after mastectomy:

1. cut the edges of the skin for the presence of bleeding;

2. color of skin edges before suturing;

3. puncture of the skin edges for the appearance of blood at the puncture site;

4. practical experience of an oncomammologist regarding the remoteness of skin mobilization after mastectomy before suturing;

5. preservation of subcutaneous tissue or excessive removal of subcutaneous tissue in order to radicalize the operation.

However, the use of these clinical methods for determining the viability of the skin before suturing the wound after mastectomy did not help to prevent marginal skin necrosis, even for experienced mammologists.

According to A.Kh. Ismagilova, R.Sh. Khasanova, A.M. Gimranova et al. (2008) (Ismagilov A.Kh., Khasanov R.Sh., Gimranov A.M. et al. Simultaneous reconstructive plastic surgery for breast cancer // Oncomammology. - 2008. - No. 1. - P. 83) after performing one-stage reconstructive - plastic surgery for breast cancer in 447 patients in the early postoperative period, the following complications were noted: when using the thoracodorsal flap, 2 cases of complete and 2 partial necrosis of the flap were found, when using the TRAM flap, 17 marginal necrosis, 11 umbilical necrosis, 4 marginal necrosis were found recipient skin.

At the second stage, the results of experimental studies performed on 20 dogs were introduced into the clinic.

In the clinic, during mastectomy and mobilization of the skin edges, the oxygen index was calculated as the ratio of oxygen saturation of hemoglobin in the arterial blood of the suture strip of the skin to the oxygen saturation of the finger of the hand, and the viability index of the suture strip of the skin was determined as the ratio of blood pressure in the skin of the suture strip to the systemic pressure on the patient's shoulder. In 56 patients, the oxygen index was equal to or greater than 0.5 at the skin margins and the skin viability index was also equal to or greater than 0.5 at mastectomy suturing. As a result of the use of the oxygen index and the viability index of the skin suture strip by blood pressure, there was no failure of the skin sutures and necrosis of the skin margins after mastectomy in 56 patients of the main group, as well as in 30 patients of the main group after organ-preserving plastic surgery.

In 59 patients of the comparison group, the viability of the skin during wound closure after mastectomy and 30 patients of the comparison group after organ-preserving and plastic surgeries did not determine blood pressure and oxygen saturation of arterial blood hemoglobin in the suture strip of the skin using the developed device.

Although oncomammologists used the above clinical methods to determine the viability of the skin after breast surgery in practice, in the comparison group, skin necrosis and suture failure with divergence of the sutured postoperative wound after mastectomy were found in 5 patients out of 59, and this complication was found in 2 patients out of 30 comparison groups after organ-preserving plastic surgery on the mammary gland for breast cancer.

However, the use of these clinical methods for determining the viability of the skin before suturing the wound after mastectomy and organ-preserving plastic surgery did not help to prevent marginal skin necrosis, even for experienced mammologists.

Information taken into account:

1. Vlasov A.P. Intestinal suture in conditions of impaired blood supply. - Bulletin of Surgery. - 1992. - No. 5. - S. 138-143).

2. Ramazanov M.R., Aliev E.A., Magomedov A.M., Nesterov M.I., Bakhmudov A.S. Method for determining the viability of the suture band of the intestine. - Patent RU 2687650, pub. May 15, 2019 Bull. 14. - prototype.

3. Nesterov M.I., Ramazanov M.R., Magomedov A.M., Aliev E.A., Abdurakhmanova Z.M. Patent "Apparatus for the study of vessels of hollow organs during surgical operations" RU 2581266 C2 dated 20.08. 2016. Bull. No. 23).

4. Ismagilov A.Kh., Khasanov R.Sh., Gimranov A.M. et al. Simultaneous reconstructive plastic surgery for breast cancer // Oncomammology. - 2008. - No. 1. - S. 83.

Claims (1)

A method for determining the viability of a suture strip of skin after mastectomy, characterized in that the oxygen index is calculated as the ratio of oxygen saturation of hemoglobin in the arterial blood of the suture strip of skin after mastectomy to the systemic saturation of the arterial blood of the finger of the hand, the viability index is additionally calculated in the form of a ratio of the blood pressure index of the medial and lateral suture strips of skin to the systemic blood pressure index, with values of the obtained indices of 0.5 or higher, the suture strip of skin is considered viable.