Subdiaphragmatic abscess symptoms in adults. Subdiaphragmatic abscess: symptoms of severe secondary disease. Transperitoneal subcostal approach

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Subdiaphragmatic abscess- limited accumulation of pus between the diaphragm and internal organs: stomach, liver, spleen, kidneys, intestines.

The subdiaphragmatic space is limited from above, behind, from the sides by the diaphragm, in front - by the abdominal wall. The liver divides it into subhepatic and suprahepatic spaces, and the falciform ligament of the liver into isolated right and left subphrenic spaces. Surgical access to subdiaphragmatic abscesses is chosen taking into account the topography of the diaphragm, pleura, lung, kidney.

Projection of the posterior borders of the lung (1) and pleura (2)

Projection of the posterior borders of the pleura (1) and diaphragm (2)

Subdiaphragmatic abscesses do not have clear boundaries, which are formed during the development of inflammation and the formation of adhesions, adhesions, but the localization of the abscess must be taken into account when determining the choice of surgical approach, drainage method, etc.

Due to the peculiarities of the topography of the subphrenic space, abscesses have a certain localization with a characteristic clinical and radiological picture. According to the anatomical principle, they can be classified as follows.

a - side view: 1 - subhepatic abscess, 2 - anterior subdiaphragmatic, 3 - superior subdiaphragmatic, 4 - posterior subdiaphragmatic, 5 - abscess of the omental bag; b - front view: 1 subhepatic abscess, 2 - superior subdiaphragmatic, 3 - left-sided subdiaphragmatic, 4 - abscess in the gate of the spleen

II. Left-sided subdiaphragmatic abscesses:
. upper (above the left lobe of the liver);
. anteroinferior (under the left lobe of the liver, abscess of pregastric localization);
. posterior (abscess of the omental bag);
. perisplenic abscess.

III. Median, central subdiaphragmatic abscesses (formed after gastric resection):
. left-sided;
. posterior extraperitoneal (central), limited by sheets of the coronary ligament.

IV. Extraperitoneal right-sided lower abscesses.

Abscesses are localized under the diaphragm, in the retroperitoneal tissue.

Right-sided subdiaphragmatic abscesses occur 6-7 times more often than left-sided ones, and half of them are in the anterior superior localization. Median abscess can be a complication of gastric resection, when the normal anatomical relationships of the organs of the subdiaphragmatic space are disturbed. The intersection of the hepatogastric ligament opens the way for pus to the median (central) part of the diaphragm, which defines the upper border of the abscess. On the right and behind the accumulation of pus is delimited by the left lobe of the liver, on the left - by the stump of the stomach, in front - by the abdominal wall and from below - by the transverse colon and its mesentery.

The main cause (75%) of subdiaphragmatic abscesses is surgical interventions: operations on the biliary tract, stomach, pancreas, and colon. This is a dangerous postoperative complication with a high risk of sepsis. Among all intra-abdominal abscesses, subphrenic abscesses are most common, followed by Douglas pouch abscess and interintestinal abscesses.

The immediate cause of subdiaphragmatic abscesses associated with surgery is infection of the subdiaphragmatic space after surgery due to ingestion of intestinal, gastric contents, bile, pus with anastomotic failure, necrosis of the organ wall. Infection is possible during surgery, and in the preoperative period - the spread of infected contents of the abdominal cavity during perforation of a hollow organ, peritonitis, organ rupture during trauma, hematoma suppuration. The effusion under the diaphragm may initially be sterile, and then it becomes infected by contact, hematogenous, lymphogenous routes.

Subdiaphragmatic abscess is possible in patients of any age and gender, it is more often caused by staphylococcus aureus, E. coli, streptococcus.

An abscess can be located in the abdominal cavity and in the retroperitoneal space, most often under the right dome of the diaphragm above the liver, both to the right and to the left of the falciform ligament of the liver. The omental sac in pancreatitis may also be involved in the purulent process. With an abscess under the left dome of the diaphragm, the spleen, the splenic flexure of the colon are pushed down.

With the retroperitoneal location of the subdiaphragmatic abscess, it is limited by the diaphragm, kidneys, and the abscess itself is located in loose retroperitoneal tissue. With an intraperitoneal location of the abscess, the source of infection is an inflammatory process that passes from neighboring organs (gall bladder, stomach, liver, etc.). In the retroperitoneal subdiaphragmatic space, pus more often enters through the lymphatic pathways with purulent inflammation of the appendix, pelvic organs, and intestines.

By contact, the infection enters the retroperitoneal space with inflammation of the pancreas, kidneys. Through the portal vein system, the infection can penetrate into the liver, and then into the subdiaphragmatic space. Inflammatory infiltrate in subdiaphragmatic abscess consists of neighboring organs, part of the diaphragm, presenting to the abscess. The inflammatory conglomerate is surrounded by a connective tissue capsule with fibrin deposits and inflammatory leukocyte infiltration.

Clinical picture

Attention is drawn to the lag during breathing of half of the chest on the affected side, retraction of the epigastric region during inhalation and bulging during exhalation, which is associated with paralysis of the diaphragm. Breathing is rapid, shallow. In the lower parts of the chest on the affected side, there is pain on palpation, tension in the abdominal muscles and pain in the upper part. Percussion can reveal high standing and immobility of the diaphragm. They listen to the weakening of breathing in the lower parts of the lungs on the affected side, the pleural friction noise (when the pleura is involved in the process), increased voice trembling.

X-ray and ultrasound methods of research are of great help in the diagnosis.

X-ray determined by the high standing of the dome of the diaphragm, its inactivity or immobility, effusion in the pleural cavity on the side of the lesion. The gas is located above the liquid level. A 2D ultrasound scan can detect a cavity with contents around which there is a dense capsule. Diaphragm movement is limited.

In the blood, leukocytosis is noted with a shift of the leukocyte formula to the left, an increase in ESR.

Subdiaphragmatic abscess should be differentiated from acute diseases of the abdominal cavity and retroperitoneal space (cholecystitis, pancreatitis, pyelonephritis, etc.), exudative and dry pleurisy, infectious diseases (typhoid fever). X-ray examination and ultrasound, as well as a puncture, which is best done under X-ray, ultrasound or computed tomography control, can help in the diagnosis.

Operated patients do x-rays in frontal and lateral projections. With a subphrenic abscess, a volumetric formation, a liquid level, a gas bubble in the subphrenic space are determined. Indirect signs: high standing of the dome of the diaphragm, accumulation of fluid in the pleura, atelectasis of the basal segments of the lung. In a multi-axial study in the vertical position of the patient, the limitation of mobility and the high location of the diaphragm, sometimes a gas bubble, and accumulation of fluid in the costophrenic sinus are determined. Indirect signs include displacement and fuzziness of the contours of adjacent organs.

Ultrasound in the early postoperative period can be performed at the patient's bedside. The method allows you to determine or exclude a limited or widespread accumulation of fluid in the abdominal cavity.

Sonography can confirm an abscess but not rule it out, and does not differentiate between infected and non-infected fluid collections in the subphrenic space. The advantages of the method include the possibility of dynamic observation in the postoperative period.

CT has advantages over ultrasound, but it requires special training; when using contrast agents, the method allows you to determine not only localized accumulations of fluid, but also its origin (hematoma, pus, serous fluid) by density.

Puncture of a fluid mass under ultrasound guidance or CT guidance resolves many diagnostic doubts. It allows you to determine the origin of the fluid, obtain material for bacteriological examination, remove pus, rinse the cavity of the abscess with an antiseptic solution, and provide drainage for subsequent sanitation. As a diagnostic invasive method, it is used when all other non-invasive methods have failed.

Treatment

Operative access to the abscess depends on its location. The success of treatment also depends on the correct establishment of the localization of the subdiaphragmatic abscess and rational operational access to it.

With right-sided anterior superior and inferior (subhepatic) abscesses (the most common localization), the main access is right-sided hypochondrium. Left-sided (upper, pregastric (anteroinferior), posteroinferior (omental bursa abscess) are opened by transperitoneal access using upper median laparotomy. To open and drain high right-sided abscesses (upper anterior, posterolateral) and left-sided upper and parasplenic abscesses, as well as retroperitoneal subdiaphragmatic abscesses, it satisfies extrapleural - Melnikov's extraperitoneal access.

The extrapleural-extraperitoneal approach is carried out along the VIII-IX ribs from the side or along the XI-XII ribs from behind with their resection. The diaphragm is exposed by exfoliating the pleural sinus upward. With such an operative access, infection of the pleural and abdominal cavities is excluded, which makes it preferable with the appropriate localization of the abscess.

The subdiaphragmatic abscess is opened in the shortest way, extrapleurally and extraperitoneally, providing adequate conditions for drainage. Access to the subdiaphragmatic abscess is determined by its localization, the conditions for drainage should be taken into account: the incision is made at the lower pole of the abscess.

Anterior approaches, especially for large abscesses, do not provide good drainage, so they are supplemented with counter-opening. Extrapleural accesses are convenient for approaching subdiaphragmatic abscesses of any localization, except for low-lying ones.

The opening of the median (central) subdiaphragmatic abscess and abscess of the pregastric bag is not difficult and is performed through the median wound or along the scar. Do not destroy the adhesions that delimit the abscess from the lower floor of the abdominal cavity. The same delimiting barrier is the transverse colon with its mesentery and adhesions formed between this intestine, the greater omentum and the peritoneum of the anterior abdominal wall. Having dissolved the skin sutures and opened the wound, the aponeurosis and peritoneum are dissected, starting from the upper end of the scar in the epigastric region. Partially open the wound and examine the abscess with a finger, remove the pus by suction. The wound is expanded to an extent sufficient for good drainage.

Opening of the anterior or anteroposterior right-sided subdiaphragmatic abscesses is performed from the anterior or lateral access. An incision 10-12 cm long starts from the outer edge of the rectus abdominis muscle and continues outwards and downwards parallel to the costal arch. Lateral access runs parallel to the costal arch from the midclavicular to the midaxillary line. Dissect the external and internal oblique muscles of the abdomen to the transverse fascia and preperitoneal tissue.

The peritoneum is exfoliated bluntly with a finger or an instrument, using, if necessary, hydraulic tissue preparation, penetrate into the space between the diaphragm and the fascia, exfoliate the fascia along with the peritoneum. The abscess is palpated with a finger, the pus is opened and aspirated with an electric suction.

a - front view; b - side view

The lowest point of the abscess is drained through the counter-opening. If the cavity of the abscess reaches the falciform ligament of the liver, which is determined by a co-trapter drawn along the upper surface of the liver to the outer edge of the falciform ligament, this ligament is pierced or bypassed from the outside, forceps are carried out under the XII rib. The end of the instrument protrudes and dissects the skin, the forceps are brought out. The wound is expanded, the abscess is emptied. In the reverse movement of the forceps, a drainage tube is carried out, which is fixed with one suture to the skin.

a - holding an instrument for imposing counter-opening and drainage; b - drainage tubes in the subphrenic space

With less extensive abscesses occupying the anterior or lateral space, additional drainage can be performed as follows. An additional skin incision 2-3 cm long is made 5-6 cm outward from the edge of the first incision in the anterior approach. In the direction of the second incision, forceps are carried out extraperitoneally from the first one and the muscles are stratified. The edges of the wound are bred, the peritoneum is exposed and it is dissected or passed in a blunt way, penetrating into the cavity of the abscess at its lower edge.

The indications for such drainage are abscesses extending into the posterior superior and lateral parts of the right suprahepatic space. In such cases, when examining the cavity of the abscess, the finger or instrument goes beyond the dome of the liver and drainage through the anterior or lateral incisions will be insufficient.

From the anterior access, you can open the anterior superior, from the lateral - the posterior superior abscess, transperitoneally open the lower (subhepatic) abscess.

Opening of the posterior inferior right-sided subdiaphragmatic abscess is performed from the subpleural transdiaphragmatic access. The patient is laid on the left side with a roller under the lower ribs, the left leg is bent at the knee joint and brought to the stomach.

The serratus posterior inferior muscle is dissected, in the oblique direction the bed of the XII rib and the intercostal muscle in front. The lower posterior surface of the diaphragm is exposed, which is crossed in the horizontal direction, and then the parietal sheet of the peritoneum is exfoliated from the diaphragm with a finger and tupfers, moving upward and anteriorly along the posterior surface of the kidney and liver.

Having felt the abscess with the index finger (if the position of the abscess cannot be determined by palpation, they resort to puncture), the surrounding tissues are isolated with napkins and the abscess is opened. Gradually, intermittently, pus is removed with an electric suction. The cavity of the abscess is examined with a finger, the jumpers are separated and a drainage tube is inserted.

Extrapleural access to the subdiaphragmatic space according to Melnikov is applicable for opening high upper anterior, posterior superior subdiaphragmatic abscesses, right and left extraperitoneal and parasplenic abscesses. In essence, this access to subdiaphragmatic abscesses is universal.

a - skin incision line; b — wound after subperiosteal resection of two ribs (dashed line indicates tissue dissection line); c — costal-diaphragmatic sinus of the pleura (1) and diaphragm (2) are exposed; g — the diaphragm (2) is dissected and the peritoneum (3) is exposed; e - opening of the abscess

The prediaphragmatic space is expanded, having mobilized the pleural sinus by crossing the connective tissue strands, the sinus is moved upward by a blunt path by 2-3 cm as a result of exfoliation of the pleura from the chest wall and diaphragm. To prevent rupture of the pleura, it is peeled off along with the fascia; if the pleura is damaged, it is sutured with separate sutures along with adjacent tissues. A.V. Melnikov recommended suturing through the pleural sinus and diaphragm.

The diaphragm is dissected along the fibers for the entire length of the incision, and its edges are sutured to the muscles of the chest wall. The intra-abdominal fascia is peeled off along with the parietal peritoneum; having found an abscess, it is opened, drained and drained with a tube with a diameter of 10-12 mm. If the abscess cannot be detected, then the peritoneum is peeled away from the incision and the subdiaphragmatic space is punctured with a needle with an empty syringe. Having found pus, open the abscess and drain its cavity.

Subcostal transperitoneal access on the right reveals subhepatic abscesses, and sometimes anterior suprahepatic abscesses, if they become an accidental finding during surgery. Upper median, laparotomy access is used for left-sided abscesses. This is relaparotomy in case of complication of purulent-inflammatory process of the immediate postoperative period after intervention on the biliary tract, stomach, duodenum. In the hypochondrium, the epigastric region, an inflammatory infiltrate and hyperemia of the skin are determined. By this time, as a rule, the abscess in the abdominal cavity is delimited by adhesions.

If at the opening of the abdominal cavity in the right hypochondrium an anterior subdiaphragmatic abscess is found, then its position, boundaries are determined and measures are taken to prevent infection of the abdominal cavity. The free edge of the liver is sutured with separate interrupted sutures to the lower edge of the abdominal wall wound, gauze swabs are brought to the lateral section. From the inside, the abscess is limited by a falciform ligament. After that, the abscess is opened and drained.

A posterior left-sided guddiaphragmatic abscess (omental bursa abscess), which may be caused by purulent pancreatitis, perforation of an ulcer of the posterior wall of the stomach, is opened transperitoneally and drained through a window in the gastrocolic ligament. An upper median laparotomic incision is used to open the abdominal cavity, the gastrocolic ligament is dissected, having previously delimited the place of opening of the ligament from the abdominal cavity with napkins.

If the abscess is adjacent to the ligament or pus is in the omental sac, it is removed by suction, the cavity of the sac is drained, and the edges of the ligament incision are sutured around the entire circumference to the parietal peritoneum. If an abscess in the omental bag is formed, delimited by adhesions, then the edges of the dissected ligament are sutured to the parietal peritoneum until the abscess is opened. Through the formed bursostomy with a diameter of 5-7 cm, the stuffing bag is drained with a tube and gauze swabs. The wound of the abdominal wall is sutured to tampons. If there are streaks of pus to the spleen, to the omental opening, then the pus is removed through the omental bag and, accordingly, additional drainages are brought.

In the postoperative period, treatment is carried out in the same way as with any other purulent disease: an adequate outflow of contents is ensured, the cavities are washed and treated with antiseptic solutions, proteolytic enzymes and physical factors are used, and detoxification, infusion and antibacterial therapy is carried out.

Subdiaphragmatic abscess with untimely, improper treatment can lead to sepsis.

With conservative treatment of subdiaphragmatic abscess, the prognosis is unfavorable, with early diagnosis and timely surgical intervention, the outcomes are favorable.

A subdiaphragmatic abscess is an encysted collection of pus between the inferior surface of the diaphragm and the superior surface of the liver (right) or the fornix of the stomach and spleen (left). A right-sided subdiaphragmatic abscess is more common. The source of a subdiaphragmatic abscess is the foci of purulent inflammation of the abdominal organs (perforated and duodenal ulcers, inflammation of the biliary tract and pancreas, liver abscess, acute appendicitis, amoebic dysentery, festering echinococcus cyst), sometimes lungs and. The cause of the formation of a subdiaphragmatic abscess can also be open and closed abdominal trauma and thoraco-abdominal injuries. Most often, a subdiaphragmatic abscess is located intraperitoneally.

The clinical picture of a subdiaphragmatic abscess is often blurred, as it usually appears against the background of a serious illness. The most typical prolonged fever, chills, and appetite, weakness, depression of the psyche. The patient takes a forced semi-sitting position. The breath is gentle. With the abdomen, muscle tension and soreness in the right hypochondrium, with - an increase in the boundaries of the liver. In the blood, leukocytosis, acceleration. In more severe cases, the symptoms of a subdiaphragmatic abscess are pain in the right hypochondrium, aggravated by deep breathing, coughing, sudden movements, radiating to the shoulder girdle, right collarbone, shoulder blade, fever, leukocytosis. with a subdiaphragmatic abscess, it plays a decisive role (the dome of the diaphragm is raised, motionless; under it is gas and a horizontal liquid level).

Complications of a subdiaphragmatic abscess: reactive, breakthrough of pus into the pleural or abdominal cavity, into the pericardium. serious, without surgery usually ends in death.

The main method of treatment of subdiaphragmatic abscess is surgical. Diagnostic puncture is permissible only on, so that when pus is obtained from the subdiaphragmatic space, immediately proceed to the operation. Access to the subdiaphragmatic abscess through the chest is transpleural and extrapleural. After emptying the abscess, its cavity is drained and tampons with Vishnevsky's ointment and rubber drains are introduced. The first time tampons are changed on the 5-7th day.

In the postoperative period, the use of antibiotics, vitamins, control of the chest and abdominal cavity is indicated. It is necessary to change the dressings, which can get wet due to purulent discharge, as well as skin care: lubrication with sterile vaseline, Lassar paste.

Subphrenic abscess (subphrenic abscess) - a limited accumulation of pus in the subphrenic space between the diaphragm and the organs adjacent to its lower surface, mainly the liver on the right, the stomach and spleen on the left.

The subdiaphragmatic space above the liver is divided by the suspensory ligament of the liver (lig. suspensorium hepatis) into a large right and a smaller left halves isolated from each other.

The coronal ligament of the liver (lig. coronarium hepatis) delimits the subphrenic fissure at the back, and two triangular ligaments (lig. triaagulare dext. et sin.) - from the sides. Normally, under the left dome of the diaphragm, there is also a gap between the diaphragm and the stomach and spleen adjacent to its lower surface. These fissures communicate with the abdominal cavity, representing essentially a part of it; and only during an inflammatory process in some part of the subdiaphragmatic space, adhesions are formed very early, with which the area of ​​inflammation is quickly delimited from the free abdominal cavity. The described sections of the subdiaphragmatic space do not communicate with each other, and therefore the suppurative process in one of them usually does not spread to others.

There are the following localizations of the subdiaphragmatic abscess: right upper anterior; right upper back; left upper back. In addition, extrahepatic subdiaphragmatic abscesses are isolated. In the upper floor of the abdominal cavity above the transverse colon and mesocolon: right lower hepatic; left lower anterior (pregastric); left lower-posterior (retrogastric). The subphrenic abscess develops predominantly in the right subphrenic space, with about half of all abscesses located in the right upper aad space. This is explained by the fact that during an inflammatory process in one of the organs of the abdominal cavity, the lymph, and with it the infection, rush to the centrum tendineum diafragmatis and, first of all, the right subdiaphragmatic space is infected.

Subdiaphragmatic abscess is usually observed in 30-50 years of age, 3 times more often in men than in women. However, a subdiaphragmatic abscess can develop in childhood and old age, but much less frequently.

Subdiaphragmatic abscess, as a rule, is a complication of inflammatory processes of the abdominal organs: perforated appendicitis, perforated gastric and duodenal ulcers, severe forms of acute cholecystitis and cholangitis. Less commonly, a subdiaphragmatic abscess develops with paranephritis, even more rarely with general purulent processes, pyemia. Finally, a subdiaphragmatic abscess can develop as a result of a breakthrough of an intrahepatic abscess, with liver injuries, after thoracoabdominal injuries.

The symptoms of a subdiaphragmatic abscess are complex. It combines general phenomena, local symptoms and symptoms of the underlying disease. Most often at present, subdiaphragmatic abscess is a complication after surgery. Thus, its symptoms are superimposed on the phenomena of the postoperative period, and then a protracted one in this case. Treatment with antibiotics greatly obscures the clinical picture. Therefore, one cannot expect violent manifestations of the classic signs - chills, fever, high leukocytosis, etc. But, despite the fact that the symptoms are not very pronounced, the general condition is still severe, the pulse is quickened, and tachypnea is evident. The expected postoperative resolution of the abdominal status is delayed. The abdomen is swollen, the intestines are paretic, there is palpation tenderness in the hypochondrium and sometimes in the epigastric region, where the abdominal wall can be stable. The skin in the projection areas of the subdiaphragmatic abscess is often pasty soft. These areas are painful on percussion.

Intercostal spaces are smoothed. Breathing on the corresponding side of the chest is slightly behind. One of the early symptoms is persistent vomiting. The third symptom complex is the clinical picture of the disease, a complication of which is a subphrenic abscess. Laboratory data are an indicator not only of the presence of a subphrenic abscess, but also of the underlying disease. There is usually a high leukocytosis, a shift to the left, lymphopenia, accelerated ESR, hypoproteinemia, a very short Veltman strip.

The clinical picture is often complicated by an accompanying pleural effusion.

Treatment.

When establishing the diagnosis of a subphrenic abscess, the latter must be widely opened and drained. It is impossible to delay opening an abscess, as it can pierce into the abdominal cavity and cause peritonitis. In addition, a long stay of an abscess causes intoxication of the body with all the negative consequences.

The abscess should be opened, if possible, extraperitoneally and extrapleurally to prevent the occurrence of peritonitis or pleural empyema, which pose a great threat to the patient's life.

To open a subdiaphragmatic abscess, access is used depending on the location of the abscess.

The right-sided suprahepatic posterior superior abscess is opened with a posterior approach (but to Melnikov).

The patient is placed on the left side with a roller under the lower back. Under endotracheal anesthesia (danger of right-sided pneumothorax), an incision up to 10 cm long is made along the XII rib and resected, preserving the periosteum. At the level of the spinous process of the 1st lumbar vertebra, the bed of the right XII rib is laterally crossed. To the right of the rib are the fibers of the intercostal muscle, to the left is the serratus posterior inferior muscle. Below them is a part of the diaphragm, which is crossed along the incision line. After that, the renal fascia is visible in the lower corner of the wound, and the liver is located under it in the upper corner of the wound.

Passing the index finger up carefully behind the kidney and liver, the posterior parietal peritoneum is separated from the inner surface of the diaphragm and, when the abscess is felt, it is punctured and then opened. Forceps are inserted into the wound, the opening is expanded with branches and the contents of the abscess are removed

Rubber drains are inserted into the abscess cavity, the wound is sutured in layers to the drains.

If the abscess is located anteriorly, between the diaphragm and the liver, an anterior approach is used to open it. The patient is also placed on the left side with a roller under the lower back. An incision up to 10 cm long is made 1.5 cm below the costal arch and parallel to it to the right to the peritoneum. The peritoneum above the liver is carefully separated from the diaphragm to the abscess with a tupfer. When palpating it with a finger, the abscess is punctured and, when pus is obtained, it is opened. The contents are removed by suction, the cavity is washed with antiseptics, drained with gauze swabs and rubber drainage tubes, the wound is sutured in layers to drains.

In the postoperative period, antibiotics are used at first with a broad spectrum of action, and then taking into account the sensitivity of the microbial flora. Conduct intensive detoxification and restorative therapy

Subdiaphragmatic abscess

Subdiaphragmatic abscess (abscessus subdiaphragmaticus; synonyms: subdiaphragmatic abscess, infradiaphragmatic abscess) is an intra-abdominal abscess located in the subdiaphragmatic space.

Pus with a subdiaphragmatic abscess is localized in natural pockets of the peritoneum, called the subdiaphragmatic space, which is located in the upper floor of the abdominal cavity and is limited from above, behind the diaphragm, in front and from the sides - by the diaphragm and the anterior abdominal wall, from below - by the upper and posterior surface of the liver and supporting it bundles.

In the subdiaphragmatic space, intraperitoneal and retroperitoneal parts are distinguished. The intraperitoneal part of the falciform ligament of the liver and the spine is divided into the right and left sections. In the right section, the anterior superior and posterior superior regions are distinguished. The anterior-upper region is limited medially by the falciform ligament of the liver, posteriorly by the upper sheet of the coronary ligament, above by the diaphragm, below by the diaphragmatic surface of the right lobe of the liver, in front by the costal part of the diaphragm and the anterior abdominal wall. The posterior-upper region is bounded in front by the posterior surface of the liver, behind - by the parietal peritoneum covering the posterior abdominal wall, from above - by the lower sheet of the coronary and right triangular ligaments of the liver (Figure 1). Both of the above areas communicate with the subhepatic space and with the abdominal cavity. The left-sided subdiaphragmatic space has a slit-like shape and is located between the left dome of the diaphragm from above and the left lobe of the liver to the left of the falciform ligament of the liver, the spleen and its ligaments, and the anterior surface of the stomach.

The retroperitoneal part of the subdiaphragmatic space has a diamond shape and is bounded above and below by the sheets of the coronary and triangular ligaments of the liver, in front - by the posterior surface of the extraperitoneal part of the left and right lobes of the liver, behind - by the posterior surface of the diaphragm, posterior abdominal wall and passes into the retroperitoneal tissue.

Most often, a subphrenic abscess occurs in the intraperitoneal part of the subphrenic space.

The etiology is quite diverse and is caused by infection in the subdiaphragmatic space from local and distant foci.

The most common causes Subdiaphragmatic abscess: 1) direct (contact) spread of infection from neighboring areas: a) with perforated ulcer of the stomach and duodenum, destructive appendicitis, purulent cholecystitis and liver abscess, b) with delimited and diffuse peritonitis of various origins, c) with postoperative complications after various operations on the abdominal organs, d) with festering hematoma due to closed and open injuries of parenchymal organs, e) with purulent diseases of the lungs and pleura, f) with inflammation of the retroperitoneal tissue as a result of purulent paranephritis, carbuncle of the kidney, paracolitis, destructive pancreatitis and others; 2) lymphogenous spread of infection from the abdominal organs and retroperitoneal tissue; 3) hematogenous dissemination of infection from various purulent foci through the blood vessels with furunculosis, osteomyelitis, tonsillitis, and others; 4) often Subdiaphragmatic abscess occurs with thoracoabdominal wounds, especially gunshot wounds.

The microbial flora of the subdiaphragmatic abscess is diverse.

The penetration of infection into the subdiaphragmatic space contributes to the negative pressure in it, resulting from the respiratory excursion of the diaphragm.

The clinical picture is characterized by significant polymorphism. This is due to the different localization of abscesses, their size, the presence or absence of gas in them, and is often due to symptoms of a disease or complication, against which a Subdiaphragmatic abscess has developed. symptoms become blurred, and the course is often atypical. In 90-95% of cases, the Subdiaphragmatic abscess is located intraperitoneally, and right-sided localization is observed, according to Wolf (W. Wolf, 1975), in 70.1%, left-sided - 26.5%, and bilateral - in 3.4% of cases.

Diagnostics

Diagnosis of a subdiaphragmatic abscess is difficult. The most important thing to think about is the possibility of such a complication. A subdiaphragmatic abscess should always be considered when, after an acute inflammatory process in the abdomen and in the postoperative period after abdominal surgery, there is a slowdown in the recovery of the general condition, when it is inexplicable why intoxication occurs, when septic temperatures appear and pain or a feeling of heaviness in the subdiaphragmatic region. These symptoms suggest the presence of a subdiaphragmatic abscess. They are not pathological. X-ray data are also indirect signs. There is a high position of the diaphragm and restriction of its movement, and with the content of gases in the abscess - a water-air shadow. A reactive exudate is usually found in the pleural sinus. For smaller abscesses, tomographic examination is necessary.

Proof of the correctness of the diagnosis can only be the evacuation of pus from the subdiaphragmatic space through a diagnostic puncture. It is valid only when ready to carry out the immediate operation. Carrying out a puncture with the evacuation of pus and the introduction of antibiotics inside, as an independent therapeutic method, is associated with dangers, unreliability of the therapeutic result.

Complications of subphrenic abscesses are most often directed to the chest cavity (pleural empyema, pneumonia, abscessing pneumonia, bronchial fistula, breakthrough of pus into the pleura, into the pericardium) and, less often, to the abdominal cavity (breakthrough of pus into the free abdominal cavity, causing peritonitis, etc. ).

In the differential diagnosis, one should keep in mind: pleural empyema, pneumonia, liver abscess, paranephritis, and typical abscesses in the epigastric region.

Subdiaphragmatic abscess is usually an acute disease, but it should be borne in mind that it can also occur chronically.

Definition

A subdiaphragmatic abscess is an abscess located in the pancreas between the diaphragm and the colon.

The subdiaphragmatic space is a section of the upper abdomen, bounded above, behind and laterally by the diaphragm, below - by the liver and spleen, splenic flexure of the colon, in front - by the anterior abdominal wall.

Spine and lig. falciforme divide the subphrenic space into two halves (right and left). Distinguish between intra- and extra-peritoneal subdiaphragmatic spaces.

Clinic and diagnosis.

Subdiaphragmatic abscess is always accompanied by a severe clinical course. Body temperature rises to 38 - 39 ° and is accompanied by chills, intoxication phenomena increase, the general condition worsens, leukocytosis increases with a shift of the formula to the left. At the same time, pains in the lower parts of the chest are often observed, often radiating to the right shoulder blade and shoulder, pressure on the IX-XI ribs causes intense pain.

X-ray reveals limitation of diaphragm mobility, sometimes its high standing. Often, an effusion is found in the pleural cavity, which can be mistakenly interpreted as pleurisy. It is not uncommon for an abscess to contain some gas, which can be seen on an x-ray (as a result of specular reflection)

Symptoms of a subdiaphragmatic abscess

The clinical picture has typical signs of general intoxication: an increase in temperature to critical values ​​(39.0-40.0 gr.), weakness, chills, malaise, increased sweating, decreased appetite or its absence, nausea, and rarely vomiting.

A striking symptom of the pathology is a pulling aching pain in the region of the left or right hypochondrium, which radiates to the shoulders or subscapular region. When pressed, pain intensifies, muscle tension is noted.

Breathing is disturbed, it is difficult to inhale or exhale, the patient may be disturbed by frequent debilitating cough, shortness of breath. A semi-sitting forced position is characteristic, the patient is afraid to move, as the symptoms intensify with the slightest movement.

Atypical signs are hiccups, heartburn, bad breath.

Features of performing operations for interintestinal abscesses

1. It is advisable to extend the incision of the anterior abdominal wall.
2. The adhesions between the loops of the small intestine must be separated only in a sharp way, while the abscesses are emptied. A thorough revision of the walls of the abscess cavity is required, i.e. determination of the degree of destructive changes in the intestinal wall and its mesentery.
3. Small defects in the serous and muscular layers of the intestine are eliminated by applying approaching gray-serous or serous-muscular sutures in the transverse direction with Vicryl No. 000 on an atraumatic intestinal needle. In the presence of an extensive defect or complete destruction of the intestinal wall, including the mucous membrane, resection of the intestine is indicated within healthy areas with the imposition of a side-to-side or end-to-side anastomosis.
4. To prevent intestinal obstruction, improve the conditions for evacuation and reparation, as well as in case of extensive adhesions between the loops of the small intestine, transnasal intubation of the small intestine with a probe should be performed at the end of the operation. In the case of bowel resection, this procedure with a probe passed beyond the anastomosis area is mandatory.
5. In addition to transvaginal, additional drains with a diameter of 8 mm are introduced transabdominally through counter-openings in the mesogastric regions for APD.
6. In order to regulate the motor function of the intestine in the postoperative period, long-term epidural anesthesia is used.

First aid and treatment

First aid is to ensure the supine position and complete rest for the patient. Neither painkillers nor antispasmodics should be given, as this will cause further difficulties in diagnosing the disease. It is forbidden to put warm heating pads, they enhance pyogenic processes.

Treatment takes place exclusively in stationary conditions. First of all, you need to clean the affected area. They do this in two ways:

1. Radically, that is, the abdominal cavity is opened, the capsule with the contents is removed, everything is treated with antiseptic solutions, drainage is placed, the wound is sutured.
2. Puncture - a thin needle with the help of ultrasound reaches the required area, pus is pumped out, antiseptics and antibiotics are introduced in parallel. It is a minimally invasive operation.

Next, conservative therapy is prescribed. Two antibiotics are prescribed or a synthetic antibacterial agent to choose from the group of penicillins, cephalosporins, macrolides, sulfonamides, fluoroquinolones, used for five to seven days

To relieve pain, signs of inflammation, it is important to use antipyretics, analgesics, antispasmodics, steroid and non-steroidal anti-inflammatory drugs. To improve metabolism, increase immunity - B vitamins, ascorbic acid, retinol, intravenous administration of magnesium, potassium, calcium, sodium, glucose solution.

Complications

Pus is able to melt the pyogenic capsule, diaphragm and penetrate into the pleural cavity. There is a possibility of developing pleurisy, empyema of the lungs, pyothorax.

As the inflammatory process spreads, the pericardial sac is affected, the situation is aggravated by pericarditis.

Once in the intestines, digestion and absorption of nutrients are disturbed, enteritis, enterocolitis joins.

With incorrect diagnosis and treatment, peritonitis occurs, with the penetration of infection into the blood - systemic inflammatory response syndrome (sepsis), toxic shock. The result may be the death of the patient.

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Treatment of subdiaphragmatic abscess

Conservative antibiotic treatment is carried out only at the initial stages of the disease. The main method of treatment is surgical opening and drainage of the abscess. The operation for a subdiaphragmatic abscess is performed by transthoracic or transabdominal access, which allows to provide adequate conditions for drainage. The main incision is sometimes supplemented with counter-opening. The subdiaphragmatic abscess is slowly emptied and its cavity is examined. The complex treatment of subdiaphragmatic abscess includes antibacterial, detoxification, symptomatic and restorative therapy.

Essential drugs

There are contraindications. Specialist consultation is required.

• Amoxiclav (broad spectrum bactericidal antibacterial agent). Dosage regimen: in / in, adults and children over 12 years of age or weighing more than 40 kg - 1.2 g of the drug (1000 + 200 mg) with an interval of 8 hours, in case of severe infection - with an interval of 6 hours.
• Ceftriaxone (broad spectrum bactericidal antibacterial agent). Dosage regimen: in / in, adults and children over 12 years of age, the average daily dose is 1-2 g of ceftriaxone 1 time per day or 0.5-1 g every 12 hours. In severe cases or in cases of infections caused by moderately sensitive pathogens, the daily dose can be increased up to 4 g.
• Cefepime (4th generation cephalosporin antibiotic). Dosage regimen: in / in, adults and children weighing more than 40 kg with normal kidney function 0.5-1 g (for severe infections up to 2 g) or deep intramuscular injection with an interval of 12 hours (for severe infections - after 8 h).
• Metronidazole (antiprotozoal, antibacterial agent). Dosage regimen: intravenously for adults and children over 12 years of age, a single dose is 0.5 g. The rate of intravenous jet or drip injection is 5 ml / min. The interval between injections is 8 hours.
• Tienam (antimicrobial, bactericidal, antibacterial agent). Dosage regimen: in / in, in the form of infusion: ≤ 500 mg - for 20-30 minutes, > 500 mg for 40-60 minutes. The average daily dose is 2000 mg (4 injections). The maximum daily dose is 4000 mg (50 mg/kg). The dose is adjusted according to the severity of the condition, body weight and renal function of the patient.
• Vancomycin (antibacterial, bactericidal agent). Dosage regimen: for adults, 0.5 g intravenously every 6 hours or 1.0 g every 12 hours. The duration of the infusion is at least 60 minutes, the rate is 10 mg / min.

Diagnostics of interintestinal abscesses

With echography, infiltrates of the abdominal cavity without abscessing have the following echographic characteristics: echo-positive formations of irregular shape without a clear capsule with reduced echogenicity in relation to surrounding tissues due to increased hydrophilicity; as part of infiltrates, intestinal loops, pathological purulent structures of various localization and foreign bodies can be identified.

When absiedding, the structure of the infiltrates themselves becomes heterogeneous (against the background of the main echo-positive structures, one or many cystic formations with a clear capsule and heterogeneous liquid content, reflecting the accumulation of purulent exudate, are determined).

Sonographic signs of interintestinal abscesses are the presence in the corresponding projection (area of ​​intestinal loops) of encysted echo-negative formations with an echo-positive capsule and liquid heterogeneous contents.

KG, NMR are highly informative diagnostic methods that should be used in difficult cases. The information content of CT in a single interintestinal abscess is 94.4%, in multiple abscesses - 94.7%.

Diagnostics

A preliminary diagnosis is made on the basis of complaints, anamnesis of the disease and a general examination of the patient. Outwardly, the intercostal spaces are enlarged in breadth, the affected area rises slightly, if the abscess is on the right side, the liver enlarges.

The doctor should palpate, percuss and listen to the abdominal cavity. On palpation, the pain increases, on percussion - dullness of the sound. Auscultatory bowel sounds are absent, as there is no peristalsis.

In the results of laboratory blood tests, an increased number of leukocytes, anemia, an increase in the erythrocyte sedimentation rate, an increase in the concentration of C-reactive protein, a decrease in the protein component.

On the chest x-ray, the border of the dome of the diaphragm is clearly seen to shift upward, the accumulation of pus in the form of a darkened area, and sometimes fluid can be found in the pleural cavity.

Ultrasound diagnostics clearly shows the presence of fluid, purulent contents, deformation of neighboring organs.

Modern methods such as computed tomography and magnetic resonance imaging provide a detailed picture of the state of the abdominal and thoracic organs, the exact localization of the pathological process.

Symptoms of intestinal abscesses

1. Patients have a history and all clinical signs of purulent inflammation of the pelvic organs, while it must be remembered that with remission of the purulent-infiltrative process and especially with the use of palliative drainage operations, palpation data during a gynecological examination may be scarce, which does not at all mean the exclusion of a gynecological nature interintestinal abscess. In such cases, a thorough history taking is crucial to establish the genesis of the disease.
2. In the remission stage, interintestinal abscesses are characterized by weakness, a tendency to constipation, and symptoms of prolonged purulent chronic intoxication.
3. In the acute stage, patients are concerned about pain, localized mainly in the mesogastric abdominal cavity and accompanied by phenomena of transient intestinal paresis or partial intestinal obstruction, as well as fever and other phenomena of purulent intoxication.

During a gynecological examination in patients, as a rule, a single conglomerate is determined, occupying the small pelvis and partly the abdominal cavity. The size of the conglomerate can reach 25-30 cm in diameter. In the study, limited mobility or, more often, complete immobility of the formation, the absence of clear contours, uneven consistency (from dense to tight elastic) and its sensitivity are determined. With exacerbation, the size of the infiltrate increases, there is a sharp local pain.

Diagnosis of a subdiaphragmatic abscess

Detection of a subdiaphragmatic abscess is facilitated after its full maturation. For the purpose of diagnosis, the data of the anamnesis and examination of the patient, the results of X-ray, ultrasound, laboratory studies, and CT are used.

Palpation of the upper abdomen with a subdiaphragmatic abscess shows soreness and muscle tension of the abdominal wall in the epigastric region or in the hypochondria. Smoothness and expansion of the intercostal spaces, protrusion of the subcostal region is revealed, with a right-sided abscess - an increase in the liver.

If the subdiaphragmatic abscess does not contain gas, percussion of the chest reveals dullness above the border of the liver, decreased or no mobility of the lower edge of the lung. With the accumulation of gas in the cavity of the subdiaphragmatic abscess, areas of different tones (“percussion rainbow”) are revealed. Auscultation shows a change in breathing (from weakened vesicular to bronchial) and a sudden disappearance of respiratory sounds at the border of the abscess.

A laboratory blood test shows changes characteristic of any purulent processes: anemia, neutrophilic leukocytosis with a shift of the leukocyte formula to the left, an increase in ESR, the presence of C-reactive protein, and dysproteinemia.

The main value in the diagnosis of subdiaphragmatic abscess is given to radiography and chest x-ray. A subdiaphragmatic abscess is characterized by a change in the area of ​​the crura of the diaphragm, a higher standing of the dome of the diaphragm on the affected side and limitation of its mobility (from minimal passive mobility to complete immobility). The accumulation of pus with gasless subdiaphragmatic abscesses is seen as a blackout above the line of the diaphragm, the presence of gas is seen as a band of enlightenment with a lower horizontal level between the abscess and the diaphragm. An effusion in the pleural cavity (reactive pleurisy), a decrease in the airiness of the lower parts of the lung is determined.

MSCT and ultrasound of the abdominal cavity can confirm the presence of fluid, pus and gas in the abdominal or pleural cavity, changes in the position and condition of adjacent internal organs (for example, deformity of the stomach, displacement of the longitudinal axis of the heart, etc.). Diagnostic puncture of an abscess is permissible only during the operation.

Subdiaphragmatic abscess is differentiated from gastric ulcer, peptic ulcer 12p. intestines, purulent appendicitis, diseases of the liver and biliary tract, festering echinococcus of the liver.

Treatment of subdiaphragmatic abscess

When an abscess is detected under the diaphragm, surgery is the main method of treatment. Usually, minimally invasive techniques are used. During the operation, the abscess is opened and drained. Then antibiotics are prescribed, the choice of which depends on the data of bacteriological studies.

The prognosis of the disease is ambiguous, since there are a lot of possible complications. Mortality is about 20%.

Subphrenic abscess refers to severe complications, the clinic, diagnosis and treatment of which are quite difficult. Compliance with preventive measures, including timely diagnosis and adequate treatment of inflammatory processes in the abdominal cavity, as well as the exclusion of postoperative infectious complications, significantly reduces the risk of pathology.

Abscesses (delimited peritonitis) with peritonitis occur in typical places where there are favorable conditions for retaining exudate and delimiting it with loose adhesions. Most often they are localized in the subdiaphragmatic, subhepatic spaces, between the intestinal loops, in the lateral canals, in the iliac fossa, in the Douglas space of the small pelvis. An abscess can form near an inflamed organ (vermiform appendix, gallbladder, etc.).

Subphrenic and subhepatic abscesses can be formed during the treatment of widespread peritonitis due to encystation of exudate under the diaphragm, in the small pelvis, i.e., in places where the most intensive absorption of exudate occurs. Often they are a complication of various operations on the abdominal organs or acute surgical diseases of the abdominal organs. Clinical picture and diagnosis. Patients are concerned about pain in the right or left hypochondrium, aggravated by a deep breath. In some cases, they radiate to the back, shoulder blade, shoulder (irritation of the phrenic nerve endings). Body temperature is elevated to febrile numbers, has an intermittent character. The pulse is fast. Leukocytosis with a shift of the formula to the left and an increase in ESR. Sometimes an abscess is manifested only by an increase in body temperature. In severe cases, there are symptoms characteristic of the syndrome of a systemic reaction to inflammation, sepsis, and multiple organ failure. With an asymptomatic course, examination of the patient does not provide significant information. An abscess can be suspected in the absence of other diseases in the presence of subfebrile temperature, accelerated ESR, leukocytosis, slight pain with pressure in the intercostal space, tapping along the right costal arch. In severe cases of the disease, there are complaints of constant pain in the right hypochondrium, pain on palpation in the right or left hypochondrium, in the intercostal spaces (according to the location of the abscess). Sometimes in these areas it is possible to determine some pasty skin. Symptoms of peritoneal irritation are determined infrequently. In the general blood test, leukocytosis, neutrophilia, a shift of the leukocyte blood formula to the left, an increase in ESR, i.e., signs characteristic of purulent intoxication, are detected.

X-ray examination reveals the high standing of the dome of the diaphragm on the side of the lesion, limitation of its mobility, "sympathetic" effusion in the pleural cavity. The direct radiological symptom of a subdiaphragmatic abscess is the presence of a fluid level with a gas bubble above it. The most valuable information for the diagnosis is provided by ultrasound and computed tomography.

Treatment. Abscess drainage is shown, for which minimally invasive technologies are currently used more often. Under the control of ultrasound, a percutaneous puncture of the abscess is performed, pus is aspirated. A special drainage is placed in the cavity of the abscess, through which it is possible to repeatedly wash the purulent cavity and inject antibacterial drugs. The procedure is less traumatic and much easier for patients than open surgery. If this technology cannot be applied, then the abscess cavity is opened and surgically drained. Both transperitoneal and extraperitoneal access according to Melnikov are used. The latter method is preferable, as it avoids massive bacterial contamination of the abdominal cavity.

Page 40 of 67

A significant number of errors occur when recognizing complications such as subdiaphragmatic or subhepatic abscess. A subdiaphragmatic abscess is a disease of unknown origin, difficult to diagnose, complex in course and severe in outcome (V. M. Belogorodsky, 1964).
With an unfavorable course of the postoperative period of a perforated ulcer of the stomach and duodenum, acute cholecystitis, acute appendicitis and pancreatitis, it is necessary to think about the possibility of subdiaphragmatic abscesses. According to 15 authors, in 3379 patients after suturing the perforated hole of the gastric and duodenal ulcer, subdiaphragmatic abscesses were observed in 1.9% of cases (I. I. Neimark, 1958).
T. A. Nadzharova (1942) cites materials from the staff of the Institute. N. V. Sklifosovsky: out of 1226 patients with perforated ulcers of the stomach and duodenum, 21 (1.7%) had a complication - subdiaphragmatic abscess.
According to V. M. Belogorodsky (1964), gastric ulcers as the cause of subdiaphragmatic abscess occurred in 24.7% of cases, appendicitis - in 20%, gallbladder disease - in 14.3% of cases.
About 85% of subdiaphragmatic abscesses were of intra-abdominal origin. Approximately 2/3 of patients underwent surgical intervention in the abdominal cavity. In 10% of patients, no reason for the occurrence of an abscess was found (Wendt, Hiibner, Kunz, 1968).
At the beginning of the development of this complication, the clinical picture is poorly expressed and diagnosis is difficult. The disease develops either acutely or slowly, the symptoms of a subdiaphragmatic abscess are vague and they may be characteristic of a liver abscess or exudative pleurisy, which is actually "sympathetic pleurisy." The symptomatology of a subphrenic abscess varies depending on its location: in front, behind, or in the upper part of the subphrenic space. Sometimes there is also a subhepatic abscess, which is located between the liver and stomach. Subhepatic abscesses can be independent or combined with subdiaphragmatic or other ulcers of the abdominal cavity. The clinical picture of subhepatic abscesses is more blurred than that of subphrenic abscesses. This is explained by the fact that a large organ is located at the top - the liver, which, covering the abscess, does not give physical changes in the lungs, therefore the position and function of the diaphragm do not change and there is no "sympathetic pleurisy". It is very difficult to determine radiographically the presence of a fluid level and a gas bubble under the liver.
The main complaints of patients: pain in the upper abdomen, high intermittent temperature with chills, a large amount of sweat, leukocytosis with a shift of the leukocyte blood count to the left. Often you can find icteric sclera, and sometimes jaundice of the skin. In connection with such a clinical picture, a diagnosis of "liver abscess or subphrenic, but not subhepatic" is made.
Subphrenic abscesses occur in patients of all ages. Intraperitoneal abscesses are more common and more rarely extraperitoneal abscesses. As a rule, subdiaphragmatic abscesses occur secondarily, are more often observed on the right (58%), less often on the left (37%) and are rarely bilateral (5%). The size of the abscess can be different: from the size of a hazelnut to the size of a cavity, with a volume of 4-5 liters, which may contain pus with a variety of microflora (streptococci, staphylococci and other microbes). E. coli gives pus a fecal smell. Pus can perforate the diaphragm and enter the lungs, bronchi, pleural and abdominal cavities, pericardium, or intestinal lumen.
In order to avoid errors, late diagnosis or non-recognition of a subdiaphragmatic abscess, the following symptoms should be taken into account: poor health or deterioration in the general condition of the patient in the postoperative period, fever up to 39-40 ° with chills and profuse sweating. The temperature drops in the morning and rises in the evening. In the blood, as a rule, an increased number of leukocytes is found with a shift of the leukocyte formula to the left, ROE is accelerated. A feeling of pressure, heaviness, fullness and pain is noted in the hypochondrium or upper outer quadrant of the abdomen or epigastric region. These pains can radiate to the back or lower back, as well as upward to the supraclavicular and scapular regions, and can intensify when the patient moves. The patient develops nausea, vomiting, hiccups and flatulence.
Pain is localized in the intercostal spaces, especially when inhaling. When pressing on the IX, X, XI ribs on the side of the lesion, severe pain is noted (M. M. Kryukov, 1901). In a patient, when breathing, the affected side of the chest lags behind, on the same side at the bottom of the lungs there may be weakened breathing; in some patients, a pleural friction rub is heard and an increase in voice trembling is determined. There is shortness of breath and dry cough, with involvement in the process of the pleura, tachycardia and severe symptoms of intoxication. With percussion, the upper border of the liver rises and tympanitis is determined above it (due to the lung tissue).
During inspiration, sometimes there is a retraction of the epigastric region, and during expiration - a protrusion (Duchenne's symptom). With significantly pronounced symptoms, the patient's intercostal spaces are smoothed or protruded, or a protrusion may appear in the lumbar region or epigastric region. Fluoroscopy reveals high standing, limited movement or immobility of the diaphragm, and low liver position. An effusion may be found in the pleural cavity on the side of the lesion. Under the diaphragm, in 25-30% of patients, a horizontal level of fluid is found, and above it, a gas bubble, which is considered characteristic of abscessus subphrenicus. A reliable sign of a subdiaphragmatic abscess is the receipt of pus when the abscess is punctured.
Patient A., aged 28, was admitted with a typical clinical picture of a subdiaphragmatic abscess on the right. In the operating room, the abscess was punctured and pus was obtained. They gave me anesthesia. Suddenly there was a stoppage of breathing, it was not possible to restore breathing. Death on the operating table.
At autopsy: festering echinococcus of the liver; no subdiaphragmatic abscess was found.
Diagnostic puncture of the subdiaphragmatic space is not an easy procedure and must be performed under local anesthesia at the site of greatest protrusion, dullness, and tenderness after analysis of fluoroscopic data. Usually, II, III and IX intercostal spaces along the axillary lines are chosen for puncture. If the needle penetrates only into the gas bubble of the abscess, then a fecal odor appears, due to the presence of Escherichia coli in it. Sometimes you have to do a lot of punctures (up to 20, according to VF Voyno-Yasenetsky, 1946) before you can find pus, sometimes they don’t get it, but an abscess is found at the autopsy. In one of the patients we observed, an abscess was found only after 12 punctures, and in another patient it was not found even after 13 punctures. The patient continued to have a fever, lost weight, the symptoms did not increase, X-ray a horizontal level and a gas bubble under the diaphragm were not noted. When pressing on the ribs, there was no pain, there were no protrusions of the intercostal spaces. During diagnostic punctures, pus was never obtained.
The patient died, and the autopsy revealed a small subdiaphragmatic abscess that had burst into the abdominal cavity.
The puncture should be performed on the operating table in order to immediately operate on the patient after receiving pus, without removing the needle, in order to avoid infection of healthy tissues, infection of the pleura, peritoneum and for a simpler approach to the abscess. With a "controversial" diagnosis, B. A. Petrov recommends performing an extrapleural or extraperitoneal opening of the site of the alleged abscess.
Lethality, according to old statistics (Maydl, Lang and Peritz), without surgical intervention reaches 85-100%. Surgery significantly reduces mortality. Before the use of antibiotics, deaths in patients from subphrenic abscesses were observed in 20% of cases.
The frequency of this disease is low. There are separate reports of the successful treatment of subphrenic abscesses by aspiration of pus, followed by the introduction of antibiotics into the cavity (Ya. D. Vitebsky, 1953; A. A. Gerasimenko, 1957; V. Ya. Shlapobersky, 1957, etc.). According to A. A. Gerasimenko, one patient recovered after 10 punctures, 2 - after 7, one - after 6, 2 - after 4, one - after 2 punctures; with a bilateral subdiaphragmatic abscess, 22 punctures were required within 90 days. After aspiration of pus, 200,000-600,000 units of penicillin, rarely 800,000 units of penicillin and 250,000 units of streptomycin were injected into the abscess cavity. V. M. Belgorodsky used sulfa drugs and penicillin in 27 patients, 13 of them recovered. The author speaks about the possibility of antibiotic treatment of infiltration and initial forms of subdiaphragmatic abscesses.

Rice. 14. Posterior extraperitoneal access to the abscess (according to W. A. ​​Oshner and Graves):
a - liver, b - abscess, c - pleura, d - diaphragm, e - peritoneum.

At present, it is impossible to underestimate the appearance of penicillin-resistant forms of microorganisms. Antibiotic treatment should be used after laboratory determination of the sensitivity of pathogens to antibiotics. Where a pyogenic abscess capsule has formed, the puncture method of abscess treatment will not be effective and surgical treatment is necessary.

Rice. 13. Diaphragm incision and exposure of the abscess capsule according to A. V. Melnikov:

a - sinus of the pleura, b - dissected diaphragm, c - ends of the excised rib, d - abscess capsule (according to V. M. Belogorodsky).

The patient is given a semi-sitting position on a healthy side and resection of the IX-X ribs is performed from the side (between the posterior and middle axillary lines) or from behind (inwards from the posterior axillary line). The abscess is opened after the parietal pleura is sutured to the diaphragm with an "overlap" suture. As a suture material, catgut or silk is used. Its thickness should be such that
when the thread was folded in half, it was not thicker than the needle, otherwise the thread will damage the pleura during stitching. After suturing the pleura in the sheathed area, the diaphragm is dissected and the abscess is drained.
This approach is dangerous in relation to infection of the pleural cavity. Infection of the pleural cavity during puncture or during surgery in these debilitated patients is often "fatal" for them. Therefore, depending on the location of the abscess - in front or behind - it is better to use an extrapleural-extraperitoneal incision. If the abscess is located in front, then the incision is made along the IX or X ribs in front from the cartilage to the middle axillary line (Fig. 13), if behind, then along the XI-XII ribs from the long muscles of the back to the middle axillary line (Fig. 14) with rib resection. The pleura is bluntly peeled upwards, the diaphragm is exposed, which is dissected, the peritoneum is peeled off to the abscess and drained. When the abscess is located in front, you cannot approach it from behind and vice versa. In the postoperative period, under the control of the X-ray screen, the patient can adjust the position of the rubber drainage in the cavity in accordance with the presence of fluid under the diaphragm.
In some patients, intraperitoneal access to a subdiaphragmatic abscess is allowed; located in the abdominal cavity. In the presence of postoperative suppuration in the wound, the latter opens. Having found an abscess, it is opened, having previously introduced tampons that isolate the abscess from the free abdominal cavity and cause after the formation of adhesions that isolate the site of the operation of the former abscess.
After the operation, the principles of treatment of subphrenic abscesses consist in a set of measures, which we briefly discussed in the peritonitis section.