RU2358666C1 - Retroperitoneal fat phlegmon drainage technique in infected pancrenecrosis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention concerns medicine and surgery. Pancreas is drained that is followed with sequestrectomy and pancreas abdomination to form omentobursostoma. It is combined with additional retroperitoneostoma that is ensured with oblique incision of skin, subcutaneous tissue, aponeurosis of abdominal external oblique muscle in left iliac region. Abdominal internal oblique muscle and transverse muscle of abdomen are split. Peritoneum is detached medially while retroperitoneal fat is uncovered to pancreas tail. Fascia of transverse muscle of abdomen is lined to aponeurosis and wound edges. Pancreas tail and small pelvis fat are drained. If extensive purulent process is observed in retroperitoneal fat and distributed to the right, retroperitoneal fat is additionally drained on the right forming retroperitoneostoma on the right similarly.

EFFECT: method allows for higher adequacy of retroperitoneal fat drainage ensured by retroperitoneostoma formation combined with reduced operative injuries.

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Description

The invention relates to medicine and can be used to drain retroperitoneal cellulitis in case of infected pancreatic necrosis.

In case of infected pancreatic necrosis complicated by phlegmon of retroperitoneal fiber, toxic shock, mortality is from 40 to 80% according to various literature sources [1, 2].

A known method of drainage of phlegmon of retroperitoneal tissue with infected pancreatic necrosis, including the formation of retrolaparostomy. The disadvantages of this method are: the use of contrapertures, which entails additional trauma to the surrounding tissues; infection of the abdominal cavity and the development of purulent peritonitis involving other organs and tissues in the pathological process and, as a result, significant mortality - up to 80% [1].

A known method of drainage of retroperitoneal fiber, including the formation of lumbostomy on the right and left. The disadvantages of this method are damage to a large array of lumbar muscles and significant mortality - up to 60% [2].

Closest to the proposed invention is a method of drainage of retroperitoneal tissue with infected pancreatic necrosis [3]. For drainage of the retroperitoneal space in the known method, drainages are made through the extraperitoneal incision in the iliac region and the preperitoneal tissue of the anterolateral abdominal wall. Further, the drainage is carried out in the retroperitoneal fiber proper after preliminary delamination of it within healthy tissues. Drainages are removed through contraception in the lateral abdomen along the posterior axillary line.

The disadvantages of this method are the inadequacy of drainage of retroperitoneal tissue and fiber of the pelvis with the spread of purulent process in the pelvis; damage to a large array of lumbar muscles due to the use of contrapertures; the lack of delimitation of subcutaneous fat leads to phlegmon of the anterior and lateral abdominal walls; the need to use non-standard expensive equipment.

A new technical problem is to increase the adequacy of drainage of retroperitoneal tissue due to the formation of retroperitoneostomy while significantly reducing the invasiveness of the operation, reducing mortality and cheapening of the method.

To solve the problem, in the method of drainage of retroperitoneal cellulitis phlegmon with infected pancreatic necrosis, including the formation of an omentobursostomy, the installation of drains and sequestrectomy, a wide omenobursostomy is formed, an additional retroperitoneostomy is formed on the left, and with a greater spread of the process, it can also be sutured and the fascia muscle is transverse to the fascia of the fascia the edges of the wound, while the retroperitoneal tissue is exposed to the tail of the pancreas and pelvis, and the drainage is set to the tail under gastric gland and pelvic tissue.

New in the method is that omentobursostomy is formed broad, additionally retroperitoneostomy is formed on the left, and with a more widespread process, on the right, by stitching the fascia of the transverse abdominal muscle to the aponeurosis and the edges of the wound, while the retroperitoneal tissue is exposed to the tail of the pancreas and pelvis, and drainages are placed on the tail of the pancreas and the tissue of the pelvis.

The method is as follows. Perform laparotomy, open cholecystectomy or cholecystostomy, pancreatic abdomination (pancreatic abdomination is performed sequentially by opening the gastrocolic ligament, dissecting the peritoneum along the lower and upper edges in the area of the body and tail of the organ, stupidly secreting the gland from the retroperitoneal papillary) like “moving” the pancreas from the retroperitoneal space to the abdominal cavity), the toilet and drainage of the abdominal cavity. Next, a wide omentobursostomy is typically applied; then perform an oblique incision of the skin, subcutaneous tissue, aponeurosis of the external oblique abdominal muscle in the left iliac region (Fig. 1), bluntly perform the stratification of the internal oblique abdominal muscle and transverse abdominal muscle, transverse fascia of the abdomen (Figs. 2, 3). The fascia of the transverse abdominal muscle is sutured with separate sutures to the aponeurosis and to the edges of the wound and, thus, retroperitoneostomy is formed (Fig. 4). The peritoneum is peeled off medially stupidly and retroperitoneal tissue is exposed, to the tail of the pancreas. Drainages made in the form of silicone tubes and rubber-gauze swabs are installed to the tail of the pancreas and the tissue of the small pelvis (Figs. 5, 6, 7). With the widespread dissemination of the purulent process, drainage of retroperitoneal fiber, according to the above method, is also carried out on the right, i.e. retroperitoneostomy is additionally formed on the right. In the future, planned heterothermal sanitation of retroperitoneostomy is carried out using the URSC 18 apparatus, until the purulent process is stopped (from 3 to 11). Subsequently, retroperitoneostomy, like omentobursostomy, is closed by secondary intention.

Example No. 1. Medical history No. 2289. Patient Mironova Svetlana Ivanovna, 41 years old, was urgently admitted to the admission department of the Moscow City Hospital №3, on April 15, 07, with a diagnosis of acute cholecystopancreatitis, was hospitalized in the surgical department where conservative therapy was carried out, diagnostic measures: ultrasound OBP dynamics, clinically no improvement it was noted and after the emergency preparation was performed on April 16, 07, laparotomy, open cholecystectomy, pancreatic abdomination were performed (pancreatic abdomination was performed after Accordingly, opening the gastrocolic ligament, dissecting the peritoneum along the lower and upper edges in the area of the body and tail of the organ, bluntly isolated the gland from the retroperitoneal parapancreatic fiber, thereby “moving” the pancreas from the retroperitoneal space to the abdominal cavity), toilet and abdominal drainage. An omentobursostomy was performed by fixing fragments of a dissected gastrocolic ligament to the parietal peritoneum along the entire perimeter in the upper third of the laparotomy wound, and drainage to the pancreas was also established. Postoperative diagnosis: infected pancreatic necrosis, cholelithiasis, reactive enzymatic calculous cholecystitis. After the operation, the patient was treated in the department of anesthesiology and intensive care, where intensive care was carried out. After stabilization, she was transferred to the purulent surgery department. After the preparation in the planned order, on April 20, 2007, heterothermal sanitation of omentobursostomy was performed, in which a purulent fusion of the pancreas, purulent inflammation of the parapancreatic tissue with the formation of retroperitoneal cellulitis on the left was visually determined.

The proposed method was performed: oblique incision of the skin, subcutaneous tissue, aponeurosis of the external oblique abdominal muscles on the anterolateral surface of the abdomen on the left, bluntly stratified the internal oblique and transverse abdominal muscles, transverse fascia. The peritoneum is exfoliated bluntly medially and the retroperitoneal tissue is exposed, to the tail of the pancreas, the fascia of the transverse abdominal muscle is sutured with separate sutures to the aponeurosis and to the edges of the wound. Thus, retroperitoneostomy is formed; drainages were established to the tail of the pancreas and the tissue of the small pelvis; sequestrectomy was performed. Postoperative diagnosis: infected pancreatic necrosis, retroperitoneal cellulitis. Then, on April 26, 2007, heterothermal rehabilitation of omentobursostomy and retroperitoneostomy, sequestrectomy was performed. Over time, intoxication (clinically, laboratory, ultrasound data) increased and 03.05.07 was performed heterothermal sanitation of omentobursostomy and retroperitoneostomy on the left, sequestrectomy, visually determined that retroperitoneal phlegmon spread and on the right, performed the same way retroperitoneostomy on the right. 05/10/07, - heterothermal rehabilitation of omentobursostomy, retroperitoneostomy, sequestrectomy. The wounds from retroperitoneostomy and omenobursostom were cleaned, closed by secondary intention. Drainages and tampons were removed after monitoring the ultrasound of the OBP, as well as the course of the wound process. Sutures were removed on a delayed day. Local treatment of dressings with antiseptics was performed. Antimicrobial therapy was carried out: cefasin, metragil, ciprofloxacin, lincomycin, maxipine. IV laser therapy course. Physiotherapy. After the measures taken - the patient is recovering, the patient was discharged 07/13/07. The number of hospital days spent - 107.

Thus, the above example shows how infected pancreatic necrosis, complicated by extensive phlegmon of retroperitoneal fiber, was stopped with minimal cost and the absence of the use of expensive equipment while maintaining the patient's life.

Example No. 2. Case history No. 1893. Patient Drobin Andrei Nikolaevich, 30 years old, was taken on March 27, 2007 by the intensive care team to the admission department of the Moscow City Hospital №3. Upon admission, acute destructive pancreatitis, the phenomenon of pancreatogenic shock, was diagnosed. Hospitalized in the intensive care unit after the surgical department. After some stabilization of the state, diagnostic measures: laparocentesis, ultrasound OBP (dynamics), clinically worsening of the condition, after the preparation was carried out on March 31, 07, under endotracheal anesthesia, the following was performed: laparotomy, pancreatic abdomination (pancreatic abdomination is performed sequentially opening the gastrocolic ligament, dissecting the peritoneum along the lower and upper edge in the area of the body and tail of the organ, bluntly secrete the gland from the retroperitoneal parapancreatic to let’s, thereby performing a “movement” of the pancreas from the retroperitoneal space into the abdominal cavity), cholecystostomy (two holders are placed on the bottom of the gallbladder, between which a needle or trocar are punctured and the contents removed, after which drainage is introduced into the bladder cavity, which is fixed with one or two purse-string sutures, the ends of which are sutured to the parietal peritoneum), omentobursostomy (formed by fixing fragments of the dissected gastrocolic ligament to the parietal peritoneum along all perimeter in the upper third of the laparotomy wound, as well as the installation of drainages to the pancreas).

Purulent fusion of the pancreas, purulent inflammation of parapancreatic fiber with the formation of retroperitoneal phlegmon on the left is visually determined. According to the proposed method, it was performed: oblique incision of the skin, subcutaneous tissue, aponeurosis of the external oblique abdominal muscle on the anterolateral surface of the abdomen on the left, bluntly stratified the internal oblique and transverse muscles of the abdomen, transverse fascia, the peritoneum is stupidly medially detached and the retroperitoneal tissue is exposed, to the tail of the pancreas glands, fascia of the transverse abdominal muscle are hemmed with separate sutures to the aponeurosis and to the edges of the wound, thus, retroperitoneostomy is formed; performed sequestrectomy, toilet and drainage of the abdominal cavity and retroperitoneal space.

Postoperative diagnosis: Infected pancreatic necrosis, peritoneal infiltrate, retroperitoneal phlegmon, common fibrinous hemorrhagic peritonitis, toxic toxic shock, reactive enzymatic cholecystitis.

After the operation, the patient was treated for a long time in the intensive care unit, where intensive care was carried out. After the preparations, the following operations were carried out repeatedly in a planned and emergency order:

04/05/07. Operation: heterothermal sanitation of omentobursostomy, retroperitoneostomy on the left. Sequestrectomy

04/10/07. Operation: heterothermal sanitation of omentobursostomy and retroperitoneostomy on the left. Sequestrectomy

04/16/07. Operation: heterothermal sanitation of omentobursostomy, retroperitoneostomy on the left. Sequestrectomy

04/20/07. Operation: Heterothermal debridement with an omeno-retroperitoneostomy. Due to the fact that the retroperitoneal phlegmon spread to the right, an oblique skin incision was made, subcutaneous tissue, an aponeurosis of the external oblique abdominal muscle on the anterolateral abdominal surface on the right, a blunt dissection of the internal oblique and transverse abdominal muscles, transverse fascia, the peritoneum was stupidly medially exfoliated and the retroperitoneal was exposed fiber, to the tail of the pancreas, fascia of the transverse abdominal muscle is sewn with separate sutures to the aponeurosis and to the edges of the wound, thus forming a retroperitoneostomy of the right wa; sequestrectomy.

04/26/07. Operation: heterothermal debridement with an omento-retroperitoneostomy. Sequestrectomy The wounds from retroperitoneostomy and omenobursostom were cleaned, closed by secondary intention. Drainages and tampons are removed after ultrasound monitoring of the abdominal organs, as well as the course of the wound process. Sutures were removed on a delayed day. Local treatment of dressings with antiseptics was performed. Antimicrobial therapy was carried out: cefasin, metragil, ciprofloxacin, lincomycin, thienam, maxipine. IV laser therapy course.

Physiotherapy. The total number of planned sanations of omentobursostomy and retroperitoneostomy was 4, emergency - 1.

After the measures taken, the patient recovered, was discharged 06/09/07, the Number of hospital days spent in the hospital - 74.

Thus, the above example shows how infected pancreatic necrosis, complicated by extensive phlegmon of retroperitoneal fiber, was stopped with minimal cost and the absence of the use of expensive equipment while maintaining the patient's life.

Example No. 3. Case history No. 2849. Patient Belomestnykh Andrey Vladimirovich, 40 years old, was transferred in critical condition from the Railway Hospital 05/19/06. On examination, the condition is extremely serious, there were phenomena of toxic toxic shock. A number of examinations were carried out, after that he was placed in the intensive care unit, preoperative preparation was carried out, on an emergency basis under an ETN on 05/19/06 at 18.00 - operation: relaparotomy. Revision of the abdominal cavity. Autopsy of liver abscesses, subphrenic abscesses on the left, on the right. Dissection of adhesions. Cannulation of the umbilical vein. Restroom. Drainage of abscesses, abdominal cavity. A visual assessment of the pancreas and surrounding tissues revealed signs of infected pancreatic necrosis and retroperitoneal cellulitis on the left.

According to the proposed method, an omentobursostomy was performed by fixing fragments of a dissected gastrocolic ligament to the parietal peritoneum along the entire perimeter in the upper third of the laparotomy wound, and drainage to the pancreas was also established. A retroperitoneostomy is formed by performing an oblique incision of the skin, subcutaneous tissue, aponeurosis of the external oblique muscle of the abdomen on the anterolateral surface of the abdomen on the left, bluntly stratified the internal oblique and transverse muscles of the abdomen, transverse fascia, the peritoneum is stupidly medially detached and the retroperitoneal tissue is exposed, the tail is left to the tail the fascia of the transverse abdominal muscle is hemmed with separate sutures to the aponeurosis and to the edges of the wound. Sequestrectomy performed. Postoperative diagnosis: infected pancreatic necrosis, retroperitoneal cellulitis. Sepsis. Septicemia. Abdominal infiltrate. Subphrenic abscesses on the right, on the left. Portal vein thrombosis. Multiple abscesses of both lobes of the liver. Infectious toxic shock. After which the patient was in the Department of Anesthesiology and Intensive Care for a long time.

Then, on 05/24/06, 05/29/06, and 05/06/07, heterothermal sanitation of retroperitoneostomy and sequestrectomy were performed.

The wounds from omentobureostomy and retroperitoneostomy were cleaned, secondary sutures were applied. Drainages and tampons were removed after monitoring the ultrasound of the OBP, as well as the course of the wound process. Sutures were removed on the 12th day. Local treatment of dressings with antiseptics was performed. Antimicrobial therapy was carried out: cefasin, metragil, ciprofloxacin, lincomycin, which were introduced both iv and into the v system. Portae (through the clotted umbilical vein according to the method of the clinic). Physiotherapy. After the measures taken, the patient is recovering, the patient was discharged 08.07.06. The number of hospital days spent in the hospital is 50.

Thus, the above example shows how infected pancreatic necrosis, complicated by retroperitoneal phlegmon, abdominal sepsis, multiple abscesses of the abdominal cavity and liver, was stopped with minimal cost and the absence of the use of expensive equipment while maintaining the patient's life.

Siberian State Medical University on the basis of the purulent surgery department of the Moscow City Hospital №3 in Tomsk from January 2003 to December 2007, 71 patients with infected pancreatic necrosis complicated by the development of phlegmon of parapancreatic and retroperitoneal tissue were treated. The research methods were: clinical analysis of case histories, laboratory data, instrumental research methods (ultrasound monitoring, R-logic methods).

The average age of the patients was 44.9 years. There were 50 men and 21 women. Between 2003 and 2004, 35 patients were treated (group I). They received traditional treatment methods. After operations, 7 relaparotomies were performed in this group for the progression of the purulent process. Of these, 11 people died, which amounted to 31.4%.

Since 2005, the clinic began to actively apply open methods of treatment of this pathology by the proposed method. During this period 36 patients were treated (group II). During the first operation, a bile duct operation was necessarily performed, a wide omentobursostomy was imposed. In 4 cases, cryodestruction of the pancreas was performed. In the presence of retroperitoneal cellulitis phlegmon, retroperitoneostomy was applied on the left, and in the presence of an extensive purulent process in the retroperitoneal tissue - on the right. Planned reorganizations by omentobursostomy, retroperitoneal space were performed every 2-4 days in the presence of signs of pancreatic sequestration, and the purulent process progressed. This was indicated by hectic temperature, increased leukocytosis, ultrasound monitoring data. During repeated interventions, heterothermal debridement was performed using ultrasonic cavitation (apparatus URSK 7N - 18), pancreatic sequestra were removed, newly emerged foci of destruction were opened and drained. The number of readjustments ranged from 1 to 9 (average - 3.1 per patient). In this group of patients, intravenous, laser irradiation of blood with the Mulat apparatus was actively used. In addition to massive antimicrobial, detoxification, antienzyme therapy, these patients received immunocorrective therapy. For this, polyoxidonium and roncoleukin were used. From group II, 4 patients died - 11.1%.

Thus, the proposed method of drainage of retroperitoneal cellulitis phlegmon allows you to quickly stop retroperitoneal cellulitis phlegmon with minimal trauma and save the patient's life without resorting to the use of expensive equipment.

Literature

1. Vashenko R.V., Tolstoy A.D., Kurygin A.P. Acute pancreatitis and pancreatic injury. - St. Petersburg., 2000 .-- 309 p.

2. Guidelines for emergency abdominal surgery. Ed. B.C. Saveliev. - M., "Triad-X", 2005, p. 640.

3. RU No. 2145805 C1, Galimzyanov F.V., Nishkevich E.V., 02.27.2000 (prototype).

Claims (1)

A method for draining retroperitoneal tissue with infected pancreatic necrosis, including installing drainages, sequestrectomy, characterized in that the pancreas is abdominated, form an omentobursostomy and drainage to the pancreas, additionally form a retroperitoneostomy on the left, for which oblique obstruction of the skin is performed, for which oblique oblique cell growth is performed, for which abdominal muscles in the left ileal region, stratification of the internal oblique and transverse abdominal muscles, exfoliation of the peritoneum medially with an obn By applying retroperitoneal tissue to the tail of the pancreas and suturing the fascia of the transverse abdominal muscle to the aponeurosis and the edges of the wound, drainages are made to the tail of the pancreas and the tissue of the pelvis, in the presence of an extensive purulent process in the retroperitoneal tissue with its spread to the right, the retroperitoneal tissue is drained to the right to the right, retroperitoneostomy on the right.

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