The method of drainage of the pleural cavity

 

The invention relates to medicine and is intended for operative treatment of victims with injuries of the chest. Set in the pleural cavity of the upper drainage in V or VI intercostal space between srednechrochnoy line and the anterior axillary line. With the help of the leader of the drainage down to the dome of the pleural cavity along the anterior wall of the thorax. Optionally set the average drainage in the seventh or eighth intercostal space in the interval between the mid-axillary line and the posterior axillary line using the sender bring its distal end to the dome of the pleural cavity along the posterior wall of the thorax. The lower drainage installed in the VIII or IX intercostal space. Using the sender install it into the rear of the rib-diaphragmatic sinus. The method can reduce the severity of pleuro-pulmonary complications. 1 Il.

The invention relates to medicine, particularly surgery.

Patients with trauma to the chest, as well as in other types of injuries, accompanied by shock, in the development of traumatic disease there are certain features characteristic of each of its periods.

In the acute period of traumatic disease, the most frequent is gova injury. In the early post-shock period in the first place are pulmonary complications, which, according to various authors, are found in 46,6-83% of patients with multiple and combined injuries of the chest. Have 31-58% of patients with severe concomitant injuries of the chest, died in intensive care, the primary cause of death was a pulmonary embolism. Causes of complications arising from injury to the chest may be insufficient drainage of the pleural cavity, the use of punctures when the coiled hemothorax, poor stabilization of multiple rib fractures, inadequate analgesia, underestimation of therapeutic breathing exercises and physiotherapy. Traumatic empyema may be the result of multiple or combined injuries of the chest, defective sanitation the pleural cavity during thoracoabdominal injuries, as well as getting the contents of hollow organs of the abdomen in the pleural cavity. Prevention of traumatic empyema effective if the following principles of treatment of hemothorax: early drainage of the pleural cavity; lavage of the pleural cavity; removing blood clots from the pleural cavity by thoracoscopy is possible to achieve, subject to the following conditions: to ensure the drainage of all parts of empyema cavity, including summany, shirokoproletnykh tubes; to carry out flow-washing draining large amounts of antiseptic solutions; to create a complete evacuation of the contents of the pleural cavity; set bacteriological and thoracoscopic control of the usefulness of rehabilitation of the pleural cavity; to carry out targeted antibiotic therapy; conduct systematic correction of water and electrolyte, protein and immune disorders (Seleznev S. A., Cherkasov C. A., Concomitant injury and traumatic disease, Perm, Perm state medical Academy, 1999, pp. 295-304).

For the treatment of pneumothorax and hemothorax with injuries of the chest domestic and foreign authors (Bienkov L. N., Zubarev B.p., Surgical treatment of infectious complications of injuries of the chest and abdomen, St. Petersburg: Logos, 1997, pages 45-50; Niederle B., Extra special surgery, Prague: Avicenum, 1984, PP 60-64) described and recommended method of drainage of the pleural cavity by one or two drains. The drains are thick-walled silicone tube with a diameter of 0.6 cm and more with 3-5 Boko co - Extra special surgical intervention - Prague: Avicenum, 1984, pp. 60-62. The upper drainage installed in the second or third intercostal space at srednechrochnoy line in the anteroposterior direction, entering the drainage tube into the chest cavity to a depth of 6-10 see After extensive skin disinfection with a scalpel in the selected intercostal space horizontally produce an incision of the skin together with subcutaneous layer with a length of about 1.5 cm Curved clip Peana adjacent to the upper edge of the ribs out of the way for the conclusion of the drainage tube between the pectoral and intercostal muscles and parietal perforined the pleura. After this clip Peana temporarily removed from the wound and its branches compress the end of the tube, the insertion immediately through the prepared hole in the chest cavity and fixed to the chest wall skin 1-2 sutures. The lower drainage installed in V or VI intercostal space on axillary lines. The drainage tube is injected with trocar, fix it fixing a seam.

The disadvantage of this method of drainage of the pleural cavity is to install the upper drainage in the second or third intercostal space, which leads to unnecessary injury to the thoracic muscles. With a long stay drainage possible subpectorally leakages. Installing the base on which you can the formation of a coiled hemothorax, summany pleuritis, pleural empyema, incomplete unfolding of the lung, which leads to the development of posttraumatic pneumonia with destruction.

There is a way drainage of the pleural cavity proposed by A. P. Kolesov and L. N. Lisenkova - Surgical treatment of gunshot wounds of the chest - Leningrad: Medicine, 1986, page 53. The lower drainage installed in the seventh or eighth intercostal space in the mid-axillary line. The scalpel to pierce the veil in the intercostal space, focusing on the upper edge of the underlying ribs, to avoid damage to the intercostal vessels and nerves. Prepared drainage tube with optional slotted side opening seize curved clamp or forceps and inserted through the incision into the pleural cavity after removal of the scalpel. The edge of the skin wound is near the drainage stitch one locking stitch and fix it on the tube. The upper drainage injected into the pleural cavity through the trocar in the second intercostal space at srednechrochnoy line. Drainage is a pipe system for blood transfusion with a diameter of 5-6 mm

The disadvantage of this method of drainage of the pleural cavity is to install the upper drainage in the second intercostal space at srednechrochnoy line is leakages. Application for drainage of the pleural cavity of the tube from the system for blood transfusion with a diameter of 5-6 mm is undesirable because within a few hours after installing the lumen of the tube because of the small diameter clogged by a blood clot or fibrin and ceases to function. The introduction of the lower drainage of the pleural cavity through the forceps in the seventh or eighth intercostal space does not allow to properly install drainage of the pleural cavity, and therefore do not adequately sanitize the pleural cavity and, as a consequence, the formation of a coiled hemothorax, summany pleuritis, pleural empyema, incomplete unfolding of the lung, which leads to the development of posttraumatic pneumonia with destruction.

Closest to the claimed method is a method of drainage of the pleural cavity, the proposed centuries Lebedev, V. P. Okhotsk, N. N. Caninum - Emergency care when combined traumatic injuries - Moscow: Medicine, 1980, pp. 178-179. Drainage of the pleural cavity is performed under local anesthesia using a trocar, held in the pleural cavity through a small notch skin with a scalpel. The tube of the trocar should feel free to skip the drainage tube. At the end of the and tube. In the absence of the trocar netscout the skin with a scalpel and into the pleural cavity stupidly at the upper edge of the ribs hold the hemostatic clip. Then the done channel clip can also provide the obliquely cut end of the tube. The tube is fixed to the skin with strong thread. The upper drainage installed in the second intercostal space at the front. The lower drainage installed in the VIII or IX intercostal space on the side.

The disadvantage of this method of drainage of the pleural cavity is to install the upper drainage in the second intercostal space in the front, which leads to excessive trauma of the thoracic muscles, and with a long stay drainage possible subpectorally leakages. Introduction the lower drainage of the pleural cavity using a hemostatic clip in the VIII or IX intercostal space does not allow to properly install drainage of the pleural cavity, and when installing a bottom drain in the rear of the rib-diaphragmatic sinus drainage tube within a few hours after surgery clogged with a blood clot and fibrin and ceases to function. This method of installation of drainage is not possible to adequately sanitize the pleural cavity and, as a consequence, the formation of a coiled hemothorax, summany pleuritis, pleural empyema,the ache of the invention is to reduce plavalaguna complications by improving the efficiency of drainage of the pleural cavity.

The problem is solved in that the pleural cavity is drained by three silicone drainage: upper drainage is introduced into the pleural cavity in V or VI intercostal space between srednechrochnoy line and the anterior axillary line and using the sender is applied to the dome of the pleural cavity along the anterior wall of the thorax, the average drainage is introduced into the pleural cavity in the seventh or eighth intercostal space in the interval between the mid-axillary line and the posterior axillary line and using the sender is applied to the dome of the pleural cavity along the back wall of thorax, the lower drainage is introduced into the pleural cavity in the VIII or IX intercostal space between the middle and posterior axillary lines and using the sender is installed in the rear of the rib-diaphragmatic sinus.

The novelty of the method:

1. The upper drainage is introduced into the pleural cavity in V or VI intercostal space between srednechrochnoy line and the anterior axillary line and using the sender is applied to the dome of the pleural cavity along the anterior wall of the thorax.

2. Secondary drainage is introduced into the pleural cavity in the seventh or eighth intercostal space in the interval between the mid-axillary line and the rear podmyce is I.

3. The lower drainage is introduced into the pleural cavity in the VIII or IX intercostal space between the middle and posterior axillary lines and using the sender is installed in the rear of the rib-diaphragmatic sinus.

The proposed set of essential features in the literary sources not found.

Compared with the prototype of this method has several advantages:

1. Less traumatic upper drainage due to the introduction of the upper drainage of the pleural cavity in V or VI intercostal space between the middle clavicle line and the anterior axillary line, so as not to injure the chest muscle.

2. Quick unfolding of the lung due to the rapid discharge of air and fluid from the pleural cavity, as are 3 of drainage.

3. Adequate sanitation pleural cavity due to more complete coverage of drainage of the pleural cavity as the upper drainage is applied to the dome of the pleural cavity along the anterior wall of the thorax, the average drainage is applied to the dome of the pleural cavity along the posterior wall of the thorax, the lower drainage installed at the rear of the rib-diaphragmatic sinus.

4. The possibility of directional lavage of the pleural cavity slinoj cavity with simultaneous effective drainage through the bottom drainage.

The invention is illustrated in the drawing, which shows the right pleural cavity in the lateral projection with the established drainage 1, 2, 3.

The method consists in the following.

The patient is on the operating table on the back (with bilateral damage) or on the healthy side (unilateral damage). Pain management - endotracheal anesthesia.

Traceroot for videothoracoscopy stupidly entered through a skin incision in the IV, V or VI intercostal space between the anterior axillary line and the mid-axillary line. After a visual assessment of the damage begin installing drains. The drains are silicone tube with a diameter of 0.8-1.0 cm 25-35 cm, with 3-5 lateral holes at one end of the tube.

The upper drainage 1 is introduced in V or VI intercostal space between srednechrochnoy line and the anterior axillary line. Incision of the skin along the intercostal space up to 1.5 cm long. Clip stupidly channel is formed in the pleural cavity. In the lumen of the drainage introduces the sender, such as endoscopic manipulator. With the help of the leader of the drainage tube is inserted into the pleural cavity and along the front surface of the light conducted to the dome of the pleural cavity and installed. the grouting of the pleural cavity.

The average drainage 2 is set in the seventh or eighth intercostal space in the interval between the mid-axillary line and the posterior axillary line. Incision of the skin along the intercostal space up to 1.5 cm long. Clip stupidly channel is formed in the pleural cavity. In the lumen of the drainage introduces the sender, such as endoscopic manipulator. With the help of the leader of the drainage tube is inserted into the pleural cavity and along the rear surface of the light conducted to the dome of the pleural cavity and installed. Drainage is fixed to the skin two ligatures from different sides of the tube along the incision, thereby sealing the pleural cavity.

Bottom drainage 3 is installed in the VIII or IX intercostal space between the mid-axillary line and the posterior axillary line. Incision of the skin along the intercostal space up to 1.5 cm long. Clip stupidly channel is formed in the pleural cavity. In the lumen of the drainage introduces the sender, such as endoscopic manipulator. With the help of the leader of the drainage tube is inserted into the pleural cavity and installed at the rear of the rib-diaphragmatic sinus. Drainage is fixed to the skin two ligatures from different sides of the tube along the incision, thereby sealing pleural is 10 kPa. As we work through three drainage at the same time, achieves a very quick release of the pleural cavity from the air and fluid and easy quickly spread. The upper drainage 1 is removed within the first two days. The criterion for removal of the drain is no air vent drainage and full smoothing the damaged light on the control x-ray of the chest. Through the middle drainage 2 in the pleural cavity is entered to 400 ml of antiseptic solution and drawn in through the bottom drainage (leaching). The pleural cavity lavage is performed 1-2 times a day to clean water. If necessary, the average drainage can be reduced with the help of optical drive installed in place of the accumulation of fluid or clotted of hemothorax with the aim of adequate sanitation and directional lavage of the pleural cavity. 2-3 day removed the average drainage. The criterion for removal of the drain is the lack of a detachable drainage and full unfolding of the lung. If necessary, the pleural cavity lavage, you can continue along the lower drainage 3. The bottom drain is removed in 3-4 days. Before removing the lower drainage of the pleural cavity is entered 100-150 ml antiseptic rest lalami pain in the chest, the spine, shortness of breath.

From the anamnesis: the Trauma of production, for 1 hour before admission was littered with rocks in the mine. Fainted once was vomiting. From the mine victim brought to the surface by the mine rescue team, delivered to the receiving Department of MSU (GNCC OSS).

Objectively: General condition due to severe thoracic trauma, respiratory failure. The position forced, lying on a gurney in the back. Skin stained coal dust. Visible cyanotic mucous membranes, dry. Auscultation of breath listening over all lung fields, weakened, more in the upper right. Palpation and percussion of the chest sharply painful. Respiratory rate 28-30 in minutes muffled heart sounds, acadeny, regular rhythm, the relation of tones stored. The pulse on the radial artery to 120 beats./min. HELL 100-90/70-60 mm RT.article The abdomen is not swollen, symmetric, and participates in the act of breathing. Palpation is noted muscle tension and mild tenderness to palpation in the epigastrium. The sluggish peristalsis. Urine derived catheter, bright. Rectal without features.

Locally determined by Palpation crepitus I through V of edges in the parasternal line and from VI to X of the edges on the front and middle podmix is from the supraclavicular region to X ribs and left in above - and infraclavicular region and places of rib fractures. Palpation is determined tenderness and crepitus in the angle and the upper third of the body of the sternum. Moderate tenderness to palpation of the spinous processes Th X, XI, XII vertebrae. In the epigastric region on the anterior abdominal wall has bruises and abrasions 310 see

After blood sampling and sanitary treatment of the skin in the receiving Department at 19.40 hours the patient is transported to the radiology Department.

On survey radiographs of the chest showed multiple fractures VII-X of the ribs on both sides, injury of the upper lobe of the right lung, subcutaneous emphysema of the soft tissues of the chest on both sides. Hydrothorax on the right.

On the x-ray sternum in lateral projection revealed a fracture of the body of the sternum in the upper third.

On radiographs of the thoracic and lumbar spine revealed a compression fracture of the bodies of the eleventh and twelfth thoracic vertebrae.

Preliminary diagnosis:

Dz: Polytrauma. Multiple closed fractures of the ribs on both sides with tissue damage in both lungs. Contusion of the right lung. Bilateral hemopneumothorax. Subcutaneous emphysema on both sides. Respiratory failure II Art. Closed fracture of the body of the sternum. Soskova injury, the concussion of moderate severity. Traumatic shock II Art.

At 20.15 h the patient is transported to the emergency operating room, where, after tracheal intubations performed diagnostic fibrobronchoscopy - pulmonary bleeding from the S1 and S2 segments of the right lung.

At 2105 hours in an emergency procedure performed operation - videothoracoscopy right and left, drainage of both pleural cavities, diagnostic laparoscopy.

Operation No. 1. - Videothoracoscopy right, drainage of the right pleural cavity.

Endotracheal anaesthesia. The position of the patient on the back. The operative field, double-processed alcoholic chlorhexidine. In the fifth intercostal space on the right anterior axillary line through a skin incision of 1.5 cm in the right pleural cavity is entered videothoracoscopy. When a panoramic overview of the right lung pale pink color, collobiano at 1/3 volume. On the surface of the right lung more in the upper lobe, there are lots of contusions and bruising of the lung tissue. In the projection of the rib fractures are subpleural bruises with damage to the parietal pleura (4 cm). In the upper floor of the anterior mediastinum is defined emphysema and bruises. The right dome of the diaphragm imbiriba pleural cavity drained three silicone drains. The upper drainage is entered in the fifth intercostal space through a skin incision of 1.5 cm along the intercostal space between srednechrochnoy line and the anterior axillary line. Clip stupidly channel formed in the pleural cavity. In the lumen of the drainage entered the leader of the endoscopic manipulator. With the help of the leader of the drainage tube is introduced into the pleural cavity and along the anterior surface of the right lung held to the dome of the pleural cavity and installed. Secondary drainage is installed in the seventh intercostal space in the interval between the mid-axillary line and the posterior axillary line. Through a skin incision along the intercostal space up to 1.5 cm long clip stupidly channel formed in the pleural cavity. In the lumen of the drainage entered the leader of the endoscopic manipulator. With the help of the leader of the drainage tube is introduced into the pleural cavity and along the rear surface of the right lung held to the dome of the pleural cavity and installed. Bottom drainage installed in the ninth intercostal space in between the mid-axillary line and the posterior axillary line. Through a skin incision along the intercostal space up to 1.5 cm long clip stupidly channel formed in the pleural cavity. In the lumen of the drainage entered the leader of the endoscopic manipulator. With the hydrated sinus. Each drain is fixed to the skin two ligatures from different sides of the tubes along the incision reached, and then sealing the pleural cavity. The right lung is expanded under visual control, and then from the pleural cavity of the trocar removed and optics. The stitches on the wound aseptic bandage.

Operation No. 2 - Videothoracoscopy left, drainage of the left pleural cavity.

Endotracheal anaesthesia. The position of the patient on the back. The operative field, double-processed alcoholic chlorhexidine. In the fifth intercostal space on the left anterior axillary line through a skin incision of 1.5 cm in the left pleural cavity is entered videothoracoscopy. When a panoramic overview of the right lung pale pink color, collobiano. On the surface of the right lung more in the lower part, there are lots of contusions and bruising of the lung tissue. In the projection of the rib fractures are subpleural bruises with damage to the parietal pleura (up to 2 cm). In the upper floor of the anterior mediastinum is defined emphysema and bruises. The left dome of the diaphragm imbibition blood. In the pleural cavity to 500 ml of liquid blood. Blood aspirated and placed on autoguemotransfuzii. The left pleural cavity drained three silicone on srednechrochnoy line and the anterior axillary line. Clip stupidly channel formed in the pleural cavity. In the lumen of the drainage entered the leader of the endoscopic manipulator. With the help of the leader of the drainage tube is introduced into the pleural cavity and along the anterior surface of the left lung held to the dome of the pleural cavity and installed. Secondary drainage is installed in the seventh intercostal space in the interval between the mid-axillary line and the posterior axillary line. Through a skin incision along the intercostal space up to 1.5 cm long clip stupidly channel formed in the pleural cavity. In the lumen of the drainage entered the leader of the endoscopic manipulator. With the help of the leader of the drainage tube is introduced into the pleural cavity and along the rear surface of the left lung held to the dome of the pleural cavity and installed. Bottom drainage installed in the ninth intercostal space in between the mid-axillary line and the posterior axillary line. Through a skin incision along the intercostal space up to 1.5 cm long clip stupidly channel formed in the pleural cavity. In the lumen of the drainage entered the leader of the endoscopic manipulator. With the help of the leader of the drainage tube is introduced into the pleural cavity and installed in the rear of the rib-diaphragmatic sinus. Each drain is fixed to the skin of the TLD the second light flying under visual control, then from the pleural cavity of the trocar removed and optics. The stitches on the wound aseptic bandage.

Operation No. 3 - Diagnostic laparoscopy, drainage of subphrenic space to the right.

Endotracheal anaesthesia. The position of the patient on the back. The operative field, double-processed alcoholic chlorhexidine. Through the skin incision to 1.0 cm in the upper-left point of the Tracing paper introduced the laparoscope. When a panoramic overview on the anterior abdominal wall in the epigastric preperitoneal Pedavena hematoma 32 cm without evidence of growth. Dome of the diaphragm imbibition blood. In the subphrenic spaces on both sides to 100 ml of liquid blood (more right). Blood aspirated. Through a separate incision in the right upper quadrant, right subphrenic space drained silicone tube. The tube is fixed two skin sutures. Other lesions of the abdominal cavity is not revealed. Done removing gas, trocars from the abdominal cavity. The stitches on the wound aseptic bandage.

Surgery duration 1 hour (21.05-22.05).

Clinical diagnosis:

Dz: Polytrauma. Multiple closed fractures of the ribs on both sides with tissue damage in both lungs (from I to V in d is leva on the anterior and mid-axillary lines). Pulmonary bleeding from the S1 and S2 segments of the right lung. Injury in both lungs. Bilateral hemopneumothorax. Subcutaneous emphysema on both sides. Respiratory failure II Art. Closed fracture of the body of the sternum. Chemoprevention in the upper anterior mediastinum. Injury of both domes of diaphragm. Injury of the anterior abdominal wall. Closed compression fracture tel Th XI and XII of the vertebrae. Closed craniocerebral injury, brain concussion moderate severity. Traumatic shock II Art.

After the surgery for further treatment and observation of the patient is transported to the intensive care unit and intensive care. At 22.30 h re-rehabilitation-diagnostic fibrobronchoscopy - ongoing pulmonary hemorrhage no. In the Department of resuscitation and intensive therapy was conducted infusion, antibiotic therapy, therapy aimed at improving the rheological properties of blood, artificial lung ventilation to treat respiratory failure and pneumatically, vitamin. 11.11.2000 on the upper drainages of the air vent no, radiographically both lungs expanded. The upper drainages translated into passive aspiration. In the evening of the same day verhnelenskiy once a day. 13.11.2000 average drains were removed on both sides. 14.11.2000 at the lower drainages on both sides in the pleural cavity was entered in 150 ml of 0.5% aqueous solution of chlorhexidine, then lower the drains were removed on the 4th day). Pneumatically continued until 24.11.2000 (before the formation of primary bone spur). During the whole period of stay in the intensive care unit and intensive care patient 2 times per day was held this year the fibrobronchoscopy. After extubation (24.11.2000) patient was transferred to the General surgery Department. The separation was performed breathing exercises and physical therapy to strengthen the back muscles. About compression fracture of the thoracic vertebrae was made corset. During the first 5 days after surgery there was an increase of temperature up to 37.4C. subsequently, the temperature during the whole period remained normal. 3 weeks after surgery the patient is in satisfactory condition was discharged home on outpatient supervision of the surgeon and traumatologist at the place of residence.

Control radiographs of the chest lung fields without focal and infiltrative changes, rib-diaphragmatic sinuses with the 38 patients. Complications in the postoperative period were observed. 32 patients examined after 1 year after surgery. No any complaints, perform any physical activity. On survey radiographs of the chest lung fields without focal and infiltrative changes, rib-diaphragmatic sinuses available.

Claims

The method of drainage of the pleural cavity, including installation in the pleural cavity top and bottom in the VIII or IX intercostal space drains, characterized in that it further establish the average drainage in the seventh or eighth intercostal space in the interval between the mid-axillary line and the posterior axillary line, using the sender bring its distal end to the dome of the pleural cavity along the posterior wall of the thorax, the upper drainage injected into the pleural cavity in V or VI intercostal space between srednechrochnoy line and the anterior axillary line and using the sender down to the dome of the pleural cavity along the anterior wall of the thorax, and the lower drainage using the sender is installed in the rear of the rib-diaphragmatic sinus.

 

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FIELD: medicine.

SUBSTANCE: method involves applying one or two parallel through draining tubes having lateral perforations. Flow lavage of the retroperitoneal space with antiseptic solutions is carried out via the perforations at room temperature and cooled solutions are administered concurrently with vacuum suction. Omental bursa is concurrently drained using the two parallel through draining tubes. Flow lavage of the omental bursa is carried out using these tubes.

EFFECT: enhanced effectiveness of treatment in healing pyo-inflammation foci.

5 cl, 1 dwg

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