RU2706028C1 - Method of local segmental anesthesia in postoperative anesthesia of the laparotomic wound of the anterior abdominal wall following emergency operations in the patients with acute obstructive colonic obstruction of tumor genesis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely surgery and anesthesiology, and can be used for local segmental anesthesia in postoperative anesthesia of laparotomic wound of anterior abdominal wall following urgent operations in patients with acute obstructive colonic obstruction of tumor genesis. Local anesthetic is introduced into sheaths of abdominal rectus muscles by means of a catheter. That is ensured by placing a prepared polyurethane catheter in the upper corner of the laparotomy wound on each side, laterally 2.5–3 cm from its edge, using a thin-walled puncture needle so that the outer part length is 8–10 cm. To the outer part catheter is connected a cannula for introduction of local anesthetic. A local anesthetic is 0.125 % of ropivacaine administered in dose of 10 ml every 6 hours for 4 days.

EFFECT: method provides adequate postoperative anesthesia and prevention of postoperative complications ensured by uniform introduction of local anesthetic, which allows avoiding the use of opioid analgesics in early activation of the patient, early intestinal paralysis.

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Description

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

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

A known method of analgesia after prosthetic hernioplasty, including with median ventral hernias, including the introduction of local anesthetics into the area of the surgical wound for analgesia. (Oskretkov V.A., Gankov V.A., Bubechikov S.P. Prosthetic hernioplasty of inguinal hernias // Endoscopic surgery. - 2008. - No. 4. - P. 18-20). But this method of anesthesia is carried out only for the operation itself, without taking into account anesthesia in the postoperative period, since a single administration of a local anesthetic has a limited effect due to its short duration of action.

A known method of blocking nociceptive afferent fibers of the peritoneum by continuous infusion of local anesthetic through a multiport catheter installed by the surgeon at the end of the operation (Beaussier M. Continuous preperitoneal infusion of ropivacaine provides effective analgesia and accelerates recovery after colorectal surgery // Anesthesiology. - 2007. - Vol. 107 (2007. - Vol. 107 ( 3). - P. 461-468). The reasons that impede the achievement of the technical result when using the above method include the fact that one catheter is installed in one anatomical region in a small space, which restricts tissue infiltration by a local anesthetic and does not allow to create a local anesthetic depot, thereby not providing adequate analgesia. In addition, the use of a combination of narcotic analgesics (morphine) does not allow to fully assess the effectiveness of the perperitoneal blockade.

A known method of drainage of the wound, where one tube is laid along the bottom of the wound to ensure the most uniform outflow, which accordingly implies uniform irrigation of the wound (Datsenko BM Theory and practice of local treatment of purulent wounds. Problems of drug therapy. - Kiev: Health, 1995 .-- 344 p.). The proposed wound irrigation using a similar tube will have a weak effect, since tissue infiltration with anesthetic is assumed only in a limited area.

The most reliable method selected as a prototype is the known method of preperitoneal blockade in the postoperative period, which consists in the formation of left and right throughout the laparotomy wound at a distance of 1.5-2 cm from its edges of the tunnels in which catheters having several holes. Through installed catheters, a local anesthetic is injected into the peritoneal space every 3 hours for 3 days (RF patent No. 2400259 C1, 09/27/2010). However, this method has its drawbacks.

1. This method does not ensure uniform distribution of the anesthetic, since a single bolus injection of fluid through an open system, which does not take into account the diameter of the perforated holes and the diameter of the catheter itself, which does not give uniform irrigation and involves the release of fluid only through the nearest (first) or largest hole available in this handset.

2. An open system increases the risk of infection of a postoperative wound.

3. Uncontrolled injection of local anesthetics into the peritoneal space can lead to overdose and undesirable side effects of anesthetics.

A reliable method selected as a prototype is also the 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 the endoprosthesis is placed under the aponeurosis in the formed space around the postoperative wound in the form oval over the plane of the endoprosthesis, a polyvinyl chloride catheter is installed at a distance of 2.5-3 cm from its edges, having all over multiple lateral openings, while in the projection of the lower corner of the wound, separate punctures are made on both sides and the ends of the catheter are brought out to the skin, the inlet of the catheter is connected to a dosing device of local anesthetic using a cannula and a controlled prolonged irrigation of 2.5% ropivacaine solution 20 is performed ml every 6-8 hours for 2-3 days (RF patent No. 2529412 C2, 09/27/2014).

However, this method has its drawbacks. In connection with the proposed stitching 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% ropivacin solution is fraught with an overdose, impracticable 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 during such operations, taking into account the proposed detachment of the muscle-aponeurotic layer from the peritoneum, the formation of a hematoma with weakening of the action of the anesthetic is often possible, and in the case of using active drainage according to Redon, the anesthetic is removed immediately after administration. This method has a narrow field of application (hernia repair with ventral hernias).

The most effective way of blocking the vagina of the rectus abdominis muscle, performed on both sides, as this results in an anesthetic depot in an anatomically closed (not artificially and traumatically created) space, and blocking the nociceptive impulse of the anterior, or intercostal, branches of the spinal nerves Th6- Th11. Coming out of the spinal cord, these nerves are divided into anterior and posterior branches. The front branches (actually the intercostal nerves) go behind the costal cartilage, then between the transverse and internal oblique muscles of the abdomen, and, penetrating into the vagina of the rectus abdominis muscles, the latter innervate and the skin above them. Therefore, local anesthetics injected through a catheter inserted into the rectus sheath blocking these nerves can reduce the severity of pain after median laparotomy. There is a method of anesthesia of the anterior abdominal wall by installing 16G epidural catheters into the vagina of the rectus abdominis muscles, having several holes at the end. (F. McDermott, J. Wilson, P. Boorman. Methods of catheterization of the vagina of the rectus abdominis muscle. Update in Anaesthesia No. 18 (Russian version), 2012, pp. 11-13). The proposed method will have a weak and limited effect due to the technical features of epidural catheters (holes are located only at the distal end of the catheter), and are economically expensive (average price ≈ 1500-2000 rubles).

The objective of the present invention is to provide effective regional anesthesia of the postoperative wound of the anterior abdominal wall during the treatment of acute surgical diseases with performing median laparotomy by uniformly administering anesthetic to the vagina of the rectus abdominis muscles. This method provides adequate analgesia, the ability to abandon the use of opioid analgesics, and also contributes to the early activation of the patient, the prevention of postoperative complications, the early relief of intestinal paresis.

The solution to this problem is provided by the fact that in the method of local segmental anesthesia in postoperative anesthesia of the laparotomy wound of the anterior abdominal wall after emergency operations in patients with acute obstructive colonic obstruction of the tumor genesis, including the introduction of local anesthetics into the vagina of the rectus abdominis using a catheter, in the upper corner of the laparotomy wound , on each side, stepping laterally 2.5-3 cm from its edge, with the help of a thin-walled puncture needle set prepared polyurethane Tanova catheter so that the length of the outer portion was 8.10 cm, which is connected to a cannula for administration every 6 hours 10 ml of 0.125% ropivacaine solution for 4 days.

The invention is illustrated using FIG. 1-5. In FIG. 1 shows the location of the catheter 1 in the vagina of the rectus abdominis 6 on a section of the anterior abdominal wall. In FIG. 2 shows the determination of the length of the required length of the catheter 1. FIG. 3 shows the placement of the surgeon's hands when holding the needle 2 through the skin 3, subcutaneous fat 4 and fascia 5. In FIG. 4 shows the inserted catheter 1 after removing the puncture needle 2. In FIG. 5 shows the introduction of local anesthetic with a syringe 12 along the catheter 1 using the installed adapter 11.

The method is carried out after the main abdominal stage of the operation before suturing the laparotomy 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, a catheter 1 is prepared by determining the required length (taking into account the individual anatomical features of the patient) and the number of perforations (Fig. 2). If necessary, additional holes are made in the proximal part of the catheter using a punch (or a thick needle such as Dufot). This is necessary for uniform distribution of the anesthetic solution in the case of the rectus abdominis muscle 9 (Fig. 1).

Then, in the upper corner of the laparotomy wound, 2.5-3 cm laterally departing from its edge, a prepared polyurethane catheter 1 ∅ 2.7 mm is installed with a shortened section with a thin-walled puncture needle 2 ∅ 3.35 × 78 mm so that the length of the outer part is 8 -10 cm. The surgeon places one hand inside the abdomen, and the other hand passes the needle through the skin 3, subcutaneous fat 4, fascia 5 and muscle 6. Palpation allows you to determine the introduction of the needle tip between the peritoneum 7 with transverse fascia 8 and muscle layer 6 ( Fig. 1, Fig. 3), and also exclude v damage inferior epigastric artery. After removing the stylet, the catheter 1 is inserted between the peritoneum 7 with the transverse fascia 8 and muscle 6 to a distance of 8-10 cm. Holding the catheter 1 in place, the surgeon removes the puncture needle 2 (Fig. 1, Fig. 4). In order to avoid inadvertent removal of the catheter 1 fix the hemming to the skin. After fixation, an adapter 11 is connected for subsequent administration of the anesthetic with a syringe 12 (Fig. 5). Intraoperatively check the patency of the catheter 1 by introducing 5 ml of physiological saline by the appearance of a roller from the side of the peritoneum 7. The procedure is repeated from the opposite side. For postoperative analgesia, a local anesthetic is administered every 6 hours. Up to 10 ml of 0.125% ropivacaine solution is injected into each catheter 1. Catheters 1 should be checked every day 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.

As a result, in the case of the rectus abdominis muscle 9 a depot of an anesthetic solution 10 is formed, which allows for effective local anesthesia of the skin by the type of conductive analgesia (Fig. 1).

Clinical example.

Patient M.E., 57 years old, was admitted to the clinic BMX BMA them. CM. Kirova 10/10/2017. at 12.20 for urgent indications with a diagnosis of Acute intestinal obstruction. Upon admission, the patient complained of nausea, vomiting of food, pain in the lower abdomen, lack of stool and gas exhaustion for 3 days. Notes weight loss over the past six months by 10 kg, periodic constipation up to 3 days in the last month.

On examination, the general condition is moderate. The skin is moist, physiological in color. Pulse satisfactory filling 96 beats per minute. Blood pressure 135/85 mm RT. Art. The tongue is dry, coated with a white coating at the root. The abdomen is swollen, soft, painful in the lower sections. Laboratory (clinical and biochemical blood analysis, coagulation, urinalysis), instrumental (ultrasound OBP, FGDS) and X-ray examination (OGK, OBP), ECG and examination of the therapist were performed. Given the clinical picture and research results, the diagnosis was made: Acute intestinal obstruction. The patient is shown surgical treatment urgently. There were no absolute contraindications to surgical treatment. Planned median median laparotomy, revision of the abdominal organs with the definition of further operational tactics.

Operation 10.10.17, 16 h 50 min - 20 h 00 min. Laparotomy Obstructive resection of the sigmoid colon of the Hartmann type, excretion of a single-barrel colostomy. Small intestine lavage, abdominal drainage.

Postoperative diagnosis: Cancer of the rectotosigmoid colon, cT4NxM1 (HEP), complicated by acute colon and small bowel obstruction. Intraoperatively before suturing the wound, catheters were installed in the vagina of the rectus abdominis muscles, 3 cm lateral to the upper corner of the postoperative wound on each side of the wound.

In the postoperative period, local segmental analgesia with 0.125% ropivacaine solution of 10.0 ml in each catheter 4 times a day for 4 days of the postoperative period was performed through cannulas (catheter inlet).

The postoperative period was uneventful, smooth. The patient received complex pathogenetic therapy. In the postoperative period, the patient complained of slight pain in the area of the postoperative wound at 1 day; starting from 2 days, she was disturbed by periodic discomfort in the projection of the wound only under load, and an analgesic effect was achieved. After transferring from the intensive care unit (15 hours after the operation), the patient is activated. The phenomena of enteric insufficiency were stopped in 1 day. The postoperative wound healed by primary intention. In satisfactory condition, the patient was discharged on October 19, 2017 under the supervision of a surgeon, an oncologist at the place of residence.

Thus, the proposed method for local segmental anesthesia in the postoperative period provides an even distribution of local anesthetic in the vagina of the rectus abdominis muscles, thereby achieving adequate postoperative analgesia, reducing the number of postoperative complications, shortening the time of postoperative intestinal paresis, which leads to early activation of the patient, as well as refusal to use narcotic analgesics.

We conducted a study in which the results of surgical treatment of 89 patients with acute obstructive colonic obstruction of tumor genesis, who underwent surgical treatment in an emergency, were analyzed. All patients had a median laparotomy with surgical access. Patients, depending on the method of anesthesia, were divided into two groups. In the main group, the method of postoperative analgesia developed by us was tested. In the control group, methods traditional for the clinic were used. The study did not include patients with advanced peritonitis, abdominal sepsis, combined complications of malignancy, who were at high risk of performing programmed relaparotomy. Traditionally, the volume of surgical intervention in tumors of the right colon was a right-sided hemicolectomy with the application of primary ileotransversoanastomosis, in case of malignant neoplasms of the distal colon, an obstructive resection of the Hartmann type was performed with the removal of a unilateral unnatural anus (colostomy), mainly.

In both groups, a visual analogue scale (VAS) was used to assess the intensity of pain, which consists of 11 points from 0 (no pain) to 10 (the most severe, intolerable pain). The main group consisted of 45 (51%) patients who, for the purpose of postoperative analgesia, had a polyurethane catheter installed in the vagina of the rectus abdominis muscles before suturing the laparotomy wound. In the postoperative period, local segmental analgesia with 0.125% ropivacaine solution of 10.0 ml in each catheter 4 times a day for 4 days of the postoperative period was performed through cannulas (catheter inlet). Seven patients needed additional analgesia for NSAIDs (on-demand) during the first two days after surgery. The comparison group consisted of 44 (49%) patients who were prescribed opioid analgesics for 1-2 days of the early postoperative period and non-steroidal anti-inflammatory drugs for pain relief.

The results of the study are presented in the table.

As a result, according to the intensity of the pain syndrome, the early postoperative period in patients of the main group was reduced by 2 days.

Thus, the proposed method for local segmental anesthesia in the postoperative period provides an even distribution of local anesthetic in the vagina of the rectus abdominis muscles, and thereby achieves adequate postoperative analgesia, refusal to use narcotic analgesics, extremely limited use of NSAIDs (in patients with a low threshold of pain sensitivity) early activation, which directly affects the reduction in the number of early postoperative (including infectious) complications, is reduced timing of enteral insufficiency, reducing the patient's length of hospital stay, improved emotional state and quality of life of operated patients. The method is universal, applicable for any surgical interventions (in a planned manner and according to urgent indications), where the access to the abdominal cavity is median laparotomy.

Claims (1)

The method of local segmental anesthesia in postoperative anesthesia of the laparotomy wound of the anterior abdominal wall after emergency operations in patients with acute obstructive colonic obstruction of the tumor genesis, including the introduction of local anesthetics into the vagina of the rectus muscles of the abdomen using a catheter, characterized in that in the upper corner of the laparotomy wound, on each side , stepping laterally 2.5-3 cm from its edge, using a thin-walled puncture needle, a prepared polyurethane catheter is installed with this calculation, so that the length of the outer part is 8-10 cm, to which a cannula is connected for administration every 10 hours with 10 ml of 0.125% ropivacaine solution for 4 days.

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