RU2848403C1 - Method for closing a wound in the sacrococcygeal region with the formation of a t-shaped line of sutures - Google Patents

Abstract

FIELD: medicine; coloproctology.

SUBSTANCE: epithelial coccygeal passage located in the projection of the intergluteal fold is excised as a single block with the cavity located in the gluteal region, within the limits of the altered tissues. Two skin-fat flaps are formed on both sides of the wound in the gluteal region by making relaxing incisions in the fatty tissue to a depth of at least 2 cm from the skin surface. Counter traction is performed on the two formed skin-fat flaps towards each other and then traction towards the intergluteal fold. A drainage tube is placed at the bottom of the wound. The wound is sutured layer by layer, forming a T-shaped line of sutures.

EFFECT: improvement of cosmetic results of surgical treatment of primary and recurrent epithelial coccygeal tract in the presence of a cavity located in the gluteal region; reduction of tissue tension during their movement, reduction of the number of disease recurrences, reduction of the severity of pain syndrome in the postoperative period and the risk of bleeding.

1 cl, 1 ex

Description

The invention relates to medicine, specifically proctology and surgery, and can be used in the surgical treatment of patients with primary and recurrent epithelial coccygeal tract (hereinafter referred to as ECC) who require radical surgery. The invention can also be used in reconstructive plastic surgery for the repair of wounds in the sacrococcygeal and gluteal regions.

It is known that the incidence of ECC in the general population is 26 cases on 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 Dis 1995; 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 P. R., Haywood I. R. The natural history of the post anal (pilonidal) sinus. Ann R Coll Surg Engl. 1984; 66: 201–203]. Despite a long history of surgical treatment of epithelial pilonidal sinus, there is currently no “gold standard” surgical technique. A great number of surgical interventions have been proposed by Russian and foreign authors; however, the incidence of postoperative complications and relapses remains high (up to 37%), which leads to prolongation of treatment periods, long return to normal daily activity, and deterioration of the quality of life of young patients [Dultsev Yu.V., Rivkin V.L. Epithelial coccygeal passage. - M. 1988, - 128 p., Iesalnieks I., Fürst A., Rentsch M., Jauch K. W. 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 suturing can be divided into 2 large groups:

1) with preservation of the intergluteal groove,

2) with elimination of the intergluteal groove.

To eliminate the soft tissue defect after excision, various options for plastic surgery were proposed using mobilized or rotated flaps on a feeding pedicle, in which the intergluteal groove is shifted 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 explanation of its causative process. Aust NZ Surg 1992].

A known method for treating epithelial coccygeal sinus is [Rao J, Deora H, Mandia R. A Retrospective Study of 40 Cases of Pilonidal Sinus with Excision of Tract and Z-plasty as Treatment of Choice for Both Primary and Recurrent Cases. Indian J Surg. 2015 Dec;77 (Suppl 2):691-3. doi: 10.1007/s12262-013-0983-4. Epub 2013 Oct 2. PMID: 26730090; PMCID: PMC4692937], which involves closure of the sacrococcygeal region wound after excision with subsequent mutual traction and suturing of the defect. As a result, a Z-shaped suture line is formed.

A significant disadvantage of this method is the pronounced deformation of the sacrococcygeal region, as well as the possibility of necrosis of the sharp corners of the formed flap.

A known method for treating epithelial coccygeal sinus [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] consists of the following: after excision of the epithelial coccygeal sinus within the unchanged tissues up to the sacral fascia, a single-block mobilization of flaps consisting of the fibers of the gluteus maximus muscles and the fascia covering these muscles is performed, as well as separation of 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 intergluteal fold and their suturing together with the presacral fascia with single interrupted sutures. Thus, the "dead space" after excision of the ECC is eliminated by repositioning the fascial-muscular flaps. A drain was placed over the sutured fascial flaps. The wound was then closed layer by layer. This new positioning ensured less tension on the adjacent tissues during the postoperative period, resulting in a lower recurrence rate.

However, this method requires mobilization of fascial-muscular flaps, which can cause significant pain due to trauma caused by partial transection of muscle fibers. This technique also has limitations in terms of tissue tension. Its use is possible when the secondary opening is located no more than 2 cm from the intergluteal fold. Furthermore, the formation and movement of muscle flaps can disrupt microcirculation, leading to a high risk of hematoma development in the postoperative period.

The closest approach to the proposed invention is a method for suturing a wound in the gluteosacral region [RU Patent 2277865], which involves closing the wound defect with advanced flaps, which are cut through additional full-thickness skin and subcutaneous fat incisions at a 60-degree angle to the edges of the primary wound defect. Two triangular flaps are cut, with one side approximately half the length of the wound defect. The flaps are alternately advanced and secured to the bottom of the wound by the lower edge of the subcutaneous fat, suturing them to each other at the edges of the wound.

The disadvantages of this method include the difficulty of flap formation due to the limited mobility of the tissue in this anatomical region, as well as the need for additional incisions, which in turn leads to prolonged wound healing, the development of infection foci, and, consequently, increased disability. Furthermore, additional lateral incisions significantly impair the cosmetic outcome of the surgery, significantly deforming the sacral region.

The problem addressed by the proposed invention is to improve the immediate and long-term cosmetic results of surgical treatment of primary and recurrent epithelial coccygeal tract located in the projection of the intergluteal fold without deformation of the sacrococcygeal region.

The technical result of the invention is both an improvement in cosmetic results, avoiding deformation of the sacrococcygeal region, and a reduction in the number of relapses of the disease due to the formation of a T-shaped line of sutures, which allows for the elimination of "dead space" and, as a result, a reduction in tissue tension during their movement, performing plastic surgery of the soft tissue defect of the sacral and gluteal region, without increasing the severity of pain in the postoperative period and the risk of bleeding.

The technical result is achieved by implementing a method for closing a wound in the sacrococcygeal region after excision of the epithelial coccygeal tract, located in the projection of the intergluteal fold, in a single block with a cavity located in the gluteal region, within the altered tissues, including the formation of two skin-fat flaps located on both sides of the wound in the gluteal region, by performing relaxing incisions in the fatty tissue to a depth of at least 2 cm from the skin surface, their subsequent counter traction towards each other and further to the intergluteal fold with tissue replacement; installation of a drainage tube at the bottom of the wound, layer-by-layer suturing of the wound with the formation of a T-shaped suture line.

The proposed method has the following advantages:

- the formation of cutaneous-subcutaneous flaps located on the gluteal region allows to reduce tension during primary wound suturing by reducing the width of the wound;

- mutual traction of the formed flaps to each other and central placement to the intergluteal groove allows for the elimination of “dead space”;

- there is no disruption of microcirculation due to the absence of formation of sharp angles.

The proposed method works as follows.

The cavity of the epithelial coccygeal passage is stained through the primary openings located in the projection of the intergluteal fold, the secondary opening located in the gluteal region for the purpose of better visualization of the altered tissues with a solution of brilliant green with a 3% solution of hydrogen peroxide using a syringe. Elliptical skin incisions are made around all primary and secondary openings, followed by subcutaneous fat incisions around the primary and secondary openings using a scalpel or monopolar coagulator. The skin and subcutaneous fat are excised en bloc within the cavities containing the coccygeal tract within the intact tissue. Next, skin-fat flaps are created on either side of the wound in the gluteal region by making two spaced relaxing incisions in the fat to a depth of at least 2 cm from the skin surface. The mobilized flaps are brought together, thereby reducing tissue tension. A tubular drainage system, up to 3 mm in diameter, made of silicone/polyvinyl chloride, is inserted through a counter-opening in the superior corner of the postoperative wound along the entire length of the postoperative wound. By suturing it to the skin with a separate interrupted suture. The wound is closed layer by layer. Separate interrupted sutures are placed along the entire length of the wound on the formed mobilized flaps, securing them together and creating an intergluteal fold, for example, as follows: At a distance of 0.7-0.8 cm from the edge of the mobilized gluteal flap, insert a needle with an abacterial, atraumatic suture within the fatty tissue. The needle is withdrawn and the insertion is made, capturing the fatty tissue of the opposite mobilized flap in the suture. Next, a puncture is made on the opposite side, capturing the fatty tissue located along the midline, in the projection of the intergluteal fold. The suture is tightened, thus bringing the wound edges closer to the intergluteal fold, reducing its width and thereby reducing tension. Sutures are placed similarly along the entire length of the mobilized skin and fat flaps, spaced 1 cm apart. The postoperative wound is then closed tightly, without tensioning the edges, for example, with individual interrupted vertical sutures according to Donati: 1.5-2 cm from the wound edge, a needle with an abacterial atraumatic thread is inserted into the skin and, having passed through the deepest point of the wound, the needle is removed from the other side at a symmetrical point. The needle is then reinserted on the side from which it was inserted, 5-8 mm from the wound edge, in line with the first insertion, so that it emerges in the middle of the dermis. On the opposite side, the needle is also inserted through the middle of the dermis and the exit is made on the opposite side onto the skin surface, 5-8 mm from the skin edge. When the applied vertical mattress suture is tightened, the wound edges are precisely brought together, fixed to the base and slightly raised, and the dermis and epithelial layers are precisely aligned. Sutures are placed along the entire wound in a similar fashion, spaced 1-1.5 cm apart, forming a T-shaped suture line. The junction of the three sides is further closed with an interrupted suture, incorporating all three skin flaps. A corrugated reservoir for collecting biological fluid is connected to the drainage system for active negative pressure drainage. An aseptic dressing is applied.

The invention is confirmed by a clinical example.

Patient M., 22, was admitted to the oncology and proctology department of City Clinical Hospital No. 2 with a diagnosis of primary epithelial coccygeal tract. Three primary openings, each up to 0.2 cm in diameter, were identified in the sacrococcygeal region. There was no discharge from the openings, but tufts of protruding hair were visible. Hair removal was performed. A secondary opening with an area of hypergranulation and up to 0.7 cm in diameter was also identified 4 cm from the intergluteal fold, in the projection of the gluteal region. A postoperative scar, located in the projection of the intergluteal fold, was up to 7 cm long. No discharge was observed from the opening when pressure was applied.

The operation was performed in accordance with the proposed method.

During the excision procedure, the cavity of the epithelial coccygeal tract was stained through the inferior opening, located in the projection of the intergluteal fold, with a solution of brilliant green and 3% hydrogen peroxide using a syringe. Contrast was injected from all openings. Elliptical shapes are made Skin and subcutaneous fat incisions were made around the primary and secondary openings using a scalpel. Hemostasis was maintained. The epithelial coccygeal tract was excised en bloc, along with the primary and secondary cavities located in the gluteal region, within the intact tissues. Next, skin-fat flaps at least 2 cm thick, located on both sides of the wound in the gluteal region, were mobilized by creating relaxing incisions. A tubular drainage system was inserted into the fundus through a counter-opening in the upper corner of the postoperative wound, covering the entire length of the wound. Layer-by-layer wound suturing was performed, starting from the fundus, using single interrupted sutures. Next, a series of interrupted sutures were applied to the skin-fat flaps using the method described above. The wound was then sutured tightly with individual interrupted vertical Donati sutures. An active negative pressure drainage system was connected to the drainage system. An aseptic dressing was applied.

The postoperative period was uneventful. The drain was removed on the fifth day. The wound healed by primary intention. The sutures were removed on the 13th postoperative day. The patient returned to work on the 21st postoperative day. Postoperative follow-up revealed no complications or recurrence. Ultrasound revealed no fluid accumulation along the postoperative incision with leakage.

Claims (1)

A method for closing a wound in the sacrococcygeal region after excision of the epithelial coccygeal tract located in the projection of the intergluteal fold, as a single block with a cavity located in the gluteal region, within the altered tissues, including the formation of two skin-fat flaps located on both sides of the wound in the gluteal region by performing relaxing incisions in the fatty tissue to a depth of at least 2 cm from the skin surface, their subsequent counter traction towards each other and further to the intergluteal fold with tissue replacement; installation of a drainage tube at the bottom of the wound, layer-by-layer suturing of the wound with the formation of a T-shaped line of sutures.