The way to prevent complications after extensive suturing median laparotomic wound with a pronounced fat, long crushed relentlessly by anorexicly with its deliberate microbial contamination

 

The invention relates to medicine, namely to surgery, and may be applicable for the prevention of complications after extensive suturing median laparotomic wound with a pronounced fat, long crushed relentlessly by they, with its obvious microbial contamination. Excised preperitoneal fat fibre and up to 2 cm subcutaneous fat along the edge of the wound. Aponeurosis is sutured cross is eight-figurative separate seams with tying knots on its outer surface. Produce the cross stitches, which captured the peritoneum, on the inner surface juxtaposed tissues. Stack on the aponeurosis along the line of the seams, double barreled sewn back to back with absorbable thread drainage. Taken in the subcutaneous fat removable eight-figurative vertical compressicauda skin and subcutaneous aponeurotic seam. Knotted stitches so that each previous stitch guide is for later, tying his produce after imposition of subsequent weld on the background of adapting its vertical traction. Remove the postoperative drainage gradual excretion in opposite directions. The method reduces the probability is e relates to medicine, namely, surgery, and can be used for closing large median laparotomic wounds of the anterior abdominal wall in patients with acute subcutaneous fat layer after extended radical and reconstructive operations on the abdominal organs (surgical gastroenterology).

Suppuration laparotomic RAS is a frequent complication in surgery of the abdominal cavity. Extensive (total) suppuration laparotomic wound fraught with the development of eventrate and secondary peritonitis, completed the formation of incisional hernias. Pyo-inflammatory complications lengthen the time of treatment, and in the case of education ligature fistula significantly tighten it.

Most susceptible to injury and infection of the subcutaneous and preperitoneal fat tissue. Long its compression by anorexicly causes a profound disturbance of microcirculation with foci of hemorrhage and ischemia. In addition, the subcutaneous fat is subjected to massive microbial contamination, and prolonged surgical interventions loses moisture, “dries up”, which increases its alteration. Ideally adapt dissected wide layers of the subcutaneous fat layer is difficult, and when applying a simple hub hematoma, seroma, which are the primary foci of suppuration, these lesions coalesce and purulent process covers the seams of the aponeurosis and potamonautes tissue. Often the primary foci are formed in podporujici tissue and can spread easily on the subcutaneous fat layer in the area of traumatic it seams that inevitably leads to extensive suppuration laparotomic wound.

Dozens of methods of suturing median laparotomic wound with and without its drainage. Similar may be the way Ancheta (Wounds and wound infection. Kuzin, M. I., Kostyuchenok B. M. M.: Medicine, 1990), in which in addition to the suturing wounds white line used simple removable hub seam, which is carried out through all layers of the abdominal wall, with the exception of the peritoneum, through the edges of the sheaths of direct muscles and tied over the skin on the gauze balls. This seam is not compresses subcutaneous fat layer, and squeezes it, though not cuts, as the events captured in the seam aponeurosis and skin. It is their compression increases gauze ball, over which is fastened a simple hub seam. Gauze ball squeezes and also the skin. The disadvantage of this method is that the removable seam this configuration compresses the elements of the abdominal wall,failed, the result suppuration, in the case of microbial contamination of adipose tissue.

Or how Condamine (Ed. St. USSR №1796158, class. And 61 In 17/00, 1993): median wound white line is sutured single interrupted sutures through the medial edge of the sheaths of direct muscles. The main disadvantage of the simple knotted suture is expressed ischemia all captured into the joint tissue, ischemic their necrosis and cutting the seam. The zone of necrosis and is the primary focus of suppuration. Undergo suppuration any infected tissue captured in the hub seam. The seam and is a focus of suppuration. This method, due to the eruption of the joints even without suppuration them, does not prevent the occurrence of incisional hernias.

And how Cantina (Ed. St. USSR №1113136, class a 61 M 27/00, 1984): active drainage of surgical wounds, including washing of the wound cavity and the active vacuum aspiration. The disadvantage is that adipose tissue is not adapted by the seams and between the layers dissected subcutaneous fat is formed wide wound channel, long filled wound secret and easily infected after removal of the drains.

For the prototype accepted method of suturing of surgical wounds using uslove agenie seams produce through all layers of the wound with capture her bottom.

The disadvantages of this method are:

1. Lack of drainage of wounds: produce suturing netrenirana wounds, which increases the probability of suppuration with extensive wound infection in the presence of a local inflammatory process and is unacceptable in the long operational interventions and in the conditions of notorious microbial contamination of the wound (the opening of the lumen of the intestinal tube).

2. No suture the subcutaneous fat and the use of a continuous suture leads to the formation of coarse postoperative scar because of the possible shirring fabric. Mapping heterogeneous tissues and circulatory disorders of wound edges along the seam lines also affect the cosmetic properties of the postoperative scar.

Objectives of the invention are: guaranteed prevention, i.e. prevention, suppuration laparotomic wound as the main complications leading to eventrule and education ligature fistula and postoperative ventral hernias; maintenance of healing of wounds by type of primary tension with a good cosmetic effect.

The invention consists in the fact that after a preliminary dissection of the preperitoneal fat and up to 2 cm is by tying knots on its outer surface, thus the intersection of stitches, which captured the peritoneum, is produced on the inner surface of the mapped tissue, aponeurosis, near the line of stitches, stack Winternitz sewn back to back with absorbable thread drainage, subcutaneous adipose tissue is sutured removable eight-figurative vertical compressicauda skin and subcutaneous aponeurotic suture and tying sutures produce such a way that each weld bead is the pilot for the subsequent, tying his produce after imposition of subsequent weld on the background of adapting its vertical traction, and postoperative drains removed gradual excretion in opposite directions.

The method is as follows.

Description of the method illustrated in Fig. 1-7, where 1 is a cross eight-figurative seams peritoneum; 2 - transverse eight-figurative seams aponeurosis; 3 - skin; 4 - subcutaneous tissue; 5 - the aponeurosis of the rectus abdominis muscle; 6 - peritoneum; 7 - compassrose vertical eight-figurative skin and subcutaneous aponeurotic seams; 8 - Winternitz silicone drainage; 9 - cutaneous sutures.

Pre-produce marginal excision of prerusenou and subcutaneous fat, as the fat of views is rasshiriteli. Practically perform isolated primary surgical treatment of wound surface fat. Thus the edges of the peritoneum and aponeurosis skeletonize from fat than reach a thorough adaptation of the most resistant to infection same layers. Initially ahead of one stitch impose eight-figurative cross seams 1 on the peritoneum 6. Then put in the corners of the wound two eight-figurative cross seam 2 on the aponeurosis 5, not tying them, for convenience, the ends of the threads take on the clips-“handles” by which produce a vertical traction for adaptation and dosed compression (Fig. 1, 2). Tying the suture on the peritoneum is made only after setting the above it aponeurotic seam, which is already captured and the edges of the peritoneum. Thus, the seams on the peritoneum lay ahead for one or two seams, but tied after completion of another seam on the aponeurosis than achieve the prevention of the detachment of the peritoneum and the full integrity of the abdominal cavity and podobovetskogo space. Capture seams cut aponeurosis carry out widely, stepping back from the edge by 1.5-2 cm on both sides, that is almost on the edge of the aponeurotic case of recti. Operacao seam occurs on the inner surface of the aponeurosis, moreover, in the intersection catch and peritoneum with its seam that closes and seam, and the rear wall of the aponeurosis, which prevents the formation of cavities under the aponeurosis. Tying threads eight-figurative seam is produced on the outer surface of the aponeurosis on the one hand, under the edge stupidly debonded fat layer. Strictly parallel, 1-1,5 cm from each other, the location of the stitches on the outside of the aponeurosis, that is strictly parallel to the adjacent stitch shivanie second stitch eight-figurative seam in the aponeurosis, not only promotes the uniform distribution of tension across the weld line, thereby preventing excessive compression of the tissue, but also the preservation of blood supply in the captured suture the edges of the aponeurosis. Applying and tying aponeurotic joints as follows. Beginning in the corners of the wound impose two eight-figurative seam on the aponeurosis, not tying them. The ends integrated into the aponeurosis of the threads take on the clips-“handles” by which the vertical traction adapt and dosed compressorium edge of the aponeurosis. Both sewn into the aponeurosis of the eight-figurative seam pulls himself up and dosed compressorium well mapped edge of the aponeurosis. In the ongoing natrenirovan edge of the aponeurosis, and the first seam assumes the role of ultimate fixation perfectly matched edges of the aponeurosis. Next, sewn into the edge of the aponeurosis of the next eight-figurative seam, and begins the rule of two joints, gradually changing its function (Fig. 2). Now each successive stitch perfectly matches and holds adapted edge of the aponeurosis, and the previous optimal seam, compression, captures perfectly adapted edge of the aponeurosis. The functional role of joints gradually changing: the next - maps, and previous records, and later becomes previous. In addition, each weld bead is guides for each subsequent. So the last seam is not tied to see overlapping boundaries subsequent weld. Tying the previous seam produced after blending and subsequent tension suture. The tie goes to the background adapting vertical traction later, still not fastened seam.

For a perfect matching of subcutaneous fat using a removable vertical compressible its seam 7 (Fig. 4-7), which includes the line aponeurotic seam, both walls of the subcutaneous fat and skin. First, grab the bottom of the wound at the seam of the aponeurosis, Verny, capturing the wide, steep arc, subcutaneous fat, goes right under the skin and intersects with the counter subcutaneous thread. Then the threads are moving to the opposite side, going under the skin and appear on the skin. Thus, the skin and subcutaneous aponeurotic weld two points of support - skin and aponeurosis. Seams are imposed at a distance of 2-2,5 cm from each other. Compressible skin and subcutaneous aponeurotic seam allows not only to adapt, not damaging, but also to achieve compression, i.e. a dense mapping of the fat layer that prevents the creation of conditions for suppuration. Tying produce is similar to tying aponeurotic seams, using the rule of two joints - adapting and fixing. The skin between the skin and the subcutaneous aponeurotic seams map the separate removable compressicauda interrupted sutures, the distance from the edges of the wound 3-5 mm, the distance between stitches 5-7 mm. Tying skin seams is carried out only up to a tight contact of the skin so that the seams do not erupted.

To eliminate microbial contamination and removal of wound secretion from subcutaneous fat layer using a flow-leaching drainage system (Fig. 3): at the bottom of the wound near the seam Augusto perforated silicone drainage. Of the same diameter, densely spaced perforating holes contribute to a good contact with the walls of the wound and to improve the outflow of the contents of the wound channel. When long laparotomic wound use a technology staple bystrorassasyvayuschikhsya thread (catgut) two double barreled drains in the middle of the wound. When small wounds using one odnoproletny densely perforated drain tube. After the establishment of drainage and complete overlay removable compressicauda seams under pressure from a large (50 ml) syringe to wash out the drain tube with an antiseptic solution. Under ideal hemostasis of blood clots in tube should not be. Blood quickly washed for the first 1-2 hours of continuous perfusion. By the end of the first day is pure liquid color antiseptic solution. Washing produce continuously for 8-10 days until around the tube is formed of fibrous granulation channel. Drainage is produced constantly drip of antiseptic solutions through a large skylight that provides mechanical removal of wound. After 8-10 days produces a gradual “pulling up” - removing drains 1-1,5 cm in opposite directions within necke of antiseptic solution produced through a thin stroke of the drainage tube.

After complete removal of the drainage tube in the remaining course of installing microirrigation, which is removed after 1-2 days. On the 10-12 day produce suture removal.

The proposed method of suturing and drainage vast middle laparotomic wound with a pronounced fat first tested in the clinic and the Centre in 1979 and has been applied in more than 5 thousand patients. When monitoring patients under 20 years signs of ligature fistula, hernia protrusions is not revealed.

Example. Patient M., 67 years old, was admitted with a diagnosis of Cancer ampullares division of the rectum (12 cm from the anal verge), obesity 3-4 degrees. Transaction: abdomino-anal resection of the rectum with the reduction of the transverse colon; recto-transversovittatus; ilio-pelvic and paraaortal lymphadenectomy; the drainage of the abdominal cavity. The wound of the anterior abdominal wall is sutured by the following procedure: after a preliminary dissection of the preperitoneal fat and up to 2 cm subcutaneous fat along the edge of the wound was carried out layer-by-layer suturing of the anterior abdominal wall, namely, the peritoneum and the aponeurosis of the cross stitched separate eight-figurative seams with tying knots on its outer surface and Zech is tracasseries thread drainage. Subcutaneous fat stitched removable eight-figurative vertical compressicauda skin and subcutaneous aponeurotic seam. Tying sutures were carried out with observance of the rules of the two seams. The skin is mapped to a separate interrupted sutures. Installed flowing-cleansing drainage system: the drainage produced a drip of antiseptic solutions. On the 8th day, after the gradual removal of drains in opposite directions, made its replacement by microirrigation, on the 10th day microirrigation removed on the 12th day the sutures were removed. Found wound healing by first intention.

The patient was examined in terms of 6 months, 1.5 years, 3 years and 10 years. Ligature fistula, hernia protrusions is not revealed. On the anterior abdominal wall is linear postoperative scar.

This method of suturing of surgical wounds and how to allow drainage when used to reduce the number of postoperative complications, improve the quality of surgical treatment, to reduce the period of stay of the patient in the hospital.

Claims

The way to prevent complications after extensive suturing median laparotomic wound with severe subcutaneous girl mapping the edges of the same layer of the wound, characterized in that after a preliminary dissection of the preperitoneal fat and up to 2 cm subcutaneous fat along the wound edges of the aponeurosis is sutured cross is eight-figurative separate seams with tying knots on its outer surface, with the cross stitches, which captured the peritoneum, is produced on the inner surface of the mapped tissue, aponeurosis, near the line of stitches, stack Winternitz sewn back to back with absorbable thread drainage, subcutaneous adipose tissue is sutured removable eight-figurative vertical compressicauda skin and subcutaneous aponeurotic suture and tying sutures produce such a way that each previous stitch is the pilot for the subsequent, tying it is produced after applying the subsequent seam on the background of adapting its vertical traction, and postoperative drains removed gradual excretion in opposite directions.

 

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