Method for preperitoneal block following median postoperative ventral hernioplasty

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to abdominal surgery and anaesthesiology, and can be used where it is necessary to anaesthetise after the prosthetic hernioplasty for median postoperative ventral hernias. That is ensured by placing an endoprosthesis under the aponeurosis, a polyvinylchloride catheter is placed into the formed spaced around the periphery of a postoperative wound in the form of an oval above the endoprosthesis plane at 2.5-3 cm from its edges. Along its full length, the catheter has multiple side holes. Single openings are created in a projection of a lower corner of the wound, and the catheter ends are brought out onto the skin. An inlet of the catheter is attached to a local anaesthetic dosage device by means of a cannula. That is followed by a controlled prolonged irrigation with 2.5% Ropivacaine 20 ml every 6-8 hours during 2-3 days.

EFFECT: method enables the adequate postoperative anaesthesia, as well as the length of the postoperative intestinal distention by providing the uniform controlled administration of the local anaesthesia solution.

7 dwg, 1 ex

 

The invention relates to medicine, namely surgery and anesthesiology. The method can be used in herniology if necessary, anesthesia, after protesilaus hernioplasty with a median postoperative ventral hernias.

The known method standard pain management using opioid narcotic analgesics.

However, early postoperative period is undesirable introduction of narcotic analgesics, given the side effects: nausea, vomiting, dynamic paresis of the gastrointestinal tract, respiratory depression, addiction and physical dependence. (Alyautdinov R.N. Pharmacology. - M.: Medicine, 2004. - 197 S.).

There is a method of pain relief after protesilaus hernioplasty, including with a median ventral hernias, including the introduction of a local anesthetic into the area of the wound for pain. (V.A. Ostretsov, VA Hankow, S. p. Bubencikov Protesilaus hernioplasty for inguinal hernias // Endoscopic surgery - 2008. No. 4. - P.18-20). But this method of analgesia is only for the actual surgery itself, without regard to pain relief in the postoperative period, as a single injection of local anesthetic has a limited effect because of its short duration of action.

The known method blockade of nociceptive the x afferent fibers of the peritoneum by continuous infusion of local anesthetic via established by the surgeon at the end of operation multiport catheter (Beaussier M Continuous preperitoneal infusion of ropivacaine provides effective analgesia and accelerates recovery after colorectal surgery. Of Anesthesiology. - 2007. - Vol.107 (3). - P.461-468).

For reasons that impede the achievement of the technical result by using the above method, is that one catheter in the same anatomical region in a small space, which limits the infiltration of the tissue by local anesthetic and does not allow you to create a depot local anesthetic, thereby not providing adequate analgesia. In addition, the use in combination of narcotic analgesics (morphine) does not allow to fully evaluate the effectiveness of preperitoneal blockade.

There is a method of draining wounds, using just one tube, laid on the bottom of the wound to ensure the most uniform outflow, respectively, and assumes uniform irrigation of the wound (Theory and practice of local treatment of purulent wounds (drug therapy) // Dotsenko BM, Kiev, Health, 1995, p.121-123).

The proposed irrigation of the wound with the help of such a tube will have little effect, as the tissue infiltration anesthetic is expected only in a limited area.

The most reliable method, selected as a prototype, is a well-known method preperitoneal blockade in the postoperative period, etc in the formation of left and right throughout the laparotomic wound, at a distance of 1.5-2 cm from its edges, in the tunnel are catheters with multiple holes. Through established catheters into the preperitoneal space is injected local anesthetic every 3 hours for 3 days (patent RF №2400259 C1, 27.09.2010).

However, this method has its disadvantages.

1. This method does not provide a uniform distribution of anesthetic, as a single bolus of fluid on an open system, which does not take into account the diameter of the perforated holes and the diameter of the catheter which does not provide uniform irrigation and supposes that the fluid only through the nearest (first) or the large hole, available in the handset.

2. Open-loop system increases the risk of infection of surgical wounds.

3. Uncontrolled introduction of local anesthetics into the preperitoneal space can lead to overdose and adverse side effects of anesthetics.

The present invention is to increase the efficiency of the method preperitoneal blockade in patients after protesilaus hernioplasty median postoperative ventral hernias, consisting in the fact that is controlled uniform irrigation of local anesthetic that provides adequate analgesia and reduces quantities of the postoperative complications, and also contributes to early activation of the patient.

The invention is illustrated by drawings, where:

figure 1 - shows the image of the midline wound on the anterior abdominal wall;

figure 2 - the wound in the side after implantation of a mesh implant

where 1 - postoperative wound, 2 - perforated catheter, 3 - cannula catheter (inlet catheter), 4 - metering device for introducing anesthetic, 5 - barometer to measure the pressure preperitoneal fat, 6 - cannula of the catheter (the outlet of the catheter), 7 - subcutaneous fat, 8 - outer aponeurotic layer of the anterior abdominal wall of the abdomen, 9 - the rectus abdominis, 10 - mesh implant, 11 - preperitoneal space, 12 - peritoneum.

The stages of operation shown on the picture, where:

Photo 1. Shows uniform distribution of the solution of brilliant green mogadischu catheter.

Photo 2. Installation of the conductor on the stiletto into the operating wound.

Photo 3. The process of inserting the catheter into the preperitoneal tissue.

Photo 4. The process of removing the second end of the catheter to the skin.

Photo 5. Megacity catheter installed in the preperitoneal tissue, the wound sutured.

The method is performed in the following way, after the main phase of Greenacre with the installation of the implant 10 between the peritoneum and the muscular-aponeurotic layer in straights and corners is consistent preperitoneal space 11 around the circumference of the wound in the form of an oval 1 above the plane of the endoprosthesis 10 is installed PVC catheter 2 at a distance of 2.5-3 cm from the edges, having throughout multiple side holes. In the projection of the lower angle of the wound 1 on both sides perform a separate punctures and output ends of the catheter to the anterior abdominal wall. The inlet of the catheter is attached to the device, the metering injection of local anesthetic through the cannula 3. Through the dispenser 4 is controlled prolonged irrigation of 2.5% solution of ropivacaine 20 ml every 6-8 hours for 2-3 days. At the same time through the barometer 5, which is connected via cannula 6 with the outlet of the catheter, if necessary, measurement of pressure in the preperitoneal tissue. The catheter is fixed in several places absorbable interrupted sutures to the endoprosthesis. During implantation (installation) of a mesh implant the peritoneum peeled from the musculoaponeurotic layer for 6-8 cm in all directions. The result will create preperitoneal space, where a depot is formed of anesthetic solution, which allows not only efficient local local anesthesia, but also gives the effect of wiring analgesia.

Clinical example

Patient A.B., 58 years old, was admitted to the 1st Department of surgery GAUSE city clinical hospital №7, Kazan g 8 h in a planned manner with a diagnosis of Large postoperative ventral hernia. On admission the patient Ave is Djalal complaints-like protrusion of the postoperative scar, pain during exercise above the mass of the protrusion. In 2005, he underwent surgery for stab wounds to eliminate colostomy. In the same year he performed reconstructive surgery: closure of the colostomy. Subsequently developed postoperative ventral hernia. In this connection, he sought medical help and was hospitalized in the surgical Department No. 1 GAUSE city clinical hospital№7, Kazan in a planned manner.

When inspecting General condition of the patient is satisfactory. Skin moist, physiological color. Pulse satisfactory filling of 76 beats per minute. Blood pressure 130/80 mm Hg

Tongue moist, clean, not coated. The abdomen is moderately painful and tense in the field of hernial protrusion, which is defined in natureway and in a horizontal position in the area after the surgical scar. A bulge is noticeable falls freely into the abdominal cavity, the skin over it is not modified, without evidence of infringement up to size 15 see Patient is diagnosed: a Large postoperative ventral hernia and shows surgical treatment in a planned manner. Laboratory tests within normal limits. Contraindications to operative treatment is not revealed. Planned gryzhesechenie with plastic polypropylene implant.

Operation 26.09.12. 9 h 00 min -11 h 20 min Gryzhesechenie. In lay plastic p is DIPROPYLENE implant. Under endotracheal anesthesia two bordering incision with excision of the scar and highlighted the hernia SAC. Gryzenia gate length 15 cm, width 10 cm Peritoneum tsepilova from the deep leaf of the aponeurosis of the rectus abdominis muscle. Preperitoneal under the aponeurosis of the fixed polypropylene mesh implant, and circumferentially wound in a space formed at a distance of 3 cm from the edges of the wound installed catheter having throughout many holes for local anesthesia. The cannula (outer hole) was taken on the anterior abdominal wall. The catheter was fixed to the implants, absorbable suture material. The edges of the aponeurosis stitched interrupted sutures. Layered seams on the wound. Aseptic bandage.

Postoperative diagnosis: Large postoperative ventral hernia.

In the postoperative period through the cannula (the inlet of the catheter) has been extended local analgesia of 2.5% Rasbora of ropivacaine 20,0 ml every 6 hours using a metering device injection of anesthetic for 2 days. The postoperative period was uneventful and smooth. The patient received a complex pathogenetic therapy. The patient in the postoperative period did not complain of pain, analgesic effect was achieved. Paresis of the intestine was resolved in 2 days.

Postoperative wound healed PE the primary tension. In a satisfactory condition, the patient was discharged 9.10.2012 under the supervision of the surgeon on a residence.

Thus, the proposed method preperitoneal blockade in the postoperative period provides uniform distribution of local anesthetic into the preperitoneal tissue, and thereby achieve adequate postoperative pain, fewer postoperative complications, reduces postoperative paresis of the intestine that leads to early activation of the patient and away from the use of narcotic analgesics.

We have conducted a study that analyzed the results of surgical treatment of 77 patients with large and giant postoperative hernias. Patients, depending on the method of anesthesia were divided into two groups. In the comparison group (first) used traditional clinic methods. In the main group was tested our method of postoperative pain management. In our work, we have applied all three fixation of the endoprosthesis for a plastic closure of the hernia gate: onlay, inlay, sablay.

In both groups to assess the intensity of pain used a numerical rating scale Numerical rating scale (NRS). NRS consists of 11 points from 0 (no pain) to 10 (most severe pain you can imagine).

<> In the main group consisted of 26 (34%) patients, which aimed prolonged local analgesia and prevention of wound complications, have established a PVC catheter in preperitoneal tissue, around the circumference of the wound over the implant. Through the dispenser is prolonged controlled irrigation of the wound of 2.5% solution of ropivacaine: 20 ml every 6-8 hours for 2-3 days.

The comparison group consisted of 51 (66%) patients, which for pain were prescribed non-steroidal anti-inflammatory drugs and narcotic analgesics.

The criterion for the effectiveness of the analgesia was the intensity of the pain syndrome, expressed in points on the NRS. Observations showed that the average level of pain in patients of the main group was 3,81±0.40 points. The level of pain in the comparison group - 5,3±0.40 points.

As shown by the research results, preperitoneal irrigation ropivacaine with saline solution provides adequate postoperative analgesia, reduces the number of postoperative complications, shortens hospital stay, and refusal to narcotic analgesics reduces the paresis of the intestine, and consequently the risk of developing syndrome of abdominal compression.

The way preperitoneal blockade after protesilaus of hernioplasty the median postoperative ventral hernias, including the introduction of local anesthetics into the preperitoneal space via a catheter, characterized in that after installation under the aponeurosis of the endoprosthesis in the space formed around the circumference of the surgical wound in the form of an oval above the plane of the endoprosthesis install a PVC catheter at a distance of 2.5-3 cm from its edges with throughout multiple side holes, with the projection of the lower angle of the wound on both sides perform a separate punctures and output ends of the catheter to the skin, the inlet of the catheter is attached to the metering device injection of local anesthetic through the cannula and carried out a controlled prolonged irrigation of 2.5% solution of ropivacaine 20 ml every 6-8 hours for 2-3 days.



 

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1 tbl, 1 dwg, 3 ex

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to anaesthesiology, and may be used as an anaesthesia care of a surgical intervention for carotid endaterectomy or internal carotid artery resection after pathological deformation thereof. That is ensured by general anaesthesia in a combination with deep and superficial cervical plexus blockade. Pre-medication is used the day before the operation and on the operative day in the morning. Diazepam is introduced intramuscularly 30 minutes before the operation in a combination with phentanyl; the introduction is followed by ECG monitoring and heart rate count, plethysmography with arterial blood saturation, non-invasive blood pressure measurement and neuromonitring according to a bispectral index or entropy. Catheterisation of patient's peripheral or central vein is followed by an infusion therapy, an ionotropic therapy, a cardiotropic therapy, peripheral resistance maintenance. If heart rate is no more than 80 beats per minute, the anaesthesia is induced to reach an anaesthetic depth according to the bispectral index or entropy within 40-60 units. Analgesia is provided by the intravenous introduction of 0.005% phentanyl; myoplegia is ensured by the intravenous introduction of a myorelaxant. After tracheal intubation, the patient is transferred to forced volumentic artificial pulmonary ventilation with the CO2 level within 35-45 mm Hg according to capnography. The anaesthesia is maintained by supplying an inhalation anaesthetic to the steam level of 0.8-1.0 MAK 0.8-0.9 litre of the air and oxygen flow containing 50% oxygen with controlling the inhalation anaesthetic volume by the level of the anaesthetic depth according to the bispectral index or entropy. That is followed by deep cervical plexus blockade. A tubercle of the VI cervical vertebra (a carotid tubercle) and a mastoid process are localised; thereafter a line connecting the above reference points is drawn on skin. The second line is drawn 1 cm below the first one in parallel. To verify an injection point of a local anaesthetic, the spines of IV, III, II cervical vertebras being at 1.5 cm from each other are palpated, and the reference point is the VI cervical vertebra. The needle is inserted perpendicularly to the skin and slightly in the caudal direction to reach the spines. The anaesthetic is introduced in a dose of 5-7 ml in each point C4, C3, C2. Another 5-7 ml of the anaesthetic is introduced in a point found in an apex of the mastoid process. The superficial cervical plexus blockade requires introducing he fan-shaped introduction of the anaesthetic solution in a dose of 15 ml in a point found in the middle of a lateral crus of the nodding muscle under the above muscle, 4-5 ml in each direction from the same point; the first and following injections are performed at a depth of a usual intramuscular needle perpendicularly to nodding muscle.

EFFECT: method provides the adequate and safe anaesthesia ensured by avoiding linear blood velocity reduction in the medial cerebral artery during the surgical intervention, preventing intracranial pressure increase, reducing cerebral perfusion pressure in a combination with providing adequate protection against surgical invasion with maintaining stroke volume and arterial pressure.

4 cl, 3 ex

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EFFECT: method provides the complete prevention of developing postoperative pain syndrome ensured by the intravenous introduction of the NSAIC at the specific stages of anaesthesia in certain doses.

1 tbl, 5 ex

FIELD: medicine.

SUBSTANCE: what is involved is infusion therapy with crystalloid solutions at 15 ml/kg of a patient's body weight. That is followed by puncturing and catheterising an epidural space at the level of ThVII-ThVIII according to the standard practice and introducing a test dose of 2% lidocaine 3 ml. If observing no signs of intrathecal introduction of local anaesthetics 10 minutes later, a basic dose containing 0.75-1% naropin 10 ml or 0.25-0.5% marcaine 10 ml and clofelin 3-5 mcg/kg is introduced. Total intravenous anaesthesia follows 20 minutes after pre-medication with atropine 0.01 mg/kg, 1% diphenylhydramine 1 ml and relanium 10 mg and urethral catheterisation. A narcosis is induced with propofol in a dose of 2 mg/kg. Anaesthesia is maintained with propofol 2-4 mg/kg·h. After that, within the first hour following the detoxification, naloxone 12 mg is introduced intravenously; a naloxone measurement rate is supposed to make 0.8 mg/h for 4-5 following hours of general anaesthesia. The repeated introduction of 0.75-1% naropin 6 ml or 0.25-0.5% marcaine 6 ml and clofelin 2-3 mcg/kg into the epidural space is performed 90 minutes later. After the procedure is terminated, and the patient recovers, prolonged epidural analgesia is conducted by introducing 0.2% naropin 10 ml and clofelin 1 mcg/kg into the epidural space every 4 hours for 24-48 hours.

EFFECT: method provides safety of ultrafast opioid detoxification and prolongs the remission in the given category of patients.

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