RU2785491C1 - Method for surgical treatment of chronic inflammation of the epithelial coccygeal passage. - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to coloproctology. Preoperative sanitation of fistulas, excision of the epithelial coccygeal passage, purulent fistulas and infiltrates, hemostasis and wound closure are performed. At the same time, preoperative debridement of the wound is carried out with a 3% solution of hydrogen peroxide, ozonated saline at a concentration of 2.5 mg/l. Wherein the length and distribution of the epithelial coccygeal passage are additionally preliminarily specified by probing. Then the skin and subcutaneous tissue of the epithelial coccygeal passage is dissected by two semi-oval incisions of the leaf-like type with an indent from the intergluteal fold at a distance of 2 cm and 2 cm above and below the primary opening of the passage with the capture of secondary fistulous passages without opening their lumen. At the same time, the excision of the pathological focus is carried out within healthy tissues without damaging the periosteum in such a way that in its middle part the excision depth is maximum, in the upper and lower edges of the incision it is minimal, forming a navicular shape. Closure of the resulting wound is carried out from the bottom up, and the subcutaneous tissue is sutured to ½ of the depth of the wound with interrupted sutures from absorbable suture material, the ends of the threads are cut off, on each side of the reduced wound, retreating from the skin down, and from the previously applied interrupted sutures upward, wedge-shaped in in the form of an equilateral triangle with a height equal to the depth of the wound and a base located towards the wound, the subcutaneous tissue is excised from both sides. Threads are inserted intradermally, parallel to the wound edge, to a depth of 5 mm, the ends of which are directed towards the wound, while the ends of the threads alternately capture the subcutaneous tissue with the thread passing at the level of the bottom of the wound sutured with the first row of sutures. The ends of the threads are brought to the skin 1.5 cm from the skin edge of the wound. Then the threads are tied together, reducing the skin edges of the wound to its bottom with the formation of an intergluteal fold to a flat configuration of the buttocks.

EFFECT: method allows to simplify and reduce the time of the operation and reduce the duration of postoperative recovery.

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Description

The field of technology to which the invention belongs

The invention relates to medicine, namely to coloproctology, in particular, to a method for the surgical treatment of chronic inflammation of the epithelial coccygeal tract in patients with an average configuration of the buttocks and can be used in the surgical treatment of purulent inflammation of the epithelial coccygeal tract in the intergluteal fold, as well as secondary fistulas, infiltrates located far on both sides of the intergluteal fold.

State of the art

A known method of suturing the 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 at the same time 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, published on September 10, 2007, bull. No. 25).

The disadvantage of this method is the long postoperative recovery.

A known method of surgical treatment of chronic inflammation of the epithelial coccygeal tract (ECC), which consists in the fact that to clarify the extent and prevalence of the ECC, it is probed, then it is stained through the primary or fistulous openings of the ECC with a 1% alcohol solution of brilliant green using a special needle, the skin and subcutaneous tissue are dissected with two semi-oval incisions (like leaf-shaped) 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 secondary fistulous passages without opening their lumen, excised without damaging the periosteum, the pathological focus is within healthy tissues in such a way that in its middle part the excision depth is maximum, in the upper and lower edges of the incision it is minimal, while the wound has a navicular shape, thorough hemostasis is performed, the wound is sanitized with a 1% aqueous solution of chlorhexidine biglu- konata, then in the upper and lower corners of the wound, perpendicular but to her and along the elastic fibers, additional incisions are made on both gluteal regions. Their length is equal to the height of the buttocks + the width of the wound from the midline to its edge. At this length, the skin with subcutaneous tissue is mobilized, the subcutaneous fat is wedge-shaped excised on both sides, and the mobilized flap is brought down 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 G.I. Fundamentals of coloproctology / G.I. Vorobyov. - M .: Medical Information Agency LLC. - 2006. - 432 p.).

The disadvantage of this method is the departure of the edges of the wound from its bottom, prolonged healing.

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 inserted into the external opening of one of them, advanced to the center to the external opening of the epithelial passage itself, the skin with subcutaneous tissue is dissected above this probe, thereby the upper wall of the purulent passage is opened in the same way, then the rest of the fistulous passages are dissected along the probe in the same way, the resulting superficial wound along the fistulous passages is scraped out with a Volkmann spoon and treated with a 1% iodanate solution, then the resulting irregularly shaped wound is tamponed with narrow tapes with a water-soluble ointment (see Dultsev YV Epithelial coccygeal passage / YV Dultsev, VL Rivkin / Moscow: Medicine, 1988. - 127 p.).

The disadvantage of this method is the complexity and trauma of the operation, long healing time, the possibility of postoperative complications: hematomas, hypertrophic scars, cosmetic defects.

The closest in technical essence and the positive effect achieved and adopted by the authors as a prototype is a method for the surgical treatment of chronic inflammation of the epithelial coccygeal tract, including preoperative sanitation of fistulas, excision of the epithelial coccygeal tract, purulent fistulas and infiltrates, hemostasis and wound closure, while after excision of the epithelial coccygeal external fistulous openings are excised with fringing incisions to the depth of the skin, then in the upper and lower corners of the wound, perpendicular to it, additional incisions are made on both gluteal regions with their length equal to 1/3 of the height of the buttocks plus the width of the wound from the midline to its edge, with at this length, the skin with subcutaneous tissue is mobilized up to the previously excised external fistulous openings, then the mobilized flap with subcutaneous tissue is turned away, pathologically altered tissues with previously isolated external fistulous openings are removed, enriched thrombocytes are injected into the wound walls the plasma with a platelet content of 10 ⁶ /μl, using a 1.0 syringe with a BogMark injection needle 0.5 × 16, and then the resulting wound is sutured from the bottom up by stitching with a double synthetic thread, the sacrococcygeal ligaments are captured with a stitch length of 1.0 up to 1.5 cm, then the subcutaneous tissue of one of the walls of the wound is stitched with the ends of the first thread at 2/3 of the depth of the wound in the form of a U-shaped suture, the second thread is similar to the other wall of the wound, interrupted sutures are tied, then the ends of the first thread on both sides intradermally the edges of the wound are captured, which are brought down and fixed to the bottom of the wound sutured to 2/3 of the depth by tying the ends of this thread, similarly performed with the ends of the second thread, obtaining two interrupted intradermal sutures at a distance of 1.0 to 1.5 cm from each other with subsequent repetition with threads of all sutures necessary for suturing the entire length, with the possibility of forming an intergluteal fold and a path in the form of a narrow strip up to 0.5 cm wide for outflow of wound discharge, and additional incisions on the buttocks are sutured with an intradermal suture (see Fig. Pat. RU No. 2737413, IPC A61V 17/00, A61K 35/19, A61R 17/00, publ. November 30, 2020, bul. 34).

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

Disclosure of invention

The objective of the invention is to develop a method for the surgical treatment of chronic inflammation of the epithelial coccygeal tract in patients with an average buttocks configuration, which simplifies and reduces the time of the operation method by a one-stage operation to completely remove the focus of purulent inflammation with primary wound plasty with local tissues and reduce the duration of postoperative recovery.

The technical result that can be obtained using the present invention is to simplify and reduce the time of the operation method and reduce the duration of postoperative recovery.

глубины раны узловыми швами из рассасывающегося шовного материала, концы нитей отрезаются, с каждой стороны уменьшенной в размерах раны, отступя от кожного покрова вниз, а от наложенных ранее узловых швов вверх, клиновидно в виде равностороннего треугольника с высотой, равной глубине раны, и основанием, расположенным в сторону раны, иссекают подкожную клетчатку с обеих сторон, интрадермально, параллельно краю раны, на глубину 5 мм проводят нити, концы которых направлены в сторону раны, при этом концами нитей поочередно захватывают подкожную клетчатку с проведением нити на уровне дна ушитой первым рядом швов раны, а концы нитей выводят на кожный покров в 1,5 см от кожного края раны, затем нити связывают между собой, низводя кожные края раны к ее дну с формированием межъягодичной складки и плоской конфигурации ягодиц.The technical result is achieved using a method for the surgical treatment of chronic inflammation of the epithelial coccygeal tract in patients with an average configuration of the buttocks, including preoperative sanitation of fistulas, excision of the epithelial coccygeal tract, purulent fistulas and infiltrates, hemostasis and wound suturing, while preoperative sanitation of the wound is carried out with a three percent hydrogen peroxide solution , with ozonized saline at a concentration of 2.5 mg/l, and additionally pre-specify the length and distribution of the epithelial coccygeal passage by probing, then the skin and subcutaneous tissue of the epithelial coccygeal passage are dissected with two semi-oval incisions indented from the intergluteal fold at a distance of 2 cm and 2 cm above and below the primary opening of the passage with the capture of secondary fistulous passages without opening their lumen, while the excision of the pathological focus is carried out within healthy tissues without damaging the periosteum in such a way that in its middle part the excision depth is maximum, in the upper and lower edges of the incision - the minimum, forming a navicular shape, the wound is sanitized with a 3% hydrogen peroxide solution, ozonated saline at a concentration of 2.5 mg/l, and the closure of the resulting wounds are carried out from the bottom up, while the subcutaneous tissue is sutured on

the depth of the wound with interrupted sutures from absorbable suture material, the ends of the threads are cut off, on each side of the reduced wound, retreating from the skin down, and upwards from the previously applied interrupted sutures, wedge-shaped in the form of an equilateral triangle with a height equal to the depth of the wound, and a base, located towards the wound, the subcutaneous tissue is excised on both sides, intradermally, parallel to the edge of the wound, threads are passed to a depth of 5 mm, the ends of which are directed towards the wound, while the ends of the threads alternately capture the subcutaneous tissue with the thread at the bottom level sutured with the first row of sutures wounds, and the ends of the threads are brought to the skin 1.5 cm from the skin edge of the wound, then the threads are tied together, bringing the skin edges of the wound down to its bottom with the formation of an intergluteal fold and a flat configuration of the buttocks.

The essence of the proposed method of surgical treatment of chronic inflammation of the epithelial coccygeal passage with an average configuration of the buttocks is as follows (see Fig. 1, 2, 3, 4, 5, 6, 7, 8).

глубины раны узловыми швами из рассасывающегося шовного материала, концы нитей отрезаются, с каждой стороны уменьшенной в размерах раны, отступя от кожного покрова вниз, а от наложенных ранее узловых швов вверх, клиновидно в виде равностороннего треугольника с высотой, равной глубине раны, и основанием, расположенным в сторону раны, иссекают подкожную клетчатку с обеих сторон, интрадермально, параллельно краю раны, на глубину 5 мм проводят нити, концы которых направлены в сторону раны, при этом концами нитей поочередно захватывают подкожную клетчатку с проведением нити на уровне дна ушитой первым рядом швов раны, а концы нитей выводят на кожный покров в 1,5 см от кожного края раны, затем нити связывают между собой, низводя кожные края раны к ее дну с формированием межъягодичной складки и плоской конфигурации ягодиц.A method of surgical treatment of chronic inflammation of the epithelial coccygeal tract in patients with an average configuration of the buttocks, including preoperative debridement of fistulas, excision of the epithelial coccygeal tract, purulent fistulas and infiltrates, hemostasis and wound suturing, while preoperative debridement of the wound is carried out with a 3% hydrogen peroxide solution, ozonized saline at a concentration of 2.5 mg / l, and additionally pre-specify the length and distribution of the epithelial coccygeal passage by probing, then the skin and subcutaneous tissue of the epithelial coccygeal passage is dissected with two semi-oval incisions indented from the intergluteal fold at a distance of 2 cm and 2 cm above and below the primary opening of the passage with the capture of secondary fistulous passages without opening their lumen, while the excision of the pathological focus is carried out within healthy tissues without damaging the periosteum in such a way that in its middle part the depth of excision I is the maximum, in the upper and lower edges of the incision - the minimum, forming a navicular shape, and the closure of the resulting wound is carried out from the bottom up, and the subcutaneous tissue is sutured on

the depth of the wound with interrupted sutures from absorbable suture material, the ends of the threads are cut off, on each side of the reduced wound, retreating from the skin down, and upwards from the previously applied interrupted sutures, wedge-shaped in the form of an equilateral triangle with a height equal to the depth of the wound, and a base, located towards the wound, the subcutaneous tissue is excised on both sides, intradermally, parallel to the edge of the wound, threads are passed to a depth of 5 mm, the ends of which are directed towards the wound, while the ends of the threads alternately capture the subcutaneous tissue with the thread at the bottom level sutured with the first row of sutures wounds, and the ends of the threads are brought to the skin 1.5 cm from the skin edge of the wound, then the threads are tied together, bringing the skin edges of the wound down to its bottom with the formation of an intergluteal fold and a flat configuration of the buttocks.

Brief description of drawings and other materials

In FIG. 1 shows the method of surgical treatment of chronic inflammation of the epithelial coccygeal tract (ECH) in patients, the nature of surgical interventions in the traditional method of treatment of ECC (n=140), table 1.

In FIG. 2, too, radical operation with blind suture of the wound (low configuration).

In FIG. 3, also, a radical operation - with suturing the edges of the wound to its bottom (low configuration).

In FIG. 4, also, a radical operation - excision of the ECX with suturing the edges of the wound to its bottom in the modification of the Research Institute of Proctology of the Ministry of Health of the Russian Federation (medium configuration).

In FIG. 5, also, a radical operation - excision of the ECX with skin grafting with a displaced flap (high configuration).

In FIG. 6, also, early postoperative complications in patients with various clinical forms of ECC treated with traditional methods (n=140), table 2.

In FIG. 7, also, early postoperative complications in patients with ECC treated with traditional methods (n=140), table 3.

In FIG. 8, also, early postoperative complications in patients with ECC, depending on the height of the buttocks (n=140), table 4.

Implementation of the invention

Examples of a specific implementation of the method of surgical treatment of chronic inflammation of the epithelial coccygeal passage (ECH) in patients with an average configuration of the buttocks, is as follows.

Example 1

Conduct a survey 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 gluteosacral-coccygeal region; identification of primary and secondary openings of the fistulous passages, their distance 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% alcohol solution of brilliant green. Some patients, according to indications, perform X-ray examination of the sacrum and coccyx, fistulography.

Operation - a method of surgical treatment of chronic inflammation of the ECX complicated by secondary fistulas of the gluteal-sacral-coccygeal region in patients with an average configuration of the buttocks, located indented from the intergluteal fold at a distance of 2 cm and 2 cm above and below the primary opening of the course (see Fig. 1 , 2, 3, 4, 5, 6, 7, 8).

Operation technique.

Conduct a thorough treatment of the surgical field. To clarify the extent and prevalence of ECC, its probing is carried out, this preoperative sanitation of fistulas is carried out with a three percent solution of hydrogen peroxide, a solution of chlorhexidine bigluconate, and the extent and distribution of the epithelial coccygeal passage is additionally specified by staining it with a 1% alcohol solution of brilliant green through the primary or fistulous openings of the ECC; the skin and subcutaneous tissue are dissected with a radio wave knife (Surgitron), two semi-oval incisions (like a leaf-shaped one) with an indent from the intergluteal fold by 2 cm and 2 cm above and below the primary opening of the passage with the capture of secondary fistulous passages without opening their lumen. Excised without damage to the periosteum, 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 - minimal. The wound has a navicular shape. Hemostasis control. Sanitation of the wound with a 3% solution of hydrogen peroxide, ozonized saline 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 on 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. At this length, the skin with subcutaneous tissue is mobilized, subcutaneous fat is not wedge-shaped excised.

The resulting wound is sutured from the bottom up as follows: the bottom of the wound is sutured with a double synthetic absorbable thread along the wound; on both sides, the subcutaneous tissue is sutured to 2/3 of the depth of the wound with a thread corresponding to them in the form of a U-shaped suture; knotted sutures are tied on different walls of the wound with the knot displaced 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, which ensures adequate outflow of the wound discharge.

Example 2

Operation - excision of the epithelial coccygeal passage with ECX with suturing of the skin edges of the wound to its bottom in the modification of the Research Institute of Proctology of the Ministry of Health of the Russian Federation according to the proposed invention with an average configuration of the buttocks and fistulas of the gluteal-sacral-coccygeal region (see Fig. 1, 2, 3, 4, 5, 6, 7, 8). The initial examination of patients is carried out similarly to example 1. In patients with an average configuration of the buttocks, the technique for performing the operation is as follows.

Operation technique.

Conduct a thorough treatment of the surgical field. To clarify the extent and prevalence of ECC, its sounding is carried out. Through the primary or secondary holes of the ECX, it is stained with a 1% alcohol solution of brilliant green using a special needle. The skin and subcutaneous tissue are dissected by two semi-oval incisions (like a leaf-shaped one) with an indent from the intergluteal fold by 1 cm and 2 cm above and below the primary opening of the passage with the capture of secondary fistulous passages without opening their lumen. Excised, without damaging the periosteum, the pathological focus within healthy tissues in such a way that in its middle part the excision depth is maximum, in the upper and lower edges of the incision - minimal. The wound has a navicular shape. Careful hemostasis. On both sides, the subcutaneous fat is excised wedge-shaped, which contributes to a dense, tension-free, adherence to the bottom of the wound of the hemmed edges. Sanitation of the wound with 1% aqueous solution of chlorhexidine bigluconate. Suturing the resulting wound from the bottom up is carried out as follows: with interrupted catgut sutures, its skin edges are alternately, with a step of 1.5 cm, sutured to the bottom of the wound in such a way that, after tying the ligatures, a path is formed in the form of a narrow strip, up to 0.5 cm deep, providing adequate outflow of wound discharge.

In patients with an average configuration of the buttocks, due to the pronounced tension of the tissues when the skin edges of the wound are sutured to its bottom, complications may develop: partial or complete separation of the edges from the bottom of the wound; development of skin necrosis; suppuration of the wound; its long-term healing with the formation of non-functional, rough scars with symptoms of discomfort.

Examples of a specific implementation of a method for the surgical treatment of chronic inflammation of the epithelial coccygeal duct in patients with an average buttocks configuration, in a clinical setting, which was tested on 130 patients who were hospitalized in the coloproctological department of the 2nd City Clinical Hospital, Stavropol in the period of 2021 of the year.

In the preoperative period, fistulas are sanitized with antiseptic solutions, and a few hours before surgery, 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 (26.2%) patients - local infiltration anesthesia; 73 (56.1%) - spinal anesthesia; in 23 (17.7%) - intravenous anesthesia, of which 7 (2.6%) - in combination with local anesthesia.

A radical surgical intervention in ECC patients included excision within healthy tissues, both of the tract itself and of fistulous tracts.

The closure of the formed defect is carried out in different ways: 1. blind suture of the wound; 2. suturing the edges of the wound to its bottom; 3. skin grafting with a displaced flap.

Clinical example 3.

Patient N., aged 23, was admitted to the coloproctology department of the 2nd City Clinical Hospital with complaints of a fistula with scanty purulent discharge in the coccyx region, in the region of the left buttock, and occasional meager discharge of pus from it. Sick for about 4 months, when pain appeared in the sacrococcygeal region, which then acquired a jerking 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 area of the coccyx, followed by the formation of a fistula. During external examination of the intergluteal fold: 3 cm from the anus, the primary opening of the ECX, 5 cm, the opening of the fistulous tract with scanty purulent discharge. Probing established a connection between the fistulous tract and the primary opening of the ECX, 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 is determined, moderate pain. In the study of topographic and anatomical parameters of the gluteal-sacral-coccygeal region, the average configuration of the buttocks was established. Acetylatory activity - 6.9%. A comprehensive preoperative preparation was carried out: sanitation of the fistulous tract with a 3% solution of hydrogen peroxide and 0.5% alcohol solution of chlorhexidine bigluconate, followed by treatment with medium-frequency ultrasound No. 3. Under spinal anesthesia in one block with the skin and subcutaneous tissue within healthy tissues, ECX and fistula were excised, the skin edges of the wound were brought down and sutured to its bottom. The course of the postoperative period is smooth, the sutures were removed on the 8th day, and the patient was discharged on the 9th day. Reviewed six months later. There is no recurrence, discomfort in the sacrococcygeal region. Healthy.

Clinical example 4.

Patient S., 31 years old, was admitted to the clinic for planned surgery for ECC in remission. Five months ago, he was operated on for ECC in the stage of acute inflammation - an opening and drainage of an abscess in the coccyx area was performed. From the second stage of radical surgery without discharge from the hospital refused. On external examination: in the intergluteal fold, 3 cm from the anus, the primary opening of the ECX; 5 cm from the anus and 2.5 cm to the right of the intergluteal fold, an external opening of the fistulous tract without discharge was revealed. There is no hyperemia, pain, swelling of the tissues at the external opening of the fistula and along its course. Probing established a connection between the fistulous tract and the primary opening of the skin anomaly. In the study of topographic and anatomical parameters of the gluteal-sacral-coccygeal region, the average configuration of the buttocks was established. Acetylatory activity - 11.4%. Ultrasonic linear scanning of the tissues of the sacrococcygeal region: with echoscopy of soft tissues in the projection of the intergluteal fold at a depth of 5 mm from the skin surface, parallel to it, a tubular structure with clear echogenic walls is determined, with a lumen d of 1.5 mm, a somewhat tortuous course. A similar formation up to 2.5 cm long extends to the right of it within the subcutaneous tissue. No cavity liquid formations were detected, an operation was performed under spinal anesthesia - excision of the ECC with suturing the wound with a blind intradermal suture without leaving closed cavities. There are no complications in the early postoperative period. The sutures were removed on the 7th day and the patient was discharged. Reviewed six months later. No relapse, healthy.

Clinical example 5.

Patient F., aged 45, was admitted to the coloproctological department of the MBUZ "2nd City Clinical Hospital" with complaints of moderate pain and fistulas in the sacrococcygeal region with scanty purulent discharge. Over the course of two years, abscesses were opened twice for ECC in the stage of acute inflammation. On external examination, 5 cm from the anus, in the intergluteal fold, there is a primary opening of the ECX with a bundle of atrophic hair, and 8 cm, the external opening of the fistulous tract with scanty purulent discharge; in the region of the inner semicircle of the left buttock, 1.5 cm from the intergluteal fold, a painful area of dense consistency 3×3 cm is determined, the mobility of the tissues above it is limited. In the area of infiltration, there are 2 external fistulous openings, at a distance of up to 1 cm from each other, with scanty purulent discharge.

By probing and testing with a dye, the fistulous passages were connected with each other and with the primary opening of the ECX. In the study of topographic and anatomical parameters of the gluteal-sacral-coccygeal region, the average configuration of the buttocks was established. Acetylatory activity - 5.2%. Within 3 days, a comprehensive preoperative preparation was carried out: 2 times a day sitz baths with a solution of KMgO ₄ at a dilution of 1:2000; sanitation of fistulous passages by washing with a 3% solution of hydrogen peroxide and 0.5% alcohol solution of chlorhexidine bigluconate; treatment with mid-frequency ultrasound and the skin of the surgical field with suberythemal doses of UVR, under spinal anesthesia, excision of the ECX was performed in one block with pathologically altered tissues in the region of the inner semicircle of the left buttock outflow of wound discharge.

Taking into account the tendency to pathological scar formation, anti-scar therapy was carried out: intramuscular injection 1 time in 4 days of Longidase No. 10; locally from the 8th day Egallochit ointment against the background of systemic desensitizing therapy; ultraphonophoresis gel Kontratubeks. The course of the postoperative period is smooth. On the 10th day, the sutures were removed, on the 11th day he was discharged for aftercare at the Center for Outpatient Coloproctology. Reviewed six months later. There is no relapse, rough cicatricial deformity in the sacrococcygeal region, he is healthy.

Thus, the following results of treatment were determined (see Fig. 1, 2, 3, 4, 5, 6, 7, 8).

Tracked early postoperative complications and long-term results of treatment in patients with ECC, who used the traditional and according to the proposed invention treatment tactics. Among patients in the control group, complications in the early postoperative period were noted in 18 (12.9%) cases. In the first place in terms of frequency of occurrence is suppuration of the wound, which occurred in 7 (5%) patients with ECC. Complete suppuration of the wound process was complicated in 2 (2.4%) patients in the stage of chronic inflammation, partial suppuration was present in 5 (6.0%). Among 60 (42.9%) patients with ECC, in which the operation was completed by suturing the edges of the wound to its bottom, 5 (8.3%) had a discharge of the skin edges from the bottom of the wound. Complete separation of the edges was present in 1 (1.7%) case, partial - in 4 (6.8%). The development of this complication is associated with excessive tissue tension during tying of sutures, as well as with insufficient mobilization of the wound edges being brought down. The same reasons can explain the development in 3 (5%) patients with ECC of marginal necrosis of the skin edges of the wound at the site of their fixation with sutures to the bottom of the wound. In one observation with chronic inflammation of the ECC, the progressive development of the necrotic process required the removal of all sutures, an extended necrectomy, which led to a lengthening of the treatment period and the formation of a pathological scar in the sacrococcygeal region.

The development of less pronounced circulatory disorders in the area of wound edges fixed to the bottom due to significant tissue tension in 2 (1.4%) cases led to the formation of an inflammatory infiltrate. The development of a hematoma in the area of surgical intervention in 1 (5%) patient with ECC in the stage without inflammation is associated with insufficient hemostasis during surgery and is in no way associated with one or another clinical form of the disease.

Analyzing the dependence of the development of postoperative complications on the clinical form of ECC, we can conclude that it is necessary to take into account not only this criterion, but also others, namely, the choice of the method for completing the operation and the configuration of the buttocks.

The dependence of the development of postoperative complications on the nature of the performed surgical intervention was traced. It turned out that in absolute terms, the number of complications with the methods used to complete the operation after excision of the ECC within healthy tissues is the same - 6 each. But if you count as a percentage of the number of operations performed, the picture changes, most of the complications were recorded with the option of suturing the wound with a blind suture of the wound - 6 (19.4%), approximately the same for skin grafting with a displaced flap - in 6 (12.2%) patients and suturing the edges of the wound to its bottom - 6 (10.0%). Wound suppuration in 4 (12.9%) patients with the completion of the operation with blind sutures of the wound can be explained either by a gross violation of asepsis and antisepsis, which is unlikely, or by an inadequate choice of the completion of the surgical intervention associated with an underestimation of the configuration of the buttocks.

In the remaining three cases, the cause of suppuration was: incomplete removal of pathologically altered tissues during excision of the ECC, as well as the development of circulatory disorders in the area of fixed skin edges of the wound when they were sutured to its bottom.

Marginal necrosis, a departure from the bottom of the skin edges of the wound or a mobilized and displaced flap occurred in 8 (5.7%) cases. These complications developed in 5 (8.3%) operated patients with ECC when the edges of the wound were sutured to its bottom, and in 3 (6.1%) patients when the operation was completed with skin grafting with a displaced flap. In five patients, the configuration of the buttocks was incorrectly determined, in 3 cases, the wedge-shaped subcutaneous tissue was insufficiently excised, which led to excessive tissue tension during fixation of the skin edges of the wound to its bottom. The reasons for the development of inflammatory compaction in the thickness of the tissues or along the edges of the wound in two patients are described above.

Thus, the reasons contributing to the development of early postoperative complications in this group of patients were: underestimation of topographic-anatomical relationships in the gluteal-sacral-coccygeal region; the development of circulatory disorders in the area of the edges of the wound that are reduced and fixed to the bottom of the wound, technical errors in the performance of surgical intervention (incomplete excision of tissues altered by the pathological process, insufficient hemostasis, contamination of wounds, etc.)

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

- simplifying and reducing the time of the operation method;

- Reduced postoperative recovery time.

Claims (1)

A method for the surgical treatment of chronic inflammation of the epithelial coccygeal tract, including preoperative debridement of fistulas, excision of the epithelial coccygeal tract, purulent fistulas and infiltrates, hemostasis and wound closure, characterized in that preoperative debridement of the wound is carried out with a 3% hydrogen peroxide solution, ozonated saline at a concentration of 2, 5 mg / l, and additionally pre-specify the length and distribution of the epithelial coccygeal passage by probing, then the skin and subcutaneous tissue of the epithelial coccygeal passage is dissected with two semi-oval incisions of the leaf-like type, indented from the intergluteal fold at a distance of 2 cm and 2 cm above and below of the primary opening of the passage with the capture of secondary fistulous passages without opening their lumen, while the excision of the pathological focus is carried out within healthy tissues without damaging the periosteum in such a way that in its middle part the depth of excision is maximum al, in the upper and lower edges of the incision - minimal, forming a scaphoid shape, and the closure of the resulting wound is carried out from the bottom up, and the subcutaneous tissue is sutured to ½ of the depth of the wound with interrupted sutures from absorbable suture material, the ends of the threads are cut off, on each side of the wound reduced in size, retreating from the skin down, and from the earlier interrupted sutures up, wedge-shaped in the form of an equilateral triangle with a height equal to the depth of the wound, and a base located towards the wound, the subcutaneous tissue is excised on both sides, intradermally, parallel to the edge of the wound, to a depth of 5 mm, the threads are carried out, the ends of which are directed towards the wound, while the ends of the threads alternately capture the subcutaneous tissue with the thread at the level of the bottom of the wound sutured with the first row of sutures, and the ends of the threads are brought to the skin 1.5 cm from the skin edge of the wound, then the threads they are connected to each other, bringing the skin edges of the wound down to its bottom with the formation of an intergluteal fold to a flat configuration of berries itz.

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