Increased pressure in the abdominal cavity. Norm and levels of increase

Under pressure less than 10 mm Hg cardiac output and blood pressure are normal, but hepatic blood flow drops significantly; with intra-abdominal pressure of 15 mm Hg. unfavorable, but easily compensated cardiovascular manifestations; intra-abdominal pressure 20 mm Hg. can cause impaired renal function and oliguria, and an increase to 40 mm Hg. leads to anuria. In some patients, the negative effects of increasing intra-abdominal pressure are not isolated, but are associated with complex, interdependent factors, of which hypovolemia is the most significant, which in turn exacerbates the effects of an increase in intra-abdominal pressure.

Why didn't you meet intra-abdominal hypertension and abdominal compartment syndrome before?

Because they didn't know they existed! Any increase in organ volume abdominal cavity or retroperitoneal space leads to a rise in intra-abdominal pressure. Clinically, high intra-abdominal pressure is observed when different situations: postoperative intra-abdominal bleeding after abdominal vascular operations or major interventions (such as liver transplantation) or abdominal trauma associated with vascular edema, hematoma or tamponade of the abdomen; severe peritonitis, as well as when using a pneumatic anti-shock suit and intense ascites in patients with cirrhosis of the liver. Insufflation of gas into the abdominal cavity during laparoscopic procedures is the most common (iatrogenic) cause of intra-abdominal hypertension.

Severe intestinal edema has been described as a consequence of massive fluid replacement. with extra-abdominal trauma.

Be aware that morbid obesity and pregnancy are chronic form of intra-abdominal hypertension; various manifestations associated with such conditions (i.e., hypertension, preeclampsia) are characteristic of IAH.

Note that everything that can cause intra-abdominal hypertension and AKC, does not depend on causative ingredients. A “blockage” with feces is also possible:

An elderly patient was admitted with impaired peripheral perfusion, BP 70/40 mm Hg, respiratory rate 36 per minute. Her abdomen is very enlarged, diffusely painful and tense. Rectal examination revealed a large number of soft stool. Blood urea 30 mg% and creatinine 180 µmol/l. Blood gas analysis showed metabolic acidosis with a pH of 7.1. intra-abdominal pressure 25 cm wg. After decompressive laparotomy and resection of a significantly enlarged and partially necrotic rectosigmoid colon, recovery occurred.

Just a few years ago, we would have described this patient as suffering from "septic" shock due to " colonic ischemia". We would take vascular collapse and acidosis to the consequences of endotoxic shock. But today it is clear to us that negative effect, created by extreme expansion of the rectum and leading to cardiovascular and respiratory failure, represents a typical ACS, which in turn impairs visceral perfusion and exacerbates colorectal ischemia. Rectal release and abdominal decompression quickly resolved severe physiological manifestations abdominal hypertension.

Understanding that intra-abdominal hypertension is a "real problem", we are introducing measurement of intra-abdominal pressure (IAP) into our daily clinical practice.

To have exact numbers WAP, it must be measured. Directly in the abdominal cavity, pressure can be measured with laparoscopy, peritoneal dialysis, or with a laparostomy (direct method). To date, the direct method is considered the most accurate, however, its use is limited due to high cost. As an alternative, indirect methods for monitoring IAP are described, which involve the use of neighboring organs bordering the abdominal cavity: bladder, stomach, uterus, rectum, inferior vena cava.

Currently, the "gold standard" for indirect measurement of IAP is the use of Bladder. . The elastic and highly extensible bladder wall, with a volume not exceeding 25 ml, acts as a passive membrane and accurately transmits pressure to the abdominal cavity. This method was first proposed by Kron et al. In 1984. For measurement, he used an ordinary urinary Foley catheter, through which 50-100 ml of sterile physiological saline was injected into the bladder cavity, after which he attached a transparent capillary or a ruler to the Foley catheter and measured intravesical pressure, taking the pubic articulation as zero. However, using this method, it was necessary to assemble the system anew for each measurement, which high risk ascending urinary tract infection.

Currently, special closed systems have been developed for measuring intravesical pressure. Some of them connect to an invasive pressure transducer and monitor (AbVizer tm), others are completely ready to use without additional instrumental accessories (Unomedical). The latter are considered more preferable, as they are much easier to use and do not require additional expensive equipment.

When measuring intravesical pressure, the rate of administration of saline and its temperature play an important role. Since the rapid introduction of a cold solution can lead to a reflex contraction of the bladder and an increase in the level of intravesical, and, consequently, intra-abdominal pressure. The patient should be in the supine position, on a horizontal surface. Moreover, adequate anesthesia of the patient in postoperative period due to the relaxation of the muscles of the anterior abdominal wall, it allows you to get the most accurate IAP numbers. .

Figure 1. Closed system for long-term IAP monitoring with transducer and monitor

Figure 2. Closed system for long-term IAP monitoring without additional equipment

Until recently, one of the unsolved problems was the exact amount of fluid injected into the bladder needed to measure IAP. And today these figures vary from 10 to 200 ml. Many international studies have been devoted to this issue, the results of which have shown that the introduction of about 25 ml does not lead to a distortion of the level of intra-abdominal pressure. What was approved at the conciliation commission on the SIAG problem in 2004.

A contraindication to the use of this method is damage to the bladder or compression by a hematoma or tumor. In such a situation, intra-abdominal hypertension is assessed by measuring intragastric pressure.

INTRA-ABDOMINAL HYPERTENSION (IAH)

To date, there is no consensus in the literature regarding the level of IAP at which IAH develops. However, in 2004, at the WSACS conference, AHI was defined as: this is a persistent increase in IAP up to 12 mm Hg. and more, which is determined by three standard measurements with an interval of 4-6 hours.

The exact level of IAP, which is characterized as AHI, remains a matter of debate to this day. Currently, according to the literature, threshold values ​​of AHI vary from 12-15 mm Hg. [25, 98, 169, 136]. A survey conducted by the European Council for intensive care(ESICM) and the Council for Critical Care Management SCCM) (( www.wsacs.org.survey.htm), which involved 1300 respondents, showed that 13.6% still have no idea about AHI and the negative impact of increased IAP.

About 14.8% of respondents believe that the level of IAP is normally 10 mm Hg, 77.1% determine the AHI at the level of 15 mm Hg. Art., and 58% - SIAG at the level of 25 mm Hg.

Numerous publications describe the effect of intra-abdominal hypertension on various systems organs to a greater or lesser extent and to the whole organism as a whole.

In 1872, E.Wendt was one of the first to report the phenomenon of intra-abdominal hypertension, and Emerson H. showed the development of multiple organ failure (MOF) and high mortality among experimental animals, which artificially increased the pressure of the abdominal cavity.

However, the wide interest of researchers in the problem of increased intra-abdominal manifested itself in the 80s and 90s of the XX century.

Interest in intra-abdominal pressure (IAP) in critically ill patients is steadily growing. It has already been proven that the progression of intra-abdominal hypertension in these patients significantly increases mortality.

According to the analysis of international studies, the incidence of IAH varies greatly [136]. With peritonitis, pancreatic necrosis, severe concomitant abdominal trauma, there is a significant increase in intra-abdominal pressure, while the syndrome of intra-abdominal hypertension (IAH) develops in 5.5% of these patients.

Kirkpatrick et al. ) distinguish 3 degrees of intra-abdominal hypertension: normal (10 mm Hg or less), elevated (10-15 mm Hg) and high (more than 15 mm Hg). M. Williams and H. Simms) consider increased intra-abdominal pressure more than 25 mm Hg. Art.D Meldrum et al. allocate 4 degrees of increase in intra-abdominal hypertension: I st. - 10-15 mm Hg. Art., II Art. - 16-25 mm Hg. Art., III Art. - 26-35 mm Hg. Art., IV Art. - more than 35 mm Hg. Art.

INTRA-ABDOMINAL HYPERTENSION SYNDROME

IAH is the prodormal phase of SMAH development. According to the above, AHI combined with severe multiple organ failure is SIAH.

Currently, the definition of the syndrome of intra-abdominal hypertension is presented as follows - this is a persistent increase in IAP of more than 20 mm Hg. (with or without ADF<60 мм рт.ст.) , которое ассоциируется с манифестацией органной недостаточностью / дисфункции.

Unlike AHI, the syndrome of intra-abdominal hypertension does not need to be classified according to the level of IAP, in view of the fact that this syndrome is presented in modern literature as an “all or nothing” phenomenon. This means that with the development of the syndrome of intra-abdominal hypertension with some degree of IAH, a further increase in IAP does not matter.

Primary SIAH (previously surgical, postoperative) as a consequence of pathological processes developing directly in the abdominal cavity itself as a result of an intra-abdominal catastrophe, such as trauma to the abdominal organs, hemoperitoneum, widespread peritonitis, acute pancreatitis, rupture of an aneurysm of the abdominal aorta, retroperitoneal hematoma.

Secondary SIAH (previously therapeutic, extra-abdominal) is characterized by the presence of subacute or chronic IAH caused by extra-abdominal pathology, such as sepsis, "capillary leak", extensive burns, and conditions requiring massive fluid therapy.

Recurrent SIAH (tertiary) is the reappearance of symptoms characteristic of SIAH against the background of a resolving picture of a previously occurring primary or secondary SIAH.

Recurrent SIAH can develop against the background of the presence of an “open abdomen” in the patient or after early suturing of the abdominal wound tightly (liquidation of the laparostomy). Tertiary peritonitis is reliably characterized by high mortality.

The following predisposing factors play a role in the development of intra-abdominal hypertension syndrome:

Factors contributing to a decrease in the elasticity of the anterior abdominal wall

Artificial ventilation of the lungs, especially with resistance to the breathing apparatus

The use of PEEP (PEEP), or the presence of auto-PEEP (auto-PEEP)

Pleuropneumonia

Overweight

Pneumoperitoneum

Suturing the anterior abdominal wall under conditions of its high tension

Tension repair of giant umbilical or ventral hernias

The position of the body on the stomach

Burns with the formation of scabs on the anterior abdominal wall

Factors contributing to an increase in the contents of the abdominal cavity

Paresis of the stomach, pathological ileus

Abdominal Tumors

Edema or hematoma of the retroperitoneal space

Factors contributing to the accumulation of abnormal fluid or gas in the abdominal cavity

Pancreatitis, peritonitis

Hemoperitoneum

Pneumoperitoneum

Factors contributing to the development of "capillary leakage"

Acidosis (pH below 7.2)

Hypothermia (body temperature below 33 C 0)

Polytransfusion (more than 10 RBC units/day)

Coagulopathy (platelets less than 50,000 / mm 3 or APTT 2 times normal, or INR above 1.5)

• bacteremia

  Massive fluid therapy (more than 5 liters of colloids or crystalloids in 24 hours with capillary edema and fluid balance)

  During normal functioning, the body maintains unchanged some indicators that form its internal environment. These indicators include not only temperature, arterial, intracranial, intraocular, but also intra-abdominal pressure (IAP).

  The abdominal cavity looks like a sealed bag. It is filled with organs, fluids, gases that exert pressure on the bottom and walls of the abdominal cavity. This pressure is not the same in all areas. With the vertical position of the body, the pressure indicators will increase in the direction from top to bottom.

  Measurement of intra-abdominal pressure

  Measurement of IAP: direct and indirect methods

  Straight lines are the most efficient. They are based on the direct measurement of pressure in the abdominal cavity using a special sensor, most often the measurement is carried out during laparoscopy, perinatal dialysis. Their disadvantages can be considered complexity and high price.

  Indirect are an alternative to direct. The measurement is made in hollow organs, the wall of which either borders on the abdominal cavity, or is located in it (bladder, uterus, rectum).

  Of the indirect methods, measurement through the bladder is most often used. Due to its elasticity, its wall acts as a passive membrane, which quite accurately transmits intra-abdominal pressure. For measurement, you will need a Foley catheter, a tee, a ruler, a transparent tube, saline.

  This method makes it possible to carry out the measurement during the period of long-term treatment. Such measurements are impossible with bladder injuries, pelvic hematomas.

  Norm and levels of elevated IAP

  Normally, in adults, the intra-abdominal pressure is 5–7 mm Hg. Art. Its slight increase to 12 mm Hg. Art. can be caused by the postoperative period, obesity, pregnancy.

  
  Intra-abdominal pressure(WBD)

  There is a classification of IAP increase, which includes several degrees (mm Hg):

  1. 13–15.
  2. 16–20.
  3. 21–25.
  4. A pressure of 26 and above leads to respiratory (displacement of the dome of the diaphragm into the chest), cardiovascular (impaired blood flow) and renal (reduction in the rate of urine formation) insufficiency.

  Causes of high blood pressure

  An increase in IAP is often caused by flatulence. The accumulation of gases in the gastrointestinal tract develops as a result of stagnant processes in the body.

  They arise as a result:

  • regular problems with bowel movements;
  • disorders of intestinal peristalsis and digestion of food (IBS), in which there is a decrease in the tone of the autonomic zone of the nervous system;
  • inflammatory processes occurring in the gastrointestinal tract (hemorrhoids, colitis);
  • intestinal obstruction caused by surgery, various diseases (peritonitis, pancreatic necrosis);
  • violations of the microflora of the gastrointestinal tract;
  • excess weight;
  • varicose veins;
  
  Method for measuring intra-abdominal pressure
  • the presence in the diet of products that stimulate gas formation (cabbage, radish, dairy products, etc.);
  • overeating, sneezing, coughing, laughing and physical exertion - a short-term increase in IAP is possible.

  Exercises that increase abdominal pressure

  1. Raising the legs (body or both body and legs) from a prone position.
  2. Power twisting in the prone position.
  3. Deep side bends.
  4. Power balances in hand.
  5. Push ups.
  6. Making bends.
  7. Squats and power traction with large weights (more than 10 kg).

  When performing exercises, you should refuse to use heavy weights, breathe correctly during the exercise, do not pout and do not pull in the stomach, but strain it.

  Intra-abdominal pressure: symptoms

  An increase in pressure in the abdominal region is not accompanied by special symptoms, so a person may not attach importance to them.

  As the pressure rises, there may be:

  • bloating;
  • pain in the abdomen, which can change localization;
  • kidney pain.
  
  How is intra-abdominal pressure measured?

  Such symptoms do not make it possible to accurately diagnose an increase in intra-abdominal pressure. Therefore, when they appear, you should not self-medicate, but it is better to consult a doctor. If the doctor has been diagnosed with "increased IAP", the patient should be observed by a doctor and regularly monitor the change in this indicator.

  What is the diagnosis based on?

  Confirmation of the diagnosis of increased intra-abdominal pressure is carried out when two or more of these signs are detected:

  1. increase in IAP (over 20 mm Hg);
  2. pelvic hematoma;
  3. decrease in the volume of urine excreted;
  4. hung pulmonary pressure:
  5. an increase in the arterial blood partial pressure of CO2 above 45 mm Hg. Art.

  High blood pressure treatment

  Timely initiation of treatment will help stop the development of the disease at the initial stage and will normalize the functioning of internal organs.

  The doctor may prescribe:

  
  

  Different types of treatment are used for different degrees of the disease.:

  • Observation at the doctor and infusion therapy;
  • Observation and therapy, if clinical manifestations of abdominal compartment syndrome are detected, decompression laparotomy is prescribed;
  • Continuation of medical therapy;
  • Carrying out resuscitation measures (dissection of the anterior wall of the abdomen).

  Surgical intervention has another side. It can lead to reperfusion or entry into the blood of a nutrient medium for microorganisms.

  Prevention

  It is much easier to prevent a disease than to treat it later. The complex of preventive measures is aimed at preventing diseases of the gastrointestinal tract, the accumulation of gases, as well as maintaining the general condition of the body in the norm. It includes:

  • establishing water balance in the body;
  • healthy lifestyle;
  • proper nutrition;
  • getting rid of excess weight;
  • reduction in the diet of the number of foods that increase gas formation;
  • rejection of bad habits;
  • providing emotional stability;
  • scheduled medical examinations;

  
  The owners of the patent RU 2444306:

  The invention relates to medicine and can be used to reduce intra-abdominal pressure in obesity in abdominal surgery. Simultaneously with the main operation, resection of 2/3 of the stomach, cholecystectomy, appendectomy are performed, an anastomosis of the ileum with the stomach is performed using compression implants, and an interintestinal anastomosis is formed at a distance of 10% of the total length of the small intestine from the ileocecal angle. The method provides a stable weight loss. 2 ill., 1 tab.

  The invention relates to medicine and can be used in abdominal surgery.

  Increased intra-abdominal pressure is one of the factors adversely affecting postoperative wound healing and one of the leading causes of postoperative complications. The most common increase in intra-abdominal pressure is observed in obesity. In obese patients, the load on the tissues of the abdominal wall increases significantly as a result of increased intra-abdominal pressure, the processes of wound consolidation slow down, the muscles of the abdominal wall atrophy and become flabby [A.D. Timoshin, A.V. Yurasov, A.L. Shestakov. Surgical treatment of inguinal and postoperative hernias of the abdominal wall // Triada-X, 2003. - 144 p.]. With increased intra-abdominal pressure, phenomena of chronic cardiopulmonary insufficiency occur, which leads to impaired blood supply to tissues, including those in the surgical area. Due to the high pressure at the time and after the operation, there is an interposition of fatty tissue between the sutures, it is difficult to adapt the layers of the abdominal wall when suturing wounds, the reparative processes of the postoperative wound are disrupted [Surgical treatment of patients with postoperative ventral hernias / V.V. Plechev, P.G. Kornilaev, P.P. Shavaleev. // Ufa 2000. - 152 p.]. In patients with obesity, the recurrence rate of large and giant incisional ventral hernias reaches 64.6%. [N.K. Tarasova. Surgical treatment of postoperative ventral hernias in patients with obesity / N.K. Tarasova // Bulletin of herniology, M., 2008. - P. 126-131].

  Known methods of reducing intra-abdominal pressure as a result of suturing mesh implants [VP Sazhin et al. // Surgery. - 2009. - No. 7. - S.4-6; V.N. Egiev et al. / Tension-free hernioplasty in the treatment of postoperative ventral hernias // Surgery, 2002. - №6. - S.18-22]. When carrying out such operations, one of the leading causes of increased intra-abdominal pressure, obesity, is not eliminated.

  Methods for balancing increased intra-abdominal pressure with excess external pressure are described. Before planned operations for large hernias, a long-term (from 2 weeks to 2 months) adaptation of the patient to a postoperative increase in intra-abdominal pressure is carried out. To do this, use dense bandages, cloth tapes, etc. [V.V. Zhebrovsky, M.T. Elbashir // Surgery of abdominal hernias and events. Business-Inform, Simferopol, 2002. - 441 p.; N.V. Voskresensky, S.D. Gorelik // Surgery of hernias of the abdominal wall. M., 1965. - 201 p.]. In the postoperative period, to balance the increased intra-abdominal pressure, the use of bandages is also recommended, up to 3-4 months [N.V. Voskresensky, S.L. Gorelik. // Surgery of hernias of the abdominal wall. M., 1965. - 201 p.]. As a result of corrective external compression, the respiratory function and the cardiovascular system of the body indirectly worsen, which can lead to corresponding complications.

  The most promising method for reducing intra-abdominal pressure is to eliminate the leading factor, obesity, which affects the outcome of the operation. In abdominal surgery, to reduce fat deposits in the abdominal cavity, preoperative preparation is used, aimed at reducing the patient's body weight through a course of treatment with diet therapy (a slag-free diet, activated charcoal, laxatives, cleansing enemas are prescribed). [V.I. Belokonev et al. // Pathogenesis and surgical treatment of postoperative ventral hernias. Samara, 2005. - 183 p.]. For the patient 15-20 days before admission to the clinic, bread, meat, potatoes, fats and high-calorie cereals are excluded from the diet. They allow low-fat meat broths, yogurt, kefir, jelly, pureed soups, plant foods, tea. 5-7 days before the operation, already in a hospital, daily in the morning and evening, the patient is given cleansing enemas. The body weight of the patient during the period of preoperative preparation should decrease by 10-12 kg [V.V.Zhebrovsky, M.T.Elbashir // Surgery of abdominal hernias and events. Business Inform. - Simferopol, 2002. - 441 p.]. This method was chosen by us as a prototype.

  It should be noted that in practice diet therapy, bowel preparation and patient adaptation to increased pressure by means of bandages are usually combined, which makes preoperative preparation lengthy and complicated.

  The aim of the present invention is to develop a method for eliminating one of the leading factors of obesity that affects the formation of high intra-abdominal pressure.

  The technical result is a simple one that does not require large material costs, based on carrying out an additional operation during the period of the main operation during abdominal surgery, aimed at reducing body weight.

  The technical result is achieved by the fact that, according to the invention, simultaneously with the main operation, resection of 2/3 of the stomach, cholecystectomy, appendectomy are performed, an anastomosis of the ileum with the stomach is performed using compression implants, and at a distance of 10% of the total length of the small intestine, from the ileocecal angle, a intestinal anastomosis.

  The essence of the method is achieved by the fact that there is a steady decrease in intra-abdominal pressure due to a decrease in body weight as a result of a decrease in the absorption of fats and carbohydrates, an increase in the asepticity of operations, and a decrease in the risk of postoperative complications, and above all, purulent ones.

  The proposed method is carried out as follows: 2/3 of the stomach is resected, cholecystectomy, appendectomy is performed, an anastomosis of the ileum with the stomach is performed using compression implants, and an interintestinal anastomosis is formed at a distance of 10% of the total length of the small intestine from the ileocecal angle. Then the main abdominal operation is performed.

  The method is illustrated by graphic material. Figure 1 shows a diagram of the operation of biliopancreatic shunting, where 1 is the stomach; 2 - removed part of the stomach; 3 - gallbladder; 4 - appendix. Organs to be removed are marked in black. Figure 2 shows a diagram of the formation of inter-intestinal and gastrointestinal anastomoses, where 5 - the stump of the stomach after resection; 6 - ileum; 7 - anastomosis of the ileum with the stomach; 8 - interintestinal anastomosis.

  In the analyzed literature, this set of distinguishing features was not found, and this set does not follow explicitly for a specialist from the prior art.

  Examples of practical use

  Patient V., aged 40, was admitted to the surgical department of the Tyumen Regional Clinical Hospital with a diagnosis of postoperative giant ventral hernia. Concomitant diagnosis: Morbid obesity (height 183 cm, weight 217 kg, body mass index 64.8). Arterial hypertension 3 tbsp., 2 tbsp., risk 2. Hernial protrusion - since 2002 Hernial protrusion size 30×20 cm occupies the umbilical region and hypogastrium.

  On August 30, 2007, the operation was performed. Anesthesia: epidural anesthesia in combination with inhalation anesthesia with isoflurane. The first stage of the operation (optional). Resection of 2/3 of the stomach, cholecystectomy, appendectomy and, using compression implants, a gastrointestinal anastomosis and an interintestinal anastomosis from the ileocecal angle at a distance of 10% of the total length of the small intestine were performed.

  The second stage of the operation (main). Hernioplasty was performed with a polypropylene mesh graft of the abdominal wall defect according to the technique with the preperitoneal location of the prosthesis. Hernial orifice 30×25 cm. The elements of the hernial sac and the peritoneum were sutured with a continuous twisting suture with a non-absorbable suture material. A prosthesis 30 × 30 cm was cut, when straightened, its edges went under the aponeurosis by 4-5 cm. Next, the prepared allograft was fixed with U-shaped sutures, capturing the edges of the prosthesis and piercing the abdominal wall, stepping back from the edge of the wound by 5 cm. The distance between the sutures is 2 see Suturing the anterior abdominal wall in layers.

  The postoperative period proceeded without complications. When discharged at the control weighing, the weight is 209 kg. Body mass index 56.4. The patient was followed up for 3 years. After 6 months: Weight 173 kg (body mass index - 48.6). After 1 year: Weight 149 kg (body mass index 44.5). After 2 years: Weight 136 kg (body mass index 40.6). The level of intra-abdominal pressure before surgery (in the standing position) was 50.7 mm Hg. after 12 months; after surgery - decreased to 33 mm Hg. There is no hernia recurrence.

  Patient K., aged 42, was admitted to the surgical department of the Tyumen Regional Clinical Hospital with a diagnosis of postoperative giant recurrent ventral hernia. Concomitant diagnosis: Morbid obesity. Height 175 cm. Weight 157 kg. Body mass index 56.4. In 1998, the patient was operated on for a penetrating stab wound to the abdominal organs. In 1999, 2000, 2006 - operations for recurrent postoperative hernia, incl. using polypropylene mesh. On examination: a hernial protrusion measuring 25×30 cm, occupying the umbilical and epigastric regions.

  On October 15, 2008, the operation was performed. The first stage of the operation (optional). Performed resection of 2/3 of the stomach, cholecystectomy, appendectomy, anastomosis of the ileum with the stomach and imposed inter-intestinal anastomosis, using compression implants during the operation. Interintestinal anastomosis is imposed from the ileocecal angle at a distance equal to 10% of the total length of the small intestine.

  The second stage of the operation (main). Hernioplasty was performed with a polypropylene mesh graft of the abdominal wall defect according to the technique with the preperitoneal location of the prosthesis. Hernial orifice 30×25 cm in size. A prosthesis 30×30 cm was cut, when straightened, its edges went under the aponeurosis by 4-5 cm. Next, the prepared allograft was fixed with U-shaped sutures, capturing the edges of the prosthesis and piercing the abdominal wall, stepping back from the edge of the wound by 5 cm. The distance between the sutures was 2 cm. The postoperative period was uneventful. On the 9th day the patient was discharged from the hospital. When discharged at the control weighing - weight 151 kg. The patient was followed up for 2 years. After 6 months: Weight 114 kg (body mass index - 37.2). After 1 year: Weight 100 kg (body mass index 32.6). After 2 years: Weight 93 kg (body mass index 30.3). The level of intra-abdominal pressure before surgery (in the standing position) was 49 mm Hg, 12 months after the operation it decreased to 37 mm Hg. There is no hernia recurrence.

  Patient V., aged 47, was admitted to the surgical department of the Tyumen Regional Clinical Hospital with a diagnosis of postoperative giant ventral hernia. Concomitant diagnosis: Morbid obesity (height 162 cm, weight 119 kg, body mass index 45.3). In 2004, an operation was performed - cholecystectomy. After 1 month, a hernial protrusion appeared in the area of ​​the postoperative scar. On examination: the size of the hernial orifice is 25×15 cm.

  06/05/09 operation performed: The first stage of the operation (optional). Resection of 2/3 of the stomach, cholecystectomy, appendectomy, anastomosis of the ileum with the stomach were performed, and an interintestinal anastomosis was performed using a compression implant "with shape memory" from titanium nickelide TN-10 during the operation. Interintestinal anastomosis is imposed from the ileocecal angle at a distance of 10% of the total length of the small intestine.

  The second stage of the operation (main). Hernia repair, plastic defect with a polypropylene mesh according to the method described above. The postoperative period proceeded without complications. After removal of the drains on the 7th day, the patient was discharged from the hospital. When discharged at the control weighing - weight 118 kg. The patient was followed up for 1 year. After 6 months: Weight 97 kg (body mass index - 36.9). After 1 year: Weight 89 kg (body mass index 33.9). The level of intra-abdominal pressure before surgery (in the standing position) was 45 mm Hg, 12 months after the operation it decreased to 34 mm Hg. There is no hernia recurrence.

  The proposed method was tested on the basis of the regional clinical hospital in Tyumen. 32 operations were performed. The simplicity and effectiveness of the proposed method, which provides a reliable reduction in intra-abdominal pressure as a result of surgical intervention aimed at reducing the patient's body weight, reducing the volume of contents in the abdominal cavity, reducing the absorption of fats and carbohydrates, made it possible to reduce the volume of body fat in patients, which allowed patients with morbid obesity during abdominal operations to increase the asepsis of operations, reduce the risk of postoperative purulent complications, eliminate the possibility of anastomosis failure and reduce the risk of post-gastroresection disorders (anastomositis, stenosis).

  The proposed method eliminates the need for long-term preoperative preparation aimed at reducing body weight, and eliminates the corresponding material costs for its implementation. The use of this method will save 1 million 150 thousand rubles. during 100 operations.

  Comparative efficiency of the proposed method in comparison with the prototype
  Compare parameter	Operation according to the proposed method	Operation after preparation according to the prototype (diet therapy)
  Necessity and duration of preoperative preparation	Not required	Long term (2 weeks to 2 months)
  The need for a diet	Not required	Required
  Mean level of intra-abdominal pressure before surgery, mm Hg	46.3±1.0	45.6±0.7
  The average level of intra-abdominal	Down to normal	Does not change
  pressure 12 months after surgery, mm Hg	(36.0±0.6)	(46.3±0.7)
  Body weight after surgery	Decrease in all, without exception, by an average of 31%	60% did not change. In 40%, it slightly decreased (from 3 to 10%)
  Hernia recurrence rate (in %)	3,1	31,2
  Material costs for the treatment of 1 patient, taking into account preoperative preparation and the frequency of relapses (thousand rubles)	31,0	42,5

  A method for reducing intra-abdominal pressure in obesity in abdominal surgery, characterized in that simultaneously with the main operation, resection of 2/3 of the stomach, cholecystectomy, appendectomy are performed, an anastomosis of the ileum with the stomach is performed using compression implants and at a distance of 10% of the total length of the thin intestines, from the ileocecal angle form an inter-intestinal anastomosis.

  Many of us do not attach importance to such symptoms as bloating, aching pain in the abdominal part, discomfort when eating.

  But these manifestations can mean a complex process - intra-abdominal pressure. It is almost impossible to determine the disease right away, the internal pressure differs from the external one, and if the body system is disturbed, they begin to work defectively.

  Speaking in literary language, intra-abdominal pressure is a condition accompanied by an increase in pressure that comes from organs and fluid.

  To find out IAP, it is necessary to place a special sensor in the abdominal cavity or in the liquid medium of the large intestine. This procedure is performed by a surgeon, usually during surgery.

  

  Devices for measuring IAP

  There is another way to check pressure, but it is considered minimally invasive and less informative, this is the measurement of IAP using a catheter in the bladder.

  Reasons for the increase in performance

  Intra-abdominal pressure can cause many negative processes in the body, one of which is bloating.

  Abundant accumulation of gases usually develops due to stagnant processes as a result of individual characteristics or surgical pathologies.

  If we consider specific cases, irritable bowel syndrome, obesity and constipation can serve as a commonplace cause. Even eating a diet that includes gas-producing foods can provoke IAP. People who suffer from irritable bowel syndrome most often endure a decrease in the tone of the vegetative region of the NS (nervous system).

  It is not uncommon for diseases such as hemorrhoids and Crohn's disease to be the cause. The normal intestinal microflora is represented by a variety of trace elements that are found throughout the gastrointestinal tract. Their absence provokes the development of many diseases, the consequence of which may be intra-abdominal hypertension.

  The causes of IAP may include the following surgical pathologies: peritonitis, closed injuries in the abdomen, pancreatic necrosis.

  Symptoms and treatment

  Accompanying increased intra-abdominal pressure symptoms are as follows:

  

  • pain in the abdomen;
  • bloating;
  • dull pain in the kidneys;
  • nausea;
  • jerky sensations in the abdomen.

  As you can see, this list cannot clearly and accurately diagnose IAP, since other diseases can also have such alarming factors. In any case, you should consult your doctor and conduct a proper examination.

  The first thing you need to pay attention to in case of IAP is the degree of its development and the reasons for its appearance. For patients suffering from elevated IAP, a rectal probe is placed. This procedure does not cause pain. In particular, it is impossible to achieve a decrease in indicators with the help of such an intervention, it is used only for measurements.

  In the case of surgical intervention, the likelihood of developing abdominal compression syndrome may increase, then it is necessary to start therapeutic measures.

  The sooner the treatment process is started, the more likely it is to stop the disease at the initial stage and prevent the development of multiple organ failure.

  It is mandatory to not wear tight clothes, to be in a lying position above 20 degrees on the bed. In some cases, the patient is prescribed drugs to relax the muscles - muscle relaxants for parenteral use.

  Some precautions:
  • avoid infusion load.
  • do not remove fluid by stimulating diuresis.

  When the pressure passes the frame 25 mm. rt. Art., the decision to conduct surgical abdominal decompression in most cases is not negotiable.

  Timely intervention in a larger percentage makes it possible to normalize the functioning of the organs and systems of the body, namely, to stabilize hemodynamics, diuresis, and eliminate respiratory failure disorders.

  However, surgery also has a downside. In particular, this method can promote the development of reperfusion, as well as the entry into the bloodstream of an underoxidized nutrient medium for microorganisms. This moment can cause the heart to stop.

  If IAP serves to develop abdominal compression, the patient may be prescribed artificial lung ventilation procedures, with the parallel implementation of the normalization of the body's water and electrolyte balance by infusion with the help of crystalloid solutions.

  Separately, it is worth noting patients who have IAP due to obesity. A significant increase in the load on the tissue contributes to this process. As a result, the muscles atrophy and become unstable to physical activity. The consequence of the complication may be chronic cardiopulmonary insufficiency.

  In turn, this moment leads to disruption of the blood supply to blood vessels and tissues. The way to eliminate IAP in obese people is to sew in mesh implants. But the operation itself does not exclude the leading cause of high blood pressure - obesity.

  With excess body weight, there is a tendency to cholecystitis, fatty degeneration of the liver, prolapse of organs, cholelithiasis, which are the result of IAP. Doctors strongly recommend reviewing the diet of obese people and contacting a specialist to draw up proper nutrition.

  Exercises that increase intra-abdominal pressure

  The complex of physical natural factors that increase IAP is carried out in a natural way.

  For example, frequent sneezing, coughing with bronchitis, screaming, defecation, urination are a number of processes that lead to an increase in IAP.

  Especially often, men can suffer from gastroesophageal reflux disease, which can also be caused by increased IAP. This partly occurs in those who often exercise in gyms.

  Measurement of IAP in a medical institution

  No matter how much patients would like to measure IAP on their own, nothing will come of it.

  Currently, there are three methods for measuring IAP:

  1. Foley catheter;
  2. laparoscopy;
  3. water-perfusion principle.

  The first method is used frequently. It is available but not used for bladder trauma or pelvic hematoma. The second method is quite complicated and expensive, but will give the most correct result. The third is carried out by a special device and a pressure sensor.

  IAP levels

  To understand which value is high, you should know the levels from normal to critical.

  Intra-abdominal pressure: norm and critical level:

  • normal value It has<10 см вод.ст.;
  • mean 10-25 cm water column;
  • moderate 25-40 cm water column;
  • high>40 cm w.c.

  What is the diagnosis based on?

  An increase in intra-abdominal pressure can be determined by the following signs:

  

  • increased IAP - more than 25 cm of water. Art.;
  • carbon dioxide value equal to >45 ml. rt. Art. in arterial blood;
  • features of the clinical conclusion (pelvic hematoma or liver tamponade);
  • decrease in diuresis;
  • high pressure in the lungs.

  If at least three symptoms are identified, the doctor makes a diagnosis of intra-abdominal pressure.

  Related videos

  Device for functional monitoring of IAP:

  The problem of IAP was not previously such a discussed topic, but medicine does not stand still, making discoveries and research for the benefit of human health. Do not take this topic lightly. The factors considered are directly proportional to the occurrence of many life-threatening diseases.

  Do not self-medicate and be sure to contact medical institution if you are experiencing similar symptoms. Consider all the recommendations and you will no longer be concerned about the question of how to reduce intra-abdominal pressure.