RU2802748C1 - Method of surgical treatment of patients with recurrent epithelial coccygeal tract - Google Patents

Abstract

FIELD: medicine, coloproctology, surgery.

SUBSTANCE: epithelial coccygeal passage (ECC) is excised. The flap is mobilized along with the fascia of the gluteus maximus muscle. At the bottom of the wound, a plate of MM-gel 1–2 mm thick, previously cut to fit the size of the wound surface, is placed. The formed mobilized flap is moved and fixed with separate interrupted sutures throughout the wound. The gluteal fascia is fixed to its own sacral fascia, followed by layer-by-layer suturing of the wound.

EFFECT: method provides the reduction of the number of relapses of the disease, as well as wound complications, early activation of the patient without increasing the severity of pain in the postoperative period.

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Description

The invention relates to medicine, namely to coloproctology and surgery, and can be used in the surgical treatment of patients with complex and recurrent epithelial coccygeal tract (ECX).

There is a known method of surgical treatment of ECC. The clinical picture of a recurrent coccygeal tract is similar to that of a primary abscess; They are treated the same way. In specialized proctology emergency departments, even in the event of an acute (first or repeated) abscess of the epithelial coccygeal tract, it is possible and advisable to immediately perform a radical operation - opening the abscess and eliminating the primary opening (openings) of the duct along the midline. In these cases, under anesthesia, with the patient lying on the stomach or side, purulent leaks are opened on the side or on both sides of the midline, and the area of the intergluteal fold, together with the primary openings of the tract, is excised with oval incisions, i.e. remove the anterior wall of the abscess. In case of acute purulent inflammation of the coccygeal tract, in such cases a wound remains along the midline of the sacrococcygeal region, which is sanitized using the open method. Although this treatment is relatively longer than suturing the wound by suturing its edges to the bottom, as in planned operations for the coccygeal tract, but, firstly, in case of an acute abscess, a rather narrow oval of skin can be excised, and secondly, adequate drainage of lateral purulent leaks facilitates healing , because these lateral counter-apertures act as relaxing incisions [1-Dultsev Yu.V., Rivkin V.L. Epithelial coccygeal tract. - M. 1988, - 128 p.]. This method is accepted as analogous.

There is a known method of surgical treatment of ECC, including the use of complex surgical methods of plastic surgery (2-Popkov O.V. Epithelial coccygeal tract. Methods of surgical treatment. Military medicine. Minsk. - 2017. No. 1 (42). - p. 101-106). This method is accepted as analogous. However, there remains a tendency for a significant frequency of complications and relapses when using this method of treatment.

The closest to the proposed invention is a method for suturing a wound in the gluteal-sacral region [3 - patent RU 2741255 C1 dated January 22, 2021 “Method of closing a wound in the sacrococcygeal region with plastic surgery using mobilized fascial fat flaps” Tsarkov P.V. etc.], according to which the method includes making two parallel incisions of the own fascia covering the gluteus maximus muscles at the site of their attachment to the sacrum, at a distance of 1.5-2 cm from the midline along the entire length of the wound, mobilization of fascial fat flaps in in the lateral direction for no more than 2 cm and their subsequent counter traction to the midline, replacing the lack of tissue. Separate interrupted sutures are applied to the formed mobilized flaps along the entire length of the wound, with fixation to the bottom of the wound, capturing the sacral fascia in the suture, at a distance of 1 cm from each other. A drainage tube is placed at the bottom of the wound. The wound is sutured in layers. This method was adopted as a prototype [2 - patent RU 2741255 C1 dated January 22, 2021 “Method of closing a wound in the sacrococcygeal region with plastic surgery using mobilized fascial fat flaps” Tsarkov P.V. and etc.]. However, this method is not without drawbacks due to the preservation of a residual cavity above the sacral fascia, which can lead to the formation of seromas and suppuration.

The goal is to reduce the incidence of complications.

The technical result is achieved by the fact that in the method of surgical treatment of ECC, including excision of ECC, the flap is mobilized together with the fascia of the gluteus maximus muscle, after which a plate of MM-gel 1 - 2 mm thick, previously cut to the size of the wound surface, is installed at the bottom of the wound, the formed mobilized flap is moved and fixed with separate interrupted sutures along the entire length of the wound, the gluteal fascia is fixed to the own sacral fascia, followed by layer-by-layer suturing of the wound.

The method is carried out as follows.

It is known that the incidence of epithelial coccygeal duct in the general population is 26 cases per 100 thousand population. Despite the long history of surgical treatment of the epithelial coccygeal duct, there is currently no “gold standard” surgical technique. Russian and foreign authors have proposed many surgical interventions, but the rate of postoperative complications and relapses remains high (up to 37%), which leads to an extension of treatment, a long return to normal daily activity, and a deterioration in the quality of life of young patients. The main disadvantage of simply suturing a postoperative wound tightly is the formation of a cavity under the suture line, which can lead to the accumulation of serous fluid and/or blood in this area, followed by suppuration of the wound; the recurrence rate after wound suturing ranges from 7% to 42%,

Currently, polymer hydrogels are used in various fields related not only to medicine, but also to biotechnology. Their unique properties have made them attractive for a number of dynamically developing areas of medical science, such as cell and tissue engineering, technology of implants and biologically active systems, etc. To create polymer hydrogels, derivatives of polyvinyl alcohol and 2-hydroxyethyl starch are used - polymers with high biocompatibility, approved for use on the territory of the Russian Federation.

In the method of surgical treatment of ECC, including excision of ECC, the flap is mobilized together with the fascia of the gluteus maximus muscle. After this, a plate of MM-gel 1 - 2 mm thick, previously cut to the size of the wound surface, is installed at the bottom of the wound. The formed mobilized flap is moved and fixed with separate interrupted sutures along the entire length of the wound, the gluteal fascia is fixed to the own sacral fascia, followed by layer-by-layer suturing of the wound.

The proposed method has the following advantages:

- mobilization of the skin-fat-fascial flap allows you to reduce the tension when suturing the wound due to adequate mobilization of the flap;

- by eliminating tissue tension after the formation of sutures, they prevent the cutting of sutures and subsequent separation of the edges of the postoperative wound, as well as its infection;

- the use of polymer hydrogel eliminates the formation of cavities due to the hydrophilic properties of the material.

Excision of the skin and subcutaneous fat with the sinus is performed up to the presacral fascia using an electrocoagulator, then a Limberg flap is cut out. It is very important that all edges of the diamond are equal, this ensures accurate alignment of the displaced flap and tightness of the seams. In this case, the dissection of the presacral fascia is carried out along the same intended lines in order to ensure reliable fixation of the displaced flap. After complete mobilization of the flap, thorough hemostasis is carried out, after which a plate of MM-gel 1 - 2 mm thick, previously cut to the size of the wound surface, is installed on the bottom of the wound. The formed mobilized flap is moved and fixed with separate interrupted sutures along the entire length of the wound, the gluteal fascia is fixed to the own sacral fascia, followed by layer-by-layer suturing of the wound. Drainage is not installed.

Sutures are removed on the 13th day after surgery. To work - 15-18 days after surgery. During dynamic observation, no postoperative complications or relapse were detected. According to ultrasound, no accumulation of fluid along the postoperative suture with the formation of a leak was detected.

The method is confirmed by the following examples.

Example 1

Patient S., 31 years old, was admitted to the coloproctology department of the Loginov Moscow Scientific Research Center with a diagnosis of recurrent epithelial coccygeal tract. Surgical treatment from 2018: excision of the EC with suturing the wound tightly. For a long period, 10 months after the previous operation, pain and periodic discharge of purulent-hemorrhagic discharge from the newly formed holes have been bothersome. In the sacrococcygeal region, a postoperative scar is identified, located in the projection of the intergluteal fold up to 5 cm long. Fistula openings with a diameter of 0.8 cm are also identified in the projection of the postoperative scar, at a distance of 5 cm from the anus. There is no discharge from the holes on palpation.

Surgical treatment was performed in accordance with the stated method.

During the operation, the cavity of the epithelial coccygeal duct is stained through a hole located in the projection of the intergluteal fold with a solution of brilliant green with a 3% solution of hydrogen peroxide using a syringe. Swelling and deformation of the subcutaneous scar were determined.

A diamond-shaped excision was performed with a rib size of 4 cm, in a single block, involving the subcutaneous scar, to the sacral fascia within the unchanged tissues. Next, a lateral incision is made, the flap is mobilized from the grips of the fascia of the gluteus maximus muscle, without crossing the fibers of the gluteal muscles. Next, hemostasis is carried out, after which a 1 mm thick MM-gel plate, previously cut to the size of the wound surface, is installed on the bottom of the wound. The formed mobilized flap is moved and fixed with separate interrupted sutures along the entire length of the wound, the gluteal fascia is fixed to the own sacral fascia, followed by layer-by-layer suturing of the wound. Drainage is not installed. Apply an aseptic dressing.

The postoperative period proceeded smoothly. Healing by first intention. The patient was activated on the 2nd day. The sutures were removed on the 13th day after surgery. To work - on the 15th day after surgery. During dynamic observation, no postoperative complications or relapse were detected. According to ultrasound data, no fluid accumulation along the postoperative suture with the formation of a leak was detected.

Example 2

Patient A., 34 years old, was admitted to the department of coloproctology of the A.S. Moscow Scientific Research Center. Loginova with a diagnosis of stage 3 epithelial coccygeal tract. For a long period, pain periodically occurs in the sacrococcygeal region with discharge of cloudy mucus. In the sacrococcygeal region, fistulous openings are determined along the intergluteal fold, from 2 to 4 mm in D, and a lateral fistulous tract up to 1 cm in D is also determined. On palpation, there is no discharge from the holes.

Surgical treatment was performed in accordance with the stated method.

During the operation, the epithelial coccygeal tract was stained with a solution of brilliant green with a 3% solution of hydrogen peroxide through the hole in the intergluteal fold, after which the flow from the lateral fistula was noted.

A diamond-shaped excision was performed, en bloc, to the sacral fascia within the intact tissue. Next, a lateral incision was made, and a flap was mobilized from the grips of the fascia of the gluteus maximus muscle. Thorough hemostasis was carried out, after which a 2 mm thick MM-gel plate, previously cut to the size of the wound surface, was installed at the bottom of the wound. The formed mobilized flap is moved and fixed with separate interrupted sutures along the entire length of the wound, the gluteal fascia is fixed to the own sacral fascia, followed by layer-by-layer suturing of the wound. Apply an aseptic dressing. Given the properties of the MM gel, drainage is not installed. The wound is sutured in layers.

The postoperative period proceeded smoothly. Healing by first intention. The patient was activated on the 2nd day. The sutures were removed on the 11th day after surgery. To work - on the 14th day after surgery. During dynamic observation, no postoperative complications or relapse were detected. According to ultrasound data, no fluid accumulation along the postoperative suture with the formation of a leak was detected.

The method ensures a reduction in the number of relapses of the disease, as well as wound complications, early activation of the patient without increasing the severity of pain in the postoperative period.

Information sources

1. Dultsev Yu.V., Rivkin V.L. Epithelial coccygeal tract. - M. 1988, - 128 p.

2. Popkov O.V. Epithelial coccygeal tract. Methods of surgical treatment. Military medicine. Minsk. – 2017. No. 1 (42). – p.101-106.

3. Patent RU 2741255 C1 dated January 22, 2021 “Method of closing a wound in the sacrococcygeal region with plastic surgery using mobilized fascial fat flaps” Tsarkov P.V. et al.

Claims (1)

A method of surgical treatment of the epithelial coccygeal tract, including excision of the epithelial coccygeal tract, characterized in that the flap is mobilized together with the fascia of the gluteus maximus muscle, after which a plate of MM-gel 1-2 mm thick, previously cut to the size of the wound surface, is installed at the bottom of the wound , the formed mobilized flap is moved and fixed with separate interrupted sutures along the entire length of the wound, the gluteal fascia is fixed to the own sacral fascia, followed by layer-by-layer suturing of the wound.