RU2776559C1 - Method for surgical treatment of epithelial coccygeal passage - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely coloproctology. The wound after excision of the epithelial coccygeal passage is closed by successive intradermal suturing, as in DWG. 3. To do this, the ligature is passed through the skin of one of the edges of the wound, then into the wound cavity, then through the nearby corner of the wound bottom, the wound bottom is captured, after which it is led from the opposite side, along the wound wall, through subcutaneous fat, the ligature is removed intradermally to the opposite edge of the wound, subcutaneous fat is adapted under visual control before matching the edges of the wound without tension and the ligature is fixed with a surgical knot. The same manipulations are repeated until the wound remaining after excision is completely closed.

EFFECT: method makes it possible to achieve an increase in the quality of the cosmetic effect due to congruent matching of the edges of the wound, to move subcutaneous fat to the center of the gluteal cleft, which leads to the absence of the formation of residual cavities and reduces the risk of secondary infection and suppuration of the wound, as well as relapses in the postoperative period; reduction of terms of medical and social rehabilitation, reduction of bed days.

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Description

The present invention relates to medicine, namely to coloproctology and surgery, and can be used to treat patients with epithelial coccygeal tract.

The incidence of epithelial pilonidal sinus (ECS) is currently known to be 26 cases per 100,000 population (Chintapatla S, Safarani N, Kumar S. Sacrococcygeal pilonidal sinus: historical review, pathological insight and surgical options. Tech Coloproctol 2003; 7: 3- 8 Clothier, P. R., Haywood, I. R. The natural history of the post anal (pilonidal) sinus Ann R Coll Surg Engl 1984;66:201-203). The peak incidence occurs in the able-bodied population aged 18 to 40 years, with a predominance of males over females in a ratio of 3:1. In this regard, the treatment of this disease is of great social and economic importance. (Lurin I.A. Etiology and pathogenesis of pilonidal disease (literature review) / I.A. Lurin, E.V. Tsema. // Coloproctology. - 2013. - No. 3 (45). - P. 35-50., Shelygin, Y. A. Handbook of coloproctology / Y. A. Shelygin, L. A. Grateful. - M.: Litterra, 2012. - 606 p.). Currently, despite the many ways of surgical treatment of the epithelial coccygeal tract, there is no "gold standard" of surgical technique. The frequency of postoperative complications and relapses remains high (37%) according to domestic and foreign authors (Dultsev Yu.V., Rivkin V.L. Epithelial coccygeal passage. - M. 1988, - 128 p., Iesalnieks I., Ftirst A., Rentsch M, Jauch K.W. Primary midline closure after excision of a pilonidal sinus is associated with a high recurrence rate Chirurg 2003). As a result, there is an increase in the terms of disability and a decrease in the quality of life, which makes the problem relevant today.

A known method for the treatment of epithelial coccygeal passage, by radical excision and closure of the wound defect, which is carried out as follows: the edges of the wound are sutured to its bottom, leaving an open narrow wound strip along the midline, for a better outflow of contents (Dultsev Yu.V. Rivkin V.L. Epithelial coccygeal passage. - M.: Medicine, 1988. - S. 83-86).

The main disadvantage of this method is the long healing of the wound and the possibility of infection in the early postoperative period. And also an unsatisfactory cosmetic effect, due to the formation of a rough scar, fixed to the lumbosacral fascia, which can give pain during exertion. There is a high probability of recurrence of the disease due to anatomical features: the depth of the intergluteal fold and the height of the buttocks.

A known method of suturing the wound after excision of the epithelial coccygeal tract by applying parallel seams with the capture of the bottom of the wound at a distance of 2 cm from each other. Subsequently, the ends of the ligatures of the parallel sutures of each pair are tightened and tied simultaneously on one and the other side of the wound until its edges are in full contact (patent RU 2305499, published on September 20, 2002).

The main disadvantage of this method is the complexity of the formation of a postoperative scar due to the limited mobility of the tissue of this anatomical region, which will lead to excessive tissue tension, and subsequently to failure and the formation of a residual cavity. The risk of infection in the early postoperative period is high. The terms of medical and social rehabilitation and the bed-day are increasing.

The closest analogue is the method of surgical treatment of epithelial coccygeal passage with or without suppuration, including radical excision of the epithelial coccygeal passage with a sector of altered or inflamed skin within healthy tissues. Parallel to the edge of the surgical wound, a lateral skin incision 2.5-3.0 cm long is made. A skin-fat flap 2.0-2.5 cm wide is formed, connecting the lateral skin incision to the wound with a tunnel in the subcutaneous fat. Move the flap to the midline. The surgical wound is sutured tightly, without tension of its edges. Tamponade and external drainage of the wound cavity are performed through a lateral incision (Patent RU 2 595 503 dated 27.08.2016 IPC A61V 17/00, 2006).

The disadvantage of this method is that it requires an additional incision in the skin, which will lead to an unsatisfactory cosmetic effect. Performing external drainage will create an entrance gate of infection, which can subsequently lead to infection and suppuration of the wound in the early postoperative period. When the time comes to remove the drainage, additional skin sutures will be required, which will entail additional use of suture material, as well as increase the duration of medical and social rehabilitation and the bed-day.

Tasks: improving the quality of the cosmetic effect, eliminating the possibility of the formation of residual cavities, reducing the number of relapses of the disease, reducing the terms of medical and social rehabilitation and bed-days.

The essence of the invention is that the wound after excision of the epithelial coccygeal passage is closed by successive intradermal suturing, as in Fig. 3, for which the ligature is passed through the skin of one of the edges of the wound, then into the cavity of the wound, then it is passed through the nearby corner of the day of the wound, the bottom of the wound is captured, and then it is led from the opposite side - along the wall of the wound, through the subcutaneous fat, the ligature is removed intradermally to the opposite edge of the wound, adapt the subcutaneous fat under visual control until the edges of the wound are aligned without tension and fix the ligature with a surgical knot, repeat the same manipulations until the wound remaining after excision is completely closed.

The technical result achieved by the claimed invention is to improve the quality of the cosmetic effect, the movement of the subcutaneous fat to the center of the intergluteal sulcus leads to the absence of the formation of residual cavities due to the congruent comparison of all layers of the wound, which reduces the risk of secondary infection and suppuration of the wound, relapses in the postoperative period . Reduction of terms of medical and social rehabilitation, reduction of bed-days.

For better understanding, the method is shown schematically in Fig. 1-5, where Fig. 1 is a diagram of a general view of the coccygeal passage, fig. 2, wound cavity after excision with a single block of ECX, fig. 3, scheme of applying the ligature, FIG. 4, wound after adaptation of the edges, fig. 5, postoperative view,

p. 1 - epithelial coccygeal passage,

p. 2 - wound cavity after excision of ECX,

p. 3 - initial (intradermal) suturing,

p. 4 - the angle of the wound,

p. 5 - a ligature passed through the subcutaneous fat,

p. 6 - needle puncture into the intradermal point,

p. 7 - adaptation of the edges of the wound and movement of the subcutaneous fat layer without tension,

p. 8 - fixing the ligature,

p. 9 - the final view of the wound after suturing.

The method is carried out as follows: epithelial coccygeal passage 1 is excised, wound 2 after excision of the epithelial coccygeal passage is closed by successive intradermal suturing, then the ligature is passed through the skin of one of the edges of the wound, into the wound cavity, then it is passed through the nearby corner of the wound bottom, capturing the bottom 4 , after which they are led from the opposite side - along the wound wall through the subcutaneous fat 5, the ligature 6 is brought out intradermally to the opposite edge of the wound. The subcutaneous fat is adapted under visual control until the edges of the wound are aligned without tension 7. After that, the ligature 8 is fixed with a surgical knot. The same manipulations are repeated until the complete closure of the remaining wound after excision.

Example 1. Patient V., 20 years old, was admitted to the hospital in a planned manner with a diagnosis of Epithelial coccygeal passage. This disease was established at the draft board, a referral was made to the surgeon at the place of residence to resolve the issue of surgical treatment. Examined on an outpatient basis. The operation was carried out in accordance with the stated method. During the excision operation, the cavity of the epithelial coccygeal passage was stained through the lower hole located in the projection of the intergluteal fold with a brilliant green solution with a 3% hydrogen peroxide solution using a syringe. Contrast came from all holes. An elliptical incision was made in the skin and subcutaneous fat around the postoperative scar using a Hemostasis-dry scalpel. ECX was excised as a single block up to the sacral fascia within unchanged tissues. The wound was sutured according to the proposed method as follows: an intradermal suture was sequentially applied through the skin of one of the edges of the wound, then through the nearby corner of the wound bottom, the bottom of the wound was captured, after which, from the opposite side, a ligature with a needle was passed through the subcutaneous tissue of the wound, along the wall wounds, and brought intradermally to the skin of the opposite edge of the wound. Then, under visual control, pulling up the subcutaneous fat and adapting the edges of the wound, they were fixed on the surface of the skin with a surgical knot. This sequence of manipulations was performed throughout the wound. An aseptic bandage impregnated with an alcohol solution of chlorhexidine was applied. The postoperative period proceeded smoothly. Healing by first intention. The sutures were removed on the 14th day after the operation. To work - on the 18th day after the operation. Dynamic observation of postoperative complications and recurrence was not revealed. According to the ultrasound data, fluid accumulation along the postoperative suture with the formation of a streak was not detected. At the control examination after 3 months, the patient has a linear scar, without signs of keloid.

Example 1. Patient K., aged 38, was admitted to the Department of Purulent Surgery of the emergency hospital in Krasnodar with a diagnosis of recurrent epithelial coccygeal passage. From the anamnesis: earlier, in 2013 and 2021, he was operated on for an epithelial coccygeal passage with suturing the postoperative wound tightly. For a long period, pain and discharge from the coccyx area are disturbing. In the sacrococcygeal region, postoperative scars, infiltrate 2x3 cm, fistulous openings with discharge are located in the midline 4 cm from the anus. During the operation, the method described in example 1 was applied. After excision with a single block of the ECX, a suture was performed with the mobilization of subcutaneous fat and fixation on the skin surface with a surgical knot. The postoperative period proceeded smoothly. Healing by first intention. The sutures were removed on the 15th day after the operation. To work - on the 19th day after the operation. Dynamic observation of postoperative complications and recurrence was not revealed. According to the ultrasound abscesses and streaks were not revealed.

The proposed method allows to reduce the frequency of postoperative complications, improve the cosmetic effect and reduce the period of disability.

SOURCES OF INFORMATION

1. Dultsev Yu.V., Rivkin V.L. Epithelial coccygeal passage. - M. 1988, p. 83-86, 128.

2. Lurin I.A. Etiology and pathogenesis of pilonidal disease (literature review) / I.A. Lurin, E. V. Tsema. // Coloproctology. - 2013. - No. 3 (45). - S. 35-50.

3. Shelygin, Yu.A. Handbook of coloproctology / Yu.A. Shelygin, L.A. Grateful. - M.: Litterra, 2012. - 606 p.

4. Chintapatla S, Safarani N, Kumar S. Sacrococcygeal pilonidal sinus: historical review, pathological insight and surgical options. Tech Coloproctol 2003; 7:3-8.

5. Clothier, P.R., Haywood, I.R. The natural history of the post anal (pilonidal) sinus. Ann R Coll Surg Engl. 1984; 66:201-203.

6. Iesalnieks I., Furst A., Rentsch M., Jauch K. W. Primary midline closure after excision of a pilonidal sinus is associated with a high recurrence rate Chirurg 2003.

7. Patent RU 2305499, 20.09.2002r. IPC A61B 17/00, 2006.

8. Patent RU 2 595 503, 08/27/2016 IPC A61B 17/00, 2006.

Claims (1)

A method of surgical treatment of the epithelial coccygeal passage, including its excision, characterized in that the wound after excision of the epithelial coccygeal passage is closed by successive intradermal suturing, as in figure 3, for which the ligature is passed through the skin of one of the wound edges, then into the wound cavity, then it is passed through the nearby corner of the wound bottom, the bottom of the wound is captured, and then it is led from the opposite side - along the wall of the wound, through the subcutaneous fat, the ligature is brought out intradermally to the opposite edge of the wound, the subcutaneous fat is adapted under visual control until the edges of the wound are compared without tension and fix the ligature with a surgical knot, repeat the same manipulations until the wound remaining after excision is completely closed.

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