RU2823613C1 - Method of treating epithelial-coccygeal passage complicated by fistulas of gluteal-sacrococcygeal region - Google Patents

Abstract

FIELD: medicine; coloproctology.

SUBSTANCE: conducting anesthesia is performed, followed by excision of an epithelial coccygeal passage in a single block with skin and subcutaneous fat. External fistulous openings are excised to subcutaneous fat on the medial and lateral semi-circles of the buttocks. After excision of the epithelial coccygeal passage outside the tissue inflammation zone, the skin and subcutaneous fat are dissected 1 cm laterally from the outermost fistula opening from the intergluteal fold. Then skin with subcutaneous fat is mobilized to an inflammatory process in the form of two triangles, and pathologically changed tissues with previously excised external fistulous holes are removed within healthy tissues. Wound on the gluteal-sacrococcygeal region is closed with an intradermal suture. Rubber strips are introduced through holes of previously excised fistulas into subcutaneous fat for 2–4 hours. Wound after excision of the epithelial coccygeal passage in patients with a flat position of the buttocks is closed by 1/3, with an average position—by 1/2, at high—by 2/3 of wound depth, wherein with long remaining ends of threads wound edges are intracutaneously picked up on both sides, which are brought down without tension and fixed to its bottom, forming an intergluteal fold, leaving open sections of the wound in the form of a rhombus, then an aseptic dressing is applied on the wound.

EFFECT: method enables to completely remove pathologically changed tissues, simplify and reduce the length of treatment of patients and the length of wound healing, as well as reduce deformation of gluteal-sacrococcygeal region, which causes discomfort in patients.

1 cl, 4 ex, 12 dwg

Description

Field of technology to which the invention relates

The invention relates to medicine, namely to coloproctology, in particular, to a method for treating the epithelial coccygeal tract complicated by fistulas of the gluteal-sacrococcygeal region, and can be used in the surgical treatment of the epithelial coccygeal tract.

State of the art

There is a known method for dissecting the epithelial coccygeal tract, fistulas with open wound management, while under conduction anesthesia (s/m), after staining the ECC and fistulas with methylene blue, the epithelial-coccygeal tract is excised, a grooved probe is inserted into the outer opening of one of the fistulas and carefully, without forcing it, they carry it to the center and outer opening of the epithelial coccygeal tract, then the skin and subcutaneous tissue are dissected above the probe, thereby revealing the upper wall of the purulent tract, and the remaining fistulous tracts are dissected along the probe in exactly the same way, resulting in a superficial wound that is scraped out with a Volkmann spoon along the fistulous tracts, the bleeding during this operation is insignificant and was easily stopped by pressing with gauze balls, the resulting irregularly shaped wound is tamponed with narrow gauze strips soaked in Levomekol ointment, the wound heals by secondary intention, often with the formation of a pathological scar causing discomfort in the YACCO ( see V.L. Rivkin, A.S. Bronstein, S.N. Fine; Guide to coloproctology Fine. /. M.: Medprktika. - 2001 - 300 pp.).

The disadvantage of this method is the long treatment period for patients, as well as gross deformations of the gluteal-sacrococcygeal region, causing discomfort in patients.

There is a known method of treating the epithelial coccygeal tract, which includes excision of the epithelial coccygeal tract within healthy tissues to the sacral fascia, drainage of the wound with Redon active drainage, suturing the postoperative wound with separate interrupted sutures according to Donatti to the border of the middle and lower third of the wound, applying separate interrupted ones to the skin of the lower third of the wound sutures, at a distance of 0.5 cm from the edges of the lower third of the postoperative wound along the gluteus maximus muscle, having previously stretched the skin of the intergluteal fold, two tapes 5 cm wide, KTKinexib elastic type, are glued next to each other on each side, in this case, the 2 cm of KTKinexib Kinesio Tape closest to the wound are glued without stretching, then the KTKinexib Kinesio Tape is stretched by 75% to the fixation point, which is the greater trochanter of the femur, the last 2 cm of KTKinexib Kinesio Tape, closest to the fixation point, are not stretched , for better fixation of the KTKinexib Kinesio-tape, its corners are rounded, the KTKinexib Kinesio-tape is installed for 7 days, then the change is carried out according to the method described above, the total period of use of the KTKinexib Kinesio-tape is 14 days (see. Pat. RU No. 2685760, IPC A61/B 17/00, A61F 5/37, publ. 04/23/2019, bulletin. No. 12).

The disadvantage of this method is the insufficient improvement of blood circulation and insufficient reduction in the depth of the intergluteal fold of the postoperative wound.

There is a known method of treating the epithelial coccygeal tract, which consists in the fact that after radical excision of the epithelial coccygeal tract and its branches, control of hemostasis, the surgical wound is closed by applying rare interrupted sutures every 1.5-2 cm, while a needle and thread are injected into 3-4 mm from the edge of the wound on one side, grabbing only the skin, then pass along the bottom of the wound through the sacrococcygeal ligament and puncture 3-4 mm from the edge of the wound on the other side, also grabbing only the skin, form a knot, bringing the edges of the skin together and with the bottom of the wound; then a vacuum bandage is formed: foam rubber with a drainage tube in the thickness is applied to the wound over the associated skin edges, which is fixed to the wound with the remaining edges of the thread, sealed with an incision film and a negative pressure of 115-120 mm Hg is created, the vacuum bandage is removed after 3- 5 days, leaving skin sutures, then treatment of the wound is continued with dressings with an aqueous antiseptic solution (see Pat. RU No. 2764499, IPC A61/B 17/00, A61B 17/04, A61M 1/00, A61F 13/02, publ. 01/17/2022, bulletin No. 2).

The disadvantage of this method is its lack of simplicity, as well as the risk of suppuration in the postoperative period.

The closest in technical essence and the achieved positive effect and accepted by the authors as a prototype is a method of dissection and economical excision of the epithelial-coccygeal tract and fistulas, while under conduction anesthesia after staining the ECX and fistulas with methylene blue, the epithelial-coccygeal tract is excised, then along a grooved probe the upper walls of the tract, fistulas are dissected, pathological granulations are removed, then the posterior walls of the epithelial-coccygeal tract and fistulas are carefully and economically excised, after careful hemostasis, the edges of the wound are sutured to the bottom with interrupted catgut sutures, narrow gauze strips soaked in ointment "Levomekol" (see Yu.V. Dultsev, V.L. Rivkin; Epithelial coccygeal tract. - M.: Medicine. - 1988 - 125 p.).

The disadvantage of this method is the long treatment period for patients, cosmetic defects, gross deformations of the gluteal-sacrococcygeal region, causing discomfort in patients, as well as the fact that narrow branches of the fistula that were not removed during surgery may remain unnoticed, which will subsequently cause a relapse of the inflammatory process.

Disclosure of the Invention

The objective of the present invention is to develop a treatment for the epithelial coccygeal tract, complicated by fistulas of the gluteal-sacrococcygeal region, which simplifies and reduces the time of treatment of patients and the timing of wound healing, as well as reducing the deformation of the gluteal-sacrococcygeal region, which causes discomfort in patients.

The technical result that can be obtained using the present invention boils down to the complete removal of pathologically altered tissues, simplifying and reducing the time of treatment of patients and the time of wound healing, as well as reducing the deformation of the gluteal-sacrococcygeal region, which causes discomfort in patients.

The technical result is achieved using a method for treating the epithelial coccygeal tract, complicated by fistulas of the gluteal-sacrococcygeal region, including conduction anesthesia with subsequent excision of the epithelial coccygeal tract in a single block with the skin and subcutaneous tissue, while the external fistula openings are excised to the subcutaneous fatty tissue on medial and lateral semicircles of the buttocks, and perpendicular to the main wound, an incision is made in the skin with subcutaneous tissue on the buttock to the outer edge of the inflammatory process, then the skin with subcutaneous tissue is mobilized to the perimeter of the inflammatory process in the form of two triangular flaps, and the pathologically changed tissues with previously excised external fistula openings removed within healthy tissues, the wound on the gluteal-sacrococcygeal region is sutured with an intradermal suture, while rubber graduates are inserted into the subcutaneous tissue through the holes of previously excised fistulas for 2 hours, the wound after excision of the epithelial coccygeal tract in patients with flat buttocks is sutured for 1 /3, with an average standing - 1/2, with a high standing - 2/3 of the depth of the wound, and the long ends of the threads are cut off through one knot, then the edges of the wounds are picked up intradermally with the remaining ends of the threads on both sides, which are brought down without tension and fixed to to its bottom, forming an intergluteal fold, leaving open areas of the wound in the shape of a diamond for the outflow of discharge, then apply an aseptic bandage to the wound.

The essence of the proposed method for treating the epithelial coccygeal tract, complicated by fistulas of the gluteal-sacrococcygeal region, is as follows.

Conduction anesthesia is carried out followed by excision of the epithelial coccygeal tract, while the skin with subcutaneous tissue is excised, while the external fistula openings are excised to the subcutaneous fatty tissue on the medial and lateral semicircles of the buttocks, and an incision is made perpendicular to the main wound of the skin with subcutaneous tissue on the buttock to the outer edges of the inflammatory process, then the skin with subcutaneous tissue is mobilized to the perimeter of the inflammatory process in the form of two triangular flaps, and the pathologically changed tissues with previously excised external fistula openings are removed within healthy tissues, the wound in the gluteal-sacrococcygeal region is sutured with an intradermal suture, while through the holes of previously excised fistulas, rubber graduates are inserted into the subcutaneous tissue for 2 hours; the wound after excision of the epithelial coccygeal tract in patients with a flat buttock position is sutured to 1/3 depth, with an average position - to 1/2, with a high position - to 2/3 depth wounds, and the long ends of the threads are cut off through one knot, then the edges of the wounds on both sides are picked up intradermally with the remaining ends of the threads, which are brought down without tension and fixed to its bottom, forming an intergluteal fold, leaving open areas of the wound in the shape of a diamond for the outflow of discharge, then apply an aseptic bandage to the wound.

Brief description of drawings and other materials

In fig. 1-4, a method is given for the treatment of the epithelial coccygeal tract, complicated by fistulas of the gluteal-sacrococcygeal region, the stages of surgery for high-standing buttocks.

In fig. 5-8, the same, stages of the operation with the middle position of the buttocks.

In fig. 9-12, the same, stages of surgery for low-standing buttocks.

Carrying out the invention

Examples of a specific implementation of a method for treating an epithelial coccygeal tract complicated by fistulas of the gluteal-sacrococcygeal region.

Example 1. Patient G., 42 years old, medical history No. 862, was admitted to the clinic on March 14, 2019 with complaints of fistulas in the left buttock area with purulent discharge from them. Has been ill for 10 years. During this period of time, the patient was operated on 4 times for acute inflammation of the epithelial coccygeal tract and 5 times the ulcers in the gluteal-sacrococcygeal region were opened spontaneously with the formation of fistulas.

Locally: in the intergluteal fold at a distance of 4 cm from the anus, there are coccygeal retractions, the position of the buttocks is average, in the area of the inner and outer semicircle of the left buttock, 6 external fistulous openings are identified, located at a considerable distance from each other with moderate purulent discharge.

When probing fistulas, the probe moves towards the intergluteal fold. A test with methylene blue revealed that some of them communicate with each other and with the coccygeal passage. After sanitizing the fistula tracts with antiseptics, on March 18, 2019, under spinal anesthesia (s/m), the coccygeal tract and external fistula openings on the left buttock were excised to the subcutaneous tissue. Hemostasis. Perpendicular to the main wound in the center of the lesion, without affecting the external fistula openings, an incision was made in the skin with subcutaneous tissue to the outer edge of the inflammatory process. The skin and subcutaneous tissue are mobilized to the perimeter of the inflammatory process. Pathologically altered tissue with previously excised external fistula openings was removed within healthy tissue. The incision on the left buttock is sutured tightly with an intradermal suture. After excision of the external fistula openings, rubber drainage strips are inserted through skin defects for 3-4 hours. The wound after excision of the epithelial coccygeal duct to 1/2 depth is sutured with a monofilament synthetic absorbable thread with an antiseptic coating. The ends of the threads are cut off one after another. The remaining long ends of the threads are intradermally stitched with the edges of the wound, which are brought down and fixed to its bottom, forming a diamond-shaped open area of the wound for the outflow of wound discharge. The postoperative period proceeded smoothly. On the 10th day - discharge for outpatient follow-up treatment. Inspection after 3 years. Healthy.

Example 2. Patient A., 39 years old, medical history No. 1246, was admitted to the clinic on October 13, 2019 with complaints of multiple fistulas with slight purulent discharge from the external fistula openings. Ill for 9 years. He was operated twice for acute inflammation of the epithelial coccygeal tract, after which 6 more times ulcers in the gluteal-sacrococcygeal region were opened spontaneously with the formation of external fistulous openings with purulent discharge.

Locally: The topographic-anatomical structure of the buttocks is flat. In the intergluteal fold, 5 cm from the anus, there is a skin retraction with a tuft of hair protruding from it. On the medial and lateral semicircle of the right buttock - the external fistulous openings, located at different distances from each other (at least 2.5 cm), the skin and subcutaneous tissue between them are unchanged and mobile.

After marking the coccygeal tract and fistulas with dye, the epithelial coccygeal tract is removed by excision of the skin with subcutaneous tissue 1 cm to the sides of the intergluteal fold, 3 cm below and 4 cm above the skin retractions. The external fistula openings are excised down to the subcutaneous tissue. Perpendicular to the right edge of the wound, after excision of the epithelial coccygeal tract outside the zone of tissue inflammation, the skin and subcutaneous tissue are dissected 1 cm lateral to the external fistulous opening furthest from the intergluteal fold. We mobilize the skin with subcutaneous tissue to the perimeter of the inflammatory process in the form of two triangles. Pathologically altered tissues with previously excised external fistula openings are removed within healthy tissues. The wound on the buttock is sutured with an intradermal suture, the wound is sutured tightly after excision of the epithelial coccygeal duct to 1/3 of its depth. The ends of the threads are cut off through one knot. The remaining long ends of the threads are used to stitch the edges of the wound intradermally, which are brought down and fixed to the bottom of the partially sutured wound, forming diamond-shaped open areas of the wound for the outflow of wound discharge. Aseptic dressing on the wound.

The postoperative period proceeded smoothly. On the 10th day he was discharged for outpatient follow-up treatment. Inspection after 3 months. Healthy.

Example 3. Patient V., 46 years old, medical history No. 1232, was admitted to the clinic on November 9, 2018 with complaints of multiple fistulas with slight purulent discharge in the area of the left buttock. She has been ill for 9 years after surgery for acute inflammation of the epithelial coccygeal duct. After opening the abscess, a fistula formed on the left buttock. In recent years, spontaneous opening of abscesses with the formation of external fistulous openings with the release of pus from them has occurred 5 times.

Locally: The topographic-anatomical structure of the buttocks is high. In the intergluteal fold, 2 cm from the anus, there is a skin retraction with a tuft of hair protruding from it, above it there are two more retractions at a distance of 1.0 cm from each other. There are five external fistulous openings on the left buttock, two of which are located on the medial and three on the lateral semicircle of the buttock.

Under spinal anesthesia, the epithelial coccygeal tract was excised in one block with the skin and subcutaneous tissue using a semi-oval incision 0.5 cm below, 4 cm above the superior skin retraction and 1 cm to the side on both sides of the intergluteal fold. External fistula openings are excised to the subcutaneous tissue. Perpendicular to the left edge of the wound, outside the zone of inflammation, the skin with subcutaneous tissue is dissected to the lateral edge of the inflammatory process. The skin and subcutaneous tissue were mobilized in the form of triangular flaps. Pathologically changed tissues with previously excised external fistula openings were removed. The wound is tightly sutured with intradermal sutures. The wound after excision of the epithelial coccygeal tract is sutured to 2/3 of its depth. The ends of the threads are cut off one at a time. The remaining long ends of the threads are used to stitch the edges of the wound on both sides intradermally, which are brought down and fixed to the bottom of the partially sutured wound to form a diamond-shaped open area of the wound for the outflow of wound discharge.

The postoperative period proceeded smoothly. Discharged on the 10th day. Inspection after 3 years. Healthy.

Example 4. Patient K., 37 years old, medical history No. 349, was admitted to the clinic on March 12, 2020, with complaints of multiple fistulas in the gluteal-sacrococcygeal region. Ill for 10 years. In 2010, he was operated on for the first time for acute inflammation of the epithelial coccygeal tract, in subsequent years he was operated on twice for relapse of the inflammatory process, and five times the abscess in the left buttock area opened spontaneously with the formation of fistulas.

Locally: The topographic-anatomical structure of the buttocks is average. In the intergluteal fold, 3.5 cm from the anus, there is a skin retraction with a tuft of hair protruding from it. In the area of the medial and lateral semicircle of the left buttock there are five external fistulous openings with moderate purulent discharge, located at a distance of more than 2-3 cm from each other. The skin and subcutaneous tissue around them are not infiltrated and mobile. After marking the epithelial coccygeal tract and fistulas, the coccygeal tract is removed with dye in one block with the skin and subcutaneous tissue. External fistula openings on the medial and lateral semicircle of the buttocks are excised to the subcutaneous tissue. Perpendicular to the left edge of the wound, after removing the coccygeal skin retraction with an incision outside the area of inflammation and 1 cm lateral from the fistulous opening furthest from the intergluteal fold, the skin and subcutaneous tissue were incised. After mobilizing the skin from the subcutaneous tissue to the perimeter of the inflammation in the form of triangular flaps, the previously excised external fistula openings with pathologically altered tissues in the subcutaneous tissue were removed. The wound on the left buttock is sutured with an intradermal suture, and after excision of the epithelial coccygeal tract, it is sutured tightly to ½ of its depth. The ends of the threads are cut off through one knot. With the long ends of uncut threads, the edges of the wound are brought down intradermally and fixed to its bottom, forming an intergluteal fold with open areas of the diamond-shaped wound for the outflow of wound discharge.

The postoperative period proceeded smoothly; on the 10th day he was discharged for outpatient follow-up treatment. Review after two years. Healthy.

The proposed invention compared to the prototype and other known technical solutions has the following advantages:

- low invasiveness of the operation;

- regardless of the number of fistulas, there are always 3 incisions and healthy skin is not excised;

- no tissue tension;

- conditions for wound suppuration are minimized, because the wound is drained through the perforations of the skin at the site of the former fistula openings, which initially function as drainage, and in the second phase of the wound process - as foci of granulation, fixing the skin to the underlying structures;

- necrosis of skin flaps does not occur, because the most optimal conditions for blood supply to any flap are maintained with its triangular shape with a wide base;

- the possibility of leaving pathologically altered tissues, which may subsequently cause relapses of the disease, is excluded.

Claims (1)

A method for treating the epithelial coccygeal tract complicated by fistulas of the gluteal-sacrococcygeal region, including conduction anesthesia followed by excision of the epithelial coccygeal tract in a single block with the skin and subcutaneous tissue, characterized in that the external fistula openings are excised to the subcutaneous fatty tissue on the medial and lateral semicircles of the buttocks, and after excision of the epithelial coccygeal tract outside the zone of tissue inflammation, the skin and subcutaneous tissue are dissected 1 cm lateral to the external fistulous opening furthest from the intergluteal fold, then the skin with subcutaneous tissue is mobilized to the inflammatory process in the form of two triangles, and the pathologically altered tissues with previously excised external fistula openings are removed within healthy tissues, the wound on the gluteal-sacrococcygeal region is sutured with an intradermal suture, while rubber strips are inserted into the subcutaneous tissue through the openings of the previously excised fistulas for 2-4 hours, the wound after excision of the epithelial coccygeal tract in patients with a flat standing of the buttocks, they are sutured to 1/3, with an average standing - to 1/2, with a high standing - to 2/3 of the depth of the wound, and with the long remaining ends of the threads, the edges of the wound are picked up intradermally on both sides, which are brought down without tension and fixed to it the bottom, forming an intergluteal fold, leaving open areas of the wound in the shape of a diamond, then apply an aseptic bandage to the wound.