RU2279255C1 - Method for surgical treatment of vast lesions in extraperitoneal rectal section accompanied with post-traumatic osteomyelitis of pelvic bones - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: it is necessary to conduct repeated surgical treatment of wound focus, form osseous-muscular or muscular transplant of soft femoral muscle or gluteus maximus muscle, direct the transplant towards rectal and sacral defect, remove defect with the help of guide sutures, tampon rectal and sacral defect edges with a replaced transplant, suture up the transplant towards sacral periostium and rectal defect edges, suture in the wound hermetically at keeping drainages, drain pelviorectal space, apply loop-type sigmostoma. After rectal wound healing it is necessary to carry out reconstructive operation upon large intestine. The innovation enables to activate reparative processes and interrupt the foci of osteomyelitis.

EFFECT: higher efficiency of therapy.

2 cl,1 ex

Description

The invention relates to medicine, namely to methods for surgical treatment of extensive injuries of the extraperitoneal part of the rectum, accompanied by post-traumatic osteomyelitis of the pelvic bones and extensive defects of the ampullar part of the rectum.

Such injuries more often occur with gunshot wounds, especially with mine-blast injuries, are combined and combined and are accompanied by shock and massive blood loss, extensive destruction of the rectum, damage to the main vessels of the rectum with a sharp deterioration in the nutrition of the intestinal wall without the hope of sprouting vessels from those surrounding the direct gut structures, fractures of the lumbar and sacral spine, pelvic bones and hips with the development of gunshot osteomyelitis, damage or contusion to retirement homes tail spinal cord and sacral plexus, damage to the urinary tract, and also accompanied by the difficulty and complexity diagnostic selection surgery.

The objective of the invention is to develop a method for the surgical treatment of extensive injuries of the extraperitoneal part of the rectum, accompanied by post-traumatic osteomyelitis of the pelvic bones.

The technical result is the creation of a well-circulated "muscle pad" to activate reparative processes in the tissues, reducing the risk of infectious complications and stopping foci of osteomyelitis in the pelvic bones, preserving the function of the rectum and its sphincter apparatus with complete physical and social rehabilitation of the wounded.

The technical result in the implementation of the invention is achieved by the fact that the proposed method of surgical treatment of extensive injuries of the extraperitoneal part of the rectum, accompanied by post-traumatic osteomyelitis of the pelvic bones, including performing general combined anesthesia, expanding the wound or performing parasacral access to the damaged part of the rectum, conducting an audit of the wound and wound channel repeated surgical treatment of the wound site, including with the removal of foreign bodies and / or freely living bone fragments, performing necro- and sequestrectomy, performing debridement of the wound and lumen of the rectum, mobilizing the edges of the rectal defect 2-3 cm from the surrounding tissues, performing an incision along the medial surface of the thigh in the projection of the tender muscle with the release of the tender thigh muscle along the length from the internal condyle to the neurovascular bundle and then cutting it off with the tendon to form a displaced musculocutaneous or muscle graft of the tender femoral muscle or an incision on the right or left buttock from the large trochanter of the thigh to the projection of a defect of the rectum and sacrum, isolation of the gluteus maximus muscle and cutting off of its part from the greater trochanter of the thigh with a section of its periosteum on the neurovascular bundle, including the inferior or superior gluteal artery, commit veins and nerve, with the formation displaced skin-muscle or muscle graft of the gluteus maximus muscle, then the formation of a tunnel in the subcutaneous tissue of the perineum from the level of the neurovascular bundle to the wound of the rectum and sacrum and subsequent through the formed tunnel of the displaced skin-muscle or muscle transplant of the extracted tender muscle of the thigh into the sacral space or bringing the displaced skin-muscle or muscle transplant of the selected part of the gluteus maximus to the defect of the rectum and sacrum, redevelopment of the wound and lumen of the rectum, reducing the edges rectal defect with suggestive sutures from absorbable material; plugging of the edges of the rectum and sacrum defect with displaced musculocutaneous or muscular with an implant of the isolated tender muscle of the thigh or part of the gluteus maximus muscle and suturing of the graft to the periosteum of the sacrum and the edges of the rectal defect along the edge of the entire defect with sutures from absorbable material, suturing the wound tightly with silicone drainages in it and in the bed of the displaced muscular-skin or muscle graft, drainage of the pelvic rectal space, as well as subsequent reconstructive surgery of the colon after healing of the rectal wound. In this case, an additional laparotomy is performed and a loop double-barreled sigmoid is superimposed in its absence.

The method is as follows. General combined anesthesia is performed according to a standard technique. In the absence of a sigmostomy, a laparotomy and the application of a loop double-barreled sigmoid are performed. They expand the wound or perform parasacral access to the damaged part of the rectum. Then, a revision of the wound and wound canal is carried out, as well as repeated surgical treatment of the wound site, including removal of foreign bodies and / or freely lying bone fragments. A necrotic and sequestrectomy is performed and then a wound and rectal lumen are sanitized. They carry out the mobilization of the edges of the rectal defect 2-3 cm from the surrounding tissues. Depending on the nature and extent of damage to the rectum and the complexity of post-traumatic osteomyelitis of the pelvic bones, the type of displaced musculoskeletal or muscle transplant is chosen for further use. When using the tender thigh muscle as a graft, an incision is made along the medial surface of the thigh in the projection of the tender muscle. Tender thigh muscle is isolated along the length from the internal condyle to the neurovascular bundle, it is cut off from the tendon portion to form a displaced skin-muscle or muscle graft of the tender thigh muscle. Then, a tunnel is formed in the subcutaneous tissue of the perineum from the level of the neurovascular bundle to the wound of the rectum and sacrum, and a transplanted musculocutaneous or muscle transplant of the selected tender femoral muscle into the presacral space is passed through the formed tunnel. When using the gluteus maximus muscle as a transplant, an incision is made on the right or left gluteal region from the greater trochanter of the thigh to the projection of the defect of the rectum and sacrum, the gluteus maximus muscle is isolated and its part is cut off from the trochanteric femur with a section of its periosteum on the neurovascular bundle, including the lower or upper gluteal artery, committing veins and nerve, with the formation of a displaced skin-muscle or muscle graft of the gluteus maximus muscle. The displaced skin-muscle or muscle transplant of the selected part of the gluteus maximus muscle is brought to the rectum and sacrum defect. Then, redevelopment of the wound and lumen of the rectum is carried out and the edges of the rectal defect are brought together by suggestive sutures from absorbable material. Tamponing of the edges of the rectum and sacrum defect is carried out with a displaced skin-muscle or muscle transplant of the isolated tender muscle of the thigh or part of the gluteus maximus muscle and hem it to the periosteum of the sacrum and the edges of the rectum defect along the edge of the entire defect with sutures from absorbable material. The wound is sutured tightly, leaving silicone drains in it and in the bed of the displaced musculoskeletal or muscle graft. Pelviorectal space is drained. At the final stage of surgical treatment after healing of the rectal wound, reconstructive surgery is performed on the colon.

Experimental studies of the proposed method of surgical treatment of extensive injuries of the extraperitoneal part of the rectum, accompanied by post-traumatic osteomyelitis of the pelvic bones, in the clinical conditions of the hospital showed its high efficiency. Using all the distinguishing features of the proposed technical solution, the creation of a well-circulated muscle pad with activation of reparative processes in the tissues was achieved. The risk of infectious complications is reduced and the elimination of foci of osteomyelitis of the pelvic bones is achieved. Preserved function of the rectum and its sphincter apparatus, while the narrowing of the rectum is not observed. Received a full physical and social rehabilitation of the wounded.

The implementation of the proposed method for the surgical treatment of extensive gunshot injuries of the extraperitoneal part of the rectum is illustrated by the following clinical examples.

Example 1. Injured T., 19 years old, was admitted to 3 CVKG with the diagnosis: "a mine-explosive wound, combined fragmentation penetrating wound of the abdomen and pelvis with extra-abdominal damage to the rectum, gunshot fracture of the sacrum." Upon receipt, the rectal closure apparatus is preserved. There is no sigmostoma. There is an extensive wound of the perineum and gluteal region measuring 15 × 8 cm posterior to the external opening of the anus, through which a defect of the posterior wall of the rectum from the internal opening of the anal canal to the projection of the II sacral vertebra is determined. The size of the defect in the posterior rectal wall is 8 × 4 cm. Part IV and V of the sacral vertebrae and tailbone are absent. In addition, there is no part of the anterior surface of the II-IV sacral vertebrae. Repeated previous sanitation of the wound and necrosecestrectomy of the foci of osteomyelitis that have been carried out have been ineffective.

Surgical intervention was performed - the imposition of a double-barreled loop sigmoid, necrosecestrectomy of the sacrum with the closure of the rectus and sacrum defect of the femoral muscle by the transplanted graft.

Conducted a general combined anesthesia by a standard method. A laparotomy was performed and a loop double-barreled sigmoid was placed. Then they performed the expansion of the wound and performed an audit of the wound and wound canal. Re-surgical treatment of the wound site was performed, including the removal of foreign bodies and freely lying bone fragments. A necrotic and sequestrectomy was performed and then a debridement of the wound and rectal lumen was performed. They carried out the mobilization of the edges of the rectal defect 2-3 cm from the surrounding tissues. An incision was made along the medial surface of the right thigh in the projection of the tender muscle. Tender femoral muscle was isolated along the length from the internal condyle to the neurovascular bundle and was cut off with the tendon part to form a displaced musculocutaneous graft. Then, a tunnel was formed in the subcutaneous tissue of the perineum from the level of the neurovascular bundle to the wound of the rectum and sacrum and a transplanted musculoskeletal transplant of the selected tender femoral muscle was passed through the formed tunnel into the presacral space. Then, re-sanitation of the wound and lumen of the rectum was performed and the edges of the rectal defect were reduced by suggestive sutures from absorbable material. Tamponation of the edges of the rectum and sacrum defect was carried out with a displaced skin-muscle transplant of the extracted tender muscle of the thigh and hemmed to the periosteum of the sacrum and the edges of the rectum defect along the edge of the entire defect with interrupted sutures from absorbable material. The wound was sutured tightly, leaving silicone drains in it, in the sacral space and in the bed of the displaced musculoskeletal graft.

The postoperative period was uneventful. Healing of postoperative wounds by primary intention. One month after surgery, complete epithelization of the rectal mucosa was noted at the site of the stitched displaced muscle graft of the tender muscle of the thigh. The rectal defect was completely epithelized; there was no narrowing of the rectum at the site of damage. The function of the obturator apparatus of the rectum is preserved. Osteomyelitis of the sacrum is completely stopped.

At the final stage, after 4 months, the wounded man underwent reconstructive surgery to restore the continuity of the colon with the closure of the double-barreled sigmoid. Both physical and social rehabilitation of the wounded was achieved.

Example 2. Patient M., 23 years old, during the fighting received a penetrating penetrating bullet wound to the abdomen and pelvis with damage to the mid-ampullar part of the rectum. Gunshot hole fracture of 2-3 sacral vertebrae, contusion of the nerve sacral plexus. The double-barreled sigmostoma is imposed. Upon admission, the general state of moderate severity, is inactive, disturbed by pain in the left lower limb, sharply aggravated by the slightest movements in it. The wound disease was complicated by severe cachexia, gunshot osteomyelitis of the sacrum. At the border of the left gluteal and sacral region, the wound is 8 × 5 cm in size, made by granulation, the bottom of the wound is a sacrum with a defect of 4 × 3 cm. A wound of the posterior rectal wall with a defect of 3 × 4 cm adjoins it.

The operation was performed: necrsecvestrectomy, transplantation of the gluteus maximus muscle transplant to the position of the sacrum defect and presacral space with tamponade of the rectum and sacrum defect.

Conducted a general combined anesthesia by a standard method. Then, parasacral access to the damaged part of the rectum was performed and the wound and wound canal were revised. Re-surgical treatment of the wound site was performed, including the removal of freely lying bone fragments. A necrotic and sequestrectomy of osteomyelitic foci of the sacrum was performed, and then a wound and lumen of the rectum were reconstructed. They carried out the mobilization of the edges of the rectal defect 2-3 cm from the surrounding tissues. An incision was made on the right gluteal region from the greater trochanter of the thigh to the projection of a defect of the rectum and sacrum and a part of the gluteus maximus muscle with the lower neurovascular bundle was isolated. Then it was cut off from the greater trochanter of the thigh with a section of its periosteum on the neurovascular bundle, including the inferior gluteal artery, the joint veins and nerve, with the formation of a displaced muscle graft of the gluteus maximus muscle. A displaced muscle graft of the extracted part of the gluteus maximus muscle was deployed and brought to the rectum and sacrum defect. Then, re-sanitation of the wound and lumen of the rectum was performed and the edges of the rectal defect were reduced by suggestive sutures from absorbable material. Tamponation of the edges of the rectum and sacrum defect was carried out with the displaced muscle graft of the part of the gluteus maximus muscle and hemmed to the periosteum of the sacrum and the edges of the rectum defect along the edge of the entire defect with sutures from absorbable material. The wound was sutured tightly, leaving silicone drains in it, in the pelvorectal space and in the bed of the displaced muscle graft. Performed by drainage of pelvic rectal space.

The postoperative period was uneventful. 2 months after surgery, a funnel-shaped retraction of the rectal mucosa is present at the site of the stitched displaced muscle graft of a part of the gluteus maximus muscle. The fistula is eliminated, the rectal defect is completely epithelized, there is no narrowing of the rectum at the site of damage. The function of the obturator apparatus of the rectum is preserved. Osteomyelitis of the sacrum is completely stopped. The clinical manifestations of canthus nerve sacral plexus decreased significantly.

At the final stage, after 3 months, the wounded man underwent reconstructive surgery to restore the continuity of the colon: closing the double-barreled sigmoid. Both physical and social rehabilitation of the wounded was achieved.

Claims (3)

1. A method for the surgical treatment of extensive injuries of the extraperitoneal part of the rectum, accompanied by post-traumatic osteomyelitis of the pelvic bones, comprising conducting combined anesthesia, expanding the wound or performing parasacral access to the damaged part of the rectum, conducting an audit of the wound and wound canal, and re-treating the wound site, in including removal of foreign bodies and / or freely lying bone fragments, performing necr- and sequestrectomy, conducting wound rehabilitation, and light of the rectum, mobilization of the edges of the rectal defect 2-3 cm from the surrounding tissues, the formation of a skin-muscle or muscle graft of the delicate muscle of the thigh or gluteus maximus muscle, bringing the transplant to the defect of the rectum and sacrum, reducing the rectal defect by inducing sutures from absorbable material, plugging the edges of the rectum and sacrum defect with a displaced graft, hemming the graft to the periosteum of the sacrum and the edges of the rectum defect along the edge of the entire defect with sutures from the absorbable material, suturing the wound tightly, leaving silicone drains in it and in the bed of the displaced graft, draining the pelvic rectal space, performing laparotomy and applying a loop double-barreled sigmostomy in its absence, as well as the subsequent colon surgery after healing of the rectal wound. 2. The method according to claim 1, characterized in that during the formation of a graft of the tender thigh muscle, an incision is made along the medial surface of the thigh in the projection of the tender thigh muscle with the release of the tender thigh muscle along the length from the internal condyle to the neurovascular bundle, followed by cutting off the muscle from the tendon in part, they form a tunnel in the subcutaneous tissue of the perineum, conduct a graft of the tender thigh muscle through the formed tunnel into the sacral space. 3. The method according to claim 1, characterized in that when the transplantation of the gluteus maximus muscle is performed, an incision is made in the right or left gluteal region from the greater trochanter to the projection of the defect of the rectus muscle and sacrum, the gluteus maximus muscle is isolated, part of the muscle is cut off from the greater trochanter of the thigh with a section of the periosteum on the neurovascular bundle, including the lower or upper gluteal artery, committing veins and nerve.