Intra-abdominal pressure and functioning of internal organs. Treatment of increased intra-abdominal pressure

Any "internal" pressure in the human body plays a very important role. In addition to the most common problems with high blood pressure, about increased intraocular pressure, increased intracranial pressure. In addition, recently the concept of increased intra-abdominal pressure has often been included. Increased intra-abdominal pressure as a risk factor is very dangerous, because as a result it causes a dangerous complication such as compartment syndrome, which leads to difficulty in the work of all organs and systems of the body, and intra-abdominal hypertension also leads to a stable bacterial translocation from the large intestine to the circulatory system.

How can intra-abdominal pressure increase?

Increased intra-abdominal pressure, most often occurs as a result of the accumulation of gases in the intestines. A persistent increase in gases occurs as a result of congestion, both in various hereditary and severe surgical pathologies, and in more commonplace diseases such as constipation, irritable bowel syndrome, or eating foods that cause active gas release: cabbage, radish, radish . All of the above plays as a risk factor, with possible complications.

Diagnosis by invasive methods

Diagnosis consists of several methods for measuring intra-abdominal pressure. Basically, the methods are surgical, or rather invasive, which implies instrumental intervention in the human body. The surgeon places a sensor either in the large intestine or in the space of the abdominal cavity, which detects any changes. This method is used in patients who undergo third-party surgery on the abdominal organs, that is, the measurement of intra-abdominal pressure is not the main purpose of these operations, but is only an additional method for diagnosing complications.

The second less invasive way is to place a transducer into the bladder. The method is simpler to implement, but no less informative.

In newborns and children of the first year of life, increased intra-abdominal pressure is measured through the setting of a gastric tube. Hypertension of the abdominal cavity in newborns, as a risk factor, is very dangerous, as it causes bacterial translocation and can trigger pathological mechanisms associated with disruption of the main organs and systems.

Increased intra-abdominal pressure outside the hospital

Intra-abdominal hypertension is not a particularly pleasant fact, even in healthy people. When it occurs, a person usually feels pain in the abdomen of a bursting nature, rapid changes in the place of pain are possible. To clarify, the accumulation of excess gases in the intestines leads to such symptoms. In addition, it can manifest itself as unpleasant consequences in the form of gas discharge. All of these symptoms actually indicate the presence of a problem. Increased intra-abdominal pressure almost always accompanies such diseases as: irritable bowel syndrome with a predominance of decreased tone of the autonomic nervous system, inflammatory bowel diseases, such as: Crohn's disease, various colitis, even hemorrhoids can be accompanied by this symptom. In addition to the above, it is worth adding such a surgical pathology as intestinal obstruction. There is even a specific symptom of intestinal overbloating, which occurs due to intra-abdominal hypertension, the so-called symptom of the "Obukhov Hospital"

Increased intra-abdominal pressure in children

Very often, the above symptoms of the disease can occur in preschool children. The child will be swollen and disturbed by pain in the abdomen, in addition, this problem can be diagnosed by placing a hand on the stomach, determining the degree of tension in the abdominal muscles, and the grumbling and tension of the intestines, the latter can growl quite strongly under your fingers. In general, abdominal pain in children should be extremely careful, it can act as a risk factor for severe surgical complications.

Alcohol as a risk factor for complications in intra-abdominal hypertension

According to the results of the studies, it has been proven that the use of alcoholic beverages, especially those made by fermentation, dramatically increases intra-abdominal pressure in people with already elevated marks. So if you feel the above symptoms, strong advice is to refrain from drinking alcohol, this will not add to your health.

Methods for the treatment of intra-abdominal hypertension

With inpatient treatment, the method of struggle is aimed at removing excess accumulation of gases from the intestines, this can be achieved with special therapeutic enemas, or by setting a gas outlet tube. In home treatment, it is easiest to use decoctions of carminative herbs, you should also stick to a diet, and do not eat foods that lead to especially large gas formation. Be sure to eat light soups several times a week. Physical activity on the body should be treated with caution, since any kind of intensive work triggers the mechanisms for the formation of increased metabolism and catabolism.

Conclusion

Measurement of intra-abdominal pressure is a relatively new direction in medicine. Its pros and cons are still not sufficiently defined, however, both persistent and non-persistent hypertension is a rather aggravating risk factor for abdominal diseases, which, of course, should be paid attention to by both doctors and patients. Attentive attitude to your health is the key to a good standard of living.

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.

Measurement of intra-abdominal pressure

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).

There are frequent cases when diseases such as hemorrhoids and are 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;
• dizziness;
• 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 surgery, 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.

With hypertension in the abdominal cavity, it is customary to resort to abdominal surgery to reduce pain spasm and tension. In order to normalize the pressure, analgesics and sedatives are prescribed.

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 allows you to normalize the process 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 using 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.

Venous pressure is an important indicator necessary for the most accurate diagnosis of cardiovascular pathologies. Measurement of I.P. is necessary to monitor patients with heart or lung disease.

The level of blood pressure during the day changes several times. You can find out how you can track this indicator and how the daily change in blood pressure occurs here.

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 a medical institution if similar symptoms begin to bother you. Consider all the recommendations and you will no longer be concerned about the question of how to reduce intra-abdominal pressure.

What is Blood pressure - a brief educational program on the site

Blood pressure is the process of squeezing the walls of capillaries, arteries and veins under the influence of blood circulation. Types of blood pressure:

• upper, or systolic;
• lower, or diastolic.

When determining the level of blood pressure, both of these values ​​\u200b\u200bmust be taken into account. The units of its measurement remained the very first - millimeters of a mercury column. This is due to the fact that mercury was used in the old devices to determine the level of blood pressure. Therefore, the BP indicator looks like this: upper blood pressure (for example, 130) / lower blood pressure (for example, 70) mm Hg. Art.

Circumstances that directly affect the range of blood pressure include:

• the level of strength of contractions performed by the heart;
• the proportion of blood pushed out by the heart during each contraction;
• resistance of the walls of blood vessels, which is the flow of blood; the amount of blood circulating in the body;
• fluctuations in pressure in the chest, which are caused by the respiratory process.

Blood pressure levels can change throughout the day and with age. But for most healthy people, a stable blood pressure indicator is characteristic.

Definition of types of blood pressure

Systolic (upper) blood pressure is a characteristic of the general condition of the veins, capillaries, arteries, as well as their tone, which is caused by contraction of the heart muscle. It is responsible for the work of the heart, namely, with what force the latter is able to expel blood.

Thus, the level of upper pressure depends on the strength and speed with which heart contractions occur. It is unreasonable to assert that arterial and cardiac pressure is the same concept, since the aorta also participates in its formation.

Lower (diastolic) pressure characterizes the activity of blood vessels. In other words, this is the level of blood pressure at the moment when the heart is maximally relaxed. Lower pressure is formed as a result of the contraction of peripheral arteries, through which blood enters the organs and tissues of the body. Therefore, the state of blood vessels is responsible for the level of blood pressure - their tone and elasticity.

Each person has an individual blood pressure norm, which may not be associated with any diseases. The level of blood pressure is determined by a number of factors that are of particular importance:

• age and gender of the person;
• personal characteristics;
• life style;
• lifestyle features (work activity, preferred type of recreation, and so on).

Even blood pressure tends to rise when performing unusual physical exertion and emotional stress. And if a person constantly performs physical activity (for example, an athlete), then the level of blood pressure can also change both for a while and for a long period. For example, when a person is under stress, his blood pressure can rise to thirty mm Hg. Art. from the norm.

However, there are still certain limits of normal blood pressure. And even every ten points of deviation from the norm indicate a violation of the body.

You can also calculate the individual value of blood pressure using the following formulas:

1. For men:

• upper BP \u003d 109 + (0.5 * number of full years) + (0.1 * weight in kg);
• lower BP \u003d 74 + (0.1 * number of full years) + (0.15 * weight in kg).

2. For women:

• upper BP \u003d 102 + (0.7 * number of full years) + 0.15 * weight in kg);
• lower blood pressure \u003d 74 + (0.2 * number of full years) + (0.1 * weight in kg).

The resulting value is rounded to an integer according to the rules of arithmetic. That is, if it turned out to be 120.5, then when rounded it will be 121.

What to do to normalize the pressure?

These tips will help you feel alert all day if you are hypotensive.

1. Don't rush to get out of bed. Wake up - do a little warm-up lying down. Move your arms and legs. Then sit down and stand up slowly. Perform actions without sudden movements. they can cause fainting.
2. Take a contrast shower in the morning for 5 minutes. Alternate water - a minute warm, a minute cool. This will help to cheer up and is good for blood vessels.
3. A good cup of coffee! But only a natural tart drink will raise the pressure. Drink no more than 1-2 cups a day. If you have heart problems, drink green tea instead of coffee. It invigorates no worse than coffee, but does not harm the heart.
4. Sign up for a pool. Go at least once a week. Swimming improves vascular tone.
5. Buy a tincture of ginseng. This natural "energy" gives tone to the body. Dissolve 20 drops of tincture in ¼ cup of water. Drink half an hour before meals.
6. Eat sweets. As soon as you feel weak - eat ½ teaspoon of honey or a little dark chocolate. Sweets will drive away fatigue and drowsiness.
7. Drink clean water. Daily 2 liters of pure and non-carbonated. This will help keep your blood pressure at a normal level. If you have a sick heart and kidneys, a doctor should prescribe a drinking regimen.
8. get enough sleep. A rested body will work as it should. Sleep at least 7-8 hours a day.
9. Get a massage. According to experts in oriental medicine, there are special points on the body. By acting on them, you can improve your well-being. The point that is located between the nose and the upper lip is responsible for the pressure. Gently massage it with your finger for 2 minutes in a clockwise direction. Do this when you feel weak.

First aid for hypotension and hypertension

If you feel dizzy, severe weakness, tinnitus, call an ambulance. In the meantime, the doctors go, act:

1. Open the collar of your clothes. The neck and chest should be free.
2. Lie down. Lower your head down. Place a small pillow under your feet.
3. Smell ammonia. If it is not available, use table vinegar.
4. Have some tea. Definitely strong and sweet.

If you feel the approach of a hypertensive crisis, then you also need to call the doctors. In general, this disease should always be supported by preventive treatment. As first aid measures, you can resort to the following actions:

1. Organize a foot bath with hot water, which is pre-added with mustard. An alternative would be to apply mustard compresses to the area of ​​the heart, back of the head and calves.
2. Lightly bind the right, and then the left arm and leg for half an hour each side. When the tourniquet is applied, a pulse should be felt.
3. Drink a drink from chokeberry. It can be wine, compote, juice. Or eat jam from this berry.

To reduce the risk of occurrence and development of hypotension and hypertension, you should adhere to a healthy diet, prevent excess weight, exclude harmful foods from the list, and move more.

Pressure should be measured from time to time. When observing a trend of high or low blood pressure, it is recommended to consult a doctor to determine the causes and prescribe treatment. Prescribed therapy may include methods to normalize blood pressure, such as taking special medicines and herbal infusions, dieting, performing a set of exercises, and so on.

Intra-abdominal pressure: symptoms and treatment of abnormalities - tips and tricks on the site

The information on the site is for reference and generalizing, collected from publicly available sources and in no case can be the basis for making a decision on the use in the course of treatment. If in any doubt, contact your doctor.

To have accurate IAP numbers, 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 its 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 the bladder. . The elastic and highly extensible bladder wall, with a volume not exceeding 25 ml, acts as a passive membrane and accurately transfers 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 reassemble the system at each measurement, which suggested a high risk of developing an 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 the postoperative period due to the relaxation of the muscles of the anterior abdominal wall makes it possible to obtain the most accurate IAP values. .

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]. Survey conducted by the European Council for Intensive Care Medicine (ESICM) and the Council for Critical Care Medicine 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 impact of intra-abdominal hypertension on various organ systems to a greater or lesser extent and on 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 result 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)

  
  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 persistent 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: resection of 2/3 of the stomach, cholecystectomy, appendectomy are carried out, 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 distinctive 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 TN-10 titanium nickelide compression implant 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 the operation (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, exclude 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.

  Summary

  Normally, intra-abdominal pressure is slightly higher than atmospheric pressure. However, even a slight increase in intra-abdominal pressure can adversely affect kidney function, cardiac output, hepatic blood flow, respiratory mechanisms, organ perfusion, and intracranial pressure. A significant increase in intra-abdominal pressure is observed in many conditions, often encountered in intensive care units, in particular, with perforation of an arterial aneurysm, abdominal trauma and acute pancreatitis. The abdominal compartment syndrome is a combination of elevated intra-abdominal pressure and organ dysfunction. This syndrome has a high mortality rate, mainly as a result of sepsis or multiple organ failure.

  Often, when examining a patient, we find a swollen abdomen, but, unfortunately, we do not often think about the fact that a swollen abdomen is also an increased intra-abdominal pressure (IAP), which can have a negative impact on the activity of various organs and systems. The effect of increased IAP on the functions of internal organs was described as early as the 19th century. So, in 1876, E. Wendt in his publication reported on undesirable changes occurring in the body due to an increase in pressure in the abdominal cavity. Subsequently, separate publications of scientists described hemodynamic, respiratory and renal disorders associated with increased IAP. However, only relatively recently its negative effects were recognized, namely the development of abdominal compartment syndrome (SAH, in the English literature - abdominal compartment syndrome) with a mortality rate of up to 42-68%, and in the absence of appropriate treatment reaching up to 100%. Underestimating or ignoring the clinical significance of IAP and intra-abdominal hypertension (IAH) are circumstances that increase the number of adverse outcomes in the intensive care unit.

  The basis for the occurrence of such conditions is an increase in pressure in a limited space, which leads to circulatory disorders, hypoxia and ischemia of organs and tissues located in this space, contributing to a pronounced decrease in their functional activity up to its complete cessation. Classical examples are conditions arising from intracranial hypertension, intraocular hypertension (glaucoma), or intrapericardial hemotamponade of the heart.

  Regarding the abdominal cavity, it should be noted that all its contents are considered as a relatively incompressible space, subject to hydrostatic laws. The formation of pressure is influenced by the state of the diaphragm, the abdominal muscles, as well as the intestines, which can be empty or full. An important role is played by the tension of the abdominal press with pain and arousal of the patient. The main etiological factors that lead to an increase in IAP can be grouped into three groups: 1) postoperative (peritonitis or abdominal abscess, bleeding, laparotomy with contraction of the abdominal wall during suturing, postoperative edema of internal organs, pneumoperitoneum during laparoscopy, postoperative ileus, acute dilatation of the stomach); 2) post-traumatic (post-traumatic intra-abdominal or retroperitoneal bleeding, swelling of internal organs after massive infusion therapy, burns and polytrauma); 3) as a complication of internal diseases (acute pancreatitis, acute intestinal obstruction, decompensated ascites in cirrhosis, ruptured abdominal aortic aneurysm).

  When studying the effects of IAH, it was found that its increase most often can cause hemodynamic and respiratory disorders. However, as practice shows, pronounced changes not only in hemodynamics, but also in other vital systems do not always occur, but only under certain conditions. Obviously, therefore, J.M. Burch in his works identified 4 degrees of intra-abdominal hypertension (Table 1).

  The recently held World Congress on ACS (December 6-8, 2004) proposed for discussion another version of the IAH gradation (Table 2).

  Considering that normal pressure in the abdominal cavity is near zero or negative, its increase to the indicated figures is naturally accompanied by changes in various organs and systems. At the same time, the higher the IAP, on the one hand, and the weaker the body, on the other, the more likely the development of undesirable complications. The exact level of IAP that is considered IAP remains a matter of debate, but it should be noted that the incidence of SAH is proportional to the increase in IAP. Recent experimental data obtained in animals have shown that a moderate increase in IAP ~ 10 mm Hg. (13.6 cm water column) has a significant systemic effect on the function of various organs. And with IAP above 35 mm Hg. SAH occurs in all patients and without surgical treatment (decompression) can be fatal.

  Thus, the increase in pressure in a closed space has a uniform effect in all directions, of which the most significant is the pressure on the posterior wall of the abdominal cavity, where the inferior vena cava and aorta are located, as well as the pressure in the cranial direction on the diaphragm, which causes compression of the chest cavity.

  Numerous authors have proven that an increase in pressure in the abdominal cavity slows down blood flow through the inferior vena cava and reduces venous return. Moreover, a high IAP pushes the diaphragm upward and increases mean intrathoracic pressure, which is transmitted to the heart and blood vessels. Elevated intrathoracic pressure reduces the pressure gradient across the myocardium and limits diastolic ventricular filling. The pressure in the pulmonary capillaries increases. Venous return suffers even more and stroke volume decreases. Cardiac output (CO) decreases despite compensatory tachycardia, although at first it may not change or even increase due to the “squeezing out” of blood from the venous plexuses of the internal organs of the abdominal cavity by high IAP. Total peripheral vascular resistance increases as IAP increases. This is facilitated, as indicated above, by a decrease in venous return and cardiac output, as well as the activation of vasoactive substances - catecholamines and the renin-angiotensin system, changes in the latter are determined by a decrease in renal blood flow.

  Some argue that a moderate increase in IAP may be accompanied by an increase in effective filling pressure and, as a result, an increase in cardiac output. Kitano showed no change in CO when IAP was less than 16 mmHg. . However, when the intraperitoneal pressure is above 30 cm of water column, the blood flow in the inferior vena cava and CO are significantly reduced.

  Experimentally, C. Caldweli et al. it has been shown that an increase in IAP by more than 15 mm Hg. causes a reduction in organ blood flow for all organs located both intra- and retroperitoneally, with the exception of the cortical layer of the kidneys and adrenal glands. The decrease in organ blood flow is not proportional to the decrease in CO and develops earlier. Studies have shown that blood circulation in the abdominal cavity begins to depend on the difference between the mean arterial and intra-abdominal pressure. This difference is called the abdominal perfusion pressure and is believed to be the magnitude that ultimately determines visceral ischemia. It manifests itself most clearly in the deterioration of the gastrointestinal tract - due to a decrease in mesenteric blood flow under conditions of respiratory acidosis, ischemia occurs and progresses, the peristaltic activity of the gastrointestinal tract and the tone of the sphincter apparatus decrease. This is a risk factor for the occurrence of passive regurgitation of acidic gastric contents into the tracheobronchial tree with the development of acid aspiration syndrome. Moreover, changes in the state of the gastrointestinal tract, impaired central and peripheral hemodynamics are the cause of postoperative nausea and vomiting. Acidosis and edema of the intestinal mucosa due to IAH occurs before clinically detectable SAH appears. IAH causes deterioration of blood circulation in the abdominal wall and slows down the healing of postoperative wounds.

  Some studies point to the possibility of additional mechanisms of local regulation. IAP with an increase in arginine-vasopressin levels probably reduces hepatic and intestinal oxygenation and reduces portal blood flow. Hepatic arterial blood flow decreases when IAP is greater than 10 mm Hg, and portal - only when it reaches 20 mm Hg. . A similar decrease occurs in the renal blood flow.

  A number of authors have shown that an increase in intra-abdominal pressure can cause a reduction in renal blood flow and glomerular filtration rate. It is noted that oliguria begins at IAP 10-15 mm Hg, and anuria - at IAP 30 mm Hg. . Possible mechanisms for the development of renal failure are an increase in renal vascular resistance, compression of the renal veins, an increase in the level of antidiuretic hormone, renin and aldosterone, as well as a decrease in CO.

  An increase in intra-abdominal volume and pressure limits diaphragmatic movement with increased ventilation resistance and decreases lung compliance. Thus, compression of the lungs leads to a decrease in functional residual capacity, collapse of the capillary network of the pulmonary circulation, an increase in pulmonary vascular resistance, an increase in pressure in the pulmonary artery and capillaries, and an increase in afterload on the right heart. There is a change in the ventilation-perfusion relationship with an increase in blood shunting in the lungs. Severe respiratory failure, hypoxemia and respiratory acidosis develop, and the patient is transferred to mechanical ventilation.

  Important in IAH is respiratory support through the selection of artificial lung ventilation modes. FiO 2 is known to be greater than 0.6 and/or P peak greater than 30 cm of water column. damage healthy lung tissue. Therefore, the modern tactics of mechanical ventilation in these patients requires not only the normalization of the blood gas composition, but also the choice of the most sparing support regimen. P media, for example, is preferable to increase by increasing positive end-expiratory pressure (PEEP), rather than tidal volume (TO), which, on the contrary, should be reduced. These parameters are selected according to the "pressure - volume" (extensibility) of the lungs. At the same time, it must be remembered that if in the primary syndrome of acute lung injury, the extensibility of the lung tissue first of all decreases, then in SAH, the extensibility of the chest. There are studies showing that in patients with SAH, high PEEP recruits collapsed but viable alveoli into ventilation and leads to improved compliance and gas exchange. Therefore, timely and adequate selection of ventilation modes for IAH reduces the risk of developing iatrogenic baro- and volumotrauma.

  Interesting work on the effect of IAH on intracranial pressure (ICP). The authors indicate that acute IAH contributes to the growth of ICP. Possible mechanisms are a violation of the outflow of blood through the jugular veins due to increased intrathoracic pressure and the action of WBG on the cerebrospinal fluid through the epidural venous plexus. Obviously, therefore, in patients with severe combined trauma of the skull and abdomen, mortality is two times higher than with these injuries separately.

  Thus, IAH is one of the main factors in the disorder of the vital systems of the body and a pathology with a high risk of adverse outcomes that requires timely diagnosis and immediate treatment. The symptom complex in SAH is nonspecific, its manifestation can occur in a wide variety of surgical and non-surgical pathologies. So, oliguria or anuria, a high level of central venous pressure (CVP), severe tachypnea and a decrease in saturation, a profound impairment of consciousness, a drop in cardiac activity can be interpreted as manifestations of multiple organ failure against a background of traumatic disease, heart failure or a severe infectious process. Ignorance of the pathophysiology of IAH and the principles of treatment of SAH, for example, the appointment of diuretics in the presence of oliguria and high CVP, can adversely affect the patient's condition. Therefore, timely diagnosis of IAH will prevent misinterpretation of clinical data. To diagnose IAH, you need to know and remember about it, however, even examination and palpation of a swollen abdomen will not give the doctor accurate information about the size of IAP. IAP can be measured in any part of the abdomen - in the cavity itself, uterus, inferior vena cava, rectum, stomach or bladder. However, the most popular and simplest method is to measure the pressure in the bladder. The method is simple, does not require special, sophisticated equipment, allows monitoring this indicator over a long period of patient treatment. Measurement of bladder pressure is not performed if there is damage to the bladder or compression of its pelvic hematoma.

  In conclusion, it should be noted that IAH is another real factor that must be taken into account in the management of patients in the intensive care unit. Underestimation of it can lead to a violation of almost all vital functions of the body, IAH is a fatal pathology that requires timely diagnosis and immediate treatment. Clinicians realized the need to measure abdominal pressure following intracranial and intrathoracic pressure. As numerous researchers point out, adequate monitoring of intra-abdominal hypertension allows timely recognition of the level of IAP that threatens the patient and timely implementation of the necessary measures to prevent the occurrence and progression of organ disorders.

  The measurement of intra-abdominal pressure is becoming a mandatory international standard for patients with abdominal accidents. That is why in the Department of Surgical Resuscitation of the RRCEMMP, which is the base of the Department of Anesthesiology and Resuscitation of TashIUV, today research is being carried out aimed at studying the problems associated with the effects of IAH. In a comparative aspect, various modes of mechanical ventilation and methods for correcting disorders that occur in various organs and systems of the body are studied.

  
  

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