RU2845987C2 - Method for active drainage of presacral space in injuries of extraperitoneal rectum - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgery, and can be used for active drainage of presacral space in extraperitoneal rectal injuries. In the gluteal region, to the right and to the left of the anus, two skin incisions are made. Forceps are inserted through the skin incision from the right side and delivered into the pathological cavity of the presacral space. Silicone tube is delivered from the small pelvis cavity through the opened pelvic peritoneum; the tube is removed with the use of a forceps through the incision in the gluteal region. Second tube is inserted similarly from the opposite side from the anus. Perforated tube with adjustable end caps, as in Fig. 1, is inserted from the side of a lesser pelvis into a lumen of the two tubes set earlier. Ends of the tube of a smaller diameter are brought out on a side of the drainage tubes of a larger diameter, outside the skin of the gluteal region; the plugs are closed. Further, continuity of the previously opened pelvic peritoneum is restored, and the anterior abdominal wall is closed. Pathological presacral cavity is actively drained, and the larger-diameter tubes are alternatively washed through one of the ends of the smaller-diameter tube by opening a respective plug.

EFFECT: method allows at any time, without anaesthetic management, to wash the closed space of the presacral region; provides improved results of treatment of patients with injuries of rectum of extraperitoneal localization in form of reduction of mortality, reducing the number of recurrent surgical treatments of pelvic wounds under general anaesthesia, reducing the length of patient's staying in hospital and improving quality of life due to developed drainage system with tubes of different diameters.

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Description

The invention relates to medicine, namely to surgery, and can be used in the surgical treatment of patients with wounds of the extraperitoneal parts of the rectum.

According to domestic scientists, in a modern combat situation, the proportion of victims with abdominal injuries is up to 20% of the incoming flow [Zuev V.K., 2004, Gumanenko E.K., 2011, Kraynyukov P.E., 2019, Denisov A.V., 2020].

The proportion of intestinal injuries is up to 68% of the total number of abdominal injuries, and in the group of deceased it reaches 80% [Gumanenko E.K., 2011, Goldberg J.E., 2010].

The incidence of rectal injuries during military conflicts in recent decades reaches 5-10% and shows no tendency to decrease [Bykov I.Yu. et al., 2009, Clemens MS, 2018]. Isolated rectal injury occurs in 0.6% of all abdominal and pelvic injuries, and in 4.6% it is combined with injuries to other organs [Komyakov B.K., 2002; Lebedev M.A., 2011; Hurtuk M., 2006].

It is noted that defects in surgical treatment are detected in 4.9% of cases. Errors in the diagnosis of damage to internal organs lead to corresponding technical errors in the surgical intervention. The total number of defects during the counter-terrorist operation in the North Caucasus (15.8%) was higher than during the Afghan war (9.7%). There were more diagnostic defects - 7.7 and 2.9%, and, accordingly, surgical intervention techniques - 11.4 and 4.9% [Alisov P.G., 2021].

In case of extraperitoneal injuries of the rectum, the scope of surgical intervention includes two main stages. The first stage involves the imposition of a decompression single-barrel or loop colostomy and washing of the distal part of the rectum. The scope of the second stage of the operation is determined depending on the nature and location of the wound of the rectum. In case of injuries to its perineal part with partial destruction of the sphincter, primary surgical treatment of the wound is performed with economical excision of tissues in the sphincter area. In this case, the operation can be completed by installing a wide polyvinyl chloride tube into the lumen of the rectum or loose tamponade of the wound. In case of ruptures and proximal displacement of the rectum, the latter is usually brought down and sutured to the skin. It is also recommended to drain the ischiorectal space [Gumanenko E.K., 2008, Bykov I.Yu. et al., 2009, Samokhvalov I.M. et al., 2023]. Technical aspects of drainage are not given much attention in the literature.

Experimental and clinical studies have shown that in almost 80% of observations, within 12-24 hours after surgery, drainage tubes lose patency due to blockage of their lumens by wound discharge [Gostischev V.K., 2002; Salakhov E.K., 2012; Shevchenko Yu.L., 2012; Zubritsky V.F., 2016].

At the same time, some authors believe that for successful treatment of wounds of the extraperitoneal parts of the rectum, it is sufficient to form a double-barreled colostomy, and drainage and lavage of the distal part of the rectum are not necessary [Brown SR, 2013, Bosarge PL, 2016].

Thus, if most authors do not have questions about the advisability of disconnecting the rectum, the methods of drainage of pararectal tissue differ.

A well-known method is as follows:

In perineal-rectal wounds, the damaged skin, subcutaneous fat, gluteal muscles and perineum are dissected until the bottom of the wound channel is reached in such a way that it is possible to visually determine the condition of the surrounding tissues, the localization of the wound channel in relation to the hollow organs, urethra and coccygeal bones. If additional purulent-inflammatory cavities are detected, they are widely opened and drained. Excision of reliably non-viable tissues, freely lying tissue fragments is performed with hemostasis, using an electrocoagulator or a ligature method.

In case of transanal injury to the rectum, surgical treatment consists of dissection of the perineal skin and wide drainage of the wound channel to its upper edge.

After excision of non-viable tissues and hemostasis, a polyvinyl chloride drainage is installed in the bottom of the wound, which is a wide-bore perforated drainage tube or a rubber drain. Loose tamponade with ointment-impregnated napkins is also possible. The wound is sutured with rare sutures in layers, the skin is also sutured with rare sutures at intervals of 3 cm.

The method has its drawbacks.

Despite the smooth internal surface, the drainage tube becomes clogged with both coarse fibrinous-purulent masses and blood clots, which undoubtedly complicates the outflow of pathological contents against the background of a persistent infectious process.

The clogged tubes lose their drainage function, washing them out is ineffective, which leads to the accumulation of pathological contents and, accordingly, the progression of the inflammatory process.

The method of drainage of pararectal tissue is taken as a prototype with the indicated disadvantages.

When developing the new method, the following tasks were set:

1. To develop a method for effective active drainage of the presacral space.

2. Develop a method for efficient, maximum possible operation of the drainage system using active removal of pathological contents.

To solve the set tasks, we proposed and successfully implemented into practice a method of active drainage of the presacral space in case of injuries of the extraperitoneal parts of the rectum.

The purpose of the invention is to improve the treatment results for patients with extraperitoneal rectal wounds in the form of reduced mortality, a decrease in the number of repeated surgical treatments of pelvic wounds under general anesthesia, a reduction in the length of the patient's hospital stay, and an increase in the quality of life.

The technical result of the proposed method is an increase in the effectiveness of treatment due to a decrease in mortality, a decrease in the number of postoperative complications, a decrease in the number of dressings under general anesthesia, a reduction in the length of stay of patients in the hospital, and thereby an improvement in the quality of life, a decrease and shortening of the duration of the inflammatory syndrome.

What is new in achieving the technical result is the possibility of both active removal from the pathological cavity and passive outflow of pathological contents of the pelvic cellular spaces, as well as the possibility of washing the drainage tubes.

As a result of the use of complex treatment of rectal wounds of extraperitoneal localization using the method of active drainage of the presacral space, it was possible to achieve more effective and safe removal of pathological contents without repeated staged surgical treatments under general anesthesia.

A comparable analysis with the prototype shows that the proposed variant of drainage of the pelvic cellular spaces allows improving the treatment results in the form of reducing the frequency of dressings performed under general anesthesia; reducing the duration of the phases of the wound process and the length of stay of patients in the hospital, reducing mortality, reducing the number of postoperative complications, thereby achieving an improvement in the quality of life and a decrease in the degree and duration of the inflammatory syndrome. This feature is not known from the state of the art and is new.

The new set of functioning of the drainage system of the presacral space allows to increase the efficiency of treatment of patients with extraperitoneal rectal wounds. The synergism of their therapeutic effect obtained in modern studies undoubtedly has great clinical significance, as it leads to the timely outflow of pathological contents of the pelvic cellular spaces. This feature is not known from the state of the art and is new.

Creating conditions for continuous drainage of the pathological cavity facilitates faster delimitation of the inflammation focus, preservation of the volume of healthy tissues not involved in the inflammatory process, which subsequently reduces the need for reconstructive and plastic surgeries, thereby reducing the length of hospital stay. All this reduces the cost of treatment, which meets the criterion of "industrial applicability".

The invention is illustrated by Fig. 1, which schematically depicts the arrangement of silicone tubes relative to the pelvic regions for active drainage of the pathological cavity of the presacral space.

During laparotomy, revision of the abdominal cavity and pelvic organs, the required volume of surgical intervention is performed.

The surgical assistant makes two perpendicular skin incisions, each up to 1.5 cm long, in the gluteal region, on the right and left, at a distance of 4 cm from the anus. A curved forceps is inserted "bluntly" through the corresponding skin incision on the right side and the cellular spaces of the pelvis into the pathological cavity of the presacral region. From the pelvic cavity, through the opened pelvic peritoneum, the operating surgeon feeds a silicone tube, 1 cm in diameter, with a lateral perforation opening 0.5 cm in diameter in its distal part (element 4), which is removed through the skin of the gluteal region (element 1) with the previously installed forceps. Similar actions are performed on the opposite side. The silicone tubes, 1 cm in diameter, are fixed to the skin of the gluteal region using the known ligature method.

From the side of the small pelvis, an additional silicone tube with a diameter of 0.5 cm, having lateral perforations along its length, up to 0.3 cm wide (element 5), is installed into the proximal ends of two drainage tubes, each 1 cm in diameter (element 4). The ends of this tube are brought out to the outer side of each drainage tube, 1 cm in diameter, through previously formed perforation openings corresponding to the drainage diameter of 0.5 cm, outside the skin of the gluteal region (element 1), and are sealed with adjustable plugs (element 3). The integrity of the pelvic peritoneum (element 2) is restored with a continuous sealing suture in a known manner. The operation ends with layer-by-layer suturing of the wound of the anterior abdominal wall, also in a known manner.

An additional silicone tube with a diameter of 0.5 cm installed inside the lumens of two drainage tubes, each 1 cm in diameter, allows for active drainage of the pathological cavity of the presacral region at any time, without anesthesia. The available adjustable plugs of the silicone drainage with a diameter of 0.5 cm allow for active drainage of the pathological cavity of the presacral region, as well as for alternate flushing of larger diameter tubes through a smaller diameter tube by opening the corresponding plug.

Thus, the system of double-lumen perforated silicone tubes allows for active drainage of the pathological cavity of the presacral space, significantly reducing the focus of the infectious process in the early stages, thereby promoting regression and relief of purulent-inflammatory processes in the pelvic tissue.

The method is illustrated by the following clinical example.

Patient V., born in 1988. Complaints upon admission of pain in the projection of postoperative wounds, drainage sites, general weakness.

Medical history: On October 16, 2022, he received a penetrating gunshot wound to the abdomen and pelvis with damage to the ileum, bladder, rectosigmoid and upper ampullary parts of the rectum while performing his military duties. On October 16, 2022, he was taken to a level 1 medical unit, where on October 17, 2022, an operation was performed - laparotomy, obstructive resection of the rectum and upper ampullary parts of the rectum, suturing of the wound of the posterior wall of the bladder, resection of the small intestine with the formation of a side-to-side hardware anastomosis, sanitation and drainage of the abdominal cavity, perivesical space, and primary surgical treatment of wounds. On October 18, 2022, he was evacuated to the 1602 Military Clinical Hospital of the Russian Ministry of Defense. The patient was hospitalized in the emergency surgery department, where comprehensive treatment measures were continued for the purpose of preoperative preparation. On October 18, 2022, after stabilization of the condition, the patient was taken to the operating room. During the surgery, a revision of the abdominal cavity and pelvis was performed. The existing effusion in the lateral canals, subhepatic, had a light yellow color, with a volume of up to 100 ml, was drained. An examination of the small intestine was performed from the Treitz ligament - along its entire length. At 1 m from the Treitz ligament, a functional interintestinal hardware anastomosis was found, up to 4 cm wide, competent. A revision of the liver and spleen was performed - the sizes are not enlarged, the surface is homogeneous, smooth. The gallbladder is partially emptied, the walls are not thickened, no stones are detected in the lumen. The colon is examined along its entire length - without pathology. In the left iliac region, a transparent yellow effusion with fibrin elements was determined, the omentum was partially soldered to the parietal peritoneum. During further revision of the bladder, a linear suture up to 3 cm long was visualized on the anterior wall, a Foley urethral catheter was determined in the lumen of the bladder. The sutures of the bladder are also competent. The sigmoid colon is brought out in the form of a single-barrel stoma in the left half of the abdomen, fixed to the skin with separate ligatures. During revision of the pelvis, an open pelvic peritoneum was found. The stump of the rectum - without signs of failure. Presacral, up to 100 ml of turbid effusion was determined. The surrounding tissues were hyperemic, edematous, with fibrin deposits. Presacral, according to the specified technique, silicone tubes with a diameter of 1.0 cm were installed on both sides, brought out to the skin of the gluteal regions. A perforated tube of similar material, 0.5 cm in diameter, was installed inside the lumen of the said tubes using the previously described technique. The pelvic peritoneum was restored with a continuous sealing suture. The abdominal cavity was washed with 6 liters of physiological solution until the water was clear. A drainage polyvinyl chloride tube, 1 cm in diameter, was reinstalled into the small pelvis through a separate puncture in the right iliac region 2 cm above and in front of the anterior superior external iliac spine and fixed to the skin with a ligature. The peritoneum was sutured. Sutures were applied to the anterior abdominal wall in layers. Sutures on the skin. Aseptic adhesive tape. The postoperative period was uneventful and complication-free.

On the 2nd day, the function of the gastrointestinal tract was restored, and gases were passed. With the help of the active drainage system, it was possible to achieve a constant outflow of pathological contents. In this case, it was necessary to use active washing of the drains, 1 cm in diameter, twice to remove clots of pus and blood. On the 6th day, the drains were replaced with rubber graduates. The stitches were removed on the 12th day after the operation, the laparotomy wound healed by primary intention. Healing of the wounds of the gluteal regions is by secondary intention. The patient was discharged with recommendations to be monitored by a surgeon at the clinic. Follow-up examination in 1 month. No complaints. The postoperative scar of the anterior abdominal wall is 22 x 0.1 cm, without signs of inflammation. On the skin of the gluteal regions there are two postoperative scars, 1 x 0.3 cm, without signs of inflammation. The colostomy is functioning.

Claims (1)

A method for active drainage of the presacral space in case of wounds of the extraperitoneal parts of the rectum, including the installation of perforated tubes in the area of the cellular spaces of the pelvis, characterized in that two skin incisions are made in the gluteal region, to the right and left of the anus, a curved forceps is inserted through the skin incision on the right side and passed into the pathological cavity of the presacral space, a silicone tube with a diameter of 1 cm with a lateral perforation hole with a diameter of 0.5 cm in its distal part is passed from the pelvic cavity through the opened pelvic peritoneum, then using the forceps the tube is removed through an incision in the gluteal region, a second tube with a diameter of 1 cm is installed in a similar manner on the opposite side from the anus; then, from the side of the small pelvis, into the lumen of the two previously installed tubes, each 1 cm in diameter, a perforated tube 0.5 cm in diameter with adjustable plugs at the ends is installed, as in Fig. 1, the ends of the tube of smaller diameter are brought out to the side of the drainage tubes of larger diameter, outside the skin of the gluteal region, the plugs are closed; then the continuity of the previously opened pelvic peritoneum is restored and the anterior abdominal wall is sutured; the pathological cavity of the presacral space is actively drained and additionally alternate washing of the tubes of larger diameter is carried out through one of the ends of the tube of smaller diameter by opening the corresponding plug.