RU2741255C1 - Method for wound closure of sacrococcygeal region with plasty of mobilized fascial-fat flaps - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely to coloproctology and surgery, and can be used in surgical treatment of patients with primary and recurrent epithelial coccygeal course. Method involves two parallel incisions of intrinsic fascia covering gluteus muscles at their attachment to sacrum, at distance of 1.5-2 cm from median line along entire length of wound, mobilization of fascial-fat flaps in lateral direction for not more than 2 cm and their subsequent opposite traction to median line replacing deficiency of tissue. Separate interrupted sutures are applied on the formed mobilized flaps all along the wound, fixing to the wound bottom, grasping the sacral fascia at distance at 1 cm from each other. A drainage tube is placed on the wound bottom. Wound is sutured in layers.EFFECT: method provides reduced number of recurrences without pain manifestation of pain syndrome in postoperative period and risk of bleeding due to formation of fascial-fat flaps.1 cl, 1 ex, 3 dwg

Description

The technical field to which the invention relates

The invention relates to medicine, namely to coloproctology and surgery, and can be used in the surgical treatment of patients with primary and recurrent epithelial coccygeal duct (ECH), who are planned to perform radical surgical intervention. Also, the invention can be used in reconstructive plastic surgery for the restoration of wounds in the sacrococcygeal region.

State of the art

It is known that the incidence of epithelial coccygeal duct (ECC) in the general population is 26 cases per 100,000 population (Sondenaa K. 1995, Sondenaa K, Andersen E, Nesvik I, Soreide JA. Patient characteristics and symptoms in chronic pilonidal sinus disease. Int J Colorectal Dis1995; 10: 39-42, Chintapatla S, Safarani N, Kumar S. Sacrococcygeal pilonidal sinus: historical review, pathological insight and surgical options.Tech Coloproctol 2003; 7: 3-8, Clothier, PR, Haywood, IR The natural history of the post anal (pilonidal) sinus. Ann R Coll Surg Engl. 1984; 66: 201-203). Despite the long history of surgical treatment of the epithelial coccygeal passage, there is currently no "gold standard" surgical technique. Russian and foreign authors have proposed a huge variety of surgical interventions, however, the frequency of postoperative complications and relapses remains high (up to 37%), which leads to lengthening the treatment time, a long return to normal daily activity, and a deterioration in the quality of life of young patients (Dultsev Yu. Rivkin V.L. Epithelial coccygeal passage. - M. 1988, - 128 p., Iesalnieks I., Fürst A., Rentsch M., Jauch KW Primary midline closure after excision of a pilonidal sinus is associated with a high recurrence rate Chirurg 2003; 74 (5): 461-8, Seyed Vahid Hosseini; Mohammad Rezazadehkermani; Reza Roshanravan; Khairallah Muzhir Gabash; Mahmoud Aghaie-Afshar, Pilonidal Disease: Review of Recent Literature, Ann Colorectal Res. 2014 June). All techniques with primary wound closure can be divided into 2 large groups: 1) with preservation of the intergluteal groove, 2) with the elimination of the intergluteal groove. To eliminate the soft tissue defect after excision, various options for plasty were proposed with mobilized or rotated flaps on the feeding pedicle, in which the intergluteal sulcus is displaced laterally from the midline (I. Iesalniek & A. Ommer & S. Petersen & D. Doll & A. Herold , German national guideline on the management of pilonidal disease, Springer-Verlag Berlin Heidelberg 2016, Karydakis GE. Easy and successful treatment of pilonidal sinus disease after explation of its causative process. Aust NZ Surg 1992). The results of a 2014 meta-analysis on the example of 25 randomized trials with a total group of 2949 patients indicate that the approach with elimination of the intergluteal sulcus has advantages over the median approach with wound closure in radical surgical treatment of ECC (JM Enriquez-Navascues, JI Emparanza, M. Alkorta, C. Placer, Meta-analysis of randomized controlled trials comparing different techniques with primary closure for chronic pilonidal sinus, Tech Coloproctol, April 2014). However, the median approach provides the best cosmetic effect, since the postoperative scar is located in the midline in the intergluteal groove. In some studies, it is proposed to modify the median approach by mobilizing the musculo-fascial flaps of the gluteus maximus muscles, which makes it possible to eliminate the defect, while reducing the frequency of disease recurrence and the risk of dehiscence of the wound edges in the postoperative period when the patient is activated (Krand O, Yalt T, Berber I, Kara VM, Tellioglu G (2009) Management of pilonidal sinus disease with oblique excision and bilateral gluteus maximus fascia advancing flap: result of 278 patients. Dis Colon Rectum; 52: 1172-7. Https://doi.org/10.1007/DCR. 0b013e31819ef582, El-Shaer WM (2010) The modified gluteal sliding plication closure in the treatment of chronic pilonidal sinus. Int J Colorectal Dis; 25: 887-94. Https://doi.org/10.1007/s00384-010-0911- z.).

In particular, a method for the treatment of the epithelial coccygeal passage is known (Arslan S, Karadeniz E, Ozturk G, Aydinli B, Bayraktutan MC, Atamanalp SS. Modified Primary Closure Method for the Treatment of Pilonidal Sinus. Eurasian J Med; 48: 84-9. 2016 ), which consists in the fact that after excision of the ECC within the unchanged tissues to the sacral fascia, a single block is made to mobilize the flaps consisting of the fibers of the gluteus maximus muscles and fascia covering these muscles, as well as to separate the fascial-muscular flap from the subcutaneous fat. The next step is mutual traction of the fascial flaps together with the gluteus maximus muscles to the midline and suturing them together with the presacarral fascia with single interrupted sutures. Thus, the "dead space" after excision of the ECC was eliminated by moving the fascial-muscle flaps. The drain was placed over the sutured fascial flaps. Then the wound was sutured in layers. The new positioning position provided less tension in the matched tissues in the postoperative period, which led to a lower recurrence rate.

However, according to this method, the mobilization of fascial-muscle flaps is performed, which can be the cause of severe pain syndrome due to trauma by partial intersection of muscle fibers. Also, the formation and movement of muscle flaps can lead to a violation of microcirculation with a high probability of developing hematoma in the postoperative period. In addition, the installation of a drain with active aspiration over the sutured fascial flaps does not allow drainage of the space under the flaps.

There is also known a method of surgical treatment of the epithelial coccygeal passage (patent RU2277865, publ. 20.06.2006), which consists in closing the wound defect with displaced flaps, which are cut out by additional incisions of the skin and subcutaneous fat for the entire thickness at an angle of 60 degrees to the edges of the main wound defect. Cut out 2 triangular flaps, the length of one of the sides of which is close to the size of half the length of the wound defect. The flaps are alternately moved and fixed to the bottom of the wound by the lower edge of the subcutaneous fat, stitching them together with the edges of the wound.

The disadvantages of this method include the complexity of the flap formation due to the limited mobility of the tissue of this anatomical region, as well as the need to perform additional incisions, which in turn leads to prolonged wound healing, the formation of foci of infection and, as a consequence, an increase in the period of disability. In addition, additional lateral incisions significantly worsen the cosmetic result of the operation, significantly deforming the relief of the sacral region.

Closest to the proposed invention is a method of suturing a wound in the gluteal-sacral region (patent RU 2604768 C1 dated 09.24.2015 Tsar'kov P.V.), according to which two parallel incisions are made at a distance of 2 cm from the midline along the entire length of the wound. fascia covering the medial edges of the gluteus maximus muscles, followed by the intersection of the gluteus maximus muscle fibers at the attachment to the sacrum on both sides parallel to the previously made fascia incisions. Then the mobilized muscle flaps are reduced, replacing the soft tissue defect. A drainage is installed at the bottom of the wound for active aspiration of secretions from the wound. The wound is sutured in layers.

However, this method is not devoid of disadvantages due to the preservation of a residual cavity over the sacral fascia, which can lead to the formation of seromas and suppuration. In addition, excessive mobilization of flaps with the intersection of the gluteus maximus muscle fibers and the reduction of muscle-fascial flaps along the midline can cause severe pain in the postoperative period. Also, the intersection of muscle fibers leads to disruption of the microcirculatory bed of muscle tissue with a high probability of the formation of seroma or hematoma, the formation of partial necrosis of muscle tissue is not excluded.

The technical problem to be solved by the invention is to reduce the number of disease relapses without increasing the severity of pain in the postoperative period and the risk of bleeding while improving the immediate and long-term cosmetic results of surgical treatment of primary and recurrent epithelial coccygeal passage.

Disclosure of the essence of the invention

The technical result of the invention is to reduce the number of relapses of the disease due to the formation of fascial-fatty flaps, which allow you to eliminate the "dead space" and, as a result, to reduce the tension of tissues during their movement, performing plastic surgery of the soft tissue defect of the sacral region, without increasing the severity of pain in the postoperative period and the risk of bleeding due to the lack of intersection of the gluteus maximus muscle fibers.

The technical result is achieved through the implementation of the method of closing the wound of the sacrococcygeal region after excision of the epithelial coccygeal passage in a single block to the sacral fascia, including the execution of two parallel incisions of its own fascia, covering the gluteus maximus muscles in the place of their attachment to the sacrum, at a distance of 1.5-2 cm from the midline along the entire length of the wound, mobilization of fascial fat flaps in the lateral direction for no more than 2 cm and their subsequent counter traction to the midline with replacement of tissue deficiency; installation of a drainage tube on the bottom of the wound, layer-by-layer wound closure.

The proposed method has the following advantages:

- Formation of fascial-fatty flaps allows you to reduce tension during the primary wound closure by reducing the width of the wound;

- Mutual traction of the flaps and their reduction along the midline allows you to eliminate the "dead space" by replacing tissues with a fascial-fatty flap;

- There is no violation of microcirculation in the muscle tissue due to the fact that it remains intact when mobilizing only fascial flaps;

- Lack of tissue tension after suturing the fascial-fatty flap followed by suturing on the skin prevents sutures from erupting and subsequent divergence of the edges of the postoperative wound.

Brief Description of Drawings

The invention is illustrated by the illustrations shown in Figures 1-3.

FIG. 1 shows a view of an operating wound after excision with a single ECC block. Figure 2 shows the stage of mobilization of the fascia of the gluteus maximus muscles in the lateral direction from the sacrum for 2 cm (indicated by arrows). Figure 3 shows a view of the operating wound after suturing.

Positions in the illustrations indicate:

1 - gluteus maximus muscle, 2 - subcutaneous fatty tissue, 3 - intrinsic fascia covering the gluteus maximus muscle, 4 - sacral fascia, 5 - cavity formed after ECC excision, 6 - mobilized own fascia covering the gluteus maximus muscle, 7 - mobilized fascial-fatty flap, 8 - own fascia sutured along the midline, covering the gluteus maximus muscles, 9 - drainage.

Implementation of the invention

The proposed method is carried out as follows.

The cavity of the epithelial coccygeal passage is stained through the primary or secondary holes in order to better visualize the altered tissues with a brilliant green solution with 3% hydrogen peroxide solution using a 10 cm ³ syringe. An ellipsoidal incision of the skin, then the subcutaneous fat around the primary and secondary openings, is made bordering all primary and secondary openings, using a scalpel or a monopolar coagulator. The skin and subcutaneous fat are excised in a single block to the sacral fascia, bearing the coccygeal passage within the unchanged tissues (Fig. 1). Laxative incisions of own fascia are performed, covering the gluteus maximus muscles, bordering the tailbone on both sides along the length of the wound at a distance of 1.5-2 cm from the midline, after which the fascial fat flaps are mobilized in the lateral direction from the sacrum for no more than 2 cm, while the fibers of the gluteus maximus muscles remain intact (Figure 2). The mobilized flaps are reduced to the center of the wound along the midline. Through counteropening in the upper corner of the postoperative wound, a tubular drainage is installed for the entire length of the postoperative wound with a diameter of up to 3 mm from silicone / polyvinyl chloride, sutured to the skin with a separate interrupted suture. The wound is sutured in layers (Fig. 3). At the same time, on the formed mobilized flaps, consisting of the fascia of the gluteus maximus muscles and subcutaneous fat, separate interrupted sutures are applied throughout the wound, with fixation to the bottom of the wound, capturing the sacral fascia into the seam, for example, as follows: retreating 0.7- 0.8 cm from the edge of the mobilized fascia of the gluteus maximus muscle, a needle with an abacterial atraumatic thread is injected into the fascial-fatty flap, the needle is punctured and an injection is made from the bottom of the wound, capturing the sacral fascia into the seam, then an injection is made on the opposite side, capturing into the seam fascial fat flap of the opposite side. The suture is tightened, thus bringing the edges of the wound closer to the center, reducing its width and thereby reducing tension. In a similar way, sutures are applied throughout the mobilized fascial-fatty flaps at a distance of 1 cm from each other. Then the postoperative wound is sutured tightly, without tensioning the edges, for example, with separate interrupted vertical sutures according to Donati: departing from the edge of the wound 1.5-2 cm, a needle with an abacterial atraumatic thread is injected into the skin and, passing at the level of the deepest point of the wound, the needle is punctured on the other side at a symmetrical point. Then the needle is injected again on the side where it was taken out, 5-8 mm from the edge of the wound, in line with the first injection, and so that it comes out in the middle of the dermis layer. On the opposite side, the needle is also inserted through the middle of the dermis, and the puncture is made on the opposite side to the skin surface, 5-8 mm from the edge of the skin. When tightening the superimposed vertical mattress suture, the edges of the wound are precisely brought together, fixed to the base and somewhat raised, the dermis and epithelial layer are precisely matched. In a similar way, stitches are applied throughout the wound at a distance of 1-1.5 cm from each other. A system from a corrugated reservoir is connected to the drain to collect the biological fluid for active drainage with negative pressure. Apply an aseptic bandage.

Statistical data

Surgical treatment was provided to 86 patients from April 2017 to January 2020: 41 patients were included in the group with plastic mobilized fascial fat flaps according to the proposed method, 45 patients were included in the group with primary wound suturing tightly. The recurrence rate was significantly lower in the group of patients with wound repair with mobilized fascial-fat flaps (2 patients, 2.3%) than in the group with tight wound suturing (10 patients, 11.6%). There were no significant differences in operation time, pain syndrome, intraoperative blood loss.

Clinical example.

Patient M., 35 years old, was admitted to the Department of Oncological Coloproctology of the Clinical Hospital No. 2 with a diagnosis of recurrent epithelial coccygeal passage. Surgical treatment from 2016: excision of the ECC with tight wound suturing. For a long period, 6 months after the previous operation, pains, periodic discharge of purulent-hemorrhagic discharge from the newly formed holes are disturbing. In the sacrococcygeal region, a postoperative scar is determined, located in the projection of the intergluteal fold up to 7 cm in length.Fistula holes with a diameter of up to 1 cm in the projection of a postoperative scar, in the amount of 3 pieces, are also determined, the hole closest to the anus is 4 cm.When pressing the discharge from no holes.

The operation was performed in accordance with the claimed method.

During the excision operation, the cavity of the epithelial coccygeal passage was stained through the lower opening located in the projection of the intergluteal fold with a brilliant green solution with 3% hydrogen peroxide solution using a syringe. Contrast came from all the holes. An elliptical incision of the skin and subcutaneous fat around the postoperative scar was made using a Hemostasis-dry scalpel. A single block excised recurrent ECC to the sacral fascia within the unaltered tissues. Laxative incisions were made in the fascia covering the gluteus maximus muscles at the point of their attachment to the sacrum, at a distance of 2 cm from the midline, without crossing the gluteal muscle fibers. Further, the mobilization of fascial-fatty flaps was performed in the lateral direction for 2 cm from the sacrum with their subsequent mutual traction to the midline. Through the counterperture in the upper corner of the postoperative wound, a tubular drainage is installed on the bottom for the entire length of the postoperative wound. The first row of interrupted sutures was applied to the fascial fat flaps as described above. Further, the wound was sutured tightly with separate interrupted vertical sutures according to Donati. The drain is connected to a negative pressure active drain system. Aseptic dressing.

The postoperative period was uneventful. The drainage was removed on the 5th day. Healing by first intention. The stitches were removed on the 15th day after the operation. To work - 20 days after the operation. Dynamic observation of postoperative complications and relapse were not revealed. According to the ultrasound data, no accumulation of fluid along the postoperative suture with the formation of leakage was detected.

Claims (1)

A method of closing the wound of the sacrococcygeal region after excision of the epithelial coccygeal passage in a single block to the sacral fascia, including performing two parallel incisions of its own fascia, covering the gluteus maximus muscles at their attachment to the sacrum, at a distance of 1.5-2 cm from the midline throughout along the length of the wound, mobilization of fascial-fatty flaps in the lateral direction for no more than 2 cm and their subsequent counter traction to the midline with replacement of the lack of tissue; installation of a drainage tube on the bottom of the wound; the imposition of separate interrupted sutures on the formed mobilized flaps along the entire length of the wound with fixation to the bottom of the wound, capturing the sacral fascia into the suture; layer-by-layer wound closure.

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