RU2342909C1 - Method of necrotomy with heat injury - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: indulating lengthwise and transverse sections of necrotising skin and hypoderm crossing local over fascial lymphatic vessels are made. If local deep burns are witnessed, necrotomy is carried out by contour sectioning with dissection of hypoderm and crossing over fascial lymphatic vessels along periphery of the burn in the distance of 0.5-1 cm from the edge of an unaffected skin area.

EFFECT: decrease of penetration of toxic products into lymphatic system and infection of the burned surface, optimal conditions to carry out vulnerosorption and paravulnerosorption for further necrotomy and autoplasty, improvement of treatment functional results.

6 dwg, 2 ex

Description

The present invention relates to medicine, namely to surgery and traumatology.

The treatment of deep, extensive burn wounds continues to be relevant at present. Against the background of the development of intracellular and interstitial edema as a result of burn damage, the formation of a thick dense scab can cause serious disturbances in tissue microcirculation. An increase in interstitial pressure in combination with the formation of a hard scab primarily causes venous insufficiency (Karvayal HF, Parks D.Kh. Burns in children: Transl. From English - M .: Medicine, 1990, 512 p.).

If there is a dense circular burn scab in the form of a shell on the body, compressing the chest, neck or limbs, then it can seriously complicate breathing and blood circulation, which contributes to the growth of edema and deepening tissue necrosis. In such cases, decompression necrotomy is shown, consisting in applying longitudinal sections of the scab in the area of compression (Yudenich V.V. Treatment of burns and their consequences: Atlas. - M .: Medicine, 1980, 192 p.).

Also, with deep and borderline circular burns, areas of tissue compression arise, which leads to an increase in edema in the distal extremities. Thermal exposure enhances the permeability of the vascular wall, which leads to serious violations of tissue microcirculation, an increase in interstitial pressure causes venous insufficiency, leading to thrombosis. The accumulation of fluid under the scab leads to compression not only of blood vessels, but also of nerve trunks and muscles.

Necrotomy facilitates the drying of areas of necrosis, allows you to specify the depth of the lesion, reduce the absorption of toxic products from necrotic tissue, creates adverse conditions for the development of infection.

The need for necrotomies for deep burns was indicated by many domestic and foreign authors (Yudenich V.V., 1980; Orlova A.N., 1973; Bennet and Lewis, 1958; Kaplan and White 1961 and others).

The goal of necrotomy in case of burns of the extremities is to improve the trophism of the distal parts, and in case of burns of the body, to eliminate the mechanical obstructions of ventilation of the lungs. Necrotomy is also indicated for girdle burns of the neck, in which the neck veins are at risk of compression.

The prototype of the invention is a method of necrotomy, which consists in the fact that the necrotomy is carried out 1-3 days after injury, after stabilization of hemodynamics. There are two types of necrotomies: "lamp" and cell. With "strip" necrotomy, incisions are made parallel to each other at a distance of 5-10 cm throughout the entire area of necrosis. In cell necrotomy, a few more perpendicular sections are added to the first incisions. The cut lines should coincide with the longitudinal axis of the limb. The technique of the operation is simple: a scalpel produces a longitudinal dissection of the burn scab to the entire depth of necrosis, supplementing with transverse incisions. Since necrotic areas lack blood supply, there is no or minimal bleeding. On the body, the incisions are made along the axillary lines in combination with transverse incisions at the level of the ribs until normal respiratory activity is achieved (Karvayal H.F., Parks D.K. Burns in children: Transl. From English - M .: Medicine, 1990, p. 512. Surgery: Under the general editorship of Prof. I. Littmann, Publishing House of the Hungarian Academy of Sciences, Budapest, 1985, p. 1175. Yudenich VV Treatment of burns and their consequences: Atlas. - M .: Medicine, 1980, 192 p.).

The technical result is the reduction of toxic products in the general lymphatic system and infection of the burn surface, the creation of optimal conditions for carrying out vulnerosorption and paraululosorption, for further necrectomy and autodermoplasty, improving the functional results of treatment.

The specified technical result is achieved by the fact that in the method, including the longitudinal and transverse sections of necrotic skin, the incision is made in the form of a wave, in addition, an incision is made in the subcutaneous adipose tissue, regional suprafascial lymph vessels are crossed, and in case of a local burn, contour incisions are made with dissection of the subcutaneous fat fiber and the intersection of suprafascial lymphatic vessels on the periphery of the burn at a distance of 0.5-1 cm from the edge of a healthy area of the skin.

The proposed method is illustrated by the following drawings: Figs. 1-2 show undulating longitudinal and transverse sections according to the proposed method in a patient according to Example 1, Fig. 3 is a view of a wound in the early postoperative period, and Fig. 4 is a view of a local deep burn according to an example. 2, figure 5 - contour sections on the right shoulder according to example 2, figure 6 is a view of the wound after necrectomy and autodermoplasty on the 10th day.

The proposed method for necrotomy for burns of the limbs and trunk is as follows. They produce wave-like longitudinal and transverse sections of necrotic skin, as well as subcutaneous fatty tissue with the intersection of regional suprafascial lymphatic vessels. With local deep burns, necrotomy is carried out by contour cuts with dissection of subcutaneous fat and intersection of suprafascial lymphatic vessels along the periphery of the burn at a distance of 0.5-1 cm from the edge of a healthy area of the skin. The wave-like necrotomy allows you to increase the length and area of the incisions, thereby reducing the ingress of toxic products into the general lymphatic system, which creates optimal conditions for carrying out volnerosorption. Crossed and removed supra-fascial lymphatic vessels with deep burns after epithelization and scarring restore their structure and function within 1 year from the moment of injury. The application of the method allows to provide a satisfactory functional and cosmetic result in the long term.

The rationale for the proposed method

The nature of the healing of the surgical wound depends not only on constitutional and hormonal-metabolic factors, but also to a greater extent on local factors, among which one of the main ones is the direction of the incision line.

Langer (Langer 1861) described the direction of incisions that contribute to the good healing of the wound. Robin and Crassel (Robin 1948, Kraissl 1951) recommended making a skin incision vertically with respect to the underlying muscle. This direction of the incision is chosen due to the fact that the skin is connected by connective tissue with fascia passing in the same direction. Significant is the fact that granulation of the surgical incision is associated with irritation that occurs from muscle movement. If the cut line corresponds to the main muscle movement, then for some time a hypertrophic scar arises, which subsequently shrinks (Surgical Surgery. Edited by Prof. I. Littmann. Third (stereotyped) publication in Russian. Publishing House of the Hungarian Academy of Sciences. Budapest, 1985 , 1175 p.).

It should be borne in mind that the flow of toxic products from the burned skin into the bloodstream occurs through the lymphatic system. Superficial lymphatic vessels located outside the superficial fascia of the human body are located next to or near the saphenous veins. These vessels are formed from the lymphatic capillaries of the skin, subcutaneous tissue. (Human Anatomy. In 2 volumes. Vol. 2 / Auth .: E.I. Borzyak et al.; / Ed. By M.R. Sapin. - M.: Medicine, 1987. - 480 p.).

The amount of lymph flowing through the drainage from the thoracic lymphatic duct in the burned during the day ranged from 500 to 5100 ml. The concentration of the direct fraction of bilirubin increased by 5-6 times, and the indirect - by 4 times, residual nitrogen - by 2 times, urea - by 5-6 times, creatinine - by 8 times higher than normal. ALT activity increased 4 times, and ACT 7 times. Lymph is infected 3 times more than blood. (E.N. Matchin et al. Our experience of sorption reinfusion of lymph and plasma in severely burned patients. Problems of hematology and blood transfusion, No. 5, 1981, pp. 31-35).

Recently, the method of vulnerosorption has become more widely used. Vulnerosorption (application sorption) is a method of releasing toxic components through the wound surface. (Selected lectures on disaster medicine / Under the general editorship of prof. S.V. Trifonov. - M.: GEOTAR - MED, 2001. - 304 p.).

In the available sources of scientific, medical and patent information, the authors did not find an identical method of necrotomy for deep and borderline burns in patients with thermal injury. Thus, the claimed method meets the criterion of "Novelty."

The authors found that the proposed method of wave-like and contour necrotomies minimizes hemostasis and microcirculation disorders during surgery, reduces the level of body intoxication in the postoperative period and creates optimal conditions for subsequent necrectomy, autodermoplasty, which will lead to accelerated wound epithelization. Thus, the claimed method meets the criterion of "Inventive step".

In this way, 23 patients with deep burns were operated on at the Republican Burn Center, Municipal Clinical Hospital No. 18. In all cases, the proposed method has proven effective.

We give examples of clinical use of the proposed method.

Example No. 1. Patient A. was admitted to the Republican Burn Center, Municipal Clinical Hospital No. 18 of Ufa with a diagnosis of a burn of the II-IIIAB-IV degree of the trunk and lower extremities 52% (36%). Upon receipt, burn shock is extremely severe. After stabilization and normalization of hemodynamics on the second day an operation was performed - a wave-like necrotomy on the lower extremities. Wavy longitudinal and transverse sections were made up to the fascia with dissection of the subcutaneous fat and intersection of the supra-fascial lymphatic vessels on the lower extremities along the outer and inner surfaces. Diastasis of necrotome incisions was 2-3 cm. Hemostasis - coagulation and the imposition of nodal and Z-shaped hemostatic sutures. The duration of the operation is 40 minutes. (Figure 1-2). In the early postoperative period (1-3 days), there was abundant serous discharge from wound surfaces and a decrease in swelling of burn wounds (Figure 3). Subsequently, staged necrectomy and autodermoplasty with a split mesh flap were performed. After complete epithelization and an early course of rehabilitation, the patient was discharged on day 72 of treatment. During the control examination in 2007, post-burn scars on the lower limbs of flesh-colored, soft, not fused with underlying tissues, movement in the joints in full. Signs of lymphostasis and venous insufficiency are absent.

Example No. 2. Patient N. was admitted to the Republican Burn Center, Municipal Clinical Hospital No. 18 of Ufa with a diagnosis of a burn of the II-IIIAB-IV degree of the face, neck, upper limbs 20% (10%). Upon receipt of severe shock (Figure 4). On the second day, a contour necrotomy was performed on the right shoulder. Contour sections were made along the border of a deep burn to the fascia with dissection of the subcutaneous fat and intersection of the supra-fascial lymphatic vessels on the right shoulder. Diastasis was 1.5-2 cm. Hemostasis - coagulation. On the hands produced wavy necrotome incisions, the divergence of the edges of the wounds 1-1.5 cm. Hemostasis - coagulation (Figure 5). On the 7th day from the moment of the injury, a necrectomy was performed on the right shoulder, hands, and on the 9th day an autodermoplasty was performed with a split mesh flap. On the 30th day after the injury, the patient was discharged with a satisfactory result (Fig.6).

The proposed method is easily reproducible in a hospital environment and when it is used, the indicated technical result is achieved. Thus, the claimed invention meets the criterion of "Industrial applicability".

Claims (1)

The method of necrotomy for burns of the extremities and trunk by means of longitudinal and transverse sections of necrotic skin, characterized in that the incision is made in a wavy manner, while additionally performing an incision of the subcutaneous adipose tissue, the regional suprafascial lymphatic vessels are intersected, and in case of a local burn, contour incisions are made with dissection of the subcutaneous fat fiber and the intersection of suprafascial lymphatic vessels on the periphery of the burn at a distance of 0.5-1 cm from the edge of a healthy area of the skin.

Images