The European Clinic of Surgery and Oncology treats severely ill patients with somatic and cancer diseases. Each patient receives the best medical care at the level of Western standards, and even if the problem cannot be radically solved, everything possible is done to improve the person’s well-being and prolong his life.
One of the serious complications of many diseases is ascites, which is sometimes very resistant to conservative treatment and in this case it is necessary to resort to invasive manipulations.
Ascites provokes severe respiratory failure and pain in the abdominal cavity and, therefore, needs to be eliminated.
Doctors at the European Clinic have mastered the most modern methods of treating ascites, and people admitted here can count on rapid normalization of their condition not only in relation to the underlying disease, but in all existing complications.
Ascites formation
A small amount of fluid is contained in the abdominal cavity of a healthy person, but it is constantly removed through the lymphatic vascular system. If the volume of ascites does not exceed 500 ml, then it is not subjectively felt at all. In a number of diseases, its production is so intense that the amount of liquid can exceed 10 liters. Then they talk about tense ascites.
Such ascites can form in heart failure when the heart has difficulty pumping the available volume of blood, for example, against the background of post-infarction cardiosclerosis or myocarditis.
In this situation, the emphasis in treatment is on stimulating myocardial function through cardiac glycosides and reducing venous return, which is possible when prescribing nitrates, diuretics, ACE inhibitors, etc.
Portal hypertension caused by liver cirrhosis inevitably leads to ascites. The liver stroma degenerates, connective tissue growths appear in it, and this leads to disruption in the portal vein system. Preference is given to treatment of the underlying disease and puncture of the abdominal cavity is performed, diuretics are given under the control of blood pressure.
Sometimes kidney disorders can also provoke ascites. The main mechanism of development in this case is associated with protein loss and changes in oncotic pressure in the bloodstream. Renal pathology should be treated.
Peritoneal carcinomatosis and other types of cancer in the abdominal cavity can provoke the formation of effusion, sometimes reaching very significant volumes.
Conservative therapy only provides a slowdown of the process and temporary relief. To get rid of cancer, surgery is required, and if the patient is not operable, then a puncture is made in the abdominal wall to remove the resulting fluid.
In addition to surgery, the oncological process can be influenced by radioirradiation and chemotherapy.
Invasive methods for treating ascites
Abdominal puncture is usually performed when there is a large accumulation of ascitic fluid. The process is usually carried out in a treatment room. It is performed by the attending physician and assisted by a nurse.
A puncture of the anterior abdominal wall is not performed in the case of severe adhesions, intestinal bloating, injuries and purulent-inflammatory reactions in the abdominal cavity. The manipulation itself is performed using a metal trocar, which consists of a stylet and a tube with a valve.
There are many different designs of such equipment, but the basic idea is that the stylet is inserted into the tube, and after penetration into the abdominal cavity, the stylet is removed and the proximal exit of the tube communicates with the abdominal cavity.
The area of the intended puncture is first infiltrated with 1% novocaine or 2% lidocaine. After the anesthesia has taken effect, a small incision is made in the skin and subcutaneous aponeurosis 2-3 cm below the navel. Then a trocar is installed in this place and a puncture is made in the anterior abdominal wall.
When the stylet reaches the abdominal cavity, it is removed and the tube is moved forward another 2-3 cm so that during the procedure it does not rest against soft tissue.
After this, the valve on the tube is opened and the ascitic fluid is drained. Part of it is sent to laboratories for cytological analysis of the sediment. The process of releasing the liquid itself is carried out very carefully and slowly.
In case of large ascites, no more than one liter is removed in 5 minutes, so as not to cause severe decompression of the intra-abdominal vessels and loss of consciousness.
Simultaneously with the release of ascitic contents, the physician's assistant compresses the abdomen from the outside with a long towel in order to compensate for the loss of intra-abdominal pressure.
The patient (if well-being allows) carries out the entire procedure in a sitting position, leaning slightly forward, which makes it possible to more effectively remove the contents. In this case, the assistant can support him from behind by the shoulders or with the help of a stretched towel.
Possible complications of laparocentesis
Air should not be allowed to be sucked into the abdominal cavity, as this provokes mediastinal emphysema, in which gas infiltrates the tissue in the abdominal and thoracic cavity.
Another complication of this procedure is trauma to blood vessels of various sizes, intestinal damage, peritonitis, and phlegmon of the abdominal wall.
If the patient cannot sit, the puncture is performed in the supine or lateral position.
It is prohibited to remove more than 10 liters of liquid in one procedure.
Laparocentesis is not always effective and is often done under ultrasound control. Sometimes, with rapid re-formation of ascitic fluid, a drain is installed, which is connected to the proximal trocar tube and the fluid may continue to come out for some time.
There is a clamp on the drainage that prevents air from being sucked in when the liquid is not poured out.
The drainage is 25 cm long and runs in the side canal of the abdominal cavity, descending into the pelvis, which allows the maximum volume of ascitic discharge to be removed.
Application of the Redon system for ascites
In the West, they use the so-called Redon system, which, in essence, is also a drainage with an adjustable valve for the release of liquid.
The purpose of such a system is to help patients with persistent formation of ascitic fluid due to inoperable cancer that produces effusion.
Installing drainage is technically similar to performing a puncture. An incision is also made in the abdomen and a puncture of the anterior abdominal wall under ultrasound guidance.
Then the plastic drainage itself is installed, the outer end of which is fixed to the skin with sutures and adhesive tape. At the outer cutaneous end there is a tap that allows you to drain fluid and close it when there is no fluid - to seal the abdominal cavity.
Aspiration of ascites during surgery
The invention relates to medicine, surgery, and can be used in the surgical treatment of peritonitis. Fluid formations of the abdominal cavity are drained in the dorsoventral direction.
A through drainage tube is passed through counter-apertures along the midline of the abdomen 2-3 cm below the xiphoid process and 2-3 cm above the symphysis pubis. The patient is placed in the prone position in the postoperative period. The method allows you to effectively drain the abdominal cavity during peritonitis. 1 ill.
The invention relates to medicine, namely to surgery, and can be used in the treatment of peritonitis.
Treatment of peritonitis continues to be a serious problem for practical medicine, accompanied by the development of a large number of complications in the postoperative period, reaching from 13.5 to 41.3% (Sazhin V.P. et al. Laparostomy in the complex treatment of widespread peritonitis. - Kuban Scientific Medical Bulletin , 1998, 1-2, p. 29), and high mortality. According to a number of authors, it reaches 60-90% (Shalimov A.A. et al. Acute peritonitis. Kiev: Naukova Dumka, 1981, p. 287; Grinev M.V. et al. Some mechanisms of development of toxic-septic shock in peritonitis - Abstract of the 8th All-Russian Congress of Surgeons (Krasnodar, 1995, p. 582).
It is generally accepted in the treatment of peritonitis to perform surgical intervention, usually by midline laparotomy (Skripnichenko D.F. Emergency abdominal surgery. Kyiv: Health, 1986, p. 287). During the operation, the following is performed: elimination of the source of peritonitis, sanitation of the abdominal cavity, decompression of the gastrointestinal tract, drainage of the abdominal cavity.
There are many known methods of draining the abdominal cavity using gauze, rubber, tubular drainages, and methods of combined use of drainage devices. Drainage is carried out in order to create favorable conditions for the outflow of pathological exudate with high microbial contamination from the abdominal cavity (Kazansky V.I. Diseases of the peritoneum. - Manual of surgery edited by Petrovsky B.V., 1960, v. 7, p. 689; Shaposhnikov V.I. Etiopathogenetic treatment of acute peritonitis. Temryuk, 1991, p. 59). However, all analogues of abdominal cavity drainage are not fundamentally different from each other and do not provide adequate outflow of pathological fluid formations (Savelyev V.S. et al. Perfusion and infusion in the treatment of purulent peritonitis. - Surgery, 1974, N 4, p. 3- 9), lead to the progression of peritonitis, the development of complications and force one to resort to relaparotomy in 4.9-6.1% of cases after operations for peritonitis (Sazhin V.P. et al. Laparostomy in the complex treatment of widespread peritonitis. - Kuban Scientific Medical Bulletin, 1998, N 1-2, p.26). Various modifications of drainage - batch, fan, membrane drainage (Nesterov M.A. et al., 1989; Nifantiev et al., 1989), methods of active aspiration, flow-flushing drainage - have not solved the problem of adequate outflow.
There is a known method of drainage of the abdominal cavity, carried out during surgery after eliminating the source of inflammation and sanitizing the abdominal cavity. The abdominal cavity is drained with 4 glove-tubular drainages through punctures in both hypochondrium and iliopsoas regions. The ends of the tubes are installed in the subhepatic, subphrenic space, and pelvic cavity. Active aspiration of exudate from the abdominal cavity is possible in combination with the introduction of antibiotics and antiseptics into it (Skripnichenko D. F. Emergency surgery of the abdominal cavity. Kyiv: Health, 1986, p. 288). This method of drainage of the abdominal cavity during peritonitis is adopted as a prototype. The position of the installed drains is shown in the drawing.
The disadvantage of this method of draining the abdominal cavity during peritonitis is the insufficient effectiveness of the drainage devices used in the postoperative period. These drainages partially remove pathological exudate from the abdominal cavity and contribute to the formation of residual cavities in the abdominal cavity.
The anatomical features of the structure of the abdominal cavity, the attachment of the intestinal mesentery, the location and orientation of the ligaments of the abdominal cavity, the spatial orientation of the pockets and inversions of the peritoneum and its bursae in the classic position of the patient on the back do not allow adequate drainage of pathological exudate from all cavities formed by the peritoneum by installing drains using the method prototype. The lack of drainage of the abdominal cavity in case of peritonitis using this method is also confirmed by the fact that the development of new methods of treating peritonitis continues in order to provide adequate drainage of the abdominal cavity. Methods for the treatment of peritonitis are being improved by performing planned or programmed laparotomies (Gostishchev V.K. et al. Laparostomy for widespread peritonitis. - Bulletin of Surgery, 1991, No. 2, p.; Marchenko N.V. Method of repeated revisions of the abdominal cavity in the treatment of diffuse purulent peritonitis. - Dissertation of Candidate of Medical Sciences. Krasnodar, 1995).
The objectives of the invention are to improve the results of treatment of peritonitis: reducing the number of postoperative complications, reducing the number of repeated surgical interventions and postoperative mortality.
The essence of the invention is to perform drainage of the abdominal cavity through contra-apertures along the midline of the abdomen with a through silicone tube passed through points located 2-3 cm below the xiphoid process and 2-3 cm above the symphysis pubis, and treatment in the postoperative period is carried out in the patient's position on the stomach. Previously, this method of inserting a drainage tube for the purpose of draining the entire abdominal cavity was considered as anatomically unfavorable, since it was performed at the most anterior point of the peritoneal cavity and did not provide adequate and effective drainage (with the patient in the supine position, these points are the highest). The drainage tube was placed along the linea alba of the abdomen between the intestinal loops and omentum on one side and the parietal peritoneum on the other due to the fact that in the postoperative period the patient is given a position that adequately drains fluid accumulations of the abdominal cavity in the dorsoventral direction. In combination with this sign, it is justified to place a drainage tube along the white line of the abdomen. In the prone position, the anterior abdominal wall will have the shape of a flat boat, the edges of which are represented by the peritoneum in the projection of the rectus abdominis muscles, and the projection of the linea alba will correspond to the lowest points of the abdominal cavity.
The abdominal cavity is the largest of the internal body cavities and is a coelomic body cavity. The abdominal cavity is lined from the inside with a serous membrane - the peritoneum. The parietal layer of the peritoneum, lining the walls of the abdomen from the inside, forms a number of folds, various depressions and protrusions. The visceral peritoneum, covering the internal organs, has a different relationship to these organs. In some cases, the peritoneum lines the organ completely with the formation of the mesentery, in others - on three sides, in others - only in front. The mesenteries of the small and large intestines are attached to the posterior wall of the abdominal cavity. Within the upper floor of the abdominal cavity there are 7 pockets formed by the peritoneum: the blind sac of the spleen, the superior eversion of the omental bursa, the cardial pocket of the cavity of the lesser omentum, the splenic eversion, the duodenosplenic eversion, the gastro-pancreatic eversion, the inferior eversion of the omental bursa. In the lower floor of the abdominal cavity there are 6 pockets, or inversions: intersigmoid inversion, duodenojejunal inversion, superior ileocecal pouch, inferior ileocecal pouch, retrocecal pouch or fossa, paracolic inversions. In the abdominal cavity, the following bursae are distinguished: omental, right hepatic, left hepatic, pancreas; two mesenteric sinuses - right and left. There are two canals in the abdominal cavity - right and left (Frauchi V.H. Topographic anatomy and operative surgery of the abdomen and pelvis. Kazan, 1966, p. 80-105).
Under pathological conditions, all the described pockets, bags, channels formed by the peritoneum, all sloping areas of the abdominal cavity can be a container for the accumulation of various exudates. The drainage methods used do not allow, due to the peculiarities of the anatomical structure of the peritoneal formations, to completely evacuate the pathological exudate. Conducted studies on the bodies of the deceased by staining the abdominal cavity with a dye, followed by removal of the dye with various drainage devices currently used, made it possible to confirm the data on the impossibility of removing exudate from the abdominal cavity in the traditional position of the human body on the back, even if drainage was carried out through a counter-aperture in the very at the dorsal point of the abdominal canals, which is rare in practice, as it involves drainage through the powerful muscle mass of the back and lumbar regions. Active aspiration also turned out to be ineffective. Thus, 9 pockets out of 13 existing ones, 2 bursae out of 4 existing ones, the right mesenteric sinus, partially the right and left lateral canals, and the pelvic cavity are practically not drained. The intermesenteric spaces of the small intestine are not drained, which leads to the frequent development of interloop abscesses. Conducted studies involving painting the abdominal cavity with dye and then placing the human body (the studies were carried out on the bodies of the dead) in a prone position made it possible to show that the lowest point of the abdominal cavity in this position is a segment in the projection of the white line of the abdomen 2-3 cm below the xiphoid process sternum and 2-3 cm above the symphysis pubis. This was the reason for choosing the location for counter-apertures for subsequent drainage of the abdominal cavity. The studies made it possible to confirm the anatomical data on the complete drainage of fluid accumulations of the abdominal cavity in the dorso-ventral direction in the proposed drainage position from all anatomical formations of the peritoneum, with the exception of the cavity of the omental bursa. It should be noted that in the latter, during peritonitis, accumulation of exudate is rarely observed, however, drainage of the omental bursa, if necessary, is possible by conducting additional drainage through the hole in the gastrocolic ligament.
In practice, the method is carried out as follows. After eliminating the source of peritonitis, thorough sanitation of the abdominal cavity and performing any other manipulations (intestinal intubation, enterostomy, catheterization of the retroperitoneal space, etc.), a silicone drainage tube is placed for flow-through drainage along the midline of the abdomen in the projection of the laparotomy incision. The drainage tube is passed through contra-openings along the midline of the abdomen above and below the laparotomy wound so that it is located between the loops of the small intestine and the greater omentum on one side and the parietal peritoneum on the other side. When the patient is positioned on his stomach, the drainage tube, occupying a lower position than the intestinal loops, does not put pressure on them and practically eliminates the formation of bedsores. This allows you to significantly extend the period of its stay in the abdominal cavity. The drainage itself should be a single-lumen silicone tube with an internal diameter of 8-10 mm with walls of sufficient thickness (at least 1.5 mm) to prevent it from sticking in cases where active aspiration is used. The side holes are placed at a distance of mm from each other along the entire length of the part of the tube located in the abdominal cavity. The diameter of the side holes is at least 5 mm. This allows purulent exudate with a significant amount of fibrin to be evacuated from the abdominal cavity. If necessary, in particular for draining encysted cavities, drainage can be performed with additional drainage tubes. The drainage is fixed to the skin of the abdomen. If necessary, in order to enhance the effect of drainage of liquid formations along the perimeter of the drainage tubes, it is possible to install glove drainages. Subsequently, the patient is placed on a specially designed bed in a prone position. In this position, further treatment is carried out. To carry out dressings and other procedures, it is permissible to turn the patient onto his back for a short time. The criterion for transferring the patient to the traditional “on his back” position for further treatment is the relief of peritonitis.
Clinical testing of the proposed method of drainage of the abdominal cavity was carried out on 23 patients with diffuse peritonitis at the Department of General Surgery of the Kuban Medical Academy in the Department of Purulent Surgery of the Regional Clinical Hospital of the Krasnodar Territory.
Examples: B. B., 36 years old, IB 17299, transferred from the Crimean Central District Hospital of the Krasnodar Territory to the purulent surgery department of the Regional Clinical Hospital, where he was treated since 05.09. to 09.23.99, with a diagnosis of widespread fibrinous-purulent peritonitis after a penetrating stab wound of the abdominal cavity with injury to the colon. 07.09. due to suspicion of failure of the sutured wound of the colon, a relaparotomy was performed. An accumulation of purulent exudate was found in the flanks of the abdomen, under the liver, in the area of the spleen, between the loops of the small intestine and in the pelvis. No leakage of the colon sutures was detected. Sanitation of the abdominal cavity using ultrasonic cavitation and drainage of the abdominal cavity with a single-lumen silicone tube placed between the loops of the small intestine, the greater omentum and the anterior abdominal wall strictly in the projection of the white line of the abdomen were used. The ends of the drainage tube are brought outside the laparotomy wound under the xiphoid process of the sternum and above the pubis, 2 cm from the latter. The laparotomy wound is sutured with removable aponeurotic sutures. Rare wide-section interrupted sutures are applied to the skin. The patient was transferred to the intensive care unit for further treatment, where he was placed in a prone position on a special mattress. Constant aspiration from the drainage tube was established with periodic washing of the drainage with antiseptic solutions.
In the postoperative period, treatment was carried out with the patient in the prone position for the first 5 days. Dressings were carried out with the patient in the lateral position. The complex treatment of peritonitis included intensive infusion therapy, detoxification therapy, polyantibiotic therapy, immunotherapy, stimulation of intestinal motility, and analgesic therapy. On the third day after surgery, the patient underwent plasmapheresis. During the first two days, the amount of discharge from the abdominal cavity, excluding administered antiseptics, reached 500 ml per day. On the third day, the amount of discharge decreased to 200 ml, and by the end of the fifth day it stopped. On the third day, intestinal peristalsis appeared, on the fourth day there was independent stool. On day 5, the patient was transferred to the “supine” position. The further postoperative period proceeded smoothly. Tubular drainage was removed on the 6th day. The sutures were removed on the 14th day due to the fact that the wound was sutured with removable aponeurotic sutures. Healing by primary intention. The patient was discharged for outpatient treatment on the 16th day after surgery in satisfactory condition.
B-y R., 31 years old, IB 17299, July 25, 1999, was hospitalized at the Belorechensk Central District Hospital with a diagnosis of acute pancreatitis. He was treated conservatively. On August 25, 1999, due to deterioration of his condition, he was transferred to the Regional Clinical Hospital of the Krasnodar Territory. Due to the presence of purulent pancreatitis and diffuse purulent fibrinous peritonitis in the patient, an operation was performed according to emergency indications: median laparotomy, sequestration and necrectomy of the pancreas, sanitation of the omental bursa and abdominal cavity. The operation ended with the imposition of a bursoomentopancreatostomy in the left hypochondrium and the passage of a through silicone single-lumen drainage tube through counter-apertures outside the laparotomy wound along the white line of the abdomen, made 3 cm below the xiphoid process of the sternum and 3 cm above the symphysis pubis. The drainage tube is placed between the intestinal loops and the omentum on one side and the parietal peritoneum on the other. The laparotomy wound is sutured with removable aponeurotic sutures. Rare wide-section interrupted sutures are applied to the skin.
In the postoperative period, the patient was placed in the prone position on a special mattress, complex multicomponent therapy, flow-through drainage with active aspiration from the abdominal cavity were performed. Treatment in the drainage position was carried out for 6 days, dressings were carried out with the patient turning on his side. During the therapy, the symptoms of peritonitis stopped on the 6th day. The abdominal drainage was removed on the 7th day, and the patient was transferred for further treatment to the traditional “supine” position. The further postoperative period proceeded smoothly. The patient did not require relaparotomy. The sutures were removed on the 14th day, healing by primary intention. Subsequently, treatment was carried out aimed at drainage and sanitation during ligation of the bursoomentopancreatostomy. The discharge of small sequestra of the pancreas and the drainage of scanty serous-purulent discharge from the omental bursa were observed for four weeks after surgery. The drainage of the omental bursa was changed and its cavity was washed. The wound in the area of bursoomentopancreatostomy healed by secondary intention. The patient was discharged in satisfactory condition for outpatient follow-up treatment on the 35th day after surgery.
The clinical results of using this method are regarded as satisfactory, which is supported by the successful use of the method for the treatment of 23 patients with general peritonitis.
The medical and social significance of the invention is to develop a method that adequately drains the abdominal cavity during peritonitis and allows to reduce the number of postoperative complications, repeated surgical interventions and reduce postoperative mortality.
A method for draining the abdominal cavity during peritonitis, characterized in that to ensure drainage of fluid formations in the dorso-ventral direction, a through drainage tube is passed through counter-openings along the midline of the abdomen 2-3 cm below the xiphoid process and 2-3 cm above the symphysis pubis, and In the postoperative period, the patient is placed in the prone position.
Abdominal drainage
In case of destructive appendicitis with peritonitis, peritonitis, intestinal resections due to obstruction, as a rule, drainage of the abdominal cavity is performed. In order for the postoperative wound to heal without complications, drainage is carried out not through it, but through an additional incision next to the surgical wound. In severe forms of peritonitis, sometimes four drains are inserted into the abdominal cavity (into the right and left hypochondrium and from the left and right iliac regions to the pelvic floor). Upper drainages are used to administer antibiotic solutions or rinse the abdominal cavity on the first day after surgery; the lower ones are also for administering antibiotic solutions and for removing fluid accumulating in the pelvis. With any drainage method, never tie up the drains or leave them in bandages. Drains should be connected to containers that are located below the patient in order to create a slight negative pressure, facilitating better evacuation of fluid from the abdominal cavity. Drains with a diameter of 0.5-0.7 cm drain the contents of the abdominal cavity worse than drains with an internal diameter of 0.3-0.4 cm. The most common drainage tubes are made of rubber. However, as experience has shown, they quickly stop functioning, since foreign bodies are delimited by fibrin, adhesions, intestinal loops and omentum. In the last decade, drainage tubes made of synthetic materials (polyethylene, polyvinyl chloride) have become widespread, through which the outflow of fluid from the abdominal cavity can continue for 4-6 days. When draining the abdominal cavity in newborns, 1-2 side holes are cut out at the end of the tube; in older children, up to 5-7 side holes are cut out.
Currently, another method of drainage of the abdominal cavity has been proposed, which is called “aspiration” [Generalov A.I. et al., 1979]. In this method, a continuous polyvinyl chloride catheter, only about 1-1.5 m long, is inserted as usual through a separate incision approximately 1.5-2 cm medial to the superior iliac spine. The abdominal wall is punctured in an oblique direction so that the catheter does not bend. The end of the catheter with additional side holes is placed on the pelvic floor. The catheter should be in contact with the inner surface of the ilium. From the outside, it is more correct to fix it with 2-3 strips of adhesive tape towards the armpit. To prevent the catheter from moving, a tight-fitting sleeve is threaded onto it, which is fixed to the skin with a provisional suture at the point where the catheter enters the abdominal wall. Next, with a short tube, the catheter is increased to one of a similar diameter and lowered into a container located 60-70 cm below the patient’s level.
If the catheter is placed correctly and functions well, it can be used to remove fluid from the abdominal cavity during flow-through lavage.
The responsibilities of the nurse for any form of abdominal drainage include careful monitoring of the function of the drains. This is very important for the occurrence of postoperative complications. If the drains do not function well enough, then fluid accumulates in the abdominal cavity, which, when infected, is the basis for the development of interloop, subdiaphragmatic, subhepatic abscesses and pelvic abscess. At the same time, fluid in the abdominal cavity can lead to divergence of the edges of the surgical wound. If the fluid does not drain through the drainage on the first day after surgery, it means that it is either bent or clogged with fibrin. The nature of the fluid flowing through the drainage (transparent, cloudy, mixed with blood, purulent) is of great importance for determining further treatment.
2. Surgery for widespread peritonitis:
Access is always a median laparotomy, which provides the possibility of a full inspection and sanitation of all parts of the abdominal cavity. If the cause of peritonitis is unclear, a midline laparotomy is usually used, and then during surgery, depending on the finding, the access is increased upward or downward.
Elimination of the source of peritonitis - removal of the inflamed organ (for example: h/application, gallbladder), or suturing of the injury (rupture of the intestine, bladder)
Sanitation and toilet of the abdominal cavity. Once upon a time, aggressive antiseptics were used for these purposes (sublimate, washing powder, etc.); the surgeon’s actions themselves were rough (cleaning the peritoneum and stripping off fibrin with hard brushes). This approach led to damage to the mesothelium and only aggravated the course of peritonitis. Currently, gentle methods are used - the abdominal cavity is washed with a large amount of warm isotonic solution “to clean water”, but effusion and fibrin are removed only gently without damaging the peritoneum.
Drainage of the abdominal cavity. For these purposes, up to 1 additional drainage can be used. So, in case of gangrenous appendicitis with local peritonitis, one “cigar” drainage is usually installed in the right iliac region. In case of diffuse purulent peritonitis, drainage can be simultaneously installed in: the right and left subdiaphragmatic spaces, in the pelvis, along the right and left lateral canals.
Tubes with side holes can be used as drainage, but during peritonitis the tubes quickly become clogged with fibrin clots or become “pasted” with internal organs. As a result, tubular drainage often stops functioning 1-2 days after surgery.
“Cigar drainage” or rubber-gauze drainage is a structure made of gauze and glove rubber up to 15 cm long. The drainage can be made even during surgery. A surgical glove is taken, the fingers are cut off, and the remaining rubber cylinder is cut along its length. A gauze cloth of the same size is placed on the resulting rubber plate measuring 15 by 10 cm, then they are rolled into a “roll”. The resulting cylinder is the cigar drain, which is installed through an opening into the abdominal cavity for its drainage.
“Cigar drainage” through the middle of which a tubular drainage is installed is a type of conventional rubber-gauze drainage. Used for large amounts of liquid effusion, bile, and blood.
Fascine drainage is nothing more than a bundle (in Latin - fascine) of tubes connected to each other and installed in the abdominal cavity. Currently forgotten and rarely used.
Cigar drains are tightened after 3-4 days and removed after 5-6 days. If necessary, new drains are installed in their place under anesthesia.
For a long time, peritoneal dialysis or abdominal lavage was used to treat advanced forms of peritonitis. Its essence is that 4 tubes were installed in the abdominal cavity (2 from above and 2 from below), and the abdominal cavity was sutured. In the postoperative period, liquid (dialysate), usually an isotonic solution with the addition of antibiotics, was drip-fed through the upper tubes. The fluid washed the abdominal cavity and flowed out through the lower tubes; up to 10 liters of dialysate per day were used. Currently, the method is not used, as it has significant disadvantages: the liquid moves through certain channels, and large spaces where the intestinal loops stick together are not washed; There is still a loss of a very large amount of protein, etc. Therefore, today, to treat advanced forms (toxic and terminal stages) of peritonitis, “open methods of managing the abdominal cavity” are used, these include:
Permanent rehabilitation (term: permanent – continuing continuously). Other names: method of planned or program relaparotomy, “program relaparotomy”. The essence of the method is as follows: after eliminating the source of peritonitis and washing the abdominal cavity, the wound is sutured “tightly” without leaving drainage, but suturing is done so that the abdominal cavity can be easily opened again. For these purposes, thick long ligatures are usually used with which the anterior abdominal wall is stitched through all layers and tied with “bows”. After a day, the patient is again taken to the operating room, the sutures are unraveled and the abdominal cavity is again subjected to sanitation, fibrinous adhesions are destroyed, effusion is removed and fibrin is removed, the abdominal cavity washed with a solution of a weak antiseptic. The seams are then tied. The procedure is repeated again after 1-2 days, usually 2-3 relaparotomies are performed. At a certain period, special devices called “ventrophiles” were used for these purposes. These plastic devices with holes and hooks were sewn to the edges of the laparotomy wound and then tightened with Mylar ligatures. Less commonly, fasteners such as “zipper” and “burdock” (Velcro) are used with their fixation with a continuous lavsan suture to the edges of the aponeurosis, less often - to the skin edges of the wound. But nowadays complex devices are practically not used due to purulent complications.
Laparostomy, or open laparostomy, the most radical method of managing peritonitis, consists in the fact that the median wound on the anterior abdominal wall does not close at all at the end of the operation. The edges of the wound are brought together with sutures to prevent the insides from falling out and are covered with a sheet of polyethylene with a large number of holes for the outflow of pus from the abdomen; gauze is placed on top of the polyethylene, which is changed during dressings.
The method is used only in the most severe cases; the indication for laparostomy may be the impossibility of suturing the abdominal wall due to phlegmon, purulent melting of the edges of the wound, severe intestinal paresis, or when it is not possible to completely remove the purulent focus from the abdominal cavity.
P.S. It should be noted that in the literature there are a large number of different terms denoting open methods of treating peritonitis, sometimes they replace each other. For example, the term “Laparostomy” can refer to all known methods of open abdominal cavity management.
In addition, in patients with severe paresis of the gastrointestinal tract, there is often a need to unload the intestines directly on the operating table in the form of intestinal stomas and intubation of the intestines with special intestinal probes.
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Peritoneal drainage is
The problem of drainage is most pressing in abdominal surgery. This is due, firstly, to the complex architectonics of the abdominal organs, secondly, the currently available drainages have a limited period of use, and thirdly, the question remains relevant regarding methods of drainage of the abdominal cavity
The problem of drainage of the abdominal cavity is especially obvious in the treatment of the “evil genius of abdominal surgery” – peritonitis. This is due to an increase in the number of patients and a high percentage of postoperative mortality. Unfortunately, surgery has not yet developed criteria that determine the appropriateness of a particular method and indications for drainage in a specific clinical situation.
Tubular drainage is currently most commonly used. When using tubular drainages, the reactogenic properties of drainages – the reaction of the interaction of the peritoneum with the drainage – are of great importance. The use of rubber, Teflon, polyvinyl chloride, polyethylene tubes often leads to an inflammatory reaction, their rapid obstruction with fibrin, irritation of surrounding tissues, with the formation of both aseptic inflammation and the formation of adhesions and abscesses.
Of great importance in the treatment of peritonitis is the timing of drainage functioning. This is primarily determined by the duration of the disease, the need for long-term drainage function and the ability of drainage to resist bacterial contamination, as well as the cause of peritonitis. The most unfavorable in this regard are rubber drainages, which function from 6 to 48 hours. Drains made of polyvinyl chloride retain their function for up to 7 days. The most effective are fluoroplastic tubes with silicone, the effect of which lasts up to 17 days)
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