WO2013002679A2

WO2013002679A2 - Chersi g. gudiev's method for preventing the development of a post-operative adhesive process in the peritoneum

Info

Publication number: WO2013002679A2
Application number: PCT/RU2012/000481
Authority: WO
Inventors: Черси Гарсолтович ГУДИЕВ
Original assignee: Gudiev Chersi Garsoltovich
Priority date: 2011-06-30
Filing date: 2012-06-21
Publication date: 2013-01-03
Also published as: WO2013002679A3; RU2011128289A; RU2477993C2

Abstract

The invention relates to the field of medicine, in particular to abdominal surgery and, specifically, to methods for manual action on organs and tissue. The aim of the present invention is to prevent the formation of adhesions in the peritoneum, i.e. not to allow adhesions to form when all of the biochemical processes for the formation thereof are present. The essence of the present invention consists in manual action and/or action with an instrument on organs in a patient's abdominal cavity, via the abdominal wall, with the aim of moving said organs from the customary locations thereof and relative to one another, in the post-operative period. The technical result of the method being patented is the prevention (hindrance) of the formation of post-operative adhesions in the peritoneum. The claimed technical result is achieved by starting to use the method in the early post-operative period (up to 48 hours after the operation), and continuing on a daily basis until the patient is fully mobile.

Description

METHOD OF CHERRY G. GUDIEV PREVENTION OF DEVELOPMENT OF POSTOPERATIVE ADHESIVE PROCESS OF PERFUME DESCRIPTION

The invention relates to medicine, in particular to abdominal surgery, and in particular, to methods of manual exposure to organs and tissues.

The present invention is a method of preventing the development of a postoperative peritoneal adhesion process (disease).

Currently, the problem of adhesive disease of the abdominal cavity is the most urgent in surgery. Fusion after surgery on the organs of the abdominal cavity occurs in 80-94% of cases and the number of complications in the form of various forms of intestinal obstruction on the basis of adhesions of the peritoneum ranges from 12 to 64% of cases. Relapse of adhesive disease reaches 30-60% and, exacerbating the condition of patients, leads to deaths in 13-55% of cases. Numerous proposed methods of treatment and prevention of adhesive diseases of the abdominal cavity allow to obtain a release effect only in 20-65% of cases. In addition, the proposed treatment regimens have a significant drawback, consisting in the individual treatment of each case of adhesive disease. An increase in the number of surgical interventions on the abdominal organs and a growing number of adhesions complicate surgeons problem - preventing the formation of postoperative adhesions.

Methods for preventing adhesive disease are known in the art.

So, from the description of the patent of the Russian Federation N ° 2236232 (published on September 20, 2004), there is a known method for treating adhesive disease by introducing a chemical agent into the surgical area, with a 5-7.5% phospholipid solution in a dose of 15-20 ml being used as a chemical agent .

In the patent of the Russian Federation N ° 2177741 (published January 10, 2002), a method for treating adhesive disease is disclosed, including mobilization, intubation of the intestine with an enteral probe, laying loops in a horizontal position, drawing the intestinal walls closer to contact and fixing them with flexible conductors, characterized in that the intestinal loops are connected fixed with microirrigators with trephination holes, conducted along the conductors through the mesentery of the intestine under pars nuda, while the ends of the microirrigators with conductors are left after the laparotomy outside the abdominal cavity, potentiate adhesions the process between the intestinal loops by mechanical and chemical desquamation of the mesothelium of the mesothelium of the peritoneal mesentery, and in the postoperative period, solutions of epsilonaminocaproic acid in a dose of 20-25 ml are administered through the lumen of microirrigators. Once a day for the first two days and contrikal at a dose of 2500-5000 ED for 20 -25 ml of isotonic sodium chloride solution 3 times a day for the next 3-5 days. In addition, there is a known method for preventing postoperative complications, including adhesions, based on the fact that in order to prevent adhesions and their consequences before suturing the laparotomy wound, the section of the anterior leaf of the greater omentum is hemmed as a patch to the parietal peritoneum at a distance of 5-6 cm from the edges of the wound. This method prevents the adhesion of intestinal loops with the abdominal wall (USSR author's certificate NQ724133, published March 30, 80). When applying the known method, the chaotic location of the small intestine in the abdominal cavity and the creation of conditions for obstruction due to the formation of cord-like and planar adhesions between the loops of the intestine are not excluded. There is no element of resorption and control of the formation of adhesions.

The proposed methods for the prevention of adhesions cannot serve as an effective way to prevent the development of the disease, because they do not give a sufficient percentage of effectiveness and depend on many factors.

The technical result of the patented method is the prevention (obstruction) of the formation of postoperative adhesions of the peritoneum and the absence of side effects.

The claimed technical result is achieved by moving the abdominal organs manually and / or by adaptation relative to each other and their usual locations in the early postoperative period until the patient is fully activated. The claimed technical result is achieved through the application of a method for preventing the development of a postoperative adhesion process (disease) of the peritoneum, which consists in the fact that the method is carried out in three stages, each of which consists of a seven-exercise procedure. The number of exercises included in the procedure can range from 2 or more at the discretion of the attending physician, depending on the nature of the disease, the condition of the patient, introoperative features and other reasons. The procedure from the amount of exercises determined by the attending physician is performed in one step with a single anesthesia for 3-5 or more minutes. Each stage may consist of one or more procedures at the discretion of the attending physician. The first stage is carried out in the first or second day (up to 48 hours) after the operation during which 1 to 3 procedures are performed per day, the second stage is carried out on the second or third day (from 24 to 72 hours) after the operation during which 1 up to 2 procedures per day, the third stage is carried out from the third to fourth days (after 48-72 hours) after the operation once a day and continues until the patient is fully activated and the peristalsis is restored.

The procedure includes the following seven exercises:

the first exercise is that they put the patient on his back, with his hands on both hands cover the anterior abdominal wall with the capture of the largest possible volume of intestinal loops, raise and lower it, perform the exercise 2 or more times, the second exercise is that the patient is placed on the left side, the abdominal wall and the internal organs hanging on the left side, with a quick push movement, the palms of the right hand are “thrown up” to the right iliac region so that the organs under their own weight would fall down to previous position, the exercise is performed 2 or more times,

the third exercise is that the patient is placed on the right side, abdominal wall and internal organs hanging on the right side, with a quick jerk of the palm of the hand, the hands are “thrown up” to the left iliac region so that the organs under their own weight would fall down to the previous position, the exercise is performed 2 or more times, the fourth exercise is that the patient is placed on his back with a raised pelvis and lower abdomen, putting a roller, fingers of both hands press on the stomach and carry out with a quick movement from the extreme edge of the pubic bone upward towards the costal arches, so that the intestinal loops would shift as much as possible upward towards the diaphragm, the exercise is performed 2 or more times,

the fifth exercise is that the patient is placed on his back, with the palms of both hands covering the left and then the right halves of the abdomen from the lower back and the anterior abdominal wall, and squeezing intensively, move the intestinal loops relative to each other, perform the exercise 2 or more times, the sixth exercise is that the patient is laid on his back and kneads the organs of the abdominal cavity in the longitudinal and transverse directions, then one hand, clenched into a fist, is immersed in the abdominal wall and its back surface, pushing, rolling the abdominal organs and soft tissues of the abdominal wall on the palm of the other hand, kneading, exercise 2 or more times,

the seventh exercise is to place the patient lying on his stomach so that the entire front abdominal wall hangs without support and produce push, vibration, pressure movements from the bottom up to the abdominal cavity, the exercise is performed 2 or more times.

The technique of the method, the duration of the steps, exercises and the method as a whole can be changed and supplemented at the discretion of the attending physician, depending on the nature of the disease and the condition of the patient. It should be unchanged earlier, in the first or second day after surgery, the beginning of the method and the duration of its application until the patient is fully activated.

By manual exposure and / or exposure to a patient by a device for moving the abdominal organs relative to each other and from their usual locations is understood to be exposure to the hands of a doctor and / or device that is harmless to the patient, if the characteristics of the device are acceptable for the purpose of the method, for example, with a vibrating massager. The patented method is not intended to affect organs and tissues with the aim of changing their trophism or innervation, like traditional massage methods, but has the goal of topographic, periodic, until the patient is fully activated after surgery, moving the abdominal organs from their usual locations and relative to each other with the purpose is to prevent the formation of adhesions (adhesions), and / or to break loose fissures of the peritoneum that are just beginning to form. The method is effective only if you start using it on the first or second day after surgery and continue until the patient is fully activated with a frequency of daily, once a day.

At the same time, the full activation of the patient should be understood as the patient’s ability to independently perform physical exercises (medical gymnastics), including breathing exercises with maximum inhalation and exhalation with abdominal and diaphragmatic (thoracic) types of breathing alternately, which are aimed at eliminating long-term abdominal organs to a friend and to ordinary anatomical formations (their locations).

It is known that the intestines are characterized by relatively free movement in the abdominal cavity. This is determined by the need to constantly adapt its volume and motor function to the nature and volume of the content. The most common reason for the restriction of intestinal motor function and its ability to shift relative to other organs _

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adhesions of the peritoneum are peritoneal adhesions (I. A. Chekmazov. MD, monograph “Adhesive disease of the peritoneum”, 2008).

It is known that the adhesion process of the peritoneum is formed within 7-14 days after the operation (I. A. Chekmazov. MD, monograph "Adhesive disease of the peritoneum" in 2008).

In this regard, before looking for ways to treat the patient’s suffering, it should be understood that after the specified postoperative periods (7-14 days), adhesions become full-fledged (completed) and exert their influence on the body with all known complications in this pathology. This circumstance determines the timing of the application of the patented method aimed at preventing development, and not on the treatment of adhesions held immediately after surgery. Therefore, the early (in the first or second day after the operation) application of the method provides one of the main requirements for the method, its safety, bearing in mind that if you start the method after the third or fourth day after surgery, the resulting adhesions can lead to ruptures (injuries) intestinal serous membranes (deserting), which, in turn, is one of the main reasons for the formation of adhesions.

Based on the foregoing, the prevention of adhesions should begin from the first day after the onset of the action of the traumatic agent, in order to prevent the smallest adhesions, which can serve as the basis for fixing the intestinal loop to a certain anatomical formation or between each other and further strengthen this park adhesion formation.

The patented method is based on the impact on the abdominal organs, traditionally involved in the adhesion process, aimed at preventing the abdominal organs from adhering (most often these are loops of the intestine) for a long time to each other and their usual locations by displacing (moving) them in order to prevent development of the adhesive process of the peritoneum. Since the abdominal organs are not accessible to direct exposure with direct contact, it is necessary, by sufficient anesthesia and possibly relaxation of the muscles of the anterior abdominal wall, to provide the maximum possible manual access to the organs through the abdominal wall.

The number of procedures and exercises in the first and second stage should be left to the discretion of the attending physician in a wide range (from 1 to 3 procedures per day, two or more exercises per procedure) in order to take into account the possible characteristics of the patient’s body, bearing in mind primarily the predisposition to adhesions and assuming that the rate of adhesion formation, as well as the predisposition to them, can and should be different. In addition, the conditions for the formation of adhesions in the so-called "clean" operations, when there are no inflammatory foci in the abdominal cavity and with peritonitis, are significantly different. Therefore, the timing, multiplicity, intensity should be selected by the attending physician. Otherwise, starting from the third, fourth day, you can stop on a single application of the method per day until the patient is fully activated.

The application of the patented method has some features that should be considered when performing the procedure. First of all, it should be remembered that if during the operation the lumen of the hollow organ was opened, then during the procedure, in the lumen of the hollow organ, at the site of suturing the wall or applying an anastomosis, high pressure can occur that can lead to failure of the sutures. Therefore, the procedure, if an opening of the hollow organ occurred intraoperatively, should be performed without projecting the pressure of the hands on a specific place. In addition, the sutures on the laparotomy wound should be applied in such a way (often in layers) so that it would be possible to manipulate the tissues of the anterior abdominal wall close enough to the sutures without fear of failure of the sutures.

The method also consists in the fact that with the ongoing biochemical processes of the formation of adhesions, the condition necessary for adhesions (adhesions) to take place is excluded. This is achieved by moving the abdominal organs relative to each other and their usual locations with sufficient multiplicity, in order to prevent prolonged adherence of the organs to each other and to their usual locations, which will not allow adhesions to take place. The novelty of the method lies in its application in the early (before the end of the first second day after the onset of the action of the traumatic agent) postoperative period, which was not previously proposed, which will not allow, despite the presence of all biochemical processes of adhesion formation, the abdominal organs to grow together or to the abdominal the wall.

This postoperative period (up to seven days on average) during which the method is applied, until the patient is fully activated and begins to engage in therapeutic gymnastics, especially breathing exercises, will overcome the period (up to two weeks) of active biochemical processes during which adhesions occur ( fusion) viscero-visceral and / or viscero-parietal peritoneal sheets. Moreover, this is the period of intensive treatment of the patient, which eliminates one of the main causes of mass adhesions of the peritoneum - inflammation of the peritoneum (infectious or non-infectious - traumatic origin). After two weeks of the postoperative period, the patient should be focused on a long active, meaning therapeutic gymnastics, life period (up to 6-12 months) in order to prevent the development of adhesions. This is especially important for women, often suffering from an inflammatory process of the pelvic organs. It should be expected that the adhesion process can be "started" with small non-surgical infectious inflammatory processes of the abdominal organs. Therefore, the alertness of the patient and the doctor about the need prolonged use of therapeutic exercises after an acute postoperative period are mandatory. Dates up to two weeks should be considered conditional, since the patient can show sufficient activity much earlier than the indicated dates, as well as later. But you should not reduce the time less than the period of removal of sutures from the laparotomy wound.

Clinical trials are a preliminary confirmation of the effectiveness of the method and the possibility of its execution, without risk to the patient.

Example 1. Patient O. 13 years old, was admitted to the Children's Surgical Department for elective surgery for Payer's disease. After examination and preoperative preparation was operated on with resection of the large intestine and the application of an anastomosis. In the early postoperative period, the patient began to complain of abdominal pain, cramping. Against the background of the absence of signs of inflammation (negative symptoms of peritoneal irritation, normal body temperature, the absence of a blood reaction characteristic of the inflammatory process) and in the presence of abdominal pain characteristic of adhesive disease, the diagnosis of adhesive peritoneal disease was diagnosed. The patient after conservative measures in satisfactory condition was discharged home. After 1 1 days, the patient was admitted with a diagnosis of Acute adhesive intestinal obstruction. Operated on an emergency basis, laparotomy, the elimination of obstruction and dissection of adhesions. After surgery applied from 1 to 6 exercises to prevent the development of the postoperative adhesion process (disease) of the peritoneum for 5 days. The patient is in satisfactory condition, without complaints, was discharged home with recommendations for the use of therapeutic exercises within 6-12 months. The patient was examined 1, 2 and 3 months after discharge. No signs of adhesive disease were found.

Example 2. Patient X. A. born in 1960. Previously operated on for perforation of the stomach with peptic ulcer, blunt trauma to the abdomen and acute appendicitis. After undergoing surgical diseases, he was twice operated on for acute adhesive intestinal obstruction. He complained of frequent paroxysmal abdominal pain. According to the patient, when coughing, pain intensifies along the midline of the abdomen and in the right iliac region. Can not sleep at night on his right side. Severe dyspeptic symptoms. The patient was offered planned surgical elimination of the adhesive process, followed by the use of a method for preventing adhesive disease. Having obtained consent, and after preoperative preparation, the patient was operated on. Intraoperatively: the greater omentum is soldered to the postoperative, laparotomic scar along the entire length, the site of small intestine infringement was found, deformed by adhesions like a double-barreled shotgun, most likely there was damage during the previous operation for adhesive disease. Ileocecal angle in a pronounced adhesive process, gall bladder, more than half, shrouded in commissures, the lower edge of the liver is soldered to the parietal peritoneum. With technical difficulties, the adhesion process is completely eliminated without complications. The laparotomic wound is sutured without drainage of the abdominal cavity. 12 hours after surgery, the patient is conscious, responds adequately, complaints of pain in the area of the surgical wound. Anesthesia with promidol 2% 1 ml / m was performed and after 15 minutes the patient was asked to get up and walk. The patient without any difficulties with little support got up and went into the dressing room. On the massage table in the supine position, the patient performed a procedure of 3,4,5,6 method exercises. After the procedure, the patient independently returned to the ward. 24 hours after surgery, the procedure is repeated under anesthesia. 48 hours after surgery, after anesthesia and anesthesia (ketamine, theopental), the procedure is repeated with a deeper immersion of the hands in the abdominal cavity through the abdominal wall. Subsequently, the procedures were repeated daily once a day for three days. Further, the patient demonstrated the ability to perform breathing exercises under anesthesia with a wide range of motion of the anterior abdominal wall, and hence the diaphragm, which should lead to movements of the abdominal organs. The patient 7 days after the operation, showing a high degree of activity and correctly performing breathing exercises, asked to go home, and therefore was discharged in satisfactory condition. Examined two weeks and a month after surgery, no complaints. With the patient’s words completely stopped the pain and dyspeptic syndromes. He began to get enough sleep, a calm sleep. The patient demonstrated therapeutic exercises, which he performs daily.

The advantage of the present invention is the simplicity of exercises, allowing its repeatability in the hands of any operating surgeon. It should be noted that the method should be used by the attending physician, who operated on a patient who directly saw the intraoperative picture.

With the correct and timely application of the method, which is injury-proof for the patient, the possibility of the formation of adhesions is completely excluded. Thus, many problems are solved, ranging from solving the issue of disability and ending with an increase in surgical activity in other surgical diseases of the abdominal organs.

Claims

CLAIM

one . A method for preventing the development of the postoperative adhesion process of the peritoneum, which is an effect on the abdominal organs through the abdominal wall, manually and / or using a device aimed at moving the abdominal organs from their usual locations and relative to each other in order to prevent adhesions of the peritoneal sheets covering the organs of the abdominal cavity, characterized in that they begin to apply the method in the early postoperative period, before the occurrence of adhesions, with a frequency of daily and up to the full activation of the patient.

2. The method according to p. 1, consisting of a procedure and performed manually and / or with the help of the device consisting in the fact that it begins to be used in the early postoperative period, before 48 hours after surgery on the organs of the abdominal cavity.

3. The method according to p. 1. consisting in the fact that it is used in the postoperative period of up to 1800 hours or the complete activation of the patient.