RU2827673C1 - Method for drainage of deep fragmentation wounds of soft tissues under ultrasound control - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to surgery and ultrasonic diagnostics, and can be used for drainage of deep fragmentation wounds of soft tissues under ultrasonic control. Surgical treatment of the wound is performed under ultrasonic control. Angles and depth of wound cavities in soft tissues are determined. Through the wound approach, they are drained by a system representing a surgical glove with cut off tips of finger parts and perforated holes of at least 6 mm. Thereafter, the distal ends of the finger portions are alternately introduced into the wound canals under constant ultrasound control, then performing ultrasonic control of position of distal ends of finger parts of glove in wound channels. Proximal part of the glove is brought out onto the skin surface above the wound; a double-lumen tube is inserted into it and sutured to the proximal part of the glove. Thereafter, the wound is covered with sterile hydrophilic and absorbent dressings, followed by installation of a vacuum aspiration system.

EFFECT: method enables to reduce injuries, reduce the probability of developing infectious wound complications, reduce the length of treatment, provide medical assistance in the field, due to combination of application of ultrasonic control of depth of wound channel and drainage of several wound channels simultaneously.

1 cl, 2 ex

Description

The present invention relates to medicine, namely to surgery and ultrasound diagnostics, and can be used for draining deep wound channels of soft tissues under ultrasound control.

The morphology and pathogenesis of mine-explosive fragmentation wounds are fundamentally different from wounds of other genesis, namely: the formation of a tissue defect along the wound channel, the nature of which depends on the caliber and speed of the fragment and the location of the wound, the presence of a zone of non-viable tissue around the wound channel, impaired microcirculation in the tissues bordering the wound zone, and the burden of the wound with various microorganisms and foreign bodies.

Disturbances in local homeostasis, microcirculation, the presence of non-viable tissue, and primary bacterial contamination of wounds cause an inflammatory reaction and the development of wound infection, which leads to a protracted healing process.

The course of the wound process in a shrapnel wound is determined by many factors, but the leading ones are the nature and volume of damaged and devitalized tissues, the fate of which, all other things being equal, predetermines the clinical outcome of the wound.

Treatment of penetrating gunshot wounds of soft tissues still presents certain difficulties due to the nature of the wound channel, the frequent addition of pathogenic anaerobic infection, and the development of severe complications.

The only way to treat these wounds to date is wide excision of tissue around the wound channel.

However, this method has the following main disadvantages: high trauma, often unjustifiably large tissue removal, and it cannot be used in the early stages after injury due to organizational difficulties, which aggravates the course of the wound process.

Available experience shows that surgical treatment of gunshot and shrapnel wounds must always be supplemented with drainage.

A method of fascine drainage of delimited cavities is known, including a bundle of solid or perforated tubes of the same length, characterized in that, in order to reduce the time of cavity healing and reduce the development of complications, the length of the tubes in the cavity is reduced stepwise, and their removal is carried out sequentially, starting with the longest and ending with the shortest, (RU Patent No. 2454948, Published: 10.07.2012)

The disadvantage is the impossibility of draining several wound channels simultaneously, as well as the high risk of clogging the perforation holes of the tubes due to their small diameter.

A surgical drainage is known for treating soft tissue wounds of various etiologies (RU patent 197177U1, published 04/08/2020), made in the form of an elastic tape, characterized in that the surface of the tape is provided with transverse triangular serrated protrusions on both sides, with the vertices facing one direction to ensure the directed outflow of wound discharge, while the surgical drainage has an anti-adhesive and antibacterial coating, and the surgical drainage is also provided with an external fixator for the drainage tape and dressing material.

The disadvantage of this technical solution is the impossibility of simultaneous drainage of various wound channels through one entry hole.

As a prototype of the claimed drainage method, we have chosen a method for treating penetrating gunshot wounds of soft tissues, consisting of treating the wound with antiseptic solutions in combination with the effect of oxygen, characterized in that local treatment is carried out using transvual treatments of the wound channel with an ultra-high-pressure finely dispersed flow of antiseptic having an initial diameter of 0.7-1.0 mm and a speed of 800-850 m/s, perfused with an ozone-oxygen mixture until an ozone concentration in the solution of 400-500 μg/l is obtained, wherein the flow of ozonized solution is first directed into the wound in the direction of the outlet, then in the opposite direction, and the said change in the direction of flow direction is performed 3-5 times, and the treatments are supplemented by penetrating drainage of the wound channel with a drainage tube with one or two ozone dialysis sessions lasting for 40-50 minutes until the wound channel narrows to 0.8-1.0 cm, after which the latter is drained with two drains on both sides with their gradual tightening, and the sanitation is carried out only with the help of ozone dialysis, carried out two or three times a day for 40-50 minutes with a dose of ozone dissolved in an antiseptic of 400-500 μg / l until complete healing (patent of the Russian Federation No. 2139702, published: 20.10.1999). After the primary ozone sanitation of the wound channel, the latter is drained with a rubber or silicone drain, which is a regular rubber or silicone tube with perforation holes to ensure ozone dialysis of the wound cavity, by connecting a dropper with an ozonized solution of furacilin to the drainage tube. Ozone dialysis is performed in between ozone treatments once or twice a day for 40-50 minutes. The introduction of drainage is also necessary to prevent consolidation of the canal walls and, thus, the formation of purulent cavities.

The disadvantage of this prototype technical solution is the possibility of drainage only in case of penetrating wounds, as well as the use of silicone tubes, the lumen of which can become clogged with wound detritus. Also, this method does not allow simultaneous drainage of several wound channels.

A common drawback of all methods identified in scientific and patent literature is the impossibility of controlled adequate drainage of several fragment wound channels simultaneously, less traumatic passage of drainage through soft tissues, more precisely the aponeurotic layer of muscles, as well as the muscles themselves, since the application of significant forces during attempts to introduce instruments to a depth of more than 5 cm may result in the risk of damage to the main vessels and peripheral nerves. In addition, it is also impossible to use them through accesses from 15 to 30 mm.

The objective of the proposed invention is to expand the therapeutic possibilities of effective and safe drainage of deep fragment wounds of soft tissues under ultrasound control, with a reduction in the risk of complications.

This problem is solved due to the fact that the claimed method for draining deep fragment wounds of soft tissues under ultrasound control includes removing foreign bodies from wounds of soft tissues and treating the wound with antiseptic solutions, which is distinguished by the fact that after performing secondary surgical treatment of a wound of one localization under ultrasound control, different angles and depths of the location of wound cavities in soft tissues are determined, a surgical glove is inserted into the wound through the wound access, the distal ends of the finger parts of which are cut off and have perforations of at least 6 mm, after which these distal ends of the finger parts are inserted through various wound channels under constant ultrasound control using a direct clamp that grasps the end of the finger part of the glove and inserts it to the desired depth, after which the second and subsequent fingers of the glove are also installed in the wound channels to its lower part in the same way. After this, ultrasound control is performed to check for the presence of the distal ends of the glove fingers in the wound channels, and the proximal part of the drainage glove is brought out to the skin surface above the wound. A double-lumen tube is inserted into the cavity of the glove, which is sewn to the proximal part of the glove, for sanitation of the wound channels with antiseptic solutions, the proximal part of the glove is cut to the required size and fixed to the skin with a plaster, after which a vacuum aspiration system and sterile aseptic dressings are installed on the wound, tightly fixed to the skin.

The technical result provided by the given set of features is a reduction in traumatic intervention and prevention of the development of infectious wound complications, due to which the treatment time for deep fragment wounds of soft tissues is reduced. In addition, the arsenal of treatment methods is expanded, allowing for simple and effective medical care in field conditions.

Most often, drainage of various wound channels or cavities of various etiologies is carried out blindly, or using probes with subsequent exploratory traction in the wound channel, or during the detection of a deep-lying cavity, for example, in the muscles.

Despite incision and drainage and broad-spectrum antibiotics, the failure rate of wound infection ranges from 5 to 20%. It is possible that some of this treatment failure may be due to inadequate evacuation of the wound channel. With blind drainage, it is possible that residual purulent discharge or unforeseen satellite cavities of the developing abscess contribute to the persistence of infection.

When removing foreign bodies from soft tissues under ultrasound control in mine-explosive shrapnel wounds, it is especially necessary to highlight wounds of the same anatomical localization with multiple fragments of different diameters, which may have entry points into soft tissues close to each other, and spread deep into the soft tissues in different directions. In this case, drainage of several wound channels is necessary after removing foreign bodies in order to prevent the development of infectious complications. However, when foreign bodies are at a depth of 5 to 10 cm, especially in the thickness of muscles, it is not always possible to perform adequate drainage of several channels simultaneously. One of the optimal methods for solving the above problems in the treatment of this category of patients is drainage of deep shrapnel wounds of soft tissues under ultrasound (US) control using the claimed method.

It has become possible to effectively drain several wound channels simultaneously by using the distal finger sections of a perforated surgical glove and advancing them along the wound channels through soft tissues under ultrasound control using a medical clamp (Billroth type), which significantly reduces the risk of developing infectious wound complications.

Thus, it is possible to drain several wound channels, mainly those located deep in the muscle mass, simultaneously. In this case, the ends of the drainage are smoothly passed through the soft tissues to the required depth, which reduces the risk of postoperative complications and makes it possible to drain at certain depths in complex topical localizations.

A detailed description of the method and examples of its practical implementation

The claimed method is used when a patient has multiple shrapnel wounds of soft tissues in one anatomical zone with fragments measuring from 7 to 15 mm, which after entering the soft tissues have spread in different directions, as a result of which they have one entry hole, but different wound channels.

Preliminary, before the surgical intervention, the drainage system is prepared. For this, the distal tips of the finger parts of the surgical glove are cut off, and a number of perforation holes with a diameter of at least 6 mm are made over the entire surface of the glove, including the finger part, depending on the extent of the damage.

The method for drainage of deep fragment wounds of soft tissues under ultrasound control is performed under constant intraoperative ultrasound control using a portable ultrasound device RuScan 70P and a linear sensor L12-3E and allows drainage at any depth in complex topical localizations.

The method is implemented as follows. The first stage is the primary treatment of wound channels. After the primary sanitation of wound channels, they are drained using a prepared drainage system, which is a surgical glove with cut-off ends of the finger sections and with perforation holes of at least 6 mm to ensure drainage with a flow of antiseptic. The drainage system is inserted using surgical clamps, such as a direct Bilroth clamp.

When removing several foreign bodies of soft tissues using a portable ultrasound device RuScan 70P and a linear sensor L12-3E, a linear ultrasound sensor is applied to the edge of the wound, wound channels are found, after which, under ultrasound control, using a direct Bilroth clamp, one of the distal ends of the finger of the glove is grasped and passed through the subcutaneous fat, aponeurosis, and installed in muscle tissue to the desired depth - to its lower part, after which the branches of the clamp are opened and the instrument is removed from the wound with slow rotating movements, and the finger end of the surgical glove remains in the wound channel, which is also confirmed by ultrasound control.

The second and subsequent (up to five) wound channels are drained in the same way. After all wound channels have been drained, the proximal part of the glove is brought out onto the skin, the cavity is sanitized under ultrasound control and this echographic picture is assessed - the location of the drains in the wound channels. Then the proximal part of the surgical glove is cut to the required size, a double-lumen drainage tube is installed in the glove cavity, which is sewn to the proximal part of the glove and fixed to the skin with a plaster. The double-lumen drainage tube is divided into 2 equal halves of the same diameter by a bridge in the middle of the drainage (the diameter can vary from 1.5 cm to 3 cm, depending on the extent of the damage), thus, the wound is drained through the proximal part of the glove and through the drainage tube. After which a hydrophilic absorbent dressing is applied to the wound, followed by connection of a vacuum aspiration device, through which continuous wound sanitation will be carried out through drainage in one lumen, followed by aspiration through the other lumen of the tube.

The effectiveness of the claimed method is confirmed by the following clinical examples:

Example 1.

In patient N-v after MVOR, admitted on the 3rd day after receiving the injury, an X-ray of the back of the neck revealed foreign bodies of soft tissue 7, 11, 13, 14 mm in diameter. The entry point is about 2.5-3.0 cm. An ultrasound scan revealed the location of 4 fragments in the thickness of the trapezius muscle, along it, in the thickness of the splenius muscle of the neck, 2 more fragments were localized, as well as the presence of a liquid component with heterogeneous contents in the wound. A complete blood count (CBC) revealed leukocytosis up to 16.2x109 with a band shift of up to 10, as well as a temperature of up to 38.5 degrees. Antibacterial therapy was prescribed: Azarexon 1.0 intramuscularly 3 times a day. Removal of foreign bodies under ultrasound control according to the claimed technique was performed. Local anesthesia was performed. In order to prevent the development of wound infectious complications, local anesthesia is performed using an antibiotic: in our clinic, 1 mg of the antibacterial drug Ceftriaxone was diluted in 4 ml of novocaine, after which it was injected into the soft tissues. In the operating room, surgical treatment of the wound was performed, turbid purulent-hemorrhagic discharge was obtained. With the constant use of the RuScan 70P ultrasound device and the L12-3E linear sensor, after visualizing the evacuated foreign bodies and determining their diameter and atraumatic nature of the route, under constant ultrasound control, foreign bodies are removed from the soft tissues through the wound opening using a Bilroth clamp: they are extracted from the soft tissues with slow circular movements. After sanitation of the wound and wound canals with antiseptic solutions (H2O2 and chloramine), a pre-prepared drainage system is introduced into the wound through the wound access under ultrasound control. For this purpose, the distal tips of the finger parts of the surgical glove were cut off, and a number of through perforations with a diameter of 6 mm were made with sterile scissors over the entire surface of the glove, including the finger part. After that, the finger parts were inserted through the identified wound channels under constant ultrasound control using a Bilroth clamp, which grasps the cut end of the finger part of the glove and inserts it into the wound channel to the desired depth - to its lower part, after which the second, third, fourth ends of the fingers of the glove are inserted in the same way and also installed in the wound channel to its lower part. The remaining fingers on the glove are cut off - thereby forming an additional perforation hole for better outflow of contents from the wound.

After this, ultrasound control of the position of the distal ends of the finger parts of the glove in the wound channels is performed, and the proximal part of the glove is brought to the skin surface above the wound. A double-lumen tube is inserted into it, which is sewn to the proximal part of the glove, and the excess parts of the proximal part of the glove are cut off. The double-lumen drainage tube is divided into 2 equal halves of the same diameter by a jumper in the middle of the drainage, thus, a flow-washing system is established and the wound is drained through the proximal part of the glove and through the drainage tube. Sterile hydrophilic and absorbent dressings are applied to the wound, followed by the installation of a vacuum-aspiration system, through which constant sanitation of the wound is carried out through the drainage in one lumen, with subsequent aspiration of the contents through the other lumen of the tube.

On the following day, ultrasound control of the wound channels is performed by measuring the thickness and length of the channel, in the dressing room, the wound is sanitized with solutions of antiseptics H2O2 and chloramine, after which the glove is pulled up by 1 cm without removing the entire system. On the 2nd day, ultrasound control of the wound channels is also performed by measuring the thickness and length of the channel, with the same wound sanitization and pulling the drainage system by 1 cm. The patient did not have a temperature reaction, the control OAK showed a decrease in leukocytosis to 11.4x109. On the 3rd day, visible positive dynamics are observed in the form of a decrease in the thickness and length of the channels. The fingertips of the glove are removed from the wound channels, as well as the entire drainage system in the form of a pre-prepared surgical glove. Thus, the implementation of simultaneous drainage of each wound channel, and the possibility of daily sanitization of all channels at the same time, made it possible to achieve effective prevention of the development of infectious wound complications. After removing the drainage system we developed, we sanitized the wound with antiseptic solutions. Water-soluble ointment oflomelid was injected into the wound. A wide rubber drain was installed in the remaining cavity, after which the dressing was completely changed and daily wound sanitization was continued, with the introduction of ointment oflomelid into the wound. On the 5th day, the OAC showed leukocytes of 5.9x109, there was no temperature reaction. Stable positive dynamics were noted. By the 6-7th day, the wound is completely cleared of purulent contents, and the issue of applying secondary sutures or healing by secondary intention is decided.

Thus, the application of the claimed method in practice confirmed the reduction of the trauma of the intervention, since during the traditional method of treating gunshot wounds, wide excision of damaged tissues and full opening and drainage of each wound channel separately are performed, which significantly increases the duration of wound healing due to their vastness and also the length of hospital stay.

Example 2.

Patient I-ov was admitted on the 3rd day after receiving a mine-explosive shrapnel wound (MEW). An X-ray of the left thigh revealed foreign bodies in the soft tissues 9, 12 and 14 mm in diameter. The wound entry site was about 2.5-3.0 cm. An ultrasound scan revealed the angles and depth of the wound channels in the soft tissues: 2 fragments in the thickness of the quadriceps muscle of the thigh, and the third in the intermediate muscle of the thigh, almost at the femur, as well as the presence of a liquid component with heterogeneous contents in the wound. The patient has a subfebrile temperature of up to 37.90C, a complete blood count (CBC) showed leukocytosis up to 14x109. Antibacterial therapy was prescribed: Azarexon 1.0 IM 3 times a day. Removal of foreign bodies under ultrasound control according to the claimed method was performed. Local anesthesia was performed. In order to prevent the development of wound infectious complications, local anesthesia is performed using an antibiotic: in our clinic, 1 mg of the antibacterial drug Ceftriaxone was diluted in 4 ml of novocaine, after which it was injected into the soft tissues. In the operating room, surgical treatment of the wound was performed, turbid purulent-hemorrhagic discharge was obtained. With the constant use of the RuScan 70P ultrasound device and the L12-3E linear sensor, after visualizing the evacuated foreign bodies and determining their diameter and atraumatic nature of the route, under constant ultrasound control, foreign bodies are removed from the soft tissues through the wound opening using a Bilroth clamp: they are extracted from the soft tissues with slow circular movements. After the wound and wound channels have been sanitized with antiseptic solutions (H2O2 and chloramine), a pre-prepared drainage system is inserted into the wound through the wound access under ultrasound control. For this purpose, the distal tips of the finger parts of the surgical glove were cut off, and a number of through perforations with a diameter of 7 mm were made with sterile scissors over the entire surface of the glove, including the finger part. After that, the finger parts were inserted through the identified wound channels under constant ultrasound control using a Bilroth clamp, which grasps the cut end of the finger part of the glove and inserts it into the wound channel to the desired depth - to its lower part, after which the second and third ends of the glove fingers are inserted in the same way and also installed in the wound channel to its lower part. The remaining fingers on the glove are cut off - thereby forming an additional perforation hole for better outflow of contents from the wound.

After this, ultrasound control of the position of the distal ends of the finger parts of the glove in the wound channels is performed, and the proximal part of the glove is brought to the skin surface above the wound. A double-lumen tube is inserted into it, which is sewn to the proximal part of the glove, and the excess parts of the proximal part of the glove are cut off. The double-lumen drainage tube is divided into 2 equal halves of the same diameter by a jumper in the middle of the drainage, thus, a flow-washing system is established and the wound is drained through the proximal part of the glove and through the drainage tube. Sterile hydrophilic and absorbent dressings are applied to the wound, followed by the installation of a vacuum-aspiration system, through which constant sanitation of the wound is carried out through the drainage in one lumen, with subsequent aspiration of the contents through the other lumen of the tube.

On the following day, ultrasound control of the wound channels is performed by measuring the thickness and length of the channel, in the dressing room, the wound is sanitized with solutions of antiseptics H2O2 and chloramine, after which the glove is pulled up by 1 cm without removing the entire system. On the 2nd day, ultrasound control of the wound channels is also performed by measuring the thickness and length of the channel, with the same wound sanitization and pulling the drainage system by 1 cm. The patient's temperature returned to normal, and the control OAC showed a decrease in leukocytosis to 10x109. On the 3rd day, in the presence of positive dynamics in the form of a decrease in the thickness and length of the channels, the ends of the glove fingers were removed from the wound channels, as well as the entire drainage system in the form of a pre-prepared surgical glove. Thus, the implementation of simultaneous drainage of each wound channel, and the possibility of daily sanitization of all channels at the same time, made it possible to achieve effective prevention of the development of infectious wound complications.

After removing the drainage system we developed, we sanitized the wound with antiseptic solutions. Water-soluble ointment oflomelid was injected into the wound. A wide rubber drain was installed in the remaining cavity, after which the dressing was completely changed and daily sanitization of the wound was continued, with the introduction of ointment oflomelid into the wound.

On the 5th day, the OAC showed leukocytes of 6.2x109, no temperature reaction. Stable positive dynamics were noted. By the 6th-7th day, the wound was completely cleared of purulent contents. In the future, the issue of applying secondary sutures or healing by secondary intention is decided.

Thus, the application of the claimed method in practice confirmed the reduction of the trauma of the intervention, since during the traditional method of treating gunshot wounds, wide excision of damaged tissues and full opening and drainage of each wound channel separately are performed, which significantly increases the duration of wound healing due to their vastness and also the length of hospital stay.

The results of using the claimed method in 9 patients showed that when draining deep splinter wounds of soft tissues under ultrasound control, in the presence of several wound channels, it is possible to drain them simultaneously, the volume of surgical intervention is reduced, the frequency of development of infectious wound complications is reduced, which significantly improved the treatment results for this category of patients.

The claimed method of drainage of deep fragment wounds of soft tissues under ultrasound control allows for more effective drainage of wounds of one anatomical localization with multiple fragments of different diameters, which may have entry points into soft tissues close to each other, and spread deep into the soft tissues in different directions.

The positive effect of the proposed method is the rapid cleansing of deep fragment wounds from purulent necrotic tissues, foreign and microbial bodies. It significantly facilitates surgical treatment when performing drainage of soft tissues, and also minimizes the volume of surgical intervention during the removal of several fragments from soft tissues, significantly reduces the length of stay of patients in hospital and disability rates. The claimed method allows for simple and effective medical care in the field.

The proposed method for drainage of soft tissues under ultrasound control has been tested in a clinic. The technical simplicity and availability of the method allow it to be used in surgical hospitals and recommended for wide use in clinical practice.

Claims (1)

A method for draining deep fragment wounds of soft tissues under ultrasound control, including removing foreign bodies from soft tissue wounds and treating the wound with antiseptic solutions, characterized in that after performing surgical treatment of a wound in one location under ultrasound control, the angles and depth of the wound cavities in the soft tissues are determined, they are drained through the wound access with a pre-prepared drainage system, which is a surgical glove with cut off fingertips and with perforation holes over the entire surface of the glove, including on the finger part, at least 6 mm, after which the distal ends of the finger parts are alternately inserted into the wound channels under constant ultrasound control using a straight clamp, which grasps the end of the finger part of the glove and brings it to the required depth, after which the second and subsequent finger parts of the glove are installed in the wound channels in the same way, then ultrasound control of the position of the distal ends of the finger parts of the glove in the wound channels is carried out, the proximal part of the glove is brought to the surface of the skin above wound, a double-lumen tube is inserted into it, which is sewn to the proximal part of the glove; sterile hydrophilic and absorbent dressings are applied to the wound, followed by the installation of a vacuum aspiration system.