Poke catheter method. Endoscopy in children. Drainage of ascites

Rice. 20. Technique of puncture of the abdominal cavity in ascites.

Rice. 21. Choice of the puncture site of the abdominal cavity in case of ascites.

Laparocentesis, equipment, indications, technique

LaparocentesisThis is a puncture of the abdominal wall for diagnostic and therapeutic purposes. This manipulation is indicated: with the accumulation of fluid in the abdominal cavity, disturbing functions of vital organs and not eliminated by other therapeutic measures (ascites), the establishment of pathological exudate or transudate in the abdominal cavity in case of injuries and diseases, gas administration during laparoscopy and abdominal radiography (if a diaphragm rupture is suspected).

Contraindications, adhesive disease abdominal cavity, pregnancy ( II half).

Technical accessories for laparocentesis: a syringe with a capacity of 5-10 ml with a thin needle for anesthesia of the abdominal wall and a solution of 0.25-1.0% novocaine; scalpel; dressing material (gauze balls and napkins); needle holder, needle and silk threads for suturing; test tubes and glass slides for performing laboratory studies of the removed liquid; trocar - a metal cylinder consisting of a tube - a cannula and a stylet placed inside it. The stylet and cannula tube must be one piece, d = 4-6 mm.

Laparocentesis kit contains:

surgical scissors
anatomical tweezers

Surgical tweezers

Needle holder

Trocar
Execution technique : the preferred place for puncture is 2-3 cm below the navel in the midline of the abdomen, if there are no surgical scars in this area. AT doubtful cases The puncture is performed under ultrasound guidance. Before the puncture, the patient's bladder must be emptied.

1. The position of the patient with lowered legs with support for the arms and back.

2. Skin treatment (alcohol, iodine).

3. Anesthesia with 0.5-1.0% solution of novocaine is done at the puncture point.

4. Skin incision with a scalpel 5-10 mm

5. Take the trocar so that the stylet handle rests on the palm, and forefinger lay on the cannula of the trocar. The direction of the puncture is strictly perpendicular to the skin surface.

6. Slowly, decisively, we pierce the abdominal wall (the moment it enters the abdominal cavity - a feeling of a sudden cessation of resistance).

7. The stylet is removed.

8. If necessary, a "groping catheter" from a disposable system is inserted into the tube.

9. The trocar cannula is removed from the abdominal cavity.

10. Treatment of wound edges, skin suture, aseptic dressing

Rice. 22. Puncture point of the anterior abdominal wall during laparocentesis

(the number "1" marks the puncture point of the anterior abdominal wall; the projection of the round ligament of the liver is shaded).

Selection of all necessary instruments for laparotomy

Laparotomy- surgical operation, dissection of the abdominal wall to gain access to the abdominal organs, under the general or local anesthesia. Treatment of the surgical field 2 times with chlorhexidine.

Rice. 23. Scheme of incisions of the anterior abdominal wall during laparotomy.

To dissect tissue, you need: scalpel, you can electro, ultrasonic or laser scissors.

For stitching:needle holder, needles, threads.

For processing:iodine, alcohol, chlorhexidine, aseptic bandages.

For hemostasis: tweezers, clamps (soft, hard).

To stretch fabrics: various dilators and hooks, abdominal mirrors.

To fix the material: hoes.

Surgical kit for laparotomy includes:

Sterile scalpel blades
standard scalpel handle
surgical scissors
anatomical tweezers

Surgical tweezers
needle holder

Forceps anatomical straight

Curved anatomic forceps

Napkin clip

Tampon clip straight

Retractor

Button probe

suction tube

Hemostatic clamps

Also during laparotomy, you can use the "Mini Assistant" set (see Fig. 24).

Rice. 24. Set "Mini Assistant".

Biopsy, indications, types of conduction. Selection of everything necessary for a biopsy, the procedure for its implementation

Definition: biopsy (from the Greek "βίος" - life and "όψη" - I look) is a research method in which cells or tissues are taken from the body in vivo, followed by their microscopic examination.

Types of biopsy:

Excisional biopsy - as a result surgical intervention the entire formation or organ under study is removed.

incisional biopsy - as a result of surgical intervention, a part of the formation or organ is removed.

Aspiration biopsy - as a result of puncture of the studied formation with a hollow needle, a tissue column is taken.

Contact- an imprint from the wound on a glass slide.

Goals and objectives of the biopsy: A biopsy is the most reliable research method if it is necessary to establish the cellular composition of the tissue. It must be included in diagnostic minimum, especially if a cancer is suspected, and complements other research methods: x-ray, endoscopic, immunological. Biopsies in many cases indirectly determine the extent of surgical intervention, and primarily in cancer patients.

Indications for a biopsy : a biopsy is performed to clarify or confirm the diagnosis, with difficulties and difficulties in establishing it, to resolve issues of the surgical and therapeutic plan - the treatment of patients.

Execution Method: in diseases of the gastrointestinal tract, a biopsy is performed during endoscopic studies, or surgical intervention.

To study organs and tissues located close to the surface of the skin, a puncture biopsy is used. A puncture is made with a special long needle, often under the control of ultrasound or other non-invasive methods. The resulting material (tissue column) is sent for cytological examination. There is the possibility of a biopsy and more deeply located organs - the liver, kidneys, pancreas. In this case, the needle is passed to desired point with simultaneous fluoroscopy or ultrasound diagnostics.

Equipment and tools : almost any needle of sufficient diameter and length, a syringe with a well-ground piston (10, 20 grams) can be used for cytological biopsy. For histological biopsy, special biopsy guns with replaceable needles or disposable automatic needles are widely used today. It is also possible to perform an intraoperative biopsy when it is not possible to remove the entire formation surgically. In practice, a contact biopsy is often used, when a glass slide is applied directly to the wound and the resulting impression is examined under a microscope.

Rice. 25. Tools for biopsy and the main stages of its implementation.

Rice. 26. Biopsy technique.

Anesthesia according to Oberst-Lukashevich, indications, technique, equipment

Conduction anesthesia according to Oberst-Lukashevich is a correctly chosen method of anesthesia during surgical treatment purulent diseases hands and fingers (opening panaritiums, necrectomy, amputation of the distal phalanges of the fingers). This type of anesthesia provides bleeding and a complete analgesic effect throughout the entire operation.

Equipment:rubber tourniquet or tourniquet-ribbon, 5 gram syringe with injection needle for intramuscular injection, anesthetic ( solution of novocaine 1.0% -2.0%, rarely trimikain or lidocaine), alcohol, iodine for skin treatment.

Training:the patient is placed on the operating table, the hand is placed on a stand, a thorough toilet and aseptic processing of the hand.

Technique:The needle is injected below the tourniquet on the dorsal-lateral surface of the main phalanx of the finger and, with a simultaneous injection of an anesthetic, it is moved to the palmar-lateral surface, where 5 ml of 1.0% -2.0% solution of novocaine or lidocaine is injected. A similar manipulation is performed on the other side of the phalanx of the finger. This type of anesthesia provides a blockade of the dorsal and palmar nerves of the corresponding side of the finger. Anesthesia occurs in 5-10 minutes.

Rice. 27. The technique of conducting conduction anesthesia according to Oberst-Lukashevich.

Sepsis treatment

Sepsisis a pathological process, which is based on the reaction of the body in the form of generalized (systemic) inflammation to an infection different nature(bacterial, viral, fungal).

Sepsis is an urgent clinical problem requiring urgent action to suppress infection and maintain vitality. important indicators hemodynamics, respiration, circulatory function.

Sepsis treatmentdirected towards the hearth purulent inflammation, and to increase the body's defenses. Therapeutic measures can be minimal with small entrance gates of infection: injections, paresis, scratches.

The main directions of intensive care:

Full surgical sanitation of the focus of infection

Adequate antimicrobial therapy

Hemodynamic support

Respiratory support

Corticosteroids: “low doses” mg/day of hydrocortisone 5-7 days for SS Activated protein C: 24 mcg/kg/hour for 4 days for severe sepsis (APACHE II>25 points) or insufficiency of two or more organ systems Immunocorrection: replacement therapy drug pentoglobin ( IgG + IgM ) = 3-5 ml/kg 3 days – the best effect

Prevention of deep vein thrombosis (correction of stages and phases of acute DIC) proton pump- moose)

Efferent methods of detoxification (PA, substitution renal therapy with OPN)

Nutritional support

Antibacterial therapy sepsis is determined by the type of alleged or established pathogen. While waiting for the results of blood culture, treatment is carried out against gram-positive and gram-negative bacteria. If neither clinical nor laboratory signs allow us to establish with any certainty etiological factor, then a course of so-called empirical antibiotic therapy is prescribed.

Table 2

Empiric Antibacterial Therapy Scheme

Criteria for the duration of antibiotic therapy

Positive dynamics of the main symptoms of infection

No evidence of a systemic inflammatory response

Normalization of gastrointestinal function

Normalization of leukocytes in the blood and leukocyte formula

Negative blood culture

Rupture of the spleen. Diagnostics, emergency care

Among parenchymal organs In the abdominal cavity, the spleen is the most injured organ. This circumstance is associated with such factors as the location of the organ near the abdominal wall, significant size, the degree of its blood supply, and relatively easy displacement at the time of injury.

Ruptures of the spleen are divided into one-stage and two-stage.

Simultaneous - rupture of the parenchyma and the capsule of the spleen with bleeding into the free abdominal cavity Two-stage - rupture of the parenchyma with bleeding under the capsule (the last whole).

The reasons:trauma, injury, less often spontaneous rupture (with an enlarged spleen - its diseases).

Diagnostics:Clinic, X-ray data, ultrasound, as well as laparocentesis or laparoscopy, less often corformative laparotomy, intra-abdominal bleeding, changes in the pulse, A / D, symptoms of an acute abdomen, blood test.

Urgent care : emergency operation with one-stage damage and urgent - with two-stage damage.

The amount of the operational allowance depends on the class of the gap. 1 class - tamponade, or suturing, II class - resection and removal, with III, II - splenectomy with mandatory replanting of an autograft.

Rice. 28. Scheme of sections of the anterior abdominal wall during operations on the spleen.

1 - T-shaped section; 2 - angular section; 3 - upper median section; 4 - oblique section (Cherni, Ker); 5 - pararectal incision; b - oblique incision (Sprengel).

Suturing a spleen wound

Small marginal or longitudinal wounds with slight parenchymal bleeding sutured with separate U-shaped or interrupted catgut sutures, capturing the omentum on the leg into the seam. In some cases, the wound can be plugged with a pedunculated omentum, fixing it to the organ capsule. After suturing the wound, the accumulated blood is removed from the abdominal cavity and, after making sure that there is no bleeding, the wound of the anterior abdominal wall is sutured in layers. It should be noted that the suturing of wounds of the spleen is extremely rare, since its parenchyma is very fragile and the sutures are easily cut through.

Rice. 29. Tamponade of the wound of the spleen with a pedunculated omentum.

Spleen resection

Laparocentesis (abdominal puncture) is a surgical action, which is based on the removal of accumulated fluid in the abdominal cavity. Manipulation is carried out by means of an incision in the posterior abdominal wall. This operation is performed both for diagnostics and in medicinal purposes.

A puncture is performed if a hemorrhage in the abdominal cavity is suspected, due to a closed injury, or if the intestine is ruptured.

For therapeutic purposes, a puncture is performed with the accumulation of fluid in liver cirrhosis, pancreatic diseases, oncology of internal organs and heart disease. The resulting liquid is tested in the laboratory for the presence of hidden blood, elements of bile, as well as feces.

Indications and contraindications for laparocentesis

Laparocentesis is indicated for:

1. Closed injuries of the abdominal cavity, with the patient unconscious.
2. Internal bleeding.
3. Perforation of stomach ulcer.
4. Suspicion of intestinal perforation.
5. Thoracoabdominal trauma (damage to the area below the nipples, due to injury from a knife or firearm).
6. Ascites (accumulation of fluid in the intestinal cavity in the presence of various diseases).
7. Suspicion of peritonitis.
8. Diagnosis of ascites in outpatients.
9. Multiple injuries of the abdominal cavity.

Contraindications to laparocentesis are the following factors:

1. The presence of adhesions in the abdominal cavity.
2. Suspicion of trauma to the abdominal wall.
3. The presence of severe swelling.
4. Ventral hernia formed after surgery.
5. Progression of inflammatory and purulent processes.
6. Large tumor formation in the peritoneum.
7. Hemorrhagic diathesis, not amenable to vitamin K therapy.
8. Pregnancy.
9. Poor blood clotting.

Preparing for the operation

In preparation for laparocentesis, a number of activities are carried out. To begin with, clinical and laboratory studies are prescribed, including a blood test for coagulation, Rh factor and group, a coagulogram and a urine test. In addition, an oral survey is conducted about the presence of an allergy to drugs, about taking any medicines and about pregnancy. The patient is then sent to ultrasound examination abdominal cavity and radiography, which allows you to accurately determine the location and volume of accumulated fluid. Further, if the patient is able, a cleansing enema is given and it is proposed to empty the bladder.

Laparocentesis technique

The procedure is performed in a sitting or, if necessary, in a supine position in a sterile room (operating room or dressing room). subcutaneously, in soft tissues analgesic drugs (novocaine and lidocaine) are injected into the abdomen, the site of the proposed puncture is wiped antiseptic liquid. After that, a small incision is made with a scalpel, retreating 2 cm below the navel or slightly to the left, in rare cases, the incision is made in the middle, between the navel and the pubis. Manipulations are carried out as carefully as possible so as not to hurt the internal organs.

Next, a trocar is inserted - a special instrument consisting of a needle and drainage (a tube for draining fluid). The introduction of the trocar is performed by rotational movements at an angle of 45° relative to the sternum. For free advancement of the trocar, the umbilical ring is grasped, which provides elevation of the abdominal cavity wall. The liquid is drained very slowly, no more than 1 liter per minute. If the flow stops, then the injection site of the needle (cannula) is slightly changed.

Periodically, fluid outflows are stopped by squeezing the rubber tube with a clamp. The watery secretion is drained into a special container, from where part of the contents is taken into a sterile test tube for laboratory analysis. A surgical suture is applied to the incision and treated with an antiseptic solution. After the procedure, careful monitoring of blood pressure, color skin, body temperature, and pulse control.

Ascites is a disease that does not manifest itself in the initial stages, since the body consumes up to 1.5 liters of fluid daily. In a situation of progressive ascites, the patient develops heaviness in the abdomen, difficulty breathing, belching, nausea, and impaired urination. Sometimes a severe form of ascites causes formations umbilical hernia due to pressure on the intestines. With ascites, the level of accumulated fluid varies from 5-10 liters, which causes severe breathing complications, and squeezing blood arteries leading to heart failure. In most cases, ascites becomes a consequence of oncology.

Causes can be ovarian, breast, uterine, or colon cancer. In these cases, resort to laparocentesis under ultrasound control. The advantage of this method is not only the removal of excess fluid, but also the installation of drainage, which ensures outflow for a long time.

Laparocentesis can be performed outpatient settings. The insertion technique is standard, that is, first an incision is made, then a trocar with a tube attached to it is inserted. The liquid is slowly pumped out due to the risk of pressure fluctuations, which can lead to a state of collapse. To avoid hemodynamic disturbance, the surgeon's assistant gradually tightens the abdomen with a towel. At the end of the manipulation, when the acetic fluid is completely drained, the trocar is removed and a suture and a sterile dressing are applied to the incision site. To create the intra-abdominal pressure habitual for the patient, the towel is not removed for some time.

Important! The accuracy of laparocentesis depends on the volume of fluid received, the more material collected, the more accurate diagnosis.

Diagnostic laparocentesis

Diagnostic laparocentesis is a highly accurate method in determining the presence primary peritonitis in patients with chronic renal failure and cirrhosis of the liver. As a rule, peritonitis is diagnosed after receiving a puncture that has passed laboratory analysis. Usually the content of leukocytes in the liquid is more than 300 per 1 ml, and the leukocyte formula is shifted by 30%.

The use of laparocentesis is also advisable for acute pain of a non-traumatic nature and for suspected secondary bacterial peritonitis. The liquid obtained during this manipulation is carefully analyzed according to external and laboratory signs. For example, if it is brown or reddish in color, and the analysis contains a large number of bacteria, then a diagnosis is made - secondary peritonitis. Laparocentesis is always performed after a plain radiograph, since after surgery, in about a quarter of patients, there is a risk of filling the cavity with gases.

Important! Carrying out laparocentesis is almost the only method for determining the cause of the pathology, especially when radiography and ultrasound procedure do not give accurate predictions about the state of the organs that bring fluid into the abdominal cavity.

Most often, laparocentesis is used for diagnostic purposes, when clinical findings do not provide an accurate diagnosis. It is important to understand that there must be a good reason for this manipulation, for example, insufficient time for ultrasound diagnosis or collection of tests. The choice of laparocentesis is always individual and based on overall picture the patient's condition. You should be aware that the use of this manipulation does not give a 100% guarantee of detecting pathology, since, for example, when analyzing the withdrawn fluid during ruptures and pathological changes pancreas, the result will be revealed as a false positive. This happens especially often if the fluid analysis was done in the first two hours after sampling.

Evaluation of the received material

After receiving the material, an assessment of the appearance is made. Next, a laboratory analysis of the liquid is carried out. If impurities of urine, feces, bile, stomach contents are found, as well as when stained in gray-green or yellow, the patient urgently needs surgery. This type of fluid indicates the possibility of perforation of the walls of internal organs, peritonitis, as well as internal bleeding abdominal cavity.

At cytological analysis it is possible to detect an increased content of erythrocytes and leukocytes, which indicates the activity of intra-abdominal bleeding. In addition, special tests are performed to help determine if the bleeding has stopped. With results indicating profuse hemorrhage, the patient is urgently sent to the operating room for anti-shock therapy.

If urine is found that has a characteristic odor, a rupture is diagnosed. Bladder, and the presence of feces indicates an existing hole in the intestinal wall. If the withdrawn liquid is turbid and has a green or yellow color, and a protein is also detected, then this indicates the development purulent infection(peritonitis) in the genitals. This development of events is also indicated for an emergency open operation.

There is also a false-negative result of the analysis of the esudant. This happens due to the too high flexibility of the catheter, which can become clogged with a blood clot, be limited in movement by adhesions, and also simply not reach the place of fluid accumulation.

False-positive can be an analysis with an incorrectly performed laparocentesis. It is possible for blood to enter the catheter if the needle is inserted incorrectly, which is taken for internal bleeding.

Possible complications and postoperative period

With a correctly performed laparocentesis, complications usually do not occur, but there are still exceptions. If the surgeon is inexperienced, the trocar may damage the internal organs, as well as their rupture, which can lead to bleeding or the development of peritonitis. With a rough manipulation, a hematoma may form at the puncture site. During the introduction of the needle, the development of emphysema of the anterior abdominal wall is possible.

If hygienic and sanitary rules are not observed during laparocentesis, infection in the internal organs is possible, which leads to peritonitis of the abdominal wall, etc. With the introduction excess gas, lung function is disrupted due to a diaphragm that is too elevated, and if not administered correctly, gas may enter the soft tissues of the peritoneum, which leads to the development of emphysema of the subcutaneous layer.

Damage to large vessels is also likely, which can cause bleeding. Another possible complication is the likelihood of collapse due to pressure surges and redistribution of blood. With the incompetence or ignorance of the surgeon, with a sharp drain of the esudant, blood pressure may drop sharply, sometimes to critical indicators. With tense ascites, fluid may leak through the hole at the puncture site.

• percussion of the abdomen;
• palpation of the abdomen;
• laboratory tests;
• ultrasound examination (ultrasound);
• diagnostic laparocentesis (puncture).

Percussion of the abdomen with ascites

Palpation of the abdomen with ascites

With the help of palpation, you can find:

• Enlargement of the liver. May be a sign of cirrhosis or liver cancer. The liver is dense, its surface is bumpy, uneven.
• Enlargement of the spleen. At healthy people the spleen is not palpated. Its increase may be a sign of progressive portal hypertension (with cirrhosis or cancer), tumor metastasis, or hemolytic anemia (in which blood cells are destroyed in the spleen).
• Signs of inflammation of the peritoneum (peritonitis). The main symptom indicating the presence of an inflammatory process in the abdominal cavity is the Shchetkin-Blumberg symptom. To identify it, the patient lies on his back and bends his knees, and the doctor slowly presses his fingers on the anterior abdominal wall, after which he abruptly removes his hand. The strongest appearing sharp pains testify in favor of peritonitis.

Fluctuation symptom in ascites

A symptom of fluctuation can be detected if there is more than 1 liter of fluid in the abdominal cavity. At the same time, with severe ascites, it can be of little information, since excessively high pressure in the abdominal cavity will not allow the study to be carried out correctly and its results to be evaluated.

Tests for ascites

For ascites, your doctor may prescribe:

• general blood analysis ;
• blood chemistry;
• general urine analysis ;
• bacteriological examination;
• liver biopsy.

In infectious and inflammatory diseases of the abdominal organs (in particular, with peritonitis and pancreatitis), there may be a pronounced increase in the concentration of leukocytes (as a response of the immune system in response to the introduction of a foreign infection) and an increase in the erythrocyte sedimentation rate (ESR), which also indicates the presence of an inflammatory process in the body.

Biochemical blood test (BAC)
This study assesses the number various substances in the blood, which makes it possible to judge the functional activity of certain organs.

With cirrhosis of the liver, an increase in the concentration of bilirubin will be noted (due to a decrease in the neutralizing function of the organ). Cirrhosis is also characterized by a decrease in the concentration of proteins in the blood, since they are all formed in the liver.

In case of inflammation of the peritoneum or pancreatitis, BAC makes it possible to detect an increase in the concentration of proteins of the acute phase of inflammation (C-reactive protein, fibrinogen, ceruloplasmin, and others), and their concentration in the blood directly depends on the severity and activity of the inflammatory process. This allows you to recognize peritonitis in time, as well as monitor the patient's condition in dynamics during the treatment process and identify possible complications in time.

With renal ascites (developing as a result of kidney failure), the concentration of substances that are normally excreted by the kidneys will increase in the blood. Of particular importance are substances such as urea (norm 2.5 - 8.3 mmol / liter), uric acid (norm 120 - 350 μmol / liter) and creatinine (norm 44 - 100 μmol / liter).

The LHC is also important in the diagnosis of pancreatitis (inflammation of the pancreas). The fact is that with the progression of the disease, the tissue of the gland is destroyed, as a result of which digestive enzymes (pancreatic amylase) enter the bloodstream. Increasing the concentration of pancreatic amylase more than 50 Action Units / liter (IU / L) allows you to confirm the diagnosis.

Urinalysis (OAM)
Urinalysis reveals abnormalities in the functioning of the urinary system. AT normal conditions more than 180 liters of fluid are filtered through the kidneys daily, but about 99% of this volume is absorbed back into the bloodstream. At the initial stage of renal failure, the concentration and absorption function of the kidneys may be impaired, as a result of which a larger amount of less dense urine will be released (normally, the specific gravity of urine ranges from 1010 to 1022). At terminal stage disease, the specific gravity of urine may be normal or even slightly increased, but the total amount of urine excreted per day is significantly reduced.

With nephrotic syndrome, urine of increased density will be noted, in which an increased concentration of proteins will be determined (more than 3.5 grams per day). OAM is also valuable in the diagnosis of pancreatitis, since in this disease the concentration of amylase increases not only in the blood, but also in the urine (more than 1000 U / l).

Bacteriological research
This study is of particular value in bacterial and tuberculous peritonitis. Its essence lies in the collection of various biological material (blood, ascitic fluid, saliva) and the allocation of pathogenic microorganisms, which could cause the development of an infectious-inflammatory process. This allows not only to confirm the diagnosis, but also to determine those antibiotics that are best suited to treat the infection in this patient (the sensitivity of various bacteria to antibacterial drugs is different, which can be determined in the laboratory).

Liver biopsy
During a biopsy, a small fragment of the patient's liver tissue is removed in vivo for the purpose of examining it in the laboratory under a microscope. This study allows you to confirm the diagnosis of cirrhosis in more than 90% of cases. In liver cancer, a biopsy may not be informative, since no one can guarantee that cancer cells will be exactly in the area of ​​​​the liver tissue that will be examined.

Ultrasound for ascites

This study is absolutely harmless and safe, can be performed many times during the entire period of treatment to monitor the patient's condition and timely detection possible complications.

Ultrasound can detect:

• Free fluid in the abdomen- even a small amount of it is determined (several hundred milliliters).
• Fluid in pleural cavity and in the pericardial cavity- with systemic inflammatory diseases and tumors.
• Liver enlargement- with cirrhosis, cancer, hepatic vein thrombosis.
• Enlargement of the spleen- with an increase in pressure in the portal vein system (portal hypertension) and with hemolytic anemia(accompanied by the destruction of blood cells).
• Expansion of the portal vein- with portal hypertension.
• Expansion of the inferior vena cava- with heart failure and stagnation of blood in the veins of the lower body.
• Violation of the structure of the kidneys- with renal insufficiency.
• Violation of the structure of the pancreas- with pancreatitis.
• Anomalies in the development of the fetus.
• Tumor and its metastases.

MRI for ascites

This study allows you to detect even small amounts of ascitic fluid located in hard-to-reach places in the abdominal cavity, which cannot be examined using other methods. Also, MRI is useful in the diagnosis of liver cirrhosis, benign and malignant tumors of any localization, with peritonitis, pancreatitis and other diseases that could cause ascites.

Other instrumental studies for ascites

To identify the cause of ascites, your doctor may prescribe:

• Electrocardiography (ECG). This study allows us to evaluate electrical activity heart, to identify signs of an increase in the heart muscle, a violation of the rhythm of heart contractions and other pathologies.
• Echocardiography (EchoCG). In this study, the nature of heart contractions is assessed at each systole and diastole, and an assessment is also made structural disturbances heart muscle.
• X-ray examination. A chest x-ray is ordered for all patients with suspected ascites. This simple study eliminates infectious diseases lungs, pleurisy. X-ray of the abdominal cavity reveals an increase in the liver, the presence of intestinal obstruction or perforation (perforation) of the intestine and the release of part of the gases into the abdominal cavity.
• Dopplerography. This study is based on the principle of Doppler ultrasound. Its essence lies in the fact that during ultrasound examination, approaching and separating objects (in particular, blood in blood vessels) will reflect sound waves in different ways. Based on the results of this study, it is possible to assess the nature of the blood flow in the portal vein and other blood vessels, it is possible to identify the presence of blood clots in the hepatic veins and to identify other possible disorders.

Laparocentesis (puncture) for ascites

Diagnostic laparocentesis is contraindicated:

• In violation of the blood coagulation system, as this increases the risk of bleeding during the study.
• When the skin is infected in the region of the anterolateral wall of the abdomen, since during the puncture infection may be introduced into the abdominal cavity.
• At intestinal obstruction(there is a high risk of needle perforation of swollen intestinal loops, which will lead to the release of feces into the abdominal cavity and the development of fecal peritonitis).
• If a tumor is suspected near the puncture site (injury to the tumor with a needle can provoke metastasis and spread of tumor cells throughout the body).

Patient preparation
Preparation for the procedure consists in emptying the bladder (if necessary, a special catheter can be inserted into it), the stomach (up to washing through a tube) and intestines. The procedure itself is performed under local anesthesia (that is, the patient is conscious at the same time), so light sedatives can be prescribed for especially sensitive and emotional patients.

Lidocaine and novocaine (local anesthetics injected into soft tissues and depressing pain and other types of sensitivity for a while) quite often cause allergic reactions (up to anaphylactic shock and death of the patient). That is why before starting anesthesia in without fail an allergy test is performed. On the skin of the patient's forearm, 2 scratches are made with a sterile needle, an anesthetic is applied to one of them, and normal saline is applied to the other. If after 5-10 minutes the color of the skin over them is the same, the reaction is considered negative (no allergy). If redness, swelling and swelling of the skin is noted above the scratch with the anesthetic, this indicates that this patient is allergic to this anesthetic, so its use is strictly contraindicated.

Procedure technique
The patient takes a semi-sitting or lying (on the back) position. Immediately before the start of the puncture, it is covered with sterile sheets in such a way that only the area of ​​​​the anterior abdominal wall remains free, through which the puncture will be carried out. This reduces the risk of developing infectious complications in the postoperative period.

The puncture is usually made in the midline of the abdomen, between the navel and pubic bone(this area has the fewest blood vessels so the risk of injury is minimal). First, the doctor treats the site of the proposed puncture with an antiseptic solution (iodine solution, hydrogen peroxide), and then injects the skin, subcutaneous tissue and muscles of the anterior abdominal wall with an anesthetic solution. After that, a small skin incision is made with a scalpel, through which a trocar (a special instrument, which is a tube with a stylet inside) is inserted. The trocar is slowly, with the help of rotational movements, advanced inward until the doctor decides that it is in the abdominal cavity. After that, the stylet is removed. Leakage of ascitic fluid through the trocar indicates a correctly performed puncture. Produce a fence required amount liquid, after which the trocar is removed and the wound is sutured. The test tube with the resulting liquid is sent to the laboratory for further analysis.

Interpretation of study results
Depending on the nature and composition, two types of ascitic fluid are distinguished - transudate and exudate. This is extremely important for further diagnostics, since the mechanisms for the formation of these fluids are different.

A transudate is a plasma ultrafiltrate formed when fluid is shed through the blood or lymphatic vessels. The cause of accumulation of transudate in the abdominal cavity may be heart failure, nephrotic syndrome and other pathologies, accompanied by an increase in hydrostatic and a decrease in oncotic blood pressure. In a laboratory study, transudate is defined as clear liquid low density (specific gravity ranges from 1.006 to 1.012). The protein concentration in the transudate does not exceed 25 g/l, which is confirmed by special tests.

Exudate, unlike transudate, is a cloudy, shiny liquid rich in proteins (more than 25 g/l) and other micromolecular substances. The density of the exudate usually ranges from 1.018 to 1.020, and the concentration of leukocytes can exceed 1000 in one microliter of the test fluid. Also in the exudate, impurities of other biological fluids(blood, lymph, bile, pus), which will indicate the defeat of a particular organ.

stages of ascites

Ascites may be:

• Transient. In this case, no more than 400 ml of fluid accumulates in the abdominal cavity, which can only be detected with the help of special studies (ultrasound, MRI). Transient ascites does not impair the function of the abdominal organs or lungs, so all the symptoms present are due to the underlying disease, adequate therapy which can lead to liquid resorption.
• Moderate. With moderate ascites, up to 4 liters of ascitic fluid can accumulate in the abdominal cavity. The abdomen in such patients will be slightly enlarged, bulging of the lower part of the abdominal wall will be noted when standing, and shortness of breath (a feeling of lack of air) may appear when lying down. The presence of ascitic fluid can be determined by percussion or fluctuation symptom.
• tense. In this case, the amount of ascitic fluid may exceed 10 - 15 liters. At the same time, the pressure in the abdominal cavity increases so much that it can disrupt the functions of vital organs (lungs, heart, intestines). The condition of such patients is assessed as extremely serious, so they should be immediately hospitalized in the intensive care unit for diagnosis and treatment.

Treatment of ascites

In the treatment of ascites are used:

• diet therapy;
• physical exercises;
• therapeutic laparocentesis;
• folk methods of treatment.

Diuretics (diuretics) for ascites

Diuretics for ascites

Other medicines used for ascites

Medical treatment for ascites may include:

• Means that strengthen the vascular wall(diosmin, vitamins C, P). Vasodilation and increased permeability of the vascular wall are one of the main elements in the development of ascites. The use of drugs that can reduce vascular permeability and increase their resistance to various pathogenic factors (increased intravascular pressure, inflammatory mediators, and so on) can significantly slow down the progression of ascites.
• Means affecting the blood system(> polyglucin, reopoliglyukin, gelatinol). The introduction of these drugs into the systemic circulation contributes to the retention of fluid in the vascular bed, preventing its transition into the intercellular space and into the abdominal cavity.
• Albumin (protein). Albumin is the main protein that provides oncotic blood pressure (which keeps fluid in the vascular bed and prevents it from passing into the intercellular space). With cirrhosis or cancer of the liver, as well as with nephrotic syndrome, the amount of protein in the blood can decrease significantly, which must be compensated for by intravenous administration of albumins.
• Antibiotics. They are prescribed for bacterial or tuberculous peritonitis.

Diet for ascites

The main principles of the diet for ascites are:

• Limiting salt intake. Excessive salt intake contributes to the transition of fluid from the vascular bed into the intercellular space, that is, leads to the development of edema and ascites. That is why such patients are advised to exclude salt from the diet in pure form, a salty food take in limited quantities.
• Limiting fluid intake. Patients with moderate or intense ascites are not recommended to take more than 500 - 1000 ml of liquid (in pure form) per day, as this can contribute to the progression of the disease and worsen general well-being.
• Sufficient protein intake. As already mentioned, protein deficiency can cause the development of edema. That's why in daily diet a patient with ascites should include animal proteins (found in meat, eggs). However, it is worth remembering that with cirrhosis of the liver excess consumption protein foods can cause intoxication of the body (since the detoxifying function of the liver is disrupted), so in this case it is better to coordinate the diet with your doctor.
• Limiting fat intake. This rule is especially important in ascites caused by pancreatitis. The point is that consumption fatty foods stimulates the formation of digestive enzymes in the pancreas, which can lead to an exacerbation of pancreatitis.

Exercise for ascites

The main "limiter" of physical activity in ascites is the state of the heart and respiratory systems. So, for example, with severe heart failure (when shortness of breath occurs at rest), any physical activity is contraindicated. At the same time, with a milder course of the disease and transient or moderate ascites, the patient is recommended to walk daily on fresh air(with a light, slow step), do morning exercises and other light sports. Particular attention should be paid to swimming, as during the stay in the water blood circulation improves and, at the same time, the load on the heart is reduced, which slows down the progression of ascites.

Also, the patient's physical activity can be limited by intense ascites, in which compression of the lungs and abdominal organs is observed. Performing ordinary physical exercises in this case is impossible, since any load can lead to decompensation of the patient's condition and the development of acute respiratory failure.

Therapeutic laparocentesis (therapeutic puncture) for ascites

The technique and rules for preparing the patient are the same as for diagnostic laparocentesis. After a puncture of the anterior abdominal wall, a special drainage tube is inserted into the abdominal cavity, through which ascitic fluid will flow. A container with volume gradation is necessarily attached to the other end of the tube (to control the amount of liquid removed).

It is important to remember that ascitic fluid may contain large amounts of proteins (albumins). The simultaneous removal of a large volume of fluid (more than 5 liters) can not only lead to a drop in blood pressure (due to the expansion of previously compressed blood vessels), but also to severe protein deficiency. That is why the amount of fluid removed should be determined depending on the nature of the ascitic fluid (transudate or exudate) and the general condition of the patient.

Treatment of ascites with alternative methods

In the treatment of ascites, you can use:

• Parsley infusion. 40 grams of chopped green grass and parsley roots should be poured with 1 liter of boiling water and infused at room temperature for 12 hours. Take orally 1 tablespoon 3-4 times a day (before meals).
• A decoction of bean pods. 2 tablespoons of chopped bean pods should be poured with a liter of water, brought to a boil and boiled in a water bath for 20 to 30 minutes. After that, cool and take orally 2 tablespoons 4 to 5 times a day before meals.
• A decoction of the leaves of the mother-and-stepmother. coltsfoot pour 1 cup (200 ml) of water, bring to a boil and boil for 10 minutes. Cool, strain and take orally 1 tablespoon 3 times a day.
• Motherwort tincture. 1 tablespoon of chopped motherwort leaves should be placed in a glass jar and pour 100 ml of 70% alcohol, then infuse in a dark place at room temperature for 3-5 days. Take the tincture three times a day before meals, 30 drops, diluted in a small amount of boiled water.
• Apricot compote. It has not only a diuretic, but also a potassium-sparing effect, which is extremely important for long-term use of diuretic herbs and drugs. Compote is best prepared from dried apricots, 300 - 400 grams of which are poured with 2 - 3 liters of water and boiled for 15 - 20 minutes. It is important to remember that with intense ascites, the amount of fluid consumed should be limited, so it is not recommended to take more than 200-300 ml of compote per day.

When is surgery needed for ascites?

Surgical treatment can be applied:

• With liver cancer. Removal of the part of the liver affected by the tumor can stop the progression of the pathological process (in the absence of metastases in distant organs).
• With heart defects. Correction of valvular heart disease (replacement of a damaged valve with an artificial one) can lead to a complete recovery of the patient, normalization of heart function and resorption of ascitic fluid.
• With oncology of the abdominal cavity. Timely removal of a tumor that compresses the blood vessels of the portal vein system can lead to complete cure patient.
• With peritonitis. Bacterial peritonitis is an indication for surgical treatment. The abdominal cavity is opened, cleaned of purulent masses and washed with antiseptic solutions.
• With chylous ascites. If the penetration of lymph into the abdominal cavity is due to damage to a large lymphatic vessel in this area, its suturing during surgery can lead to a complete recovery of the patient.

Today, the method of returning ascitic fluid (more precisely, the proteins and other trace elements contained in it) to the systemic circulation through intravenous infusions is widely used, which reduces the risk of death in such patients.

Treatment of ascites in cirrhosis of the liver

Treatment for cirrhosis of the liver includes:

• Hepatoprotectors(allohol, ursodeoxycholic acid) - drugs that improve the metabolism in liver cells and protect them from damage by various toxins.
• Essential phospholipids(phosphogliv, Essentiale) - restore damaged cells and increase their resistance when exposed to toxic factors.
• Flavonoids(gepabene, carsil) - neutralize free oxygen radicals and other toxic substances formed in the liver during the progression of cirrhosis.
• Amino acid preparations(heptral, hepasol A) - cover the need of the liver and the whole body for amino acids necessary for normal growth and renewal of all tissues and organs.
• Antivirals(pegasys, ribavirin) - are prescribed for viral hepatitis B or C.
• Vitamins (A, B12, D, K)- these vitamins are formed or deposited (stored) in the liver, and with the development of cirrhosis, their concentration in the blood can significantly decrease, which will lead to the development of a number of complications.
• Diet therapy- it is recommended to exclude from the diet foods that increase the load on the liver (in particular, fatty and fried foods, any kind of alcoholic beverages, Tea coffee).
• liver transplant- the only method that allows you to radically solve the problem of cirrhosis. However, it is worth remembering that even after a successful transplant, the cause of the disease should be identified and eliminated, since otherwise cirrhosis can also affect the new (transplanted) liver.

Treatment of ascites in oncology

In the treatment of oncological diseases can be used:

• Chemotherapy. Chemotherapy is the main method of treatment of peritoneal carcinomatosis, in which tumor cells affect both sheets of the serous membrane of the abdominal cavity. Appointed chemicals(methotrexate, azathioprine, cisplatin), which disrupt the processes of tumor cell division, thereby leading to the destruction of the tumor. The main problem with this is the fact that these drugs also disrupt the division of normal cells throughout the body. As a result, during the treatment period, the patient may lose hair, ulcers of the stomach and intestines may appear, aplastic anemia (lack of red blood cells due to a violation of their formation in the red bone marrow) may develop.
• Radiation therapy. The essence of this method lies in the high-precision effect of radiation on tumor tissue, which leads to the death of tumor cells and a decrease in the size of the neoplasm.
• Surgery. It consists in removing the tumor through a surgical operation. This method is especially effective for benign tumors or in the case when the cause of ascites is squeezing of blood or lymphatic vessels by a growing tumor (its removal can lead to a complete recovery of the patient).

Treatment of ascites in heart failure

Treatment for heart failure includes:

• Diuretic drugs. Reduce the volume of circulating blood, reducing the workload on the heart and pressure in the veins of the lower body, thereby preventing further development ascites. They should be administered carefully, under supervision. blood pressure so as not to cause dehydration.
• Drugs that lower blood pressure(ramipril, losartan). With high blood pressure (BP), the heart muscle needs to do a lot of work, ejecting blood into the aorta during contraction. Normalization of pressure reduces the load on the heart, thereby helping to eliminate venous congestion and edema.
• cardiac glycosides(digoxin, digitoxin). These drugs increase the strength of heart contractions, which helps to eliminate stagnation in the veins of the lower body. They should be taken with caution, as in case of an overdose, death may occur.
• Salt free diet. Consuming large amounts of salt leads to fluid retention in the body, which further increases the workload on the heart. That is why heart failure patients are not recommended to take more than 3-5 grams of salt per day (including the salt used in the preparation of various dishes).
• Fluid restriction(no more than 1 - 1.5 liters per day).
• Compliance with the daily routine. If the state of the cardiovascular system allows, moderate physical activity (walking, morning exercises swimming, yoga).

Treatment of ascites in renal failure

Treatment for kidney failure includes:

• Diuretic drugs. In the early stages of the disease, they can positive action, however, in the terminal stage of renal failure are ineffective. This is explained by the fact that the mechanism of action of diuretics is to regulate (i.e., enhance) the excretory function of the renal tissue. At the last stage of the disease, the amount of functional renal tissue is extremely small, which leads to the lack of effect when prescribing diuretics.
• Drugs that lower blood pressure. In renal failure, there is a violation of the blood supply to the remaining functional renal tissue, as a result of which a number of compensatory mechanisms are activated aimed at maintaining renal blood flow at an adequate level. One such mechanism is an increase in blood pressure. However, an increase in blood pressure does not improve the condition of the kidneys, but, on the contrary, contributes to the progression of the pathological process, the development of edema and ascites. That is why the normalization of blood pressure is an important step in treatment to slow down the rate of formation of ascitic fluid.
• Hemodialysis. During this procedure, the patient's blood is passed through a special apparatus, in which it is purified from metabolic by-products and other toxins, after which it is returned back to the bloodstream. Hemodialysis and other methods of blood purification (plasmapheresis, peritoneal dialysis, hemosorption) are the last effective way to prolong the life of patients with chronic renal failure.
• Kidney transplant. A radical method of treatment in which the patient is transplanted donor kidney. If a the operation will take place successfully and the transplant will take root in the host organism, the new kidney can fully perform the excretory function, ensuring the normal quality and life expectancy of the patient.

Consequences and complications of ascites

Ascites may be complicated by:

• inflammation of the peritoneum (ascites-peritonitis);
• heart failure;
• respiratory failure;
• umbilical hernia;
• intestinal obstruction.

It is important that there is no visible defect of the peritoneum or internal organs, which could become a source of infection. Bacteria are thought to infiltrate into the abdominal cavity through the dilated and overstretched walls of the intestinal loops.

Regardless of the mechanism of development, the presence of peritonitis requires hospitalization of the patient and urgent surgical treatment.

Heart failure
The accumulation of a large amount of fluid in the abdominal cavity leads to squeezing of the organs and blood vessels (arteries and veins) located there, disrupting the flow of blood through them. As a result, the heart needs to do a lot of work to pump blood through the vessels.

If ascites develops slowly, compensatory mechanisms are activated in the heart, consisting in the growth of muscle fibers and an increase in the size of the heart muscle. This allows up to a certain point to compensate for the increase in load. With further progression of ascites, the reserves of the heart muscle can be depleted, which will cause the development of heart failure.

If ascites develops quickly (within a few days), the heart does not have time to adapt to the increasing load, as a result of which acute heart failure may develop, requiring emergency medical care.

hydrothorax
This term refers to the accumulation of fluid in the chest. The development of hydrothorax in ascites is facilitated by an increase in the pressure of ascitic fluid, as a result of which fluid from the blood and lymphatic vessels of the abdominal cavity can pass into the vessels of the diaphragm and chest. With the progression of the disease, the amount of free fluid in the chest will increase, which will lead to compression of the lung on the side of the lesion (or both lungs with bilateral hydrothorax) and respiratory failure.

Respiratory failure
The development of this condition can be facilitated by the rise and restriction of excursion of the diaphragm as a result of increased pressure in the abdominal cavity, as well as the progression of hydrothorax. In the absence of timely treatment, respiratory failure will lead to a pronounced decrease in the concentration of oxygen in the blood, which can be manifested by shortness of breath, cyanosis of the skin and impaired consciousness, up to its loss.

Diaphragmatic hernia
A diaphragmatic hernia is a protrusion of an organ or tissue through a defect in the diaphragm or through its esophageal opening. The reason for this is a pronounced increase in intra-abdominal pressure.

The stomach, intestinal loops, or serous membrane filled with ascitic fluid may protrude through the hernial opening. This condition is manifested by pain in the chest and in the region of the heart, in the upper abdomen. If a sufficiently large portion of the organ enters the hernial opening, it can compress the lungs and heart, leading to impaired breathing and heartbeat.

The treatment of the disease is mainly surgical, consisting in the reduction of the hernial sac and the suturing of the defect in the diaphragm.

Umbilical hernia
The cause of the formation of an umbilical hernia is also high blood pressure in the abdominal cavity. The anterior abdominal wall is covered with muscles almost throughout its entire length. The exception is the umbilical region and the midline of the abdomen, where these muscles come together and form the so-called aponeurosis of the anterior abdominal wall. This aponeurosis consists of tendon tissue, which is the “weak point” of the abdominal wall (it is here that the protrusion of the hernial sac is most often noted). The treatment of the disease is also surgical (the hernia is reduced and the hernia gate is sutured).

Intestinal obstruction
It develops as a result of compression of intestinal loops by ascitic fluid, which usually occurs with tense, refractory ascites. Violation of intestinal patency leads to the accumulation of feces above the place of compression and increased peristalsis (motor activity) of the intestine in this area, which is accompanied by severe paroxysmal pain in the abdomen. If intestinal obstruction is not resolved within a few hours, intestinal paralysis occurs, expansion and increase in the permeability of the intestinal wall. As a result, numerous bacteria (which are permanent inhabitants of the large intestine) enter the bloodstream, causing the development of formidable, life-threatening complications for the patient.

Treatment consists in opening the abdominal cavity and eliminating intestinal obstruction. If the damaged intestinal loops are not viable, they are removed, and the resulting ends of the digestive canal are connected to each other.

Prognosis for ascites

How long do people with ascites live?

The life expectancy of a patient with ascites is due to:

• Expression of ascites. Transient (mild) ascites does not pose an immediate threat to the life of the patient, while intense ascites, accompanied by the accumulation of tens of liters of fluid in the abdominal cavity, can lead to the development of acute heart or respiratory failure and death of the patient within hours or days.
• Time to start treatment. If ascites is found on early stages development, when the functions of vital organs are not impaired (or only slightly impaired), the elimination of the underlying disease can lead to a complete cure for the patient. At the same time, with long-term progressive ascites, damage to many organs and systems (respiratory, cardiovascular, excretory) can occur, which will lead to the death of the patient.
• main disease. This is perhaps the main factor determining the survival of patients with ascites. The fact is that even with the most modern treatment, a favorable outcome is unlikely if the patient has a failure of several organs at once. So, for example, with decompensated cirrhosis of the liver (when the function of the organ is almost completely impaired), the patient's chances of survival within 5 years after the diagnosis is made are less than 20%, and with decompensated heart failure - less than 10%. A more favorable prognosis for chronic renal failure, since patients on hemodialysis and following all the doctor's prescriptions can live for decades or more.

Prevention of ascites

Prevention of ascites includes:

• Timely treatment of liver diseases. The development of liver cirrhosis is always preceded by prolonged inflammation of the liver tissue (hepatitis). It is extremely important to establish the cause of this disease in time and eliminate it (carry out antiviral treatment, stop drinking alcohol, start eating healthy, and so on). This will stop the progression of the pathological process and keep the most liver tissue, which will provide the patient full life for many years.

• Timely treatment of congenital heart defects. At the present stage of development, an operation to replace a damaged heart valve or close a defect in the walls of the heart muscle can be performed in early childhood, which will allow the child to grow and develop normally and save him from heart failure in the future.
• Timely treatment of kidney diseases. Although hemodialysis can compensate for the excretory function of the kidney, it is unable to provide a number of other functions of this organ. That is why it is much easier to treat various infectious diseases of the urinary system, such as cystitis (inflammation of the bladder), glomerulonephritis (inflammation of the kidney tissue), pyelonephritis (inflammation of the renal pelvis), on time and fully than to spend on hemodialysis for 2-3 hours twice a week throughout the rest of your life.
• Diet for pancreatitis. At chronic pancreatitis to provoke an exacerbation of the disease and the destruction of pancreatic tissue can take a large amount of alcohol, sweets, spicy, smoked or fried foods. However, it should be understood that such patients should not completely exclude the above products from the diet. 1 candy or 1 piece of smoked sausage eaten per day will not provoke an exacerbation of pancreatitis, so it is extremely important for patients to eat moderately and not overeat (especially before bedtime).
• Performing planned ultrasounds during pregnancy. Pregnant women are advised to perform at least three ultrasounds during the period of gestation. The first of them is carried out in the period from 10 to 14 weeks of pregnancy. By this time, all organs and tissues of the fetus are laid, which makes it possible to identify gross developmental anomalies. The second ultrasound is performed at 18-22 weeks of pregnancy. It also allows you to identify various developmental anomalies and, if necessary, raise the issue of terminating a pregnancy. The third study is performed at 30 - 34 weeks in order to identify abnormalities in the development or position of the fetus. Termination of pregnancy at this time is impossible, but doctors can identify a particular pathology and begin its treatment immediately after the birth of a child, which will significantly increase his chances of survival.

All materials on the site are prepared by specialists in the field of surgery, anatomy and related disciplines.
All recommendations are indicative and are not applicable without consulting the attending physician.

Laparocentesis is a diagnostic surgical operation in which the doctor makes a puncture of the anterior abdominal wall to clarify the nature of the contents of the abdominal cavity.

The first attempts to puncture the abdomen were made back in late XIX century, when quite successfully with the help of this technique a rupture of the gallbladder was established after blunt trauma belly. In the middle of the last century, the method was actively mastered by surgeons. different countries and proved not only high efficiency, but also safety for the patient.

Now laparocentesis is widely used for the diagnosis various consequences injuries and in other pathological conditions - ascites, perforated ulcer, bleeding, etc. The operation is minimally invasive, less traumatic and practically does not give complications if the rules of asepsis, antisepsis and the exact technique of its implementation are observed.

Indications and contraindications for laparocentesis

Usually, abdominal puncture is used for diagnostic purposes, when the clinical picture does not allow to put reliable diagnosis. In other cases, it is carried out for treatment - the evacuation of fluid, for example. In addition, a diagnostic puncture can become therapeutic if, during its course, the doctor not only detects abnormal contents in the abdomen, but also removes it.

Laparocentesis can be performed on an outpatient basis for ascites, in a hospital it is used for traumatic injuries in case of an unclear diagnosis, as well as before laparoscopic interventions on the abdominal organs for the introduction of carbon dioxide.

Indications for laparocentesis are:

Laparocentesis is often the only possible diagnostic method when other methods (radiography, ultrasound, etc.) do not give a chance to exclude damage to internal organs with the release of contents into the abdominal cavity.

The fluid obtained during the operation - ascitic, pus, blood - is sent to laboratory research. Exudate of uncertain composition should be examined for impurities in the contents of the gastrointestinal tract, bile, urine, pancreatic juice.

Laparocentesis is contraindicated in:

1. Blood clotting disorders due to the risk of bleeding;
2. Severe adhesive disease of the abdominal cavity;
3. severe bloating;
4. Ventral hernia after previous surgical interventions;
5. Risk of intestinal injury, large tumor;
6. Pregnancy.

It is not recommended to carry out laparocentesis close to the area of ​​the bladder, enlarged organs, palpable tumor-like formation. The presence of adhesions is a relative contraindication, but adhesive disease itself implies a high risk of damage to the vessels and organs of the abdominal cavity, therefore, indications for laparocentesis in this case are assessed individually.

Preparing for the operation

In preparation for a planned laparocentesis (usually for ascites), the patient is shown standard examinations. He takes blood and urine tests, a coagulogram, undergoes an ultrasound examination of the abdominal organs, x-rays, etc., depending on the indications for manipulation.

Given the possibility of moving to a laparotomy or laparoscopy, the preparation is as close as possible to that before any other operation, but in cases of trauma or emergency surgical pathology studies take a minimum of time and include general clinical tests, determination of blood coagulability, its group and Rh affiliation. If possible - ultrasound or x-ray of the abdominal or thoracic cavity.

Immediately before the puncture of the abdominal wall, it is necessary to empty the bladder and stomach. The bladder empties on its own or with a catheter if the patient is unconscious. Gastric contents are removed by means of a probe.

At serious injuries, state of shock, coma antishock therapy to maintain hemodynamics, according to indications, artificial ventilation of the lungs is being established. Laparocentesis for such patients is performed in the operating room, where there is a possibility of a quick transition to open surgery or laparoscopy.

Laparocentesis technique

The puncture of the abdominal wall is carried out under local anesthesia, the required tools for laparocentesis - a special trocar, a tube for draining the contents, syringes, clamps. The fluid extracted from the abdominal cavity is collected in a container, and when sent for bacteriological examination - in sterile test tubes. The doctor must use sterile gloves, and with ascites, the patient is covered with an oilcloth apron or film.

The technique does not present any difficulties for the surgeon. For anesthesia, lidocaine or novocaine is used, which is injected immediately before manipulation into the soft tissues of the abdomen, then the site of the proposed puncture is treated with an antiseptic. The patient is in a sitting position if the puncture is needed to remove ascitic fluid, in other cases, the operation is performed in the supine position.

The puncture is made along the midline, retreating 2 cm down from the navel or slightly to the left, in some cases - in the middle of the distance between the navel and the pubis. Before the penetration of the trocar, the surgeon makes a small incision with a scalpel, dissecting the skin, tissue and muscles, acting as carefully as possible, since a sharp scalpel can slip deeper and damage the internal organs. Many surgeons open the tissues in a blunt way, without a scalpel, which is safer for the patient. As you move deeper, it is important to ensure that bleeding from the vessels of the skin and fiber is stopped in order to avoid unreliable results.

A trocar is directed into the resulting opening of the abdominal wall, introduced into the abdominal cavity with rotational movements at an angle of 45 degrees relative to xiphoid process sternum.

To create space for the movement of the trocar, the umbilical ring is captured, and the abdominal wall is slightly raised. A surgical thread introduced into the puncture area through the aponeurosis of the rectus muscle, through which the soft tissues of the abdomen can be lifted, also helps to facilitate and secure the puncture.

Laparocentesis for ascites

Laparocentesis of the abdominal cavity with ascites can be performed on an outpatient basis. The introduction of the trocar occurs according to the method described above, and as soon as liquid appears from the cavity of the trocar, it is tilted to a pre-prepared container, while holding the distal end with your fingers.

With the rapid extraction of ascitic fluid, fluctuations in blood pressure are possible up to collapse, since the blood is instantly redirected to the vessels of the abdominal cavity, previously squeezed by the fluid. To avoid severe hypotension, the fluid is removed slowly (no more than a liter for five minutes), carefully monitoring the patient's condition. During the manipulation, the surgeon's assistant gradually tightens the patient's stomach with a towel to avoid hemodynamic disorders.

When the ascitic fluid is completely removed, the trocar is removed, and a suture and a sterile dressing are applied to the incision. It is advisable not to remove the compressive towel, which will help create the habitual for the patient. intra-abdominal pressure and gradually adapt to the new conditions of blood supply to the abdominal organs.

Diagnostic laparocentesis

The procedure for laparocentesis in cases other than ascites is slightly different. To detect pathological contents of the abdomen, the so-called "grooving" catheter, connected to a syringe, with which the existing exudate is sucked off. If the syringe remains empty, then about 200-300 ml of saline is injected into the abdominal cavity, which is then taken out and examined for occult blood.

If during laparocentesis there is a need to examine the internal organs, then a laparoscope can be placed in the trocar tube. When diagnosing severe injuries requiring surgical intervention, the operation expands to laparoscopy or laparotomy.

Evaluation of the received material

After the surgeon has received the contents of the abdominal cavity, it is important to evaluate its appearance and take appropriate measures to further treatment. If blood, feces, impurities of urine, intestinal and stomach contents are found in the material obtained, or the liquid has a gray-green, yellow color, the patient needs an urgent operation. This kind of content can be intra-abdominal bleeding, perforation of the wall of the digestive organs, peritonitis, which means that it is impossible to hesitate to save the patient's life.

The diagnostic value of laparocentesis depends on the volume of fluid obtained during the manipulation. The larger it is, the more accurate the diagnosis, and 300-500 ml is considered the minimum, but even this volume allows you to clarify the pathology in no more than 80% of cases.

It is known that many pathological conditions and are completely inaccessible for detection by puncture of the abdominal wall in the early stages after the onset of the disease. So, damage to the pancreas can be suspected after 5-6 hours by the presence of amylase, which by this time enters the free abdominal cavity. The accumulation of blood or effusion in pockets formed by the peritoneum and organ walls, ligaments, adhesions, also cannot be established by laparocentesis.

With inconclusive results of laparocentesis, but the existing clinic of acute surgical pathology, surgeons turn to laparotomy in order not to miss precious time for the patient and not to miss a severe and deadly pathology.

In the case when it is not possible to obtain any pathological discharge, and the clinical picture or the fact of injury give clear indications of its presence, it is possible to carry out peritoneal lavage physiological solution. To do this, up to a liter of a sterile solution is injected, which is then removed for research.

Admixture of erythrocytes, leukocytes in the extracted liquid, determined by cytological examination, makes it possible to diagnose bleeding. In addition, surgeons conduct tests to clarify whether the bleeding has stopped or not. Even with a large volume of bloody masses, it is likely that the bleeding has stopped, and if it continues, then anti-shock measures are immediately started to reduce the risks during the subsequent urgent laparotomy.

The presence of urine in the contents of the peritoneal cavity, which is determined by the characteristic odor, speaks of a rupture of the bladder wall, and feces - of perforation of the intestinal wall. If the exudate has a cloudy appearance, greenish or yellow, fibrin protein flakes are determined, then there is a high probability of peritonitis due to damage to the hollow internal organs, and this situation requires urgent open surgery.

It happens that there is no pathological content in the abdominal cavity, the patient's condition is stable, but the fact of injury does not exclude the possibility of organ rupture or bleeding in the near future. For example, hematomas of the spleen or liver, located under the capsule of the organ, as they increase in size, can lead to rupture and outflow of blood into the stomach. In such cases, the surgeon after laparocentesis can leave the silicone drainage for control for 24-48 hours, setting it in such a way that the return flow of the fluid is adequate, otherwise it is possible not to detect the pathology in time.

Laparocentesis is a relatively safe, simple and, at the same time, informative manipulation, but among its disadvantages are not only possible complications, but also unreliable results, both false-positive and false-negative, therefore, the primary task of a specialist is to correctly assess the nature of the material obtained, which is often difficult.

False negative results most often associated with the fact that flexible silicone catheters are poorly controlled and may not reach fluid accumulations. The areas of the abdomen, delimited by adhesions, are not at all inaccessible to “rumbling” catheters, but fluid can accumulate there if damaged. hollow organs. A false-negative result is caused by a blockage of the catheter by a thrombus.

False positive results in relation to bleeding, they are often associated with the wrong technique of the laparocentesis procedure, the ingress of a small amount of blood from the puncture site, which can be mistaken for the contents of the abdominal cavity.

To avoid diagnostic errors, which can be extremely dangerous, when receiving fuzzy data on bleeding, a small volume of bloody discharge, or the absence of content in an obvious clinic of an “acute” abdomen, surgeons perform diagnostic laparoscopy, which is more reliable in emergency surgery.

Diagnostic laparocentesis requires hospital conditions, but it is also possible to extract ascitic fluid at home. If the diagnosis is established, the fact of injuries and severe pathology of the internal organs is excluded, and the patient only needs to remove excess liquid to facilitate well-being, it is quite possible to do this without going to the hospital.

"Home" laparocentesis is very relevant for patients who, due to existing diseases, cannot travel long distances, are forced to comply bed rest, suffer from congestive heart failure, as well as for the elderly and senile age.

At home, laparocentesis is performed after a preliminary examination, under ultrasound control. Many offer this service. paid clinics equipped with the necessary portable equipment and employing highly qualified specialists. The risk of complications of laparocentesis performed at home may be higher, so it is very important to observe both the technique of manipulation and the prevention of infectious complications.

Postoperative period and complications

Complications after laparocentesis are quite rare. The most likely infectious processes at the puncture site if the rules of asepsis and antisepsis are not followed. In severe patients, the development of phlegmon of the abdominal wall and peritonitis is possible. Damage to large vessels is fraught with bleeding, and careless actions of the surgeon can lead to injuries to internal organs with a scalpel or a sharp trocar.

Laparocentesis is used to impose a pneumoperitoneum during laparoscopic interventions. Incorrect introduction of gas into the abdominal cavity can lead to its entry into soft tissues with the development of subcutaneous emphysema, and excess disrupts the excursion of the lungs due to too high elevation of the diaphragm.

The consequences of extracting ascitic fluid can be bleeding, prolonged outflow of fluid after puncture of the abdominal wall, and during the procedure itself, collapse due to redistribution of blood.

The postoperative period proceeds favorably, since the intervention does not involve anesthesia or a large tissue incision. Skin sutures are removed on day 7, and regimen restrictions are associated with the underlying disease (for example, a diet for cirrhosis or heart failure, bed rest after removing hematomas and stopping bleeding).

After laparocentesis, physical activity is not recommended, and if the tube is left for slow fluid evacuation, the patient is advised to change the position of the body, periodically turning over to the other side, to improve the outflow of fluid.

One of modifications of abdominal puncture is the method of "groping" catheter, proposed in 1926 by N. Neuhof J., Cohen and widely used in subsequent years. Under local anesthesia with a 0.25% novocaine solution, the abdominal wall is punctured with a trocar, through which a catheter is inserted into the abdominal cavity. By changing the direction of the catheter and periodically aspirating fluid from the abdominal cavity, the presence of blood in the abdominal cavity is determined. We used a similar method in 40 children. Blood was found in 27 of them, which served as the basis for further laparotomy.

In this way, diagnostic intra-abdominal puncture is indicated in all cases that are difficult to diagnose and, first of all, in children with combined and concomitant injuries, especially in patients who are in a confused or unconscious state, which will avoid serious diagnostic and tactical errors.

Endoscopy. One of the most modern methods of direct endoscopic examination is laparoscopy. For the first time, the examination of the abdominal organs was carried out by the Russian obstetrician-gynecologist Dmitry Ott in 1901. In subsequent years, a significant number of works were published on the development of research methods, issues of indications and contraindications, as well as on the improvement of various optical devices used for laparoscopy.

However, on the application laparoscopy with a closed abdominal injury, there are only a few reports so far. Even in the large monographs of A. M. Aminov (1948), H. Kalk, V. Brfihl (1951), I. Wittmann (1966), devoted to the issues of laparoscopy, there are no indications about the use of this method for closed abdominal trauma.

At the same time, in the few works devoted to the use of laparoscopy in closed abdominal trauma, so far there is no consensus on its indications. So, R. X. Vasiliev (1968) S. J. Zoecler (1958) consider it indicated in all unclear cases, while G. N. Tsybulyak (1966), J. E. Hamilton (1942) and other surgeons, based on their own observations, indicate, that laparoscopy cannot replace laparotomy, so the use of this method in closed injuries abdominal organs is inappropriate.

In 1968, the work V. K. Kalnberz and B. A. Freidus devoted to laparoscopy in closed trauma of the abdomen and abdominal organs, in which the authors compared laparoscopic and sectional data. During laparoscopy, the authors write, it is well possible to examine the anterior sections of the upper and lower surfaces of the liver, the anterior surface of the stomach, big omentum, intestinal loops, anterior surface of the bladder, its bottom. In 94.1% of observations, they managed to detect changes in damaged abdominal organs. It was difficult to examine the non-enlarged spleen and the hilum of the liver during laparoscopy.

Some organs located retroperitoneally, even with a very thorough examination, cannot be seen through a laparoscope (for example, the pancreas, duodenum), however, according to a number of indirect signs found during laparoscopy (spots fat necrosis, retroperitoneal emphysema), damage to these organs can be diagnosed (Deryabina E. Ya., 1963).

According to N.L. Kushch, A.D. Timchenko, G.A. Sokova (1972, 1973), laparoscopy in diagnosis of intra-abdominal injuries acquires special value, since it is easy to carry out, and the information obtained in this case is very valuable. The same opinion is shared by G. A. Bairov (1975).

Literature data indicate that laparoscopy as an auxiliary method for diagnosing injuries of the abdominal organs with a closed injury of the abdomen, it has a certain value, especially with a combined injury, when diagnosis is very difficult. The only contraindication to the use of laparoscopy in children is extremely serious condition a child with a pronounced picture of shock or collapse resulting from intra-abdominal bleeding.