Obstruction of the drainage tube complications of the abdominal cavity. Traditional method of treating appendicitis in children. Scientific and practical significance of the work

As a manuscript

ALONTSEVA

Natalya Nikolaevna

ABDOMINAL DRAINAGE

IN PREVENTION AND TREATMENT

EARLY POSTOPERATIVE COMPLICATIONS

dissertations for an academic degree

candidate of medical sciences

Petrozavodsk - 2006

The dissertation was completed at the Department of Faculty Surgery of the state educational institution of higher professional education "Petrozavodsk State University"

Scientific adviser:

Dudanov

medical sciences, professor Ivan Petrovich

Official opponents:

Corresponding Member of the Russian Academy of Medical Sciences, Doctor

medical sciences, professor Bagnenko Sergey Fedorovich

Doctor of Medical Sciences,

assistant professor Fetyukov Alexey Ivanovich

Lead organization: St. Petersburg State Medical Academy named after I. I. Mechnikov of the Ministry of Health and Social Development of the Russian Federation

The defense will take place “___”______2006 at ___ o’clock at a meeting of the dissertation council K 212.190.06 at Petrozavodsk State University at the address: 185910, Petrozavodsk, Lenin Ave., 33

The dissertation can be found in the library of Petrozavodsk State University.

Scientific Secretary

dissertation council

Candidate of Medical Sciences, Associate Professor Karapetyan T. A.

GENERAL DESCRIPTION OF WORK

Relevance of the topic. Drainage (French drainer - to drain) is a therapeutic method that involves removing discharge from wounds, ulcers, the contents of hollow organs, natural or pathological body cavities.

Abdominal cavity drainage (ABD) is a frequent, necessary and important final stage of many operations, and sometimes the main method of surgical intervention (Vlasov A. A., 2004; Kemerov S. V., 2005; Kostyuchenko K. V., 2005). The history of treatment of purulent-inflammatory diseases of the abdominal organs shows that in some cases it is impossible to do without drainage. Correctly stated indications and technique can significantly affect the outcome of treatment (Polyakov N. G., 1998; Zhebrovsky V. V., 2000). The lack of unanimity among researchers in resolving many issues of DKD (indications, goals, techniques, effectiveness, complications) makes this problem extremely relevant.

In clinical practice, there is a clearly established rule for the technique of surgical intervention for purulent-inflammatory diseases of soft tissues, such as abscesses, phlegmon, purulent leaks of subcutaneous and intermuscular tissue. To do this, a wide opening of the inflammation site is performed; excision of purulent-necrotic tissue areas; drainage of the wound through the site of opening of the abscess, and in case of deep wounds - creation of additional outflow pathways (Savelyev V.S., 1967; Kanshin N.N., 1997; Shchetinin V.S., 1997). The drainage left in these cases helps to create pathways for the free outflow of purulent fluid and creates an obstacle to the adhesion of the superficial areas of the wound until it is completely cleansed and granulated. Many clinicians use such generally accepted provisions for draining purulent areas of soft tissue when draining purulent processes in the abdominal cavity.

Sometimes, when a surgeon performs a laparotomy for purulent-inflammatory diseases of the abdominal cavity (destructive appendicitis, cholecystitis, perforation of hollow organs, intestinal obstruction, peritonitis, etc.), after removing the source of the disease and washing the abdominal cavity, there is no complete confidence in the sufficiency of the sanitation performed. Quite naturally the question arises about the need for drainage of the abdominal cavity. This problem is not sufficiently covered in the literature. More often, authors in their articles write briefly, casually, “drainage of the abdominal cavity is necessary,” without indicating the purpose, task, or technique of implementation (Strukov V.I., 1965; Khryakov A.S., 2005; Linder M.M., 1987). In clinical practice, in many medical units, abdominal drainage is used quite often (20-50%) and this trend continues. In the literature, discussions about the advisability of drainage of the abdominal cavity continue to this day (Zhurikhin A. A., 2000; Karyakin A. M., 2000; Mishin V. Yu., 2002; Bagnenko S. F., 2003; Plechov V. V. , 2003).

The issues of indications and technique for drainage of the abdominal cavity remain complex and unresolved to date. In addition, when draining the abdominal cavity, you should also be aware of the negative aspects of drainage and be able to compare the feasibility and effectiveness of this treatment tactic.

Purpose of the study: to improve indications for drainage of the abdominal cavity using more effective and safe methods, to develop an algorithm for the diagnosis and treatment of early postoperative intra-abdominal complications.

Research objectives:

1. To evaluate the effectiveness of passive glove-tubular drainage used for the prevention of purulent-inflammatory complications in the abdominal cavity.
2. To study the validity of frequent abdominal drainage for prophylactic purposes.
3. To clarify the indications for drainage of the abdominal cavity for therapeutic purposes.
4. To propose more effective and safe methods of abdominal drainage.
5. To evaluate the effectiveness of minimally invasive methods for the prevention and treatment of postoperative complications.

Scientific novelty. Indications for drainage of the abdominal cavity have been improved, both for preventive and therapeutic purposes, developed based on an analysis of clinical material for the period from 1995 to 2004. This allows you to reduce the number of drainages and at the same time does not lead to an increase in the number of postoperative complications.

An analysis of abdominal drainage for prophylactic purposes was carried out and it was proven that it does not directly affect the outcome of treatment and has relative (optional) indications.

The study proved that the drainage used can become a source of postoperative complications.

An algorithm for the diagnosis and treatment of early postoperative intra-abdominal complications is proposed, which provides for the rational use of instrumental methods in accordance with the expected complication.

Scientific and practical significance of the work:

The study revealed that abdominal drainage is performed frequently and in most cases has dubious indications. Based on a study of the outcomes of operations with drainage of the abdominal cavity in the treatment of purulent-inflammatory diseases, indications for drainage were developed. Their use has made it possible to reduce the number of unnecessary drainages, associated complications and reoperations, and improve the quality of life of patients. The proposed algorithm for the diagnosis and treatment of early postoperative intra-abdominal complications helped reduce time costs by eliminating the duplication of additional research methods. On the topic of the dissertation, on October 25, 2005, No. 1116, the rationalization proposal “Laparoscopic opening and drainage of abdominal abscesses” was registered and accepted for use; No. 1117 – “Method of collecting blood for reinfusion during laparoscopy.” The research results are used in the practical activities of the surgical departments of the Petrozavodsk Emergency Hospital, in the educational process at the Department of Faculty Surgery of Petrozavodsk State University, and are included in the program of practical training for interns and clinical residents.

Main provisions submitted for defense:

1. The passive function of glove-tubular drainage, used to prevent purulent complications, is ineffective and is fraught with the development of various complications. It is necessary to abandon frequent DBP in order to prevent postoperative purulent complications due to the rarity of the development of the latter and the low effectiveness of the method used.

2. Passive drainages, used for drainage of the abdominal cavity for preventive and therapeutic purposes, often cause postoperative complications. It is possible to significantly improve the prevention of postoperative purulent-inflammatory complications through an effective, simple and safe method - adequate sanitation of the abdominal cavity.

3. Multiple active (vacuum) drainages are a more effective and safe method of drainage of the abdominal cavity for prophylactic purposes.

4. For diagnosing possible early postoperative complications, preference should be given to non-invasive and minimally invasive research methods, and in doubtful cases, diagnostic laparoscopy should be used.

Approbation of work. 11 printed works have been published on the topic of the dissertation, including 5 articles in peer-reviewed scientific and practical journals. The main provisions of the dissertation were presented at the VI Scientific and Practical Conference on Emergency Surgery of the Emergency Medical Care Hospital (Petrozavodsk, 2000); at the VIII final scientific and practical conference on emergency surgery of the Emergency Medical Care Hospital (Petrozavodsk, 2002); at the Russian Scientific and Practical Conference of Surgeons (Kondopoga, 2002), at the IV Scientific and Practical Conference of Surgeons of the North-West of Russia “Emergency Surgery of the Abdominal Organs and Injuries of the Musculoskeletal System” (Kondopoga, 2003), at the X Scientific and Practical Conference on emergency surgery at the Emergency Hospital (Petrozavodsk, 2004) and at the XI Scientific and Practical Conference on Emergency Surgery at the Emergency Hospital (Petrozavodsk, 2006).

Scope and structure of the dissertation. The dissertation is presented on 152 pages of typewritten text and includes 33 tables, 13 figures, 1 diagram. The dissertation consists of an introduction, a literature review, 7 chapters of own research, a conclusion, conclusions and practical recommendations. The list of references includes 248 sources, including 203 domestic and 45 foreign.

Materials and research methods

Clinical material. The study was conducted on the basis of the emergency medical care hospital (EMS) in Petrozavodsk. The results of examination and treatment of 8719 (57.5%) patients operated on the abdominal organs for various types of pathology from 1995 to 2004 were studied (out of 15158 (100%) operated on from 1995 to 2004. ). The age of the patients ranged from 15 to 94 years and averaged 39±2.1 years. Among the patients, 6800 (78%) were patients aged from 15 to 60 years, over 60 years old – 1919 (22%). Of these, 5109 (58.6%) were men, 3610 (41.4%) were women.

During the first day from the onset of the disease, 8029 (92%) patients were hospitalized, after 24 hours – 690 (8%) patients. All patients are divided into groups according to nosological forms. 1994 (22.2%) patients underwent elective surgery. Drainage of the abdominal cavity was performed in all cases for prophylactic purposes.

The results of treatment of 334 patients with early postoperative intra-abdominal complications were analyzed:

• 129 (38.5%) patients with abdominal abscesses that arose in the postoperative period;
• 120 (35.8%) patients with widespread peritonitis;
• 45 (13.5%) patients with intestinal obstruction;
• 14 (4.2%) – with intestinal fistulas;
• 13 (3.9%) patients with intra-abdominal bleeding;
• 13 (3.9%) – with events, as well as
• 23 (6.9%) – with fatal outcomes.

Methods of examining patients. Indications for drainage of the abdominal cavity for therapeutic or prophylactic purposes were based on medical history, the nature of the disease, clinical examination, laboratory data, and the results of examination of the abdominal organs during surgery.

To clarify the diagnosis and carry out differential diagnosis in patients with postoperative intra-abdominal complications of the abdominal cavity, laparoscopy was used as the main method.

Clinical groups. The patients were divided into 2 clinical groups. The first group consisted of patients who underwent surgical interventions in the period from 1995 to 1999. Since 2000, the tasks and indications for DBP have been revised at the emergency hospital in Petrozavodsk, and work has been carried out to reduce the need for abdominal drainage. Patients who were operated on between 2000 and 2004. formed the second clinical group. The clinical groups of the studied patients are presented in Table 1.

Table 1

Clinical groups of study patients.

During the work, a comparative analysis of macroscopic changes in the abdominal cavity and the results of bacteriological examination for the period 1995 to 2004 was carried out. The frequency of discrepancies between the intraoperative description of the condition of the abdominal cavity and the results of culture of its exudate was studied. The effectiveness of frequent drainage during surgical interventions on the abdominal organs was analyzed. Methods for the prevention of postoperative purulent-inflammatory complications have been improved, which has made it possible to reduce the number of drainages, and in some cases, refuse. A comparative analysis of postoperative purulent-inflammatory complications in the studied clinical groups was performed.

Statistical processing of results. The research results were processed using an IBM-compatible computer with a Pentium processor using the Microsoft Excel statistical software package.

RESEARCH RESULTS AND THEIR DISCUSSION

Drainage of the abdominal cavity is one of the methods for the prevention and treatment of purulent-inflammatory complications. Most often, DBP is performed in patients undergoing surgery for emergency and urgent indications. We studied the results of treatment of patients with the most common diseases for which DBP is performed.

Drainage of the abdominal cavity in acute appendicitis. The results of treatment of patients operated on for acute appendicitis over the period 1995-2004 were studied. For the period 1995-1999. 1687 patients were operated on. They made up the first group of the study. Of these, 1502 patients were operated on for acute appendicitis without peritonitis; with limited peritonitis – 175; with diffuse purulent peritonitis – 10 patients. In uncomplicated acute appendicitis, DBP was performed in 52 (12%) patients; with limited peritonitis – in 175 (100%); with diffuse purulent peritonitis – in 10 (100%). The main goal of DBP was to reduce the number of postoperative purulent-inflammatory complications in the abdominal cavity. To drain the abdominal cavity, a glove-tube drainage (three red rubber tubes wrapped in glove rubber) was used.

The second study group included 1528 patients operated on in 2000-2004. Of this group, 1399 patients were operated on for acute appendicitis without peritonitis; 122 – with limited peritonitis; 7 – with diffuse peritonitis. During this time, work was carried out in the emergency hospital to reduce the number of DBPs and change the drainage technique. Since 2000, the clinic began to use glove-tube drainage much less frequently, switching to silicone, multi-channel tubes for passive and active drainage, which, if necessary, were also used as conductors during laparoscopy. In uncomplicated acute appendicitis, DBP was performed in 1.5% of cases, in the first group – 16%. In case of limited peritonitis, DBP in the second study group was performed in 45% of cases, in the first group – 100%.

The decrease in the number of DKD did not lead to an increase in postoperative purulent-inflammatory complications. Patients were discharged 5-7 days after surgery, while the stay of patients who underwent DBP averaged 16 days.

When performing surgical interventions, the basis for the prevention of postoperative complications was thorough sanitation of the abdominal cavity.

DBP for prophylactic purposes in closed and open abdominal injuries. The results of treatment of 404 patients treated for closed and open abdominal injuries in the period from 1995 to 2004 were studied. Surgical interventions were performed in 376 (93%) patients within 6 hours from the moment of injury. There were 28 patients (6.9%) with diffuse serous-purulent and purulent peritonitis.

Drainage of the abdominal cavity after surgery was performed in 155 (38.4%) patients.

In 98 (24.3%) cases, no damage was detected during the inspection of the abdominal organs. Moreover, in 45 cases, DBP was performed (45.9%). In 306 victims, injuries to internal organs were detected during surgery; in 110 (35.8%) cases, DBP was performed. Analysis of the results indicates that DPB for abdominal trauma in most cases was performed for prophylactic purposes.

In recent years (2000-2005), a revision of the indications for drainage of the abdominal cavity has allowed us to reduce the number of DBP in abdominal injuries from 54.7% in 1995 to 25.3% in 2004. Having analyzed the results of treatment of this group of patients, We found that a decrease in the number of drainages did not lead to an increase in postoperative intra-abdominal purulent-inflammatory complications.

DBP for prophylactic purposes after laparotomies for complicated forms of gastric and duodenal ulcers. For 1995-2004 According to emergency indications, 1056 patients with complicated forms of peptic ulcer were operated on. In the first group, 572 patients were operated on for this pathology, of which 213 (37.3%) patients had indications for DKD, both for therapeutic and prophylactic purposes. In the second group, 484 patients were operated on for complicated forms of peptic ulcer; DBP was performed in 96 (20%).

928 (88%) patients with perforated gastric and duodenal ulcers and gastroduodenal bleeding were mostly operated on within 6 hours of the onset of the disease. 255 (24%) patients - in the period from 6 to 12 hours from the onset of the disease. 95 (9%) people were operated on within 12 to 24 hours from the onset of the disease. 33 (3%) were admitted to the hospital later than 24 hours from the moment of illness. DBP in the last group was performed for therapeutic purposes and had vital indications. Gastric resection was performed in 675 (64%) patients. 348 (33%) – suturing of a perforated ulcer of the stomach and duodenum was performed.

Abdominal abscesses occurred in 40 (3.8%) patients out of 1056 operated on.

After “clean” 442 operations, which included gastric resection for gastroduodenal bleeding, DBP was performed in 80 patients (18%), abdominal abscesses occurred in 10 (2.3%). In 233 patients with perforated gastric and duodenal ulcers, gastrectomy was performed. There was no peritonitis, but drainage was performed in 79 patients (34%), abdominal abscesses occurred in 6 (2.6%). In these operations, the indications for drainage were for prophylactic purposes.

DBP for therapeutic purposes was performed in 126 patients with perforated ulcers of the stomach and duodenum due to late presentation to the hospital and peritonitis that had developed in them. In these cases, the fight against the widespread purulent process was continued in the postoperative period. For this purpose, programmed laparostomy and transdrainage closed laparoscopic sanitation of the abdominal cavity were performed. When performing DBP in patients with widespread purulent peritonitis, drainage was introduced to the “favorite” places of pus accumulation. Abdominal abscesses occurred in 8 (2.1%) cases.

In patients operated on with perforated gastric and duodenal ulcers within 12 hours of the disease, DBP was performed in 41% of cases in patients of the first group. In recent years, the number of DBPs has decreased by 4 times.

Of the 226 patients who in the period 1995-1999. Gastric resection was performed for gastroduodenal bleeding; DBP was performed in 51 (22.6%) cases. In the second study period, out of 216 patients with gastric resection for gastroduodenal bleeding, DBP was performed in 33 (15.3%) cases.

During the initial period of the study, in 128 patients with gastrectomy for perforated gastric or duodenal ulcers, drainage was performed in 55 (43%) cases. In the second group of 105 patients operated on for perforated gastric or duodenal ulcers, DBP was performed in 24 (23%). And this did not lead to an increase in the number of purulent-inflammatory complications in the postoperative period.

During the study, it was found that the possible cause of abdominal abscesses was insufficient sanitation of the abdominal cavity during surgery or the lack of antibacterial prophylaxis.

DKD in patients with peritonitis. Of the 15,158 patients operated on during the study period, 716 (4.7%) were diagnosed with peritonitis.

590 (82.3%) patients were operated on with limited peritonitis: during the period 1995-1999. – 325 patients and for the period 2000-2004. – 265. 295 (50%) were admitted to the hospital within 12 hours of the onset of the disease; from 12 to 24 hours 252 (42.7%); later than 24 hours - 43 (7.3%) patients in this group.

126 (17.7%) patients with diffuse purulent peritonitis.

When performing laparotomy for purulent-inflammatory pathology after removing the source of the disease and washing the abdominal cavity, without hoping for the effectiveness of the sanitation performed, surgeons gave indications for drainage. For the period 1995-1999. DBP in patients with limited peritonitis was used in 320 (98%) patients out of 325. In the second period of the study, the number of DBP decreased significantly: to 175 (58%) cases out of 265.

The number of DKD with limited peritonitis, the cause of which was perforation of a gastric or duodenal ulcer, decreased from 83% to 13%. There was a decrease in the number of abdominal drainages in patients with trauma from 100% at the beginning of our study to 20% subsequently. In the most common pathology, namely acute appendicitis, from 100 to 61%. In case of intestinal obstruction, the number of abdominal drainages decreased to 66% compared to 100% in the initial period of the study. Reducing the number of drainages did not lead to an increase in the number of postoperative purulent-inflammatory complications in the abdominal cavity.

DBP for preventive purposes due to the wide variety of clinical situations in which it can be used, as well as the fact that this method does not directly affect the outcome of treatment of the underlying disease, has relative (optional) indications.

Drainages for unreliably applied sutures of the gastrointestinal tract are logically necessary and, in the opinion of many clinicians, justified. However, this method is not always effective due to the possible closure of the tube lumen and the spread of intestinal contents not into the drainage, but more often into the free abdominal cavity. We also cannot exclude the possibility of secondary infection through the tube and an increase in the number of adhesions. Drainage performs its function well after operations on the gallbladder and bile ducts, and during pancreatitis - in these cases, drainage was performed in 100% of cases (in 2562 patients).

Indications for drainage to prevent the formation of purulent-inflammatory complications in the abdominal cavity in patients with limited and widespread peritonitis largely depend on the severity of the local purulent-destructive process. Drainage for preventive purposes in patients with limited or widespread serous, serous-fibrinous peritonitis is relative. DBP with PC can be performed when:

1) limited peritonitis;

1. widespread serous, serous-purulent peritonitis;
2. after cholecystectomies and suturing of the bile ducts;
3. the danger of insolvency of the sutures of the gastrointestinal tract;
4. stopped bleeding or bile leakage from parenchymal organs.

In two cases, the purpose of drainage was to prevent the formation of abscesses in the “favorite” places where pus accumulates in the abdominal cavity. To do this, drainage is performed with a tube with a diameter of 0.8-1.0 cm, which is installed to the bed of the source, or with one tube with a diameter of 1.0 cm in the pelvic area, lateral sections, subhepatic and subdiaphragmatic spaces. In other cases, the task of the DBP is to create pathways for the outflow of intestinal contents, bile, blood, and inflammatory exudate from the abdominal cavity, which may be a consequence of suture failure. For this purpose, a drainage tube with a diameter of 0.3-0.5 cm is brought to the location of the possible source.

The group of patients with widespread purulent peritonitis consisted of 126 (17.7%) people out of 716. The purpose of DBP for this group of patients was to continue treatment in the postoperative period. Drainage for therapeutic purposes is indicated for:

1) abscesses of the abdominal cavity;

1. purulent-necrotic changes in the pancreas and purulent-inflammatory processes in the retroperitoneal space, disintegration of tumors, tumors when it is impossible to remove them;
2. trauma to parenchymal organs when radical intervention is impossible;
3. bleeding from arrosive vessels of inflamed necrotic tissues;
4. widespread purulent peritonitis.

In the first and second cases, the task of drainage is to create pathways for the outflow of purulent-inflammatory exudate. For this, depending on the location, one or two tubes with a diameter of 1.0 cm are used. In the third and fourth cases, the task of drainage is to tampon the site of capillary or parenchymal bleeding. In case of widespread serous-purulent and purulent peritonitis, the purpose of DBP in the postoperative period is to continue the fight against the widespread purulent process. For this purpose, multiple active (vacuum) drainages, programmed laparostomy, and transdrainage closed laparoscopic active sanitation of the abdominal cavity are used. In DKD, the virulence of the microflora, the prevalence and duration of the purulent-inflammatory disease were taken into account.

Postoperative abdominal abscesses and evaluation of their prevention

Of the 8690 patients who underwent emergency surgery, DBP for the purpose of preventing postoperative abscesses was performed in 2873, which amounted to 33.1%. Of 6468 patients after planned surgical interventions, DBP was performed in 1579 patients (24.3%) (Table 2).

table 2

Emergency and planned surgical interventions and the number of DBP for the prevention of purulent-inflammatory complications of the abdominal cavity

According to the study results, DBP for preventive purposes has been used much less frequently in recent years. In patients operated on as planned, the number of drainages decreased from 30.9% to 11.1%, that is, 2.8 times. In patients operated on for urgent reasons, from 40.9 to 20.1%, that is, 2 times. At the same time, this did not lead to an increase in the number of postoperative complications. Of 15,158 operated patients over 10 years, abdominal abscesses developed in the postoperative period in 129 (0.8%). Complications developed on the 10-20th day after surgery.

It was found that in 39 patients with DKD, during the first operation, abdominal abscesses formed in drained areas. In another group of patients, abscesses were in different anatomical areas of the abdominal cavity. In total, out of 68 formed pelvic abscesses, drainage was performed after the first operation in 18. Subhepatic abscesses formed in 49 patients, drainage of this area was performed in 21. Subdiaphragmatic abscesses occurred in 48 cases, drainage was performed in 6. In 32 cases, postoperative interintestinal abdominal abscesses. Abdominal abscesses formed in 69 patients (0.84%) during the first period of the study, and in 60 (0.74%) during the second period.

Thus, as a result of the study, it was established that abscesses occurred in all parts of the abdominal cavity, without any pattern, including in places of drainage, and a decrease in the number of DBP for preventive purposes did not lead to an increase in the number of complications. This indicates the dubious capabilities of passive drainage. The dependence of the formation of abdominal abscesses on the underlying pathology and the place of their drainage is presented in Table 3.

Table 3

Frequency and localization of developed abscesses depending on the underlying pathology

and previously performed DBP

The role of abdominal sanitation in the prevention of postoperative purulent-inflammatory complications

Purulent-inflammatory processes in the abdominal cavity in most patients occurred as a complication of various diseases. Bacteriological examination of abdominal exudate was performed in 740 patients.

According to the results of the study, in 195 patients with exudate in the abdominal cavity, no microbial growth was observed, a single growth of microorganisms was observed in 242, and multiple growth in 118. Analysis of the study results showed that Escherichia coli plays a leading role in infection of the abdominal cavity. In the initial stages of the disease, during surgery there was a yellowish effusion, without fibrin admixture. The nature of the exudate was consistent with serous peritonitis. During bacteriological examination, microbial growth was not observed or was sporadic. An increase in fibrin content in serous exudate indicates serous-fibrinous peritonitis. Microscopic examination of this group of patients observed single growth of microorganisms. Depending on the source, the exudate could have a characteristic colibacillary or putrefactive odor. This type of exudate was consistent with purulent peritonitis with multiple bacterial growth during the study.

In the postoperative period, this group of patients experienced complications:

1. abdominal abscesses – in 72 patients; preliminary drainage during the first operation was performed in 32 (44.4%) cases;
2. postoperative peritonitis – in 58 patients; after drainage in 45 (77.6%) cases;
3. early adhesive intestinal obstruction – in 40 patients, drainage after the first operation was performed in 27 (67.5%) cases;
4. eventration – in 4 patients after drainage of the abdominal cavity.
5. intestinal fistulas – in 3 patients, through wounds after drainage of the abdominal cavity.

One of the main causes of postoperative complications is insufficient sanitation of the abdominal cavity. If during the operation the exudate was not completely removed or fibrinous deposits remained on the peritoneum, then infiltrates could form in the postoperative period, followed by abscess formation. Drainage of the abdominal cavity in this group was performed in 498 (67.3%) patients out of 740. Multiple bacterial growth was observed in only 118 (16%). In these cases, DBP is performed for therapeutic purposes.

Thus, the main points in the prevention of postoperative complications are sanitation of the abdominal cavity and intravenous antibacterial prophylaxis, regardless of the nature of the pathology and the method of performing the operation.

Treatment of early postoperative intra-abdominal complications

The results of treatment of 334 (2.2%) patients out of 15,158 operated on during the study period who experienced intra-abdominal complications in the early postoperative period were studied. Repeated surgical interventions were performed in 311 (2%) patients. It should be noted that in 297 (88.9%) patients, primary surgical intervention was performed for emergency and urgent indications, 37 (11.1%) - after planned surgical interventions.

Intra-abdominal complications for which surgical treatment was repeated were the following: abdominal abscesses - in 129 patients; widespread peritonitis – 120; intestinal obstruction – 45; intestinal fistulas – in 14; eventration of the abdominal organs – in 13; intra-abdominal bleeding – in 13.

In 23 patients with existing postoperative complications, re-intervention was not performed. Deaths occurred in all patients. The main cause of death in 10 patients was colon cancer complicated by intestinal obstruction, in 5 - widespread peritonitis upon late admission to the hospital, in 3 - thrombosis of mesenteric vessels with gangrene of the small intestine, in 3 - massive intra-abdominal bleeding. Other reasons for which the complication was not recognized were: myocardial infarction - in 5 patients, pneumonia - in 2, acute cerebrovascular accident - in 1.

The main methods of treating early postoperative intra-abdominal complications were relaparotomy and minimally invasive interventions, which, for certain indications, were an alternative to relaparotomy. A total of 338 interventions were performed, 27 patients underwent relaparotomy twice. The results of 204 laparoscopies were analyzed for the purpose of diagnosis and treatment of early postoperative intra-abdominal complications. The simplest and most convenient technical solution for conducting control dynamic laparoscopy was the use of silicone drainage, installed during surgery in the periumbilical area and used as a trocar guide.

Indications for relaparotomy according to laparoscopy were determined in 50 patients. The following were determined laparoscopically: direct or indirect signs of anastomotic suture failure; perforation or necrosis of a hollow organ; widespread purulent peritonitis; multiple adhesions in the abdominal cavity with the formation of severe deformations of the small intestine; continued intense bleeding.

In 57 patients, treatment of early postoperative intra-abdominal complications was performed using the laparoscopic method: for postoperative peritonitis - in 28; abdominal abscess – 20; intra-abdominal bleeding – in 4; intestinal obstruction – in 4; eventration of the abdominal organs – in 1 patient. With widespread postoperative peritonitis, 28 patients underwent laparoscopic sanitation of the abdominal cavity. A total of 32 sanitation procedures were performed. Depending on the severity of the inflammatory process, the number of operations per patient ranged from 1 to 4. The progression of the pathological process necessitated relaparotomy in only two cases. Laparoscopic opening and drainage of abdominal abscesses was performed in 20 patients. On average, abdominal abscesses required 2 sanitation laparoscopies. A favorable result was obtained in 19 patients. Death occurred in 1 patient due to recurrent arrosive bleeding, which was an indication for multiple relaparotomy. Laparoscopic hemostasis was performed in 4 patients with intra-abdominal bleeding. Early adhesive postoperative intestinal obstruction in 4 patients was eliminated laparoscopically. When the greater omentum was released into the drainage wound, laparoscopic resection was performed.

72 patients had various complications after repeated surgical interventions. The most common occurrence was suppuration of the postoperative wound - in 38 patients, including in combination with intestinal eventration - in 9 patients. The occurrence of intestinal fistulas was noted in 7, pneumonia - in 8, gastrointestinal bleeding - in 5. Various cardiac disorders - in 29 patients, acute renal failure - in 9, liver failure - in 6. These complications determined the need to change surgical tactics and correction of the treatment.

As can be seen from the studied material, early postoperative complications are accompanied by a long stay of the patient in the hospital and high mortality. The development of minimally invasive methods of diagnosis and treatment, in particular the use of a universal, relatively safe laparoscopic method, makes it possible to improve the results of treatment of pathology in the early postoperative period and reduce the number of drainages of the abdominal cavity for prophylactic purposes, and, if necessary, to actively influence the pathological focus.

Based on the research results, an algorithm for the diagnosis and treatment of early postoperative intra-abdominal complications was proposed (Scheme 1).

Scheme 1. Algorithm for diagnosis and treatment of early postoperative intra-abdominal complications

The algorithm assumes active tactics for diagnosing complications that have arisen and the rational use of additional research methods by eliminating duplication of additional research methods

CONCLUSIONS

1. Analysis of the results of using passive glove-tubular drainage for the purpose of preventing purulent postoperative complications revealed a number of serious shortcomings:

• voluminous and coarse drainage left in the abdominal cavity for 3-5 days causes adhesive intestinal obstruction;
• drainages and wounds after their use cause eventration and the formation of intestinal fistulas;
• drainages are a source of secondary infection, as well as
• the cause of the formation of postoperative ventral hernias.

2. Drainage of the abdominal cavity for prophylactic purposes has relative indications. It is performed when:

• limited peritonitis;
• widespread serous, serous-fibrinous peritonitis;
• surgeries on the gallbladder and bile ducts;
• doubts about the integrity of the sutures of the gastrointestinal tract;
• injury to parenchymal organs, even when bleeding has stopped.

3. To create pathways for the outflow of purulent-inflammatory exudate, drainage of the abdominal cavity is performed for therapeutic purposes. For capillary and parenchymal bleeding, drainage in combination with tamponade is a method of controlling bleeding. It is shown when:

• abdominal abscesses;
• purulent-necrotic processes in the pancreas, in tumors and tissues when it is impossible to remove them;
• for injuries of parenchymal organs and the impossibility of radical intervention;
• with bleeding from arrosive vessels of inflammatory necrotic tissues, where the source of bleeding is difficult to differentiate;
• with widespread serous-purulent, purulent peritonitis.

4. For the purpose of prevention and treatment of postoperative intra-abdominal purulent-inflammatory complications, multiple active drainages are used for 1-2 days or trans-drainage closed laparoscopic sanitation of the abdominal cavity. For drainage for therapeutic purposes, one or two silicone, radiopaque tubes with a diameter of 8-10 mm are used; for drainage of the abdominal cavity for prophylactic purposes - with a diameter of 3-5 mm.

5. The basis for the prevention of postoperative complications are:

• antibacterial prophylaxis;
• adequate surgical technique;
• complete sanitation of the abdominal cavity.

1. DBP should always be performed as indicated.
2. When draining the abdominal cavity, one should take into account the duration and prevalence of the purulent-inflammatory process and the virulence of the microflora.
3. The basis for the prevention of postoperative purulent-inflammatory complications are thorough sanitation of the abdominal cavity and good surgical technique, antibacterial prophylaxis before or during surgery.
4. To diagnose early postoperative intra-abdominal complications, the use of additional research methods is indicated in accordance with the expected complication.

ON THE TOPIC OF THE DISSERTATION

1. Alontseva, N. N. Postoperative abscesses of the abdominal cavity. Causes. Assessing the effectiveness of their prevention / N. N. Alontseva, A. M. Mezhenin // Drainage in surgery: Mater. VI scientific-practical. conf. on emergency surgery. – Petrozavodsk. 2000. – P. 3-5.
2. Alontseva, N. N. Features of opening and drainage of appendiceal abscesses / N. N. Alontseva, A. M. Mezhenin, A. A. Bogdanets, [etc.] // Drainage in surgery: Mater. VI scientific-practical. conf. in emergency surgery - Petrozavodsk. 2000. – P.41-44.
3. Alontseva N. N. About the standard approach to drainage of the abdominal cavity with a purulent process / A. M. Mezhenin, I. P. Dudanov, N. N. Alontseva, Yu. V. Andreev // Current issues of thoracic, cardiovascular and abdominal surgery: Mater. anniversary scientific and practical conference, dedicated. 100th anniversary of the Department of Hospital Surgery of St. Petersburg State Medical University named after. acad. I. P. Pavlova. Saint Petersburg. 2001. – pp. 116–119.
4. Alontseva, N.N. Assessing the effectiveness of abdominal drainage / I. P. Dudanov,

A. M. Mezhenin, G. A. Sharshavitsky, Yu. V. Andreev, N. N. Alontseva, V. E. Sobolev // Bulletin of Surgery named after. I. I. Grekova. – 2001. – T. 160. No. 1. – P. 63-66.

1. Alontseva, N. N. Technical capabilities of passive drainage in the abdominal cavity for the purpose of preventing purulent complications / N. N. Alontseva, A. M. Mezhenin, Yu. V. Andreev, I. P. Dudanov // Med. acad. magazine. – 2002. – T. 2. No. 2. – Appendix. 2. – pp. 4-5.
2. Alontseva, N. N. Standards for diagnosing postoperative abscesses in the abdominal

cavities and assessment of the effectiveness of their prevention / I. P. Dudanov, N. N. Alontseva, A. M. Mezhenin // Med. acad. magazine. – 2002. – T. 2. No. 2. – Appendix 2. – P. 67-68.

1. Alontseva, N. N. Is it necessary to frequently drain the abdominal cavity for prophylactic purposes during operations for abdominal trauma / N. N. Alontseva, I. P. Dudanov, A. M. Mezhenin // Med. acad. magazine. – 2003. – T. 3. No. 2. – Appendix. 3. – pp. 14-16.
2. Alontseva, N. N. Treatment of early postoperative intra-abdominal complications in elderly and senile patients / V. E. Sobolev, N. N. Alontseva, A. L. Rasyukevich // Bulletin of Surgery named after. I. I. Grekova. – 2004. – T. 163. No. 4. – P. 49-53.
3. Alontseva, N. N. Drainage in urgent surgery of the abdominal cavity / N. N. Alontseva, Yu. V. Andreev // Emergency surgery in old and senile age: material. X scientific-practical. conf. Surgeons. – Petrozavodsk. 2004. – pp. 6-7.
4. Alontseva, N. N. The choice of surgical intervention method for duodenal injury / Yu. V. Andreev, A. L. Rasyukevich, N. N. Alontseva // Med. acad. magazine. – 2005. – T. 5. No. 2. – Appendix 6. – P. 42-44.
5. Alontseva, N. N. The role of laparoscopy in the diagnosis and treatment of early postoperative complications / V. E. Sobolev, I. P. Dudanov, N. N. Alontseva // Bulletin of Surgery named after. I. I. Grekova. – 2005. – T. 164. No. 1. – P. 95-99.

The invention relates to medicine, surgery, and can be used in the surgical treatment of peritonitis. Fluid formations of the abdominal cavity are drained in the dorsoventral direction.

A through drainage tube is passed through counter-apertures along the midline of the abdomen 2-3 cm below the xiphoid process and 2-3 cm above the symphysis pubis. The patient is placed in the prone position in the postoperative period. The method allows you to effectively drain the abdominal cavity during peritonitis. 1 ill.

The invention relates to medicine, namely to surgery, and can be used in the treatment of peritonitis.

Treatment of peritonitis continues to be a serious problem for practical medicine, accompanied by the development of a large number of complications in the postoperative period, reaching from 13.5 to 41.3% (Sazhin V.P. et al. Laparostomy in the complex treatment of widespread peritonitis. - Kuban Scientific Medical Bulletin , 1998, 1-2, p. 29), and high mortality. According to a number of authors, it reaches 60-90% (Shalimov A.A. et al. Acute peritonitis. Kiev: Naukova Dumka, 1981, p. 287; Grinev M.V. et al. Some mechanisms of development of toxic-septic shock in peritonitis - Abstract of the 8th All-Russian Congress of Surgeons (Krasnodar, 1995, p. 582).

It is generally accepted in the treatment of peritonitis to perform surgical intervention, usually by midline laparotomy (Skripnichenko D.F. Emergency abdominal surgery. Kyiv: Health, 1986, p. 287). During the operation, the following is performed: elimination of the source of peritonitis, sanitation of the abdominal cavity, decompression of the gastrointestinal tract, drainage of the abdominal cavity.

There are many known methods of draining the abdominal cavity using gauze, rubber, tubular drainages, and methods of combined use of drainage devices. Drainage is carried out in order to create favorable conditions for the outflow of pathological exudate with high microbial contamination from the abdominal cavity (Kazansky V.I. Diseases of the peritoneum. - Manual of surgery edited by Petrovsky B.V., 1960, v. 7, p. 689; Shaposhnikov V.I. Etiopathogenetic treatment of acute peritonitis. Temryuk, 1991, p. 59). However, all analogues of abdominal cavity drainage are not fundamentally different from each other and do not provide adequate outflow of pathological fluid formations (Savelyev V.S. et al. Perfusion and infusion in the treatment of purulent peritonitis. - Surgery, 1974, N 4, p. 3- 9), lead to the progression of peritonitis, the development of complications and force one to resort to relaparotomy in 4.9-6.1% of cases after operations for peritonitis (Sazhin V.P. et al. Laparostomy in the complex treatment of widespread peritonitis. - Kuban Scientific Medical Bulletin, 1998, N 1-2, p.26). Various modifications of drainage - batch, fan, membrane drainage (Nesterov M.A. et al., 1989; Nifantiev et al., 1989), methods of active aspiration, flow-flushing drainage - have not solved the problem of adequate outflow.

There is a known method of drainage of the abdominal cavity, carried out during surgery after eliminating the source of inflammation and sanitizing the abdominal cavity. The abdominal cavity is drained with 4 glove-tubular drainages through punctures in both hypochondrium and iliopsoas regions. The ends of the tubes are installed in the subhepatic, subphrenic space, and pelvic cavity. Active aspiration of exudate from the abdominal cavity is possible in combination with the introduction of antibiotics and antiseptics into it (Skripnichenko D. F. Emergency surgery of the abdominal cavity. Kyiv: Health, 1986, p. 288). This method of drainage of the abdominal cavity during peritonitis is adopted as a prototype. The position of the installed drains is shown in the drawing.

The disadvantage of this method of draining the abdominal cavity during peritonitis is the insufficient effectiveness of the drainage devices used in the postoperative period. These drainages partially remove pathological exudate from the abdominal cavity and contribute to the formation of residual cavities in the abdominal cavity.

The anatomical features of the structure of the abdominal cavity, the attachment of the intestinal mesentery, the location and orientation of the ligaments of the abdominal cavity, the spatial orientation of the pockets and inversions of the peritoneum and its bursae in the classic position of the patient on the back do not allow adequate drainage of pathological exudate from all cavities formed by the peritoneum by installing drains using the method prototype. The lack of drainage of the abdominal cavity in case of peritonitis using this method is also confirmed by the fact that the development of new methods of treating peritonitis continues in order to provide adequate drainage of the abdominal cavity. Methods for the treatment of peritonitis are being improved by performing planned or programmed laparotomies (Gostishchev V.K. et al. Laparostomy for widespread peritonitis. - Bulletin of Surgery, 1991, No. 2, p.; Marchenko N.V. Method of repeated revisions of the abdominal cavity in the treatment of diffuse purulent peritonitis. - Dissertation of Candidate of Medical Sciences. Krasnodar, 1995).

The objectives of the invention are to improve the results of treatment of peritonitis: reducing the number of postoperative complications, reducing the number of repeated surgical interventions and postoperative mortality.

The essence of the invention is to perform drainage of the abdominal cavity through contra-apertures along the midline of the abdomen with a through silicone tube passed through points located 2-3 cm below the xiphoid process and 2-3 cm above the symphysis pubis, and treatment in the postoperative period is carried out in the patient's position on the stomach. Previously, this method of inserting a drainage tube for the purpose of draining the entire abdominal cavity was considered as anatomically unfavorable, since it was performed at the most anterior point of the peritoneal cavity and did not provide adequate and effective drainage (with the patient in the supine position, these points are the highest). The drainage tube was placed along the linea alba of the abdomen between the intestinal loops and omentum on one side and the parietal peritoneum on the other due to the fact that in the postoperative period the patient is given a position that adequately drains fluid accumulations of the abdominal cavity in the dorsoventral direction. In combination with this sign, it is justified to place a drainage tube along the white line of the abdomen. In the prone position, the anterior abdominal wall will have the shape of a flat boat, the edges of which are represented by the peritoneum in the projection of the rectus abdominis muscles, and the projection of the linea alba will correspond to the lowest points of the abdominal cavity.

The abdominal cavity is the largest of the internal body cavities and is a coelomic body cavity. The abdominal cavity is lined from the inside with a serous membrane - the peritoneum. The parietal layer of the peritoneum, lining the walls of the abdomen from the inside, forms a number of folds, various depressions and protrusions. The visceral peritoneum, covering the internal organs, has a different relationship to these organs. In some cases, the peritoneum lines the organ completely with the formation of the mesentery, in others - on three sides, in others - only in front. The mesenteries of the small and large intestines are attached to the posterior wall of the abdominal cavity. Within the upper floor of the abdominal cavity there are 7 pockets formed by the peritoneum: the blind sac of the spleen, the superior eversion of the omental bursa, the cardial pocket of the cavity of the lesser omentum, the splenic eversion, the duodenosplenic eversion, the gastro-pancreatic eversion, the inferior eversion of the omental bursa. In the lower floor of the abdominal cavity there are 6 pockets, or inversions: intersigmoid inversion, duodenojejunal inversion, superior ileocecal pouch, inferior ileocecal pouch, retrocecal pouch or fossa, paracolic inversions. In the abdominal cavity, the following bursae are distinguished: omental, right hepatic, left hepatic, pancreas; two mesenteric sinuses - right and left. There are two canals in the abdominal cavity - right and left (Frauchi V.H. Topographic anatomy and operative surgery of the abdomen and pelvis. Kazan, 1966, p. 80-105).

Under pathological conditions, all the described pockets, bags, channels formed by the peritoneum, all sloping areas of the abdominal cavity can be a container for the accumulation of various exudates. The drainage methods used do not allow, due to the peculiarities of the anatomical structure of the peritoneal formations, to completely evacuate the pathological exudate. Conducted studies on the bodies of the deceased by staining the abdominal cavity with a dye, followed by removal of the dye with various drainage devices currently used, made it possible to confirm the data on the impossibility of removing exudate from the abdominal cavity in the traditional position of the human body on the back, even if drainage was carried out through a counter-aperture in the very at the dorsal point of the abdominal canals, which is rare in practice, as it involves drainage through the powerful muscle mass of the back and lumbar regions. Active aspiration also turned out to be ineffective. Thus, 9 pockets out of 13 existing ones, 2 bursae out of 4 existing ones, the right mesenteric sinus, partially the right and left lateral canals, and the pelvic cavity are practically not drained. The intermesenteric spaces of the small intestine are not drained, which leads to the frequent development of interloop abscesses. Conducted studies involving painting the abdominal cavity with dye and then placing the human body (the studies were carried out on the bodies of the dead) in a prone position made it possible to show that the lowest point of the abdominal cavity in this position is a segment in the projection of the white line of the abdomen 2-3 cm below the xiphoid process sternum and 2-3 cm above the symphysis pubis. This was the reason for choosing the location for counter-apertures for subsequent drainage of the abdominal cavity. The studies made it possible to confirm the anatomical data on the complete drainage of fluid accumulations of the abdominal cavity in the dorso-ventral direction in the proposed drainage position from all anatomical formations of the peritoneum, with the exception of the cavity of the omental bursa. It should be noted that in the latter, during peritonitis, accumulation of exudate is rarely observed, however, drainage of the omental bursa, if necessary, is possible by conducting additional drainage through the hole in the gastrocolic ligament.

In practice, the method is carried out as follows. After eliminating the source of peritonitis, thorough sanitation of the abdominal cavity and performing any other manipulations (intestinal intubation, enterostomy, catheterization of the retroperitoneal space, etc.), a silicone drainage tube is placed for flow-through drainage along the midline of the abdomen in the projection of the laparotomy incision. The drainage tube is passed through contra-openings along the midline of the abdomen above and below the laparotomy wound so that it is located between the loops of the small intestine and the greater omentum on one side and the parietal peritoneum on the other side. When the patient is positioned on his stomach, the drainage tube, occupying a lower position than the intestinal loops, does not put pressure on them and practically eliminates the formation of bedsores. This allows you to significantly extend the period of its stay in the abdominal cavity. The drainage itself should be a single-lumen silicone tube with an internal diameter of 8-10 mm with walls of sufficient thickness (at least 1.5 mm) to prevent it from sticking in cases where active aspiration is used. The side holes are placed at a distance of mm from each other along the entire length of the part of the tube located in the abdominal cavity. The diameter of the side holes is at least 5 mm. This allows purulent exudate with a significant amount of fibrin to be evacuated from the abdominal cavity. If necessary, in particular for draining encysted cavities, drainage can be performed with additional drainage tubes. The drainage is fixed to the skin of the abdomen. If necessary, in order to enhance the effect of drainage of liquid formations along the perimeter of the drainage tubes, it is possible to install glove drainages. Subsequently, the patient is placed on a specially designed bed in a prone position. In this position, further treatment is carried out. To carry out dressings and other procedures, it is permissible to turn the patient onto his back for a short time. The criterion for transferring the patient to the traditional “on his back” position for further treatment is the relief of peritonitis.

Clinical testing of the proposed method of drainage of the abdominal cavity was carried out on 23 patients with diffuse peritonitis at the Department of General Surgery of the Kuban Medical Academy in the Department of Purulent Surgery of the Regional Clinical Hospital of the Krasnodar Territory.

Examples: B. B., 36 years old, IB 17299, transferred from the Crimean Central District Hospital of the Krasnodar Territory to the purulent surgery department of the Regional Clinical Hospital, where he was treated since 05.09. to 09.23.99, with a diagnosis of widespread fibrinous-purulent peritonitis after a penetrating stab wound of the abdominal cavity with injury to the colon. 07.09. due to suspicion of failure of the sutured wound of the colon, a relaparotomy was performed. An accumulation of purulent exudate was found in the flanks of the abdomen, under the liver, in the area of ​​the spleen, between the loops of the small intestine and in the pelvis. No leakage of the colon sutures was detected. Sanitation of the abdominal cavity using ultrasonic cavitation and drainage of the abdominal cavity with a single-lumen silicone tube placed between the loops of the small intestine, the greater omentum and the anterior abdominal wall strictly in the projection of the white line of the abdomen were used. The ends of the drainage tube are brought outside the laparotomy wound under the xiphoid process of the sternum and above the pubis, 2 cm from the latter. The laparotomy wound is sutured with removable aponeurotic sutures. Rare wide-section interrupted sutures are applied to the skin. The patient was transferred to the intensive care unit for further treatment, where he was placed in a prone position on a special mattress. Constant aspiration from the drainage tube was established with periodic washing of the drainage with antiseptic solutions.

In the postoperative period, treatment was carried out with the patient in the prone position for the first 5 days. Dressings were carried out with the patient in the lateral position. The complex treatment of peritonitis included intensive infusion therapy, detoxification therapy, polyantibiotic therapy, immunotherapy, stimulation of intestinal motility, and analgesic therapy. On the third day after surgery, the patient underwent plasmapheresis. During the first two days, the amount of discharge from the abdominal cavity, excluding administered antiseptics, reached 500 ml per day. On the third day, the amount of discharge decreased to 200 ml, and by the end of the fifth day it stopped. On the third day, intestinal peristalsis appeared, on the fourth day there was independent stool. On day 5, the patient was transferred to the “supine” position. The further postoperative period proceeded smoothly. Tubular drainage was removed on the 6th day. The sutures were removed on the 14th day due to the fact that the wound was sutured with removable aponeurotic sutures. Healing by primary intention. The patient was discharged for outpatient treatment on the 16th day after surgery in satisfactory condition.

B-y R., 31 years old, IB 17299, July 25, 1999, was hospitalized at the Belorechensk Central District Hospital with a diagnosis of acute pancreatitis. He was treated conservatively. On August 25, 1999, due to deterioration of his condition, he was transferred to the Regional Clinical Hospital of the Krasnodar Territory. Due to the presence of purulent pancreatitis and diffuse purulent fibrinous peritonitis in the patient, an operation was performed according to emergency indications: median laparotomy, sequestration and necrectomy of the pancreas, sanitation of the omental bursa and abdominal cavity. The operation ended with the imposition of a bursoomentopancreatostomy in the left hypochondrium and the passage of a through silicone single-lumen drainage tube through counter-apertures outside the laparotomy wound along the white line of the abdomen, made 3 cm below the xiphoid process of the sternum and 3 cm above the symphysis pubis. The drainage tube is placed between the intestinal loops and the omentum on one side and the parietal peritoneum on the other. The laparotomy wound is sutured with removable aponeurotic sutures. Rare wide-section interrupted sutures are applied to the skin.

In the postoperative period, the patient was placed in the prone position on a special mattress, complex multicomponent therapy, flow-through drainage with active aspiration from the abdominal cavity were performed. Treatment in the drainage position was carried out for 6 days, dressings were carried out with the patient turning on his side. During the therapy, the symptoms of peritonitis stopped on the 6th day. The abdominal drainage was removed on the 7th day, and the patient was transferred for further treatment to the traditional “supine” position. The further postoperative period proceeded smoothly. The patient did not require relaparotomy. The sutures were removed on the 14th day, healing by primary intention. Subsequently, treatment was carried out aimed at drainage and sanitation during ligation of the bursoomentopancreatostomy. The discharge of small sequestra of the pancreas and the drainage of scanty serous-purulent discharge from the omental bursa were observed for four weeks after surgery. The drainage of the omental bursa was changed and its cavity was washed. The wound in the area of ​​bursoomentopancreatostomy healed by secondary intention. The patient was discharged in satisfactory condition for outpatient follow-up treatment on the 35th day after surgery.

The clinical results of using this method are regarded as satisfactory, which is supported by the successful use of the method for the treatment of 23 patients with general peritonitis.

The medical and social significance of the invention is to develop a method that adequately drains the abdominal cavity during peritonitis and allows to reduce the number of postoperative complications, repeated surgical interventions and reduce postoperative mortality.

A method for draining the abdominal cavity during peritonitis, characterized in that to ensure drainage of fluid formations in the dorso-ventral direction, a through drainage tube is passed through counter-openings along the midline of the abdomen 2-3 cm below the xiphoid process and 2-3 cm above the symphysis pubis, and In the postoperative period, the patient is placed in the prone position.

Abdominal drainage

In case of destructive appendicitis with peritonitis, peritonitis, intestinal resections due to obstruction, as a rule, drainage of the abdominal cavity is performed. In order for the postoperative wound to heal without complications, drainage is carried out not through it, but through an additional incision next to the surgical wound. In severe forms of peritonitis, sometimes four drains are inserted into the abdominal cavity (into the right and left hypochondrium and from the left and right iliac regions to the pelvic floor). Upper drainages are used to administer antibiotic solutions or rinse the abdominal cavity on the first day after surgery; the lower ones are also for administering antibiotic solutions and for removing fluid accumulating in the pelvis. With any drainage method, never tie up the drains or leave them in bandages. Drains should be connected to containers that are located below the patient in order to create a slight negative pressure, facilitating better evacuation of fluid from the abdominal cavity. Drains with a diameter of 0.5-0.7 cm drain the contents of the abdominal cavity worse than drains with an internal diameter of 0.3-0.4 cm. The most common drainage tubes are made of rubber. However, as experience has shown, they quickly stop functioning, since foreign bodies are delimited by fibrin, adhesions, intestinal loops and omentum. In the last decade, drainage tubes made of synthetic materials (polyethylene, polyvinyl chloride) have become widespread, through which the outflow of fluid from the abdominal cavity can continue for 4-6 days. When draining the abdominal cavity in newborns, 1-2 side holes are cut out at the end of the tube; in older children, up to 5-7 side holes are cut out.

Currently, another method of drainage of the abdominal cavity has been proposed, which is called “aspiration” [Generalov A.I. et al., 1979]. In this method, a continuous polyvinyl chloride catheter, only about 1-1.5 m long, is inserted as usual through a separate incision approximately 1.5-2 cm medial to the superior iliac spine. The abdominal wall is punctured in an oblique direction so that the catheter does not bend. The end of the catheter with additional side holes is placed on the pelvic floor. The catheter should be in contact with the inner surface of the ilium. From the outside, it is more correct to fix it with 2-3 strips of adhesive tape towards the armpit. To prevent the catheter from moving, a tight-fitting sleeve is threaded onto it, which is fixed to the skin with a provisional suture at the point where the catheter enters the abdominal wall. Next, with a short tube, the catheter is increased to one of a similar diameter and lowered into a container located 60-70 cm below the patient’s level.

If the catheter is placed correctly and functions well, it can be used to remove fluid from the abdominal cavity during flow-through lavage.

The responsibilities of the nurse for any form of abdominal drainage include careful monitoring of the function of the drains. This is very important for the occurrence of postoperative complications. If the drains do not function well enough, then fluid accumulates in the abdominal cavity, which, when infected, is the basis for the development of interloop, subdiaphragmatic, subhepatic abscesses and pelvic abscess. At the same time, fluid in the abdominal cavity can lead to divergence of the edges of the surgical wound. If the fluid does not drain through the drainage on the first day after surgery, it means that it is either bent or clogged with fibrin. The nature of the fluid flowing through the drainage (transparent, cloudy, mixed with blood, purulent) is of great importance for determining further treatment.

2. Surgery for widespread peritonitis:

Access is always a median laparotomy, which provides the possibility of a full inspection and sanitation of all parts of the abdominal cavity. If the cause of peritonitis is unclear, a midline laparotomy is usually used, and then during surgery, depending on the finding, the access is increased upward or downward.

Elimination of the source of peritonitis - removal of the inflamed organ (for example: h/application, gallbladder), or suturing of the injury (rupture of the intestine, bladder)

Sanitation and toilet of the abdominal cavity. Once upon a time, aggressive antiseptics were used for these purposes (sublimate, washing powder, etc.); the surgeon’s actions themselves were rough (cleaning the peritoneum and stripping off fibrin with hard brushes). This approach led to damage to the mesothelium and only aggravated the course of peritonitis. Currently, gentle methods are used - the abdominal cavity is washed with a large amount of warm isotonic solution “to clean water”, but effusion and fibrin are removed only gently without damaging the peritoneum.

Drainage of the abdominal cavity. For these purposes, up to 1 additional drainage can be used. So, in case of gangrenous appendicitis with local peritonitis, one “cigar” drainage is usually installed in the right iliac region. In case of diffuse purulent peritonitis, drainage can be simultaneously installed in: the right and left subdiaphragmatic spaces, in the pelvis, along the right and left lateral canals.

Tubes with side holes can be used as drainage, but during peritonitis the tubes quickly become clogged with fibrin clots or become “pasted” with internal organs. As a result, tubular drainage often stops functioning 1-2 days after surgery.

“Cigar drainage” or rubber-gauze drainage is a structure made of gauze and glove rubber up to 15 cm long. The drainage can be made even during surgery. A surgical glove is taken, the fingers are cut off, and the remaining rubber cylinder is cut along its length. A gauze cloth of the same size is placed on the resulting rubber plate measuring 15 by 10 cm, then they are rolled into a “roll”. The resulting cylinder is the cigar drain, which is installed through an opening into the abdominal cavity for its drainage.

“Cigar drainage” through the middle of which a tubular drainage is installed is a type of conventional rubber-gauze drainage. Used for large amounts of liquid effusion, bile, and blood.

Fascine drainage is nothing more than a bundle (in Latin - fascine) of tubes connected to each other and installed in the abdominal cavity. Currently forgotten and rarely used.

Cigar drains are tightened after 3-4 days and removed after 5-6 days. If necessary, new drains are installed in their place under anesthesia.

For a long time, peritoneal dialysis or abdominal lavage was used to treat advanced forms of peritonitis. Its essence is that 4 tubes were installed in the abdominal cavity (2 from above and 2 from below), and the abdominal cavity was sutured. In the postoperative period, liquid (dialysate), usually an isotonic solution with the addition of antibiotics, was drip-fed through the upper tubes. The fluid washed the abdominal cavity and flowed out through the lower tubes; up to 10 liters of dialysate per day were used. Currently, the method is not used, as it has significant disadvantages: the liquid moves through certain channels, and large spaces where the intestinal loops stick together are not washed; There is still a loss of a very large amount of protein, etc. Therefore, today, to treat advanced forms (toxic and terminal stages) of peritonitis, “open methods of managing the abdominal cavity” are used, these include:

Permanent rehabilitation (term: permanent – ​​continuing continuously). Other names: method of planned or program relaparotomy, “program relaparotomy”. The essence of the method is as follows: after eliminating the source of peritonitis and washing the abdominal cavity, the wound is sutured “tightly” without leaving drainage, but suturing is done so that the abdominal cavity can be easily opened again. For these purposes, thick long ligatures are usually used with which the anterior abdominal wall is stitched through all layers and tied with “bows”. After a day, the patient is again taken to the operating room, the sutures are unraveled and the abdominal cavity is again subjected to sanitation, fibrinous adhesions are destroyed, effusion is removed and fibrin is removed, the abdominal cavity washed with a solution of a weak antiseptic. The seams are then tied. The procedure is repeated again after 1-2 days, usually 2-3 relaparotomies are performed. At a certain period, special devices called “ventrophiles” were used for these purposes. These plastic devices with holes and hooks were sewn to the edges of the laparotomy wound and then tightened with Mylar ligatures. Less commonly used are fasteners such as “zipper” and “burdock” (Velcro) with their fixation with a continuous lavsan suture to the edges of the aponeurosis, less often - to the skin edges of the wound. But nowadays complex devices are practically not used due to purulent complications.

Laparostomy, or open laparostomy, the most radical method of managing peritonitis, consists in the fact that the median wound on the anterior abdominal wall does not close at all at the end of the operation. The edges of the wound are brought together with sutures to prevent the insides from falling out and are covered with a sheet of polyethylene with a large number of holes for the outflow of pus from the abdomen; gauze is placed on top of the polyethylene, which is changed during dressings.

The method is used only in the most severe cases; the indication for laparostomy may be the impossibility of suturing the abdominal wall due to phlegmon, purulent melting of the edges of the wound, severe intestinal paresis, or when it is not possible to completely remove the purulent focus from the abdominal cavity.

P.S. It should be noted that in the literature there are a large number of different terms denoting open methods of treating peritonitis, sometimes they replace each other. For example, the term “Laparostomy” can refer to all known methods of open abdominal cavity management.

In addition, in patients with severe paresis of the gastrointestinal tract, there is often a need to unload the intestines directly on the operating table in the form of intestinal stomas and intubation of the intestines with special intestinal probes.

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Peritoneal drainage is

The problem of drainage is most pressing in abdominal surgery. This is due, firstly, to the complex architectonics of the abdominal organs, secondly, the currently available drainages have a limited period of use, and thirdly, the question remains relevant regarding methods of drainage of the abdominal cavity

The problem of drainage of the abdominal cavity is especially obvious in the treatment of the “evil genius of abdominal surgery” – peritonitis. This is due to an increase in the number of patients and a high percentage of postoperative mortality. Unfortunately, surgery has not yet developed criteria that determine the appropriateness of a particular method and indications for drainage in a specific clinical situation.

Tubular drainage is currently most commonly used. When using tubular drainages, the reactogenic properties of drainages – the reaction of the interaction of the peritoneum with the drainage – are of great importance. The use of rubber, Teflon, polyvinyl chloride, polyethylene tubes often leads to an inflammatory reaction, their rapid obstruction with fibrin, irritation of surrounding tissues, with the formation of both aseptic inflammation and the formation of adhesions and abscesses.

Of great importance in the treatment of peritonitis is the timing of drainage functioning. This is primarily determined by the duration of the disease, the need for long-term drainage function and the ability of drainage to resist bacterial contamination, as well as the cause of peritonitis. The most unfavorable in this regard are rubber drainages, which function from 6 to 48 hours. Drains made of polyvinyl chloride retain their function for up to 7 days. The most effective are fluoroplastic tubes with silicone, the effect of which lasts up to 17 days)