RU2317783C1 - Surgical method for treating lymphedema cases - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves placing subcutaneous sutures over shin circumference step-by-step from foot to knee joint 4-6 cm far from each other. An additional ligature is thrown over each suture ligature on the side diametrically opposite to the first stuck-in pierce point. The additional ligature ends are left on skin surface, and subcutaneous suture ligature ends are tied up in a knot at the outgoing pierce point until the knot and ligatures connection place are buried under skin. Then, gauze tampon is placed over the knot and the subcutaneous suture ligature is fixed thereon. The sutures are additionally tightened every day during 10-21 days and then, the ligatures are removed.

EFFECT: reduced risk of skin injuries; eliminated lymphovenous and lymphomuscular edema in extremities without cellular tissue space being injured; improved cosmetic result.

2 dwg

Description

The invention relates to surgery and can be used in the treatment of lymphedema of the lower extremities of the I-III stage.

A known method of partial laser lymphostimulation in the treatment of lymphedema (RF Patent No. 2166338, IPC A61N 5/067, publ. 2001), including helium-neon phased laser irradiation of all major tracts of lymphatic organ outflow. Initially, the skin projection of the regional lymph node is irradiated with a point method, and subsequently the zone of the edema region bordering on healthy tissue is trained. With each subsequent session, the zone of laser exposure to the skin projection of the edema is shifted taking into account the removal of swelling of the tissues.

The disadvantage of this method is that with organic lesions of the lymphatic vessels at the 2-3 stages of the disease, lymph outflow does not improve, vascular hypertension, due to changes in the walls of the lymphatic vessels, narrowing of the lumen, is not amenable to reverse regression.

A known method for the treatment of elephantiasis, including radical total removal of fibrous altered fascia and subtotal removal of fibrous subcutaneous tissue by economical linear dermolipofasciectomy (RF Patent No. 2026011, IPC A61B 17/00, publ. 1995).

The disadvantage of this method is its high morbidity, the impossibility of its use in a number of categories of patients (by age, by somatic diseases), the impossibility of simultaneously affecting the entire cellular tissue of the lower leg, the formation of coarse scars in the postoperative period. The application of extensive wounds leads to a high percentage of postoperative suppuration and necrosis in the area of the edges of the wounds, neurological disorders are possible.

A known method of surgical treatment of lymphedema, including mechanical tube lipoextraction and myectomy along the external, internal and anterior contour of the limbs (RF Patent No. 2192170, IPC АВВ 17/00, publ. 2002, prototype).

This method does not allow to radically remove all affected cellular space. Closed cavities created by tube scalpels are subject to suppuration and filling with lymphatic fluid. With 3 stages of the disease, damage to the skin and muscles is possible due to the difficulty of holding tube scalpels in the scar-changing and already changed fatty tissue. High risk of arterial bleeding.

The objective of the invention is to remedy these disadvantages, increase the effectiveness of treatment while reducing trauma by eliminating damage to the skin, the formation of lymphovenous and lympho-muscular lymph discharge without radical damage to the cellular space. A high cosmetic effect is provided, neurological disorders are excluded.

To this end, in the method of surgical treatment of lymphedema of the lower extremities, it is proposed to apply subcutaneous sutures along the circumference of the lower leg sequentially from the foot to the knee joint at a distance of 4-6 cm from each other. Spread an additional ligature (preferably 12-14 cm long) on the ligature of each seam from the side diametrically opposite the first injection, leaving the ends on the skin, it facilitates the removal of the main ligature when removing the seam. The ends of the main ligature of the saphenous suture are pulled together by a knot at a single point of injection-puncture until the knot and the ligature junction are submerged under the skin, then a gauze swab is placed over the knot and the ligature is fixed on it, additional tensile stitches are carried out daily for 10-21 days, after which the ligature delete.

The fact that the sutures are applied starting from the foot to the knee joint, allows to reduce blood supply to tissues and reduce lymphatic drainage of adipose tissue during subsequent upper sutures, since the outflow of blood and lymph from the lower limb comes from the foot. The immersion of the node on the main ligature and the junction of the ligatures under the skin eliminates pressure sores. A gauze swab provides less pressure per cm ^{2 of the} skin of the fixing nodes, which also prevents bedsores from forming. Depending on the speed of decreasing lymph drainage, the number of days required for additional ligature tension is determined by damaged fatty tissue.

Figure 1 presents a diagram of the application of one subcutaneous circular removable suture on the lower leg, figure 2 is the same after tensioning the main ligature.

The drawing shows: skin - 1, subcutaneous fat - 2, fascia - 3, muscles - 4, bones - 5, main ligature - 6, additional ligature - 7, immersion unit 8 of the main ligature, nodes 9 (fixed on a tampon), cotton-gauze swab - 10, puncture holes (prick-puncture) - 11.

The implementation of the method is shown in specific clinical examples.

Example 1

Patient S., 49 years old, was admitted to the department of vascular surgery with complaints of severity and unresolved swelling of the left leg. Sick 10 years, the disease connects with heredity and repeated erysipelas of the skin of the left leg.

The patient's condition is satisfactory. By internal organs without features. A / D 130/80 mm RT. Art. Pulse 72 per minute. In the region of the left tibia, lymphedema of the 3rd degree, the skin is sharply thickened with the manifestations of hyperkeratosis, is not going to fold, skin pigmentation from the foot to the knee joint is noted, there is dense inductive edema of the left tibia. The left lower leg is circumferential compared to the right + 15-18 cm. With ultrasound, deep veins are passable.

The operation was performed under epidural anesthesia. After processing the surgical field, an incision was made 2 cm lower and parallel to the inguinal fold 4 cm long. The large saphenous vein (BPV) was bluntly distinguished, crossed between the clamps and ligated with stitching. Bandaging the BPV eliminates the risk of thromboembolism after removal of the submersible circular removable suture. We put immersion removable seams. The first seam is applied at the level of the lower edge of the ankles. The suture is applied using a needle with a removable handle through skin punctures 1. Ligature (PVC line No. 9) follows the needle through the puncture and exits through the puncture 11, and again through the puncture the needle passes the ligature to the next puncture, the ligature remains directly under the skin in fatty tissue 2. After the ligature has been completely carried out under the skin around the circumference, the needle leaves the first injection, after which the first knot 8 is tied between the ends of the ligature, which tightens the loop to the limit, while the knot is immersed subcutaneously. Then, a cotton-gauze swab 10 is placed between the ends of the ligature, and the ligature is fixed on it with a double knot 9. An additional ligature 7, 14 cm long, is thrown onto the main ligature, at the maximum distance from the first injection, which is subcutaneously immersed when the loop is tensioned, and its ends remain on the skin. Fascia, muscles and bones (3, 4, 5, respectively) are not injured during this operation. Sutures were applied 5 cm apart, from the foot to the upper third of the leg. The surgical field is treated with iodine. An aseptic dressing is applied. Elastic bandage of a limb. The tension of the sutures in this patient was carried out for 20 days with a daily replacement of gauze swabs, because swelling decreased daily, and the suture weakened. Removal of sutures for 21 days. The patient was discharged for outpatient treatment.

Inspection after a year: the shin around the circumference has the correct shape, no scars.

Example 2

Patient L., 52 years old, was admitted to the department of vascular surgery with complaints of dense, unresolved swelling of the left leg. Sick for about 8 years, the disease is associated with chronic erysipelas of the left leg. Earlier 3 years ago, a phlebectomy was performed in the BPV system of the left lower limb.

The patient's condition is satisfactory. By internal organs without deviations from the norm. A / D 140/85 mm Hg Art. Pulse 64 per minute. In the region of the left tibia, lymphedema of the 2nd degree, the skin is thickened, there is no pigmentation, the left tibia is + 6 cm, with finger pressure of pastiness not noted. With ultrasound, deep veins without features.

The operation was performed under epidural anesthesia. Suturing began at the level of the left ankle joint. An injection was made of a needle loaded with polyvinyl chloride fishing line No. 8 on the inner surface of the left lower leg at the level of the ankle joint. The needle was punctured after 6 cm, the fishing line, passing directly under the skin, came out of the hole together with the needle, then the needle and fishing line were passed through the same hole until the next injection. An additional ligature of 12 cm long is thrown over the outer surface of the lower leg onto the main line, before the needle is submerged under the skin. The needle and the fishing line following it create a kind of subcutaneous “pouch” and emerge from the first injection along the inner surface of the lower leg. We tightly tie the first knot, while it is immersed in the puncture hole. A tightly twisted gauze swab of 2 × 7 cm is taken, placed between the ends of the fishing line, and two nodes are superimposed to fix the ligature on it. After 5 cm from each other, gradually approaching the knee joint, 7 of the above joints are superimposed.

Dressings are made daily with puncture holes being treated with brilliant greens and gauze swabs are replaced. When replacing gauze tampons, an additional tension of the circular seam is performed daily, as the circumference of the lower leg was reduced daily, and the seam weakened.

Sutures were removed on day 18. The patient was discharged for outpatient treatment.

Disability recovery 30 days after the operation.

Inspection after a year: the left tibia is circumferential compared to the right +1 cm, the tibia has the correct shape, no scars.

The developed technique was used to treat lymphedema 1-3 tbsp. in nine patients.

The immediate and long-term complications were not noted. Operation time 30-40 minutes. Patients are monitored for 1-5 years.

The operation is less traumatic, performed in one step, gives a good therapeutic and cosmetic effect, does not require a patient to be in the hospital for a long time, discharge for outpatient treatment is possible on the third day after the operation, in the postoperative period, patients with pain and discomfort were not noted, bed rest is not required .

During this operation, the skin and subcutaneous tissue are not injured, which excludes suppuration and necrosis of the skin. Circular subcutaneous ligature allows you to create strong pressure on the altered fiber and thus stop lymph drainage along it, followed by sclerotherapy and scarring in this area. Subcutaneous ligature excludes pressure sores on the skin. An additional ligature ensures complete removal of the submersible circular removable seam.

Claims (1)

A method for the surgical treatment of lymphedema, characterized in that superimposed subcutaneous sutures are made around the leg circumference sequentially from the foot to the knee joint at a distance of 4-6 cm from each other, with additional ligature being thrown onto the ligature of each suture from the side diametrically opposite to the first injection, the ends of the latter are left on the skin, and the ends of the ligature of the saphenous suture are pulled together with a knot at the puncture point until the knot and the ligature junction join under the skin, then a gauze swab is placed over the knot and fixed on m ligature, conduct additional daily tension of the seams for 10-21 days, after which the ligatures are removed.

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