RU2751821C1 - Method for closing postoperative wound defect of sacrococcygeal area - Google Patents

Abstract

FIELD: medicine; surgery.SUBSTANCE: invention relates to medicine, namely to surgery, it can be used in the surgical treatment of the epithelial coccygeal passage (ECC). With the condition of preserving the gluteal muscle, the gluteal fascia is dissected with the mobilization of fascial leaves. A perforated single-lumen drainage is placed on the wound bottom, the ends of which are removed through the counterpertures from the right of the upper wound corner and from the left of the lower wound corner. The drainage is fixed to the skin with a monofilament thread of size 3/0 according to USP. Then, a blocking thread is passed through by retracting from the upper wound corner by 2-4 cm, making an injection with a needle with a monofilament non-absorbable thread of size 8 according to USP, which is removed at the wound bottom, and applying clamps-holders to the blocking thread ends. After that, the mobilized fascial flaps are stitched over the perforated drainage with monofilament non-absorbable threads of size 1 according to USP. Then, on each monofilament non-absorbable thread of size 1 according to USP, the first knot is made, then, the second knot is tied, thus forming a loop through which the blocking thread is passed. Then, the second knot is tightened until the loop is fixed around the blocking thread. After fixing the node of the last monofilament non-absorbable thread on the blocking thread, the blocking thread is removed through the subcutaneous tissue and skin at a distance of 2-3 cm from the right at the level of the lower wound edge. Monofilament threads tied on the fascia are removed through the skin wound edge, the ends of each thread are connected to each other, forming a knot at a distance of 5 cm from the skin, free thread ends 6 cm long are left above the knot, and the skin is stitched. The free ends of the blocking thread are tied over the wound, thus forming a loop-handle, on which the free ends of monofilament threads of size 1 according to USP are fixed. The wound fluid is evacuated by layer-by-layer drainage: the subfascial layer is drained by perforated single-lumen drainage, the epifascial layer is drained between the edges of the stitched wound by shifting the monofilament threads of the fascia while dressing. On the 21-24 day, the removable stitches are removed.EFFECT: method reduces tension, improves the formation of stitches and evacuation of wound fluid by preserving the gluteal muscle, dissecting the fascia with the mobilization of fascial leaves, followed by stitching the fascia with removable stitches and skin-subcutaneous-fat tissue, applying removable stitches and layer-by-layer draining the wound.1 cl, 5 dwg, 2 ex

Description

The proposed invention relates to medicine, namely to surgery and can be used in the surgical treatment of the epithelial coccygeal passage (ECC).

The problem of choosing the correct method for closing a wound defect after excision of ECC to obtain an optimal clinical and cosmetic result continues to be an urgent surgical task at the present time.

There are many ways to restore the integrity of the skin after excision of ECC, including the option of "open" wound healing, which is the "gold standard" of treatment of patients in some countries, for example, in Germany (German national guideline on the management of pilonidal disease I. Iesalnieks , A. Ommer, S. Petersen, D. Doll, A. Herold, 2016). Known methods of wound plasty with the help of Limberg and Karidakis flaps are widely used. Some authors use endoscopic and laser techniques, etc. for these purposes (Common surgical procedures in pilonidal sinus disease: A metaanalysis, merged data analysis, and comprehensive study on recurrence VK Stauffer, MM Luedi, P. Kauf, M. Schmid, M. Diek-mann, K. Wieferich, B. Schntiriger D. Doll, 2017).

In the Russian Federation, the widespread method of marsupialization of a wound defect after excision of ECC in the modification according to Moshkovich (Clinical guidelines for the diagnosis and treatment of patients with epithelial coccygeal passage, Moscow, 2013). On the formed wound, separate interrupted sutures are applied with a nylon thread. The needle is injected from the side of the skin at a distance of 1.5-2.0 cm from the edge of the wound, then the next injection is taken in the perpendicular direction of the bottom of the wound (fascia) and the third injection is made through the skin from the inside - outside the wound, to the edge of the skin, perpendicular to the level of the first injection. Similar actions are repeated throughout the wound, respectively, on each side with 3-5 stitches. Then each suture is tightened separately, while the skin edges are tightened and fixed to the bottom of the wound.

The disadvantages of this method are:

1. Tension and tight fixation of the skin edges, which in 20% of cases leads to inconsistency of the sutures and suppuration of the postoperative wound, which in the future has to be carried out "openly" and healing proceeds according to the type of secondary tension. This condemns the patient to long-term dressings for 1-3 months, depending on the size of the diastasis of the skin edges and the depth of the wound.

2. The used suture material (most often nylon) is not monofilament and therefore has "wick" properties, which significantly increases the risk of wound suppuration.

3. When one suture is erupted, deformation of the entire postoperative scar is observed, it is necessary to remove the remaining threads and lead the wound in an open way, as a result of which the wound heals by secondary intention.

4. When applying these sutures, it is not possible to achieve a high-quality comparison of the wound edges, which leads to long-term scar formation, not always a satisfactory cosmetic result, and can also lead to inconsistency of the sutures and wound infection.

5. After removing the stitches from the postoperative wound, traces remain on the skin, and the scar takes on the appearance of a "fish skeleton" (Lichman L.A. RU2655884, patent published on May 29, 2018)

Also known "Method for the treatment of epithelial coccygeal passage" (Patent RU 2277865, published 20.06.2006), which proposes surgical treatment of recurrent epithelial coccygeal passages. The method includes: performing two bordering incisions, radical excision of ECC, applying additional - laxative incisions, closing the wound defect with the help of skin-fatty grafting with displaced flaps and suturing the wound. The displaced flaps are formed by applying additional laxative incisions of the skin and subcutaneous fat throughout the entire thickness at an angle of 60 ° to the edges of the main wound defect: - while from each edge of the wound, 2 triangular flaps are cut out, the length of one of their sides is close to half the length wounds. The flaps are moved alternately on each side to the wound defect, fixed to the bottom of the wound by the lower edge of the subcutaneous tissue, then the skin wound is sutured.

The disadvantages of this method include: 1) difficulties in the formation of symmetrical skin and fat flaps of the same shape, which can lead to deformation of the suture line when closing the wound, tension of tissues with the possibility of ischemia in them and, as a result, inconsistency of the sutures, wound suppuration and relapse diseases; 2) the formed fatty skin flaps may not correspond in size to the formed defect, which can lead to deformation of the sacrococcygeal region and deterioration of the cosmetic result of the operation; 3) there is a likelihood of the formation of sub-flap cavities when cutting out large-sized skin and fat flaps and, as a consequence, the risk of developing wound infection increases (RU 2556617, published on July 10, 2015).

For the closest analogue, the method proposed by prof. P.V. Tsarkov et al. (RU 2604768, published on 10.12.2016) In practice, the method is carried out as follows: after excision of the epithelial coccygeal passage and performing hemostasis, fascial skin plasty with gluteal muscles is performed. The bottom of the wound is represented by a fascia covering the posterior surface of the sacrum and dividing into two sheets of its own fascia of the gluteal region. At the first stage, at a distance of 2 cm from the midline along the entire length of the wound, two parallel incisions of the own fascia of the gluteal region, covering the medial edges of the gluteus maximus muscles, are performed. To mobilize the gluteus maximus muscle, its fibers are crossed at the point of attachment to the sacrum from both sides in the projection of the previously made incisions of the gluteal fascia propria. Due to the counter mutually directed traction of the mobilized muscle flaps to each other, the soft tissue defect is closed. The first row of interrupted sutures is applied to the muscle, then the fascia is sutured, capturing the subcutaneous fat layer. A drainage tube is installed at the bottom of the wound for active aspiration of secretions. The skin is sutured with interrupted sutures. Aseptic dressing.

This method of wound closure has several disadvantages.

1. Produce additional trauma, - dissect the fascia, thereby not only making additional incisions, but also forcibly separating the subcutaneous tissue, which creates additional cavities that the authors do not drain layer by layer, thereby increasing the risk of postoperative wound suppuration.

2. In the wound, foreign material remains (threads on the muscles of the fascia in the bottom of the wound), which can also be the cause of the development of the inflammatory process.

3. Suturing and tying threads on muscle tissue often leads to gross scarring due to necrosis of the muscle under the thread, which leads to the eruption of the suture and an increased risk of wound suppuration.

Tasks:

- reducing the tension of the matched skin edges;

- improvement of the formation of sutures, allowing the removal of threads when a firm fixation of the edges of the fascia is achieved;

- ensuring effective layer-by-layer wound drainage; The essence of the method is that, provided that the gluteus maximus muscle is preserved, the fascia is dissected with mobilization of the fascial leaves, then a perforated single-lumen drainage is placed on the bottom of the wound, the ends of which are removed through counterpertures in the upper and lower corners on the right and fixed with a monofilament thread 3/0 in size. USP is applied to the skin, then a "blocking" suture is passed: 2-4 cm away from the upper corner of the wound, an injection is made with a needle with a monofilament non-absorbable suture of size 8 according to USP, which is removed at the bottom of the wound, clamps are applied to the ends of the sutures, and then sutured mobilized fascial flaps over perforated drainage with monofilament non-absorbable sutures of size 1 according to USP, while making the first knot, then tying a second knot, while forming a loop from one of the ends of the thread, holding a "blocking" thread, tighten the second knot until the loop is tightly fixed around " blocking "thread, after fixing the last knot" blocking "thread through the subcutaneous tissue the tissue and skin are punctured at a distance of 2-3 cm to the left at the level of the lower edge of the wound, monofilament threads tied to the fascia are brought out through the skin edge of the wound, the ends of each thread are tied together, a knot is formed at a distance of 5 cm from the skin, free ends are left above the knot sutures 6 cm long, suture the skin, then the free ends of a monofilament suture of size 8 according to USP are tied over the wound, thus forming a loop "handle" with fixing the free ends of monofilament sutures of size 1 according to USP on it, the wound fluid is evacuated by layer-by-layer drainage: subfascial layer perforated single-lumen drainage, the epifascial layer - between the edges of the sutured wound by displacement when ligating monofilament fascia threads, removable sutures are removed on the 21-24th day.

EFFECT: reduction of tension of the matched skin edges due to preservation of the gluteus muscle, dissection of the fascia with mobilization of the fascial sheets, followed by stitching of the fascia with removable sutures and skin-subcutaneous fat according to McMillan-Donatty; improvement of the formation of sutures, allowing the removal of threads, when a firm fixation of the edges of the fascia is achieved due to the holding of a "blocking" thread: they retreat from the upper corner of the wound by 2-4 cm and make an injection with a needle with a monofilament non-absorbable suture of size 8 according to USP, which is withdrawn at the bottom of the wound, clamps are applied to the ends of the threads, after which the mobilized fascial flaps are sutured over the perforated drainage with monofilament non-absorbable sutures of size 1 according to USP, while the first knot is made, then the second knot is tied, while a loop is formed from one of the ends of the thread, a "blocking" thread, tighten the second knot until the loop is tightly fixed around the "blocking" thread, the edges of the fascia are sutured with a "step" of 1.0 cm, after fixing the last knot, the "blocking" thread through the subcutaneous tissue and the skin is punctured at a distance of 2-3 cm to the left at the level the lower edge of the wound, monofilament threads tied to the fascia are brought out through the skin edge of the wound, tie the ends of each thread between d, form a knot at a distance of 5 cm from the skin, leave the free ends of a thread 6 cm long above the knot, suture the skin and subcutaneous fat layer according to McMillan-Donati, then the free ends of a monofilament thread of size 8 according to USP are tied over the wound thus forming loop - "handle" to prevent tangling of threads with fixation of free ends of monofilament threads of size 1 according to USP on it; evacuation of wound fluid due to layer-by-layer drainage of the wound: subfascial layer with perforated single-lumen drainage, epifascial layer - between the edges of the sutured wound using displacement during dressing of monofilament fascia threads.

The method was tested on 10 patients, the period of postoperative observation was 9 months.

For better understanding, figure 1-5 shows the stages of the operation, where figure 1 - epithelial coccygeal passage, item 1 - intergluteal fold, item 2 - ECC; Fig. 2 - excised ECH, item 3-subcutaneous fatty tissue, item 4 - gluteal fascia; Fig. 3-mobilized fascia, p. 5 - gluteal muscles; Fig. 4 - sutured fascia, item 6 - threads on the fascia, item 7 - "blocking thread", item 8 - perforated single-lumen drainage; Fig. 5 - sutured wound p. 9 - sutured skin, p. 10 - "handle".

The method is carried out as follows: in the position of the patient according to Depage under endotracheal anesthesia, the intergluteal fold of item 2 and the fistula of item 1 are visualized, after processing the operating field with an antiseptic solution and delimiting the operating field with sterile linen, the fistula is marked with a dye solution, then the epithelial coccygeal passage is excised to the fascia covering the gluteal muscles, item 4, thus the walls of the wound are the subcutaneous fatty tissue of item 3, and the bottom of the wound is represented by the gluteal fascia attached to the median sacral ridge, then they retreat from the median sacral ridge by 1 cm and mobilize with a single block of outer leaves fascial sheaths covering the medial edges of the gluteus maximus muscles p. 5, together with the muscles from the sacrum in the lateral direction along the entire length of the wound, about 1-1.5 cm wide on each side, then a perforated single-lumen drainage p. 8, the ends of which are brought out through the counter apertures in the upper and lower corners on the right and fixed with a monofilament suture of 3/0 size according to USP to the skin, then a "blocking" suture is carried out p. 7: 2-4 cm away from the upper corner of the wound, an injection is made with a needle with a monofilament non-absorbable suture of size 8 according to USP, which is taken out at the bottom of the wound, clamps are applied to the ends of the threads, after which the mobilized fascial flaps are sutured over the perforated drainage with monofilament non-absorbable threads of size 1 according to USP, while the first knot is made, then the second knot is tied, while forming a loop from one of the ends of the thread, pass the "blocking" thread through the loop, tighten the second knot until the loop is tightly fixed around the "blocking" thread, after fixing the last knot, the "blocking" thread through the subcutaneous fatty tissue and the skin is punctured at a distance of 2-3 cm to the left on the level of the lower edge of the wound, monofilament threads tied to the fascia, item 6, are brought out through the skin edge of the wound, tie the ends of each thread together, form a knot at a distance of 5 cm from the skin, leave the free ends of a thread 6 cm long above the knot, suture the skin, item 9, then the free ends of a monofilament thread of size 8 according to USP are tied over the wound, thus forming a loop "handle" item 10 with fixation the free ends of the USP size 1 monofilament yarns on it. The operation is completed with the imposition of an aseptic bandage. In the postoperative period, daily dressing of the wound is performed with washing of the perforated drainage with an aqueous solution of an antiseptic, which is removed, depending on the nature and amount of wound fluid, for 2-5 days, and also displacement between the edges of the sutured wound of monofilament fascia threads is performed. Skin sutures are removed for 10-12 days. Removable seams for 21-24 days.

Example 1: Patient P., 21, was admitted to the department of purulent surgery in a planned manner with a diagnosis of ECH with chronic inflammation, stage of a purulent fistula. Upon receipt of a complaint: a fistula in the sacral region. Medical history: the patient considers himself ill for a long time, when a fistula appeared in the area of the intergluteal fold. When viewed in the area of the intergluteal fold, there is a purulent fistula along the inner surface of the left gluteal region at a distance of 1.5 cm from the midline and 5 cm from the anus; a characteristic retraction of the skin is located in the center. 2. The epithelial coccygeal passage was excised, item 3, the gluteal muscles were preserved, the fascia was dissected with mobilization of the fascial sheets, item 5, after which a perforated single-lumen drainage was placed on the bottom of the wound, item 8, the ends of which were brought out through counterpertures 2 cm above and below the corners of the cutaneous wounds to the right and fixed with 3/0 USP monofilament suture to the skin. Next, a "blocking" suture was carried out in clause 7: a needle with a monofilament non-absorbable suture of size 8 according to USP was injected 3 cm away from the upper corner of the wound, which was brought out in the bottom of the wound, and retainer clips were applied to the ends of the sutures. After that, the mobilized fascial flaps were sutured over the perforated drainage with monofilament non-absorbable sutures of size 1 according to USP p. 6, while the first knot was made, then the second knot was tied, while a loop was formed from one of the ends of the thread, a "blocking" thread was drawn, tightened the second knot until the loop is tightly fixed around the "blocking" thread. The edges of the fascia were sutured with a “step” of 1 cm. After fixing the last knot, the “blocking” thread was pulled through the subcutaneous tissue and skin at a distance of 2 cm to the left at the level of the lower edge of the wound. Monofilament threads tied to the fascia were brought out through the skin edge of the wound, tied the ends of each thread together, formed a knot at a distance of 5 cm from the skin, free ends of a thread 6 cm long were left above the knot. The skin and subcutaneous fat layer were sutured according to McMillan- Donatip. 9. Next, the free ends of the USP size 8 monofilament thread were tied over the wound, thus forming a loop - "handle" of claim 10 with fixing the free ends of the USP size 1 monofilament threads on it. The postoperative period was uneventful. Skin sutures were removed on the 10th day. The patient with recovery was discharged home. Removable sutures were removed on an outpatient basis on day 21.

Example 2: Patient N. 23 l, was admitted to the department of purulent surgery in a planned manner with a diagnosis of ECC without clinical manifestations. On receipt of a complaint: retraction in the sacral region. Medical history: the patient considers himself ill for a long time, when he noticed a retraction in the area of the intergluteal fold. When viewed in the area of the intergluteal fold, there is a 5 cm from the anus, in the center there is a characteristic retraction of the skin p. 2. Excision of the epithelial coccygeal passage of p. 3 was performed, the gluteal muscles were preserved, the fascia was dissected with the mobilization of the fascial sheets, p. 5, after which on the bottom of the wound was placed a perforated single-lumen drainage item 8, the ends of which were brought out through the counterpertures 2.0 cm above and below the corners of the skin wound on the right and fixed with a monofilament suture of 3/0 USP size to the skin. Next, a "blocking" suture was carried out in step 7: 4 cm away from the upper corner of the wound, a needle with a monofilament non-absorbable suture of size 8 according to USP was injected, which was brought out at the bottom of the wound, and holding clips were applied to the ends of the sutures. After that, the mobilized fascial flaps were sutured over the perforated drainage with monofilament non-absorbable sutures of size 1 according to USP p. 6, while the first knot was made, then the second knot was tied, while a loop was formed from one of the ends of the thread, a "blocking" thread was drawn, tightened the second knot until the loop is tightly fixed around the "blocking" thread. The edges of the fascia were sutured with a "step" of 1 cm. After fixing the last knot, the "blocking" thread was punctured through the subcutaneous tissue and skin at a distance of 3 cm to the left at the level of the lower edge of the wound. Monofilament threads tied to the fascia were brought out through the skin edge of the wound, tied the ends of each thread together, formed a knot at a distance of 5 cm from the skin, free ends of a thread 6 cm long were left above the knot. The skin and subcutaneous fat layer were sutured according to McMillan- Donati p. 9. Next, the free ends of the USP size 8 monofilament were tied over the wound, thus forming a loop - "handle" of step 10 with fixing the free ends of the USP size 1 monofilaments on it. The postoperative period was uneventful. Skin sutures were removed on the 12th day. The patient with recovery was discharged home. Removable sutures were removed on an outpatient basis on the 24th day.

Long-term results: After the operation of ECC excision using the proposed method of closing the wound defect, long-term results were studied in 10 patients for 9 months. During the observation period, there were no cases of relapse or adverse outcomes. Vancouver Scar Scale (VSS) 2 points.

Applicants: on behalf of the GBUZ "Research Institute - Regional Clinical Hospital No. 1 named after Professor SV Ochapovsky" of the Ministry of Health of the Krasnodar Territory, Deputy. chief doctor in surgery.

Claims (1)

A method of closing a postoperative wound defect of the sacrococcygeal region, including excision of the epithelial coccygeal passage (ECC), making an incision of the gluteal fascia of its own, characterized in that, with the condition of preserving the gluteus muscle, the gluteal fascia is dissected with mobilization of the fascial leaves, then a perforated single-lumen drainage, the ends of which are brought out through counter-openings to the right of the upper corner of the wound and to the left of the lower corner of the wound, fix the drainage with a monofilament suture of 3/0 USP size to the skin, then pass a blocking suture: retreat from the upper corner of the wound by 2-4 cm , an injection is made with a needle with a monofilament non-absorbable suture of size 8 according to USP, which is brought out in the bottom of the wound, clamps are applied to the ends of the blocking suture, after which mobilized fascial flaps are sutured over the perforated drainage with monofilament non-absorbable sutures at each size of 1 USP monofilament The first knot is made with an absorbable suture of size 1 according to USP, then the second knot is tied, thus forming a loop through which the blocking suture is passed, then the second knot is tightened until the loop is fixed around the blocking suture, after fixing the knot of the last monofilament non-absorbable suture on the blocking suture, the blocking suture is pulled out through the subcutaneous tissue and skin at a distance of 2-3 cm to the right at the level of the lower edge of the wound, monofilament threads tied to the fascia are brought out through the skin edge of the wound, tie the ends of each thread together, forming a knot at a distance of 5 cm from the skin, leave free above the knot the ends of the thread 6 cm long, the skin is sutured, then the free ends of the blocking thread are tied over the wound, thus forming a loop-handle, on which the free ends of monofilament threads of USP size 1 are fixed; carry out the evacuation of wound fluid by layer-by-layer drainage: subfascial layer with perforated single-lumen drainage, epifascial layer - between the edges of the sutured wound by displacement during dressing of monofilament fascia threads; on the 21-24th day, the removable sutures are removed.

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