The method of closing subfascial access varicose and post-diseases with decompensated chronic venous insufficiency of the lower extremities

 

The invention relates to medicine, surgery. In the area expressed trophic disorders impose a single fasciale-fiber joints. The diastasis between the edges of the skin wound 2-3 mm method reduces the number of complications. 7 tab., 2 Il.

The present invention relates to medicine, namely to surgery, in particular phlebology, and can be used when performing subfascial dissection of perforating veins varicose (WB) or post-disease (PTB) on the background of decompensated chronic venous insufficiency (CVI II-III century).

There are various ways seam and seamless closure of postoperative wounds. So there is a method of layer-by-layer wound closure single interrupted sutures, mattress supports vertical or horizontal mattress sutures, intradermal cosmetic continuous suture one thread or two threads. Also known methods of wound closure intradermal circular suture using absorbable suture material, catgut, deksona, vicryl (1).

The disadvantages of these methods include the following. A separate host, vertical mattress or gorizontalnaja tissue hypoxia, as a result, on the background of the CVI-II-III century, when the existing syndrome capillary-venous insufficiency (2), note the high percentage of early purulent-necrotic complications in the postoperative period, reaching 14,6-70% (3, 4).

Intradermal cosmetic absorbable sutures and non-absorbable suture material optimal for unmodified skin. When decompensation, venous insufficiency (CVI II-III century), when watching pigmentation and induration of the skin and subcutaneous fat, the development of dermatitis and ulcers, the above methods of wound closure is practically not used due to the rigidity of the tissues and the inability to perform adequate drainage, and when suppuration has to “dissolve” the wound in its entirety. Initially deferred seams at the given pathology leave multiple stab defects at the edges of the wound, and the thread, as a foreign body, infected, which can lead to complications.

The closest in technical essence to the present invention is a method of wound closure, including reduction of wound edges and their fixation in a predetermined position. The essence of this method lies in the seamless closing wounds, including lakoplastyrna mixing the edges (steri-strip) (5).

the e several days, which leads to maceration of wound edges, pyoderma under the patch and desquamation of the epithelium, and suppuration especially when CVI-II-III century

The objective of the proposed technical solution is to develop a method of fascial suturing access varicose and post-diseases with decompensated chronic venous insufficiency of the lower extremities.

The technical result of the proposed method is to reduce the number of wound complications, due to the optimization of the process of wound healing after subfascial dissection of perforating veins of the leg in decompensated chronic venous insufficiency in patients with varicose and postromanticism diseases.

The technical result is achieved by a method of closing wounds with decompensated chronic venous insufficiency includes the approximation of the wound edges and their fixation.

Distinctive techniques of the proposed method lies in the fact that in the area expressed trophic disorders (induration and pigmentation of the skin and subcutaneous fat) impose a single fasciale-fiber joints, and the diastasis between the edges of the skin wound is 2-3 mm (In patients with poorly pronounced fat when the imp is Ukrainian literature showed the proposed method contains features that distinguish it not only from the prototype, but also from the other variants of wound closure. These differences allow to draw a conclusion on the conformity of the proposed technical solution the criteria of the invention of “novelty.”

Proposed by the authors stitching postoperative wounds in the area of trophic disorders of the skin in the middle and lower third of the leg (when access subfascial space) after execution of the main step of the procedure - dissection of the insolvent perforating veins is carried out by applying a single fasciale-fiber Mylar or nylon sutures, without closing the skin over the entire zone of pigmentation and induration of the skin and subcutaneous tissue.

Clinical research of the authors of the proposed method is established that the length of the unembroidered skin wounds can range from 2-3 up to 10-15 cm, and the diastasis between the opposite edges may be 2-3 mm

The proposed method of closing wounds reduces tissue pressure in the wound, ischemia, to avoid the presence of foreign bodies - suture threads, with which the surface of the skin penetrate into the subcutaneous tissue.

In the available literature we have not identified such method being sutured the pilot study on animals. This allows to conclude that the technical solutions according to the criterion of “inventive step”.

The method constituting the invention, intended for use in health care. The possibility of its fulfillment is confirmed as described in the application techniques and equipment. The inventive method achieves perceived by the applicant of the technical result, namely a decrease in the number of wound complications in the area expressed trophic disorders, therefore, the proposed solution meets the criteria of the invention "industrial applicability".

The method of closing wounds with decompensated chronic venous insufficiency is illustrated in Fig.1 and 2, which reflect the manner of its execution. In Fig.1 is a diagram of the proposed overlay seam, where 1 - skin; 2 - subcutaneous tissue; 3 - fascia; 4 - muscle; 5 - seam, 6 - diastasis. In Fig.2 - General view of the stitched subfascial access the operated extremity skin sutures in the area of unmodified tissue.

The inventive method is as follows.

After performing subfascial dissection of perforating veins varicose (WB) or post-illness (PTB) on the background of decompensated chronic veno who live single fasciale-fiber joints. The seam 5 is carried through the subcutaneous tissue 2 and the fascia 3 opposite edges of the wound, after which the seam 5 tied (Fig.1). Resulting in convergence and a good adaptation of the edges of the rigid tissue surgical wound, and the diastasis 6 between the edges of the skin wound may be 2-3 mm Seams on the skin are imposed on the edges of the wound in the area of unmodified skin (Fig.2).

Postoperative limb is in an elevated position. On the first ligation - 12 hours after the operation, note the decrease edema of the leg and foot and the almost complete closure of the edges are not stitched skin wounds. In 2-3 days the patient impose elastic bandage and allow them to go.

The essence of the proposed method is illustrated by a specific example:

Example 1. Patient K., 51,, case history No. 15912 operated in MUSIC city clinical hospital №-1 25.10.02. Diagnosis: Post-disease of the right lower limb, femoral-popliteal-rear/tibial segments, recanalization stage, low veno-venous reset, CVI-III century (trophic ulcer on the front-inner surface of the lower third of the right tibia area of 40 cm2). The diagnosis is confirmed by duplex scanning.

From the anamnesis: ill 11 years ago, when or after removal of plaster immobilization of the patient was performed phlebotomy (in one of the districts of the Irkutsk region). After discharge from the hospital immediately “opened” trophic ulcer in the lower third of the leg, which, despite treatment (dressing, autodermoplasty, physiotherapy), gradually increased over the next 10 years.

2 weeks prior to surgery the patient underwent autodermoplasty sores on Tirso. In operation, when the fascial access tied insolvent perforating vein Caccetta - 2, diameter 10 mm

The stitches held on the proposed way - with no skin sutures for 6 cm diastasis between its edges to 2-3 mm in 1st day. After 2 days on the background of reduction of edema, the edges of the skin wound closed, the patient began to walk with elastic compression of the lower limb. Healing by primary intention wound and complete epithelialization of ulcers, for 10 days the patient was discharged to outpatient treatment. Month started working - professional hunter.

At the present time MUZ IGCB-1 the proposed method for closing wounds during the operation of Linton made 318 patients, of them in the Department of vascular surgery 282 (88,6%) and in the Department of surgical infection 36 (11.4%) of patients. When WB at 239 (75.2 per cent) and PTB at 79 (24,8%) patients. The age of the operated ballyarnet CVI-II-III century from 1 year to 37 years old When this concomitant allergic dermatitis was noted in 33%, erysipelas 8%, secondary contracture of the ankle joint in 8%, and thrombophlebitis of subcutaneous veins in 5% of patients. The area of non-healing venous ulcers was at 177 (55,6%) patients from 1 to 130 cm2. When longer healed venous ulcer or area of up to 1 cm2the operation of the Linton at WB were performed simultaneously with phlebotomy 149 (46,9%). Extravasal correction valves (AVCC) deep veins with 135 (56,5%) patients. Of them, at the same level in the upper third of the femoral vein at 122 (90.4 percent), at two levels in 6 (4.4%) and at three levels in 2 (1.6%) AVCC femoral and great saphenous vein in 5 (4.1 per cent). The healing of venous ulcers after the first stage of surgical treatment occurred in the period from 2 weeks to 3 months 99 (72,3%), from 3-4 months in 33 (24,2%) and 2 (1,5%) through 9 and 12 months. At PTB a one-stage operation was performed in 48 (60,7%), combined with the switching operations of the Warren-Tier in 11 (13%) and Vedeno A. N. 8 (10,1%) patients.

When the open ulcer of the proposed method was carried out the second stage. The healing of venous ulcers after the first stage at PTB was 2-4 months. When the giant ulcers to accelerate epithelialization before or after the first stage, the more the patients.

Nearest postoperative period after subfascial ligation of perforating veins in the proposed method was uneventful at 307 (96,6%) patients. Local nadfascikle suppuration or single ligature fistula was observed in 11 (3,4%) patients. All ligature fistulas were tied with subcutaneous veins, abscesses seams on the fascia was not observed. All these complications were treated after removal of the ligature over the next 1.5-2 weeks of the postoperative period in the hospital.

Comparison of own results with literature data shows that the proposed solution gives a lower percentage of early postoperative complications and 3.4% after surgery Linton (Felder). So according to literature data, the frequency of complications after surgery Linton and Felder is 14,6 - 70% (3, 4).

In comparison with our previous observations, the authors proposed method note that after the implementation of the proposed method of closing subfascial access CVI-II-III century bed-day in the Department of surgery of vessels decreased by 7, in the Department of surgical infection in 13 days, and surgical activity increased when this pathology is 64,6 to 90.9%. This is because the earlier patients with active trap the Oia and the proposed method of closing subfascial access tibia, lead them promptly.

The effectiveness of the proposed method also confirms the authors conducted a pilot study.

The experiment conducted on rats, the components of the two animal groups - control and experimental (a total of 110 pieces). The animals were operated under ether anesthesia, the incision up to 5-6 cm conducted paravertebral. In the control group were applied single nodal joints in the test - on the proposed method of closure of the wound. Morphological study in the dynamics of wound healing from 2 hours to 20 days.

Morphological and functional changes in the wound was assessed by the degree of swelling of the wound, the number and cross-sectional area of the sanguineous vessels, indicators degranulation of mast cells, leukocytes, macrophages and fibroblasts. For evaluation of the formation of connective tissue scar was determined the concentration of collagen in the wound and biomechanical properties of the scar tissue with the determination of its strength and elasticity. The results obtained were significantly different in the control and experimental groups, they are presented in tables 1-7 (Appendix to the description on the application).

So table 1 shows the total number of leukocytes in the hearth of reriod. The maximum number of cells in the control and experimental group was observed in the 1st day of the postoperative period and were respectively 102,7 thousand/mm3and 88,2 thousand/mm3. On the 10th day in the experimental group the number of cells returned to normal 12 thousand/mm3and in the control group leukocytic infiltration lasts up to 20 days (p<0.005 percent), suggesting a more pronounced inflammatory response.

Table 2 shows the number and average cross-sectional area of the sanguineous vessels in the dynamics of wound inflammation in the control and experimental groups. The average cross-sectional area sanguineous vessels in the control and experimental groups, reaching a maximum of 6 th hour and was 438±9 mm2and 403,2±2.4 mm2(p<0.005 percent), respectively. The maximum value of this index reaches in both groups to 12 hours and is accordingly 370,4±3.2 mm2and 264±2.2 mm2(p<0.005 percent), indicating a more rapid relief of venous stasis in the experimental group.

Table 3 summarizes these indicators biomechanical properties of the scar tissue, as strength and elasticity (in grams) in the control and experimental groups of animals. The strength of the emerging post-operative scar, naoi group 284,0±gr. (p<0,005). The elasticity of scar tissue in the postoperative period significantly prevailed for 7-10 days in the experimental group and was on a 7 day - 12,3±0,35 gr, on 10 day - to 16.9±0.6 g., and in the control group - 7,0±0.27 oz. and 11.3±0,8 gr. (p<0.005 percent), respectively, indicating a significantly better postoperative scar formation.

Table 4 reflects the concentration of collagen and the number of fibroblasts in the hearth of wound inflammation (control and experiment). The number of fibroblasts in the postoperative scar in the experimental group to the 2-day reaches 148±0,85 thousand/mm3. In the control group, their concentration increases much more slowly, reaching a maximum of 3 days up 151.9±7,1 thousand/mm3. The concentration of collagen in the experimental group is growing as vigorously, reaching a maximum of 3 days 31,3±0,71.E., in the control group noted the slow accumulation of collagen, which reaches only to 7-day - 35,0±0,9 have.E. (p<0,005). These results say about the acceleration and the quality of the healing process in the experimental group.

Table 5 shows the performance of the fat cells in the lesion wound inflammation (the amount of fat cells thousand/mm3, average degranulation (SPD) fat cells (TC) is t maximum equal to 17±0.17 thousand/mm3by the 5th day. In the control group falls on the 7th day, equal to 22.5±0,75 thousand/mm3(p<0,005). The process of degranulation of mast cells in the experimental group is less pronounced and the 1st day and is 0,44 from.ed., and in the control group is 0.86.ed. (p<0,0001). The results show less activation of mast cells in the experimental group, which ultimately leads to a lower inflammatory response in the surgical wound.

Table 6 reflects the water content (edema) in the hearth of wound inflammation in the control and experimental groups of animals (in %). Swelling in the hearth of wound inflammation was maximum to 12 hour post-operative period and in the experimental group it was less for 77.2% and in control group - 79,4% (p<0,005).

Table 7 provides information about the number of macrophages in the wound (thousand/mm3) in animals from the control and experimental groups. The number of macrophages in the wound quickly grew faster and were decreased in the experimental group: 2 days 17,8 thousand/mm3in the control 14,9 thousand/mm3and only 3 days amounted to 19.7 th/mm3. To the 15th day 8 and 9.1 thousand/mm3(p<0.005 percent), respectively, indicating a more efficient and early function in opticals in the control and experimental groups.

The experimental data showed that the proposed method of closing access in the subfascial space after dissection insolvent perforating veins of the leg according to the method of Linton (Felder) with CVI II-III century provides less tissue trauma, which allows you to save in post-traumatic period, a greater number of cellular elements of the connective tissue - fibroblasts, fat cells, etc. Is also supported by the less pronounced the degranulation of mast cells, swelling of the wound edges and vascular reaction. Leukocyte infiltration of tissues is reduced. The activity of macrophages in the wound faster in the early and late period. Retain most of fibroblasts in post-traumatic period, and their subsequent active proliferation creates preconditions for accelerated development of the healing process. It should also be noted that the combination of these factors not only provides accelerated healing of wounds, but also qualitatively alters the structure of the scar tissue, improving these important biomechanical factors as strength and elasticity. All this, in turn, is reflected in the cosmetic characteristics of the postoperative scar.

Thus, the proposed method allows optinate on the background of varicose and post-illness.

Sources of information

1. Zoltan J. Cicatrix optima. Surgical technique and conditions for optimal wound healing. - Ed. Academy of Sciences of Hungary, Budapest, 1977, S. 44-76.

2. Dune E. P., Ukhov Y. I.,. Shvalb P., Physiology and pathology of the venous circulation, M.: Medicine, 1982, S. 107-114.

3. “Phlebology”. Edited by C. S. Saveliev. M. M. 2001, S. 554.

4. Zolotukhin, I. A. Surgical treatment of varicose veins under trophic disorders. Diss. Kida. the honey. of Sciences, Moscow, 1997, S. 7.

5. Zoltan J. Cicatrix optima. Surgical technique and conditions for optimal wound healing. - Ed. Academy of Sciences of Hungary, Budapest, 1977, S. 58.

Claims

The method of closing subfascial access varicose and post-diseases with decompensated chronic venous insufficiency of the lower extremities, including the approximation of the wound edges and their fixation, characterized in that in the area expressed the wound is 2-3 mm



 

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