RU2797099C1 - Method of local anesthesia of the median laparotomic wound using semi-permeable membranes. - Google Patents

Abstract

FIELD: medicine, surgery and anesthesiology.

SUBSTANCE: through the upper and lower corners of the median laparotomic wound on each side, laterally 1–1.5 cm away from its edge, a polyurethane catheter with perforations and a dialysis tube put on top of it is installed throughout the wound. The tube is fixed over the catheter with ligatures. Local anesthetic is then continuously injected into the polyurethane catheter using an infusion pump.

EFFECT: method provides adequate postoperative analgesia and prevention of postoperative complications in operated patients on the abdominal organs due to the uniform injection of local anesthetic, which makes it possible to refuse the use of opioid analgesics, to achieve early activation of the patient, to prevent intestinal paresis and to carry out a full chest excursion during breathing.

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Description

The invention relates to medicine, namely surgery and anesthesiology. The method can be used to anesthetize a postoperative wound after median laparotomy.

A known method of standard anesthesia using opioid narcotic analgesics. However, in the early stages of the postoperative period, the administration of narcotic analgesics often causes side effects: nausea, vomiting, dynamic paresis of the gastrointestinal tract, depression of the respiratory center, addiction and physical dependence (Alyautdinov R.N. Pharmacology. - M .: Medicine, 2004. - 197 p.).

A reliable method is also a well-known method of preperitoneal blockade after hernioplasty of median postoperative ventral hernias, including the introduction of local anesthetics into the preperitoneal space using a catheter, characterized in that after installation under the aponeurosis of the endoprosthesis in the formed space around the circumference of the postoperative wound in the form of an oval above the plane of the endoprosthesis, a polyvinyl chloride catheter at a distance of 2.5-3 cm from its edges, having multiple lateral holes throughout, while in the projection of the lower corner of the wound on both sides, separate punctures are made and the ends of the catheter are brought out to the skin, the catheter inlet is connected to a device for dosing local injection anesthetic using a cannula and controlled prolonged irrigation of a 2.5% solution of ropivacaine 20 ml every 6-8 hours for 2-3 days (RF patent No. 2529412 C2, 09/27/2014). However, this method also has its drawbacks. In connection with the proposed suturing of the catheter to the mesh endoprosthesis, in case of infection, this will lead to the need to remove the mesh prosthesis. In addition, the use of a 2.5% solution of ropivakine is fraught with an overdose, is not feasible in conditions of unstable hemodynamics in acute surgical diseases and concomitant cardiovascular pathology. The proposed additional devices - a dosing device, a manometer, make the system cumbersome, which will lead to patient discomfort in the postoperative period, a forced decrease in motor activity. It is well known that in such operations, taking into account the proposed detachment of the musculoaponeurotic layer from the peritoneum, it is often possible to form a hematoma with a weakening of the anesthetic effect, and in the case of using active Redon drainage, the anesthetic is removed immediately after injection. This method has a narrowly focused scope (hernia repair for ventral hernias).

As a prototype, the method of local segmental anesthesia in postoperative anesthesia of a laparotomic wound of the anterior abdominal wall after emergency operations in patients with acute obstructive colonic obstruction of tumor genesis was chosen. The method is carried out after the main abdominal stage of the operation before suturing the laparotomic wound in the following way. Optimal for this manipulation is a small set for pleural drainage Pleurocan B (Pleurocan B, average price ≈ 130 rubles). First, the catheter is prepared by determining the required length (taking into account the individual anatomical features of the patient) and the number of perforations. If necessary, additional holes are made in the proximal part of the catheter using a punch (or a thick Dufo needle). This is necessary to evenly distribute the anesthetic solution in the case of the rectus abdominis muscle. Further, in the upper corner of the laparotomic wound, laterally 2.5-3 cm from its edge, using a thin-walled puncture needle ∅ 3.35 × 78 mm with a shortened cut, a prepared polyurethane catheter ∅ 2.7 mm is installed so that the length of the outer part is 8-10 see. The surgeon places one hand inside the abdomen, and with the other hand passes the needle through the skin, subcutaneous fat, fascia and muscle. Palpation allows you to determine the insertion of the needle tip between the peritoneum with the transverse fascia and the muscle layer, as well as to exclude damage to the lower epigastric artery. After removing the stylet, the catheter is inserted between the peritoneum with the transverse fascia and the muscle at a distance of 8-10 cm. While holding the catheter in place, the surgeon removes the puncture needle. To avoid inadvertent removal, the catheter is fixed by suturing to the skin. After fixation, an adapter is connected for the subsequent injection of anesthetic with a syringe. Intraoperatively, the patency of the catheter is checked by introducing 5 ml of physiological saline upon the appearance of a roller from the side of the peritoneum. The procedure is repeated on the opposite side. For postoperative pain relief, a local anesthetic is injected every 6 hours. Up to 10 ml of 0.125% ropivacaine solution is injected into each catheter. Catheters should be checked daily for signs of inflammation or occlusion. Usually they are removed on the 4th day, but in some cases they can be left up to 7 days (RU2706028 - a method of local segmental anesthesia in postoperative anesthesia of a laparotomic wound of the anterior abdominal wall after emergency operations in patients with acute obstructive colonic obstruction of tumor genesis).

The disadvantage of this method is the lack of uniform distribution of the anesthetic in the wound, which will lead to a lower analgesic effect. Another "weak point" of this invention is the need to periodically independently supply the anesthetic through a syringe, which requires constant monitoring of the device, and also does not make it possible to clearly control the intensity of the injection of the substance itself into the wound.

The objective of the present invention is to offer effective local anesthesia of a postoperative wound of the anterior abdominal wall after median laparotomy during the treatment of surgical diseases of the abdominal organs by uniform administration of the anesthetic preperitoneally (retromuscularly) using a semipermeable membrane. This method provides adequate analgesia, the ability to refuse the use of opioid analgesics, and also contributes to the early activation of the patient, the prevention of postoperative complications, and the early relief of intestinal paresis.

The solution of this problem is ensured by the fact that in postoperative anesthesia of the median laparotomic wound of the anterior abdominal wall after operations on the abdominal organs, local anesthetics are administered retromuscularly (preperitoneally) through a dialysis tube. In the upper and lower corners of the median laparotomy wound on each side, laterally 1-1.5 cm from its edge, a polyurethane catheter (4-5 mm in diameter) is installed throughout the wound with a dialysis tube (6 mm in diameter) worn over it, which is fixed over the catheter with ligatures, while the lower edge of the tubular membrane is tied with a thread over the catheter, and the upper one is loose above the catheter (Fig. 2). A local anesthetic (0.2% solution of ropivacaine) is continuously supplied to the polyurethane catheter using an infusion pump, which diffuses evenly through the dialysis tube, which is a semi-permeable membrane, into the wound for 3-7 days, which ensures uniform infiltration anesthesia evenly. Optimal for this manipulation is the use of a dialysis tube SERVAPOR VISKING Dialysis Membranes, MWCO: 12,000-14,000 Da, 6 mm in diameter. Polyurethane catheter for medical purposes is taken from any drainage system, diameter 4-5 mm. Their length depends on the length of the laparotomic wound and the individual anatomical features of the patient.

The scheme of the device is shown in Fig. 1, fig. 2, where 1 is a dialysis tube, 2 is a polyurethane catheter, 3 is a tied ligature at the upper and lower ends of the dialysis tube, 4 is an adapter, 5 is a rubber sleeve, 6 is a plastic sleeve, 7 is an infusion pump.

The device consists of 2 dialysis tubes (semi-permeable membranes) of the required length (depending on the size of the surgical access) with a diameter of 6 mm (1 in Fig. 1, 2), which are put on over polyurethane catheters (4-5 mm in diameter) (2 in Fig. 1, 2) Catheters are located in dialysis tubes in such a way that the upper edge of the catheter does not reach the top of the dialysis tube, and the lower edge is much longer than that of the membrane, minor perforations are applied to the catheters with a Dufo needle or cut out with scissors. A nylon ligature is applied to the upper edge of the tube and tightly tied; a ligature is tied in a similar way to the lower edge of the membrane, but over the polyurethane catheter (3 in Fig. 1, 2). At the same time, in the upper section, the edges of the ligatures remain quite long (about 10-15 cm each).

This manipulation is carried out to prevent unwanted leakage of local anesthetic due to tightness in the cavity of the dialysis tube (Fig. 2).

The installation method is carried out after the main abdominal stage of the operation before suturing the median laparotomic wound in the following way. The formed complex of dialysis tubes with polyurethane tubes, described above, is placed preperitoneally (retromuscularly) on both sides of the median laparotomy wound at a distance of 1-1.5 cm. more than 5 mm. Under visual control, a uterine probe with a perforated olive (Fig. 3) is inserted into the upper incision of one side to the peritoneum, which is controlled visually and palpation by the surgeon’s hand inserted into the abdominal cavity (Fig. 4), then the probe is guided along the peritoneum to the lower incision, from where its olive is evacuated (Fig. 5), a complex of dialysis tube with a catheter is tied to it through the perforated hole due to the left long "antennae" of the ligature (Fig. 6). After fixing to the probe, the latter, under visual control, is removed in the opposite direction and, thereby, pulls the membrane with the catheter fixed inside it (Fig. 7). The complex is fixed to the skin suture of the lower incision to prevent premature removal. Similarly, another complex is set on the opposite side of the median laparotomy wound (Fig. 8). The upper incisions are sutured tightly. The median laparotomy wound is sutured (Fig. 9), a bandage is applied. At this point, the surgical stage ends, the final stage of device assembly is performed. Rubber sleeves taken from the intravenous drip system (5 in Fig. 1) are connected to the distal free end of the polyurethane catheters, in which plastic sleeves (6 in Fig. 1) with an adapter (4 in Fig. 1) from the standard Redon drainage system are installed. Another plastic sleeve is connected to the adapter hole at the top (lower free edge), to which a polyurethane catheter with a diameter of 4-6 mm is connected. An infusion pump is connected to this catheter, into which an anesthetic is poured (0.2% solution of ropivacaine) and the required rate of its supply is set (Fig. 10).

As a result, a depot of an anesthetic solution is formed in the preperitoneal space, the molecules of which are evenly distributed in the wound due to its diffusion through a semipermeable membrane (dialysis tube), which allows effective local anesthesia of the wound due to continuous infiltration anesthesia of the wound. The use of anesthesia is planned for about 3-7 days, depending on the severity of the pain syndrome in the patient.

Thus, the proposed method of local anesthesia in the postoperative period differs from others in that it provides a uniform long-term distribution of local anesthetic in the wound with a preperitoneal (retromuscular) location due to the use of not only a perforated catheter, but also a dialysis tube worn over it, which is a semipermeable membrane , while the anesthetic infiltrates through it evenly throughout the wound due to diffusion, due to the presence of micropores in the membrane, which achieves adequate postoperative analgesia, refusal to use narcotic analgesics, extremely limited use of NSAIDs (in patients with a lower pain threshold), early activation, which directly affects the reduction in the number of postoperative (including infectious) complications, shortening the duration of enteral insufficiency, reducing the length of the patient's stay in the hospital, improving the emotional background and quality of life of the operated patients. Another advantage is the mobility of the patient, as the pump is freely tolerated by the patient when moving. The method is universal, applicable for any surgical interventions (in a planned manner and for urgent indications), where access to the abdominal cavity is a median laparotomy.

Clinical example.

Patient P., aged 47, was admitted to the surgical department of the KGBUZ “KMKBSMP them. N.S. Karpovich" with a clinic of acute adhesive intestinal obstruction, operated on urgently. A device was installed intraoperatively, an infusion pump with anesthetic was connected. In the postoperative period, the patient was in the ICU, the pain syndrome was insignificant (maximum according to VAS-2-3). From the first day, the activation of the patient began. Opioid and other analgesics, with the exception of ropivacaine delivered into the wound, were not used. Due to the relief of pain, the device was removed on the 4th day. The duration of inpatient treatment was 10 days. The patient was discharged for outpatient treatment. Wound, intra- and extra-abdominal complications were not identified.

Claims (2)

1. The method of postoperative local anesthesia of the median laparotomic wound of the anterior abdominal wall after operations in patients on the abdominal organs, including the introduction of local anesthetics retromuscularly through a polyurethane catheter, characterized in that through the upper and lower corners of the median laparotomic wound on each side, retreating laterally 1- 1.5 cm from its edge, a polyurethane catheter with perforations is installed throughout the wound and with a dialysis tube put on top of it, which is fixed over the catheter with ligatures, then a local anesthetic is continuously fed into the polyurethane catheter using an infusion pump. 2. The method according to p. 1, characterized in that it is used for 3-7 days.

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