Modern problems of science and education. Who is an abdominal drain suitable for?

Nasointestinal intubation.

Laparostomy, program laparosanation.

№ 57. A patient was delivered to the surgical clinic with a diagnosis of perforated appendicitis complicated by widespread peritonitis.

1. What kind of access will you operate with? mid-lower midline laparotomy

2. How is the stump of the process processed in conditions of typhlitis? As a rule, with infiltration of the wall of the caecum, the imposition of traditional peritonizing sutures becomes not only impossible, but also dangerous. Most authors in such situations recommend ligature method treatment of the stump of the appendix or peritonization of its individual interrupted sutures without prior ligation of the stump of the appendix.

3. Name the sanitation methods abdominal cavity with peritonitis?

A method for intraoperative flow sanitation of the abdominal cavity with diffuse peritonitis, which consists in installing drains after removing the source of peritonitis, but before washing the abdominal cavity.

A method for intraoperative sanitation of the abdominal cavity in case of peritonitis with saline solution perfused with ozone with an ozone concentration of 1.2 μg/ml. Use evenly sprayed under a pressure of 60-65 atm. high-flowing jet of ozonized saline.

A method for combined sanitation of the abdominal cavity with diffuse peritonitis using hypo- and hyperthermic ozonized solutions, which alternately alternate 2-3 times during the operation.

The method of intraoperative hardware sanitation of the abdominal cavity with diffuse peritonitis using the apparatus "Geyser" and hyperosmolar polyionic solutions.

5. method for postoperative sanitation of the abdominal cavity using drains installed in the upper and lower floors of the abdominal cavity, as well as five multiperforated irrigation tubes: in the right and left lateral canals, both mesenteric sinuses and zigzag along the small intestine. 3-4 hours after the operation, under pressure, an antiseptic solution saturated with carbon dioxide. It is removed from the abdominal cavity by gravity, under the pressure of an air cushion, which was formed after bubbling CO 2, after which the antihypoxant solution "Mafusol" is injected into the abdominal cavity].

A method for sanitation of the abdominal cavity in the treatment of purulent peritonitis by peritoneosorption with a sorbent saturated with an antibiotic, Algipor preparation is used as a sorbent. Algipor therapeutic dressings are placed in the left lateral canal, left subdiaphragmatic space and envelop the anastomosis area.

A method for the sanitation of the abdominal cavity in case of generalized peritonitis, which consists in supplying oxygen through irrigator tubes installed in the right and left mesenteric sinuses, right and left subphrenic spaces, removed through a laparotomy. Physiological solution is fed into the laparostomy in the opposite direction, which is drained through drainage tubes installed in the pelvic cavity, right and left side canals.

8. methods of sanitation of the abdominal cavity in the form of relaparotomy "according to the program" and "on demand". Relaparotomy "on demand" is performed with the progression of the process, the occurrence of complications of peritonitis: bleeding from the digestive tract, perforation of a hollow organ, the formation of abdominal abscesses, etc. Program sanitation of the abdominal cavity along with the presence good points- this is constant control for the state of the abdominal cavity, have a number of disadvantages. These include the formation of intestinal fistulas, recurrence of intra-abdominal and gastrointestinal bleeding, prolonged intubation hollow organs and catheterization of the great vessels, which increases the risk of nosocomial complications, wound healing secondary tension with the subsequent formation of ventral hernias. When applying the above methods, the length of stay of patients in the hospital is from 20 to 50 days.

9. method of sanitation of the abdominal cavity, including washing the abdominal cavity, installing drains and sounding with medium (300 kHz) and low frequency (14.7 kHz) ultrasound. Sounding is carried out both during the operation and in postoperative period through the openings in the abdominal wall. The abdominal cavity is washed with an antiseptic solution. Exposure to ultrasound produced in the postoperative period. In this case, ultrasonic emitters are placed in the drainage tubes only for the time of the simultaneous sounding, followed by their removal.

4. How will you complete the operation?

Rational completion of the operation (determining indications for drainage or packing of the abdominal cavity; ensuring revisions and sanitation of the abdominal cavity using the method of open "interventions" or laparoscopically.

No. 58. A 37-year-old patient was delivered 12 hours after repeated vomiting of bile and sharp girdle pain in the upper abdomen. The disease is associated with alcohol intake and fatty foods. On examination: severe condition, pallor skin, acrocyanosis, the abdomen is swollen, participates in breathing to a limited extent, is tense and sharply painful in epigastric region. Percugorno - shortening of the sound in sloping places of the abdomen. positive symptoms Blumberg-Shchetkin and Mayo-Robson. Pulse - 96 per minute, weak content. BP - 95/60 mm Hg, body temperature -37.2 °C. Blood leukocytes - 17.0x109 / l.

With widespread purulent peritonitis, median laparotomy, exudate evacuation, and elimination of the source of peritonitis are sequentially performed. Exudate, bile, pus, urine, gastric, intestinal contents are removed using an electric suction, the source of infection is isolated with large napkins and eliminated.

The affected organ appendix, gallbladder) is removed, a hole in the intestine, stomach is sutured, necrectomy is performed for pancreatic necrosis, obstructive resection of the colon, etc. The desire for radical intervention (gastric resection, gastrectomy, resection of the colon, etc.) in conditions of widespread peritonitis is contraindicated and is strictly commensurate with the severity of the condition the patient and the severity of the purulent-destructive process in the abdominal cavity.

The abdominal cavity is washed with solutions of antiseptics - sodium hypochlorite, potassium furagin, dioxidine, as well as isotonic sodium chloride solution with ultrasonic cavitation and subsequent aspiration of the liquid with an electric pump up to " pure water". For sanitation of the abdominal cavity, only solutions that can be administered intravenously are acceptable, as this avoids intoxication caused by the absorption of drugs into the blood.

The procedure is repeated several times, spending from 2 to 7 liters of liquid. The cavity is filled to the edges of the wound with a solution of body temperature, the intestinal loops, omentum are moved into the cavity with light movements, and then the contents are aspirated with an electric suction, removing it also from under the diaphragm, from the lateral canals, small pelvis, omental bag.

Drainage of the stomach, intestines is an integral component of the treatment of patients. A nasogastric tube must be inserted. The issue of total intubation of the small intestine is decided individually. In severe paresis of the jejunum with swollen loops covered with fibrin, nasointestinal intubation is performed, passing the probe behind the Treitz ligament at a distance of 60-80 cm.

If the entire small intestine is sharply distended, its diameter exceeds 5 cm, it is full of liquid contents with toxic products of decay and fermentation throughout, the serous membrane is covered with massive fibrin overlays, with hemorrhages, or the operation was performed for peritonitis with mechanical intestinal obstruction, or was accompanied by dissection of extensive adhesions, decompression of the small intestine is indicated by its total intubation using the Miller-Abbott probe.

In any case of intubation of the small intestine, a separate probe is inserted into the stomach, since with a gaping pyloric canal, due to the intestinal probe passing through it, the intestinal contents flow into the stomach and can cause vomiting, regurgitation, and aspiration.

The residence time of the probe is determined by the presence of discharge along it and the appearance of peristaltic bowel sounds. Usually it is 3-4 days after the operation. With total splinting of the small intestine during operations for peritonitis and intestinal obstruction, the probe, if necessary, is left for up to 7 days.

If it is impossible to perform nasointestinal intubation of the small intestine, retrograde intubation through an ileostomy is used. On the ileum a purse-string suture is placed 20–80 cm from the ileocecal angle, and a Miller-Abbott type drainage tube is inserted through the puncture and carried out in a retrograde direction to the ligament of Treitz. The purse-string suture is tightened and the intestine at the site of drainage is fixed to the abdominal wall. It is possible to carry out drainage into the large intestine through a gastrostomy technique. In all cases, a nasogastric tube is performed.

Complete sanitation of the abdominal cavity during surgery is not always possible due to technical difficulties caused by the destructive process in the abdominal cavity and the violation of the relationship of organs. It needs to be taken out pathogenic microflora, toxic products of inflammation, fibrin, pus from the abdominal cavity and in the postoperative period, especially since inflammatory process in the peritoneum continues even after elimination or isolation of the source of infection.

Count on defensive forces peritoneum with a blind suture of the abdominal cavity, with advanced forms of peritonitis, it is not necessary due to the development of purulent complications and further progression of peritonitis.

Even with favorable course inflammatory process in the abdominal cavity after surgery, toxic exudate accumulates. Being absorbed into the blood, it contributes to the maintenance of toxicosis.

Indications for drainage of the abdominal cavity with peritonitis are determined primarily by inflammation of the peritoneum (form, prevalence, stage of the process). Drainage tubes with peritonitis are quickly demarcated, their lumen closes, and they cease to function. The use of gauze swabs as drainage is not only ineffective in conditions of widespread peritonitis, but also harmful. Adhesions form very quickly around the tampons, and a significant inflammatory reaction develops.

Communication with the free abdominal cavity stops, tampons become a kind of "plugs" that clog holes in the abdominal wall and contribute to the accumulation of exudate. The use of glove, glove-gauze and tubular-glove drainage is possible with local peritonitis.

Sanitation of the abdominal cavity after surgery determines its drainage. There are three types of drainage systems: fixed drainage systems - passive drainage with spontaneous discharge of exudate; immobile drainage systems using multiple drainage tubes and active influence on the inflammatory focus in the abdominal cavity (lavage, active aspiration); staged sanitation using laparostomy.

In passive drainage, upper and lower drains are installed to evacuate exudate, and rubber-gauze drainage is used to expand the zone of the drainage channel.

For active influence on the focus of inflammation, two upper drainages are placed in top floor abdominal cavity - under the liver on the right and under the diaphragm on the left, the other two are installed in the lateral channels of the abdominal cavity and drainage for evacuation of exudate from the small pelvis. If necessary, drains can be installed in different parts of the abdominal cavity, depending on the prevalence of peritonitis.

Options for drainage of the abdominal cavity with widespread peritonitis (a, b, c)

Drainage of the abdominal cavity with widespread peritonitis for peritoneal lavage (a, b, c). Use drainage tubes and cigarette drains

a - effective lavage; b, c - decrease in efficiency

Indications for laparostomy:
. widespread peritonitis III-IVA, IVB stages with severe endogenous intoxication, multiple organ failure;
. widespread or limited peritonitis with necrosis of the abdominal organs or retroperitoneal tissue;
. anaerobic peritonitis;
. delayed relaparotomies in postoperative peritonitis as in a tendency to delimitation multiple foci inflammation in various parts of the abdomen, and with a common process;
. eventration with widespread peritonitis through a purulent wound, as well as with high risk eventration (suppuration of the surgical wound with necrosis of the skin, muscles, aponeurosis).

There is a simple and available method using a zipper (zipper-laporostomy). This option of laparostomy allows you to control inflammation in the abdominal cavity and perform staged sanitation and necrectomy.

After a wide laparotomy (relaparotomy) and elimination of the source of peritonitis and sanitation of the abdominal cavity, the subhepatic and subdiaphragmatic spaces, and the small pelvis are drained. Zippers are used to temporarily close the abdominal cavity. industrial production not less than 30 cm long, each half 2-2.5 cm wide. PVC tubes are hemmed to the edges of the zipper, washed thoroughly, rinsed and stored until used in alcohol solution chlorhexidine.

Before fixing to the skin, the zipper is disconnected and alternately sutured by the fixed tube to the edges of the surgical wound. Detachable parts are fixed with U-shaped skin sutures, 2-2.5 cm away from the edges of the wound. After fixing the individual parts of the zipper to the skin, an omentum is placed on the intestinal loops, and a napkin moistened with an antiseptic is placed between the walls of the wound to prevent damage to the adjacent intestinal loops by the zipper lock.

Program postoperative management patients with widespread peritonitis during laparostomy includes: choice rational method anesthesia; multiple dressings with revision of the abdominal cavity, anastomotic zones, former source infection and washing with an antiseptic solution; necrectomy, prevention and localization of complications in the abdominal cavity; suturing the laparotomic wound.

For planned sanitation with laparostomy, local anesthesia is used - epidural anesthesia (extended); intravenous, inhalation (mask and intubation anesthesia). Indications for intubation anesthesia is the possibility of respiratory failure during planned rehabilitation abdominal cavity; Refusal of multiple use of mask and intubation anesthesia has a positive moral impact on the patient and his relatives.

The first sanitation with revision of the abdominal cavity is carried out in the operating room, 15-20 hours after the intervention. The zipper is opened, the gauze napkin is removed, the edges of the wound are inspected, loose adhesions are separated between the edges of the dissected aponeurosis and the adjacent loops of the intestine or omentum. An audit of the abdominal cavity is performed, up to 2-3 liters of an antiseptic solution are injected into it.

In other cases, with successful first sanitation, they are repeated according to the state of the inflammatory process, general condition sick. disappearance purulent exudate, subsidence inflammatory phenomena, restoration of intestinal motility serve as an indication for the removal of laparostomy and suturing the wound of the abdominal wall. The wound is sutured through all layers using Donati sutures. Spend 2-4, in extremely severe cases - 8-10 stage sanitation.

An increase in intra-abdominal pressure with widespread peritonitis is due to intestinal paresis, its overdistension with gases, liquid contents, and accumulation of fluid in the abdominal cavity. High intra-abdominal pressure causes serious violations functions of organs and systems; this is called abdominal compartment syndrome.

These changes are expressed in a disorder of cardiovascular activity (displacement of the heart as a result of moving the diaphragm, a decrease cardiac output, a decrease in visceral blood flow, including renal, an increase in pressure in the inferior vena cava and hepatic veins, an increase in CVP). The gas exchange function of the lungs is impaired due to an increase in intrathoracic pressure, impaired respiratory excursions of the lungs, a decrease in tidal volume, etc.

To reduce intra-abdominal pressure with widespread peritonitis, it is advisable to complete the operation by suturing the skin without suturing the aponeurosis, and during laparostomy using a zipper, fix the zipper behind a hemmed vinyl chloride tube with intradermal sutures.

A comprehensive program for the treatment of patients with purulent peritonitis is carried out taking into account the stage of toxicosis.

With grade I endotoxicosis, traditional infusion-transfusion therapy aimed at correcting homeostasis, as well as conventional intracorporeal detoxification using detoxifying blood substitutes and forced diuresis, is sufficient. With concomitant hepatic-renal insufficiency from efferent methods shown ultraviolet irradiation blood and hemosorption.

With endotoxicosis of the II degree, in addition to traditional corrective therapy, intracorporeal detoxification, plasmapheresis, hemofiltration, and their combination are appropriate.

With endotoxicosis III degree programmed sanitation of the abdominal cavity, infusion-transfusion corrective therapy, decompression of the gastrointestinal tract, programmed sessions of efferent detoxification and hemocorrection are shown: programmed UBI, plasmapheresis, hemofiltration.

Hemofiltration in peritonitis allows you to remove toxins from the plasma, interstitial fluid and cells. It does not cause injury cellular elements, happening minimum loss protein and intact against immune factors. Sessions of efferent methods of detoxification are carried out under the dynamic control of homeostasis and general toxic tests.

Undoubtedly, all these methods emergency assistance, but the urgent start of out-of-organ elimination of toxic products from body media should not be followed by quick ending this type of treatment. It should be borne in mind that with widespread peritonitis, the focus is first the source of intoxication. purulent inflammation organ destruction. After its elimination, the inflamed parietal and visceral peritoneum remains the main source of intoxication.

Even with a favorable course of peritonitis, a significant time is required to eliminate the inflammation of the peritoneum, the resolution of visceritis. On the background deep violation microcirculation and impaired absorption, conditions are created for the entry into the internal environment of the body of toxic products in a significant amount. The inclusion in this period of the mechanism of artificial purification of blood, lymph gives certain time to maintain and restore organ function natural system body detoxification.

An important principle of detoxification is a combination of abdominal debridement, intestinal intubation and efferent detoxification methods.

Antibacterial therapy

AT modern conditions gram-positive microflora - staphylococcus and streptococcus - in a monoculture is highly sensitive to a large set of antibiotics.

However, in order to suppress staph infection it is more rational to use semi-synthetic drugs: methicillin, ampicillin, carbenicillin, ampiox and aminoglycosides - gentamicin, kanamycin, tobromycin, amikacin. The sensitivity of the isolated staphylococcal microflora to these antibiotics is 62.5-100%.

For suppression streptococcal infection in general, the range of antibiotics used can be expanded by introducing penicillin, oleandomycin, lincomycin, etc. Significantly less sensitivity is observed in the isolation of fecal streptococcus, but even in these cases, more hope can be placed on gentamicin, carbenicillin, tobromycin, amikacin. sensitivity to which significantly exceeds 80%.

The spectrum of gram-negative microflora sensitive to antibiotics is significantly narrowed. Escherichia coli is sensitive in 60-95.2% to carbenicillin, gentamicin, amikacin. Proteus, Pseudomonas aeruginosa remain sensitive to gentamicin, tobromycin, amikacin, and rarely carbenicillin. With microbial associations, it is more effective combined application antibiotics.

When selecting antibiotics, their distribution in the body is taken into account, as well as the possibility of interaction, since the synergistic, antagonistic and indifferent effects of antibiotics are known. The best option is a combination of drugs with a synergistic effect. At the same time, drugs with different mechanisms of action should be selected (but the sensitivity of the microflora should remain high to all selected antibiotics), and contraindications to certain antibiotics should be taken into account.

In modern conditions, with purulent peritonitis, aminoglycosides (gentamicin, amikacin, tobromycin), third-fourth generation cephalosporins, carbapenems, metronidazole, dioxidine are most often used.

Various variants of the course of the inflammatory process in the abdominal cavity, depending on the nature of the pathogen and the degree of endotoxicosis, make it possible to establish the main clinical and microbiological parameters for the selection of antibacterial drugs even before identifying the microflora and determining sensitivity to antibiotics.

In extremely severe patients with MIP > 20, SAPS > 8 points, empiric antibiotic therapy is started with reserve antibiotics that have a wide range action and minimal toxicity. These are fourth-generation cephalosporins, carbapenems. Carbapenems - ideal preparations for empirical monotherapy: they cover the entire spectrum of pyogenic flora (aerobes + anaerobes), microbial flora is highly sensitive to them. If this therapy turned out to be effective, then its correction based on the results of a microbiological study should not be carried out.

Key Performance Criteria various options antibiotic therapy: body temperature, leukocytosis, dynamics of bacterial contamination of the abdominal cavity, frequency of reinfection or lack of growth of microflora.

Among the complications of antibiotic therapy for peritonitis is the Jarisch-Herxheimer reaction. Clinically, this reaction is manifested by high (up to 39.5 ° C), often hectic fever, pallor of the skin, dry mucous membranes, tongue, high leukocytosis, shift of the blood formula to the left and toxemia. Often such a reaction against the background of an improvement in the patient's condition has no logical explanation. They change the antibiotic, increase its dose, prescribe new combinations of drugs. However, the essence of such an exacerbation reaction is the development of a new wave of endogenous toxicosis, up to toxic shock as a result of the bactericidal action of antibiotics.

Irrational antibiotic therapy, unreasonably prolonged use of antibiotics in patients with peritonitis violate the natural balance of microflora. The influence of antibiotic-resistant flora is increasing. The spectrum of action of drugs should be taken into account. Otherwise, superinfection is observed, i.e. as a result of therapy new disease with specific clinical manifestations.

The causative agents of infection can be the natural inhabitants of the body, fungi, hospital flora Similar state regarded as "tertiary peritonitis". Essentially, it is a dysbacteriosis often caused by methicillin-resistant Staphylococcus aureus. Vancomycin, teikoplakin are shown. With superinfection caused by a bacillus of blue-green pus, carbopenems (name, meropenem) are effective.

Systemic fungal infection as a manifestation of dysbacteriosis occupies a significant place. She calls fungal infection organs, the development of candidiasis up to candidasepsis. The main symptom of this complication is dyspeptic disorders. Reliable diagnosis can only be established by microbiological examination and determination of the ratio of the natural intestinal microflora.

Treatment and prevention of the described complications of antibiotic therapy occupies an important place in severe peritonitis, abdominal sepsis. Differential Diagnosis Jarisch-Herksheimer reactions with developing purulent complications presents known difficulties. With a favorable course of inflammation and normalization of body temperature, and then the unexpected appearance of its significant fluctuations, antibiotics should be canceled for 2-3 days.

If this cannot be done due to the severity of the patient's condition and intractable inflammation, the combination of antibiotics is changed, minimizing their use, sulfonamides and nitrofuran preparations are used. Of the derivatives of quinoxaline, dioxidine is effective.

After 9-10 days of massive antibiotic therapy for peritonitis, more attention should be paid to the prevention of these complications, without waiting for the development of candidiasis or other dysbacteriosis. Complex therapy provides complete protein nutrition, vitamins C, group B, multivitamins. Antifungal agents are used as a means of specific protection. antibacterial drugs: nystatin, levorin, fluconazole.

An important role in the treatment of dysbacteriosis is played by the restoration of the natural intestinal microflora. For these purposes, colibacterin, bifidumbacterin or bifikol are prescribed. There are certain indications for the use of each drug, which are specified after microbiological research feces.

Drainage of the abdominal cavity after surgery is usually a necessary measure to save the patient's life. Such medical procedure carried out in order to remove the liquid content. In parallel with drainage, sanitation is often used, which involves washing the abdominal cavity. antiseptic solutions. As a result, optimal conditions for the normal functioning of internal organs.

Appointment of a medical procedure

Surgical methods of treatment of diseases are always a necessary measure. They are effective, but are associated with serious risks to the health of the patient. It is important to carry out the operation correctly and ensure qualified postoperative care. Therefore, after doing surgical intervention debridement and drainage of the abdominal cavity is often performed to remove fluid.

Usage similar procedures during surgery, including laparoscopy, to prevent the development of complications. This is an effective way of rehabilitation of patients with purulent peritonitis and other dangerous diseases. Installation of drainage also helps to prevent recurrence of pathologies, which is actively used in medical practice.

A direct indication for performing such medical manipulations is the accumulation of fluids in the peritoneum called effusion or exudate. They appear if an acute inflammatory process occurs in the body. This liquid contains great amount dead cells, pathogenic microorganisms, minerals. If the effusion is not removed with the help of installed drainage tubes, the inflammatory process will actively progress.

Additional sanitation with antiseptic solutions ensures the elimination of exudate residues and the destruction of pathogenic microorganisms. Washing the abdominal cavity after its drainage provides the most favorable conditions for quick recovery the functioning of the body.

Types of drainage

In the intraoperative period, patients undergo drainage of the abdominal cavity in two ways:

• physiological;
• surgical.

Physiological drainage involves the use of laxatives and determining the optimal position of the patient in bed, which ensures the natural drainage of fluid. Drugs that increase intestinal peristalsis are used. This contributes to the rapid absorption of the accumulated fluid. If parallel to a little raise lower part trunk, provides a large area for the absorption of substances.

Physiological methods of drainage are effective, but in practice surgical methods are used more, which are described in detail in the works of Generalov A. I. V this case special tubes are used to ensure the outflow of fluid to the outside. The functioning of drainage is possible due to the presence of intra-abdominal pressure, which increases significantly if a person takes a semi-sitting position.

Execution technique

Drainage of the abdominal cavity during laparoscopy or abdominal operations is carried out taking into account the observed clinical picture. Based on this, the doctor chooses methods of conducting such interference. Much attention is paid to the selection of instruments for drainage, sanitation fluids.

Drainage Requirements

To perform drainage, a system of tubes is used, which is introduced into the abdominal cavity. It consists of several elements:

• tubes made of rubber, plastic or glass;
• catheters and probes;
• rubber graduates;
• wipes, tampons.

These items must be sterile to ensure the effectiveness of the procedure. If the abdominal cavity is filled with pus, it is not advisable to use rubber tubes. They clog up quickly, making it difficult to drain further. In this case, doctors use a silicone system.

The diameter of the drains is selected taking into account the installation site, on average it ranges from 5-8 mm.

Drainage technique

For the effectiveness of drainage and sanitation, it is important to choose the right location for the installation of the tube system. The doctor considers character developing pathology and the condition of the patient. Typically, drains are placed in front of the lower wall of the diaphragm or near the stomach. After choosing a drainage site, proceed to the procedure itself:

1. The skin, where drainage is supposed to be installed, is carefully treated with an antiseptic solution.
2. An incision is made with a size of 3-5 cm, depending on the thickness of the subcutaneous fatty tissue.
3. The drainage system is carefully introduced. It is placed between the intestines and the washed organ. The loops of the intestines should not envelop the drainage, this can lead to the development of adhesions.
4. Drainage tubes must be fixed with a seam. This will ensure their stable position during the procedure.

The duration of the drainage in the abdominal cavity depends on the developing clinical picture. Can be used no more than 7 days. Removal of the system from the abdominal cavity should occur as quickly as possible, since as a result of prolonged contact of the tubes with the intestine, there is a possibility of pressure ulcers. Also, the drainage system quickly becomes clogged with effusion, which reduces its patency and the effectiveness of the procedure.

Features of the rehabilitation

If pus and other contaminants are detected in the peritoneum during drainage, sanitation is performed. For this, it is used isotonic solution sodium chloride, furatsilin or other drugs. Washing is carried out until there is no pus in the secreted mixture.

0.5-1 l of solution is injected into the abdominal cavity, the amount of which is determined by the complexity of the patient's condition. An electric pump is additionally used to remove the liquid. Especially thorough washing is necessary for the subdiaphragmatic space, where the presence of pus may go unnoticed.

Sanitation is also carried out in case of traumatization of the organs of the retroperitoneal space. For the procedure, it is recommended to use silicone tubes with a diameter of 1.2 cm. Washing is carried out from the side of the abdominal cavity. Especially carefully and in compliance with the rules of antiseptics, washing with solutions near the walls of the bladder is performed.

The abdominal cavity is sutured using natural threads with a continuous suture.

Complications and prognosis

Drainage and sanitation of the peritoneum is carried out in the presence of strict indications. The result of the manipulations performed depends on hygiene and antiseptic rules. The main parts of the drainage system must be replaced every 10-12 hours. This will prevent their contamination and provide optimal fluid pressure.

A serious complication of this procedure is the loss of drainage tubes. To prevent this, it is necessary to securely fix them with adhesive plaster, bandage, by suturing. During the procedure, medical personnel must constantly monitor the system. It is important not to kink the wash tubes. The movement of the fluid should be free, while the patient is not recommended to change the position of the body. Subject to the specified rules and requirements, the specified medical manipulations do not pose a danger to the patient and end safely.

Development postoperative complications associated with poor sanitation. If exudate remains after its implementation, there is a high probability of formation of infiltrates. Subsequently, the development of abscesses is observed. Improper drainage can also lead to complications such as eventration, fistulas, intestinal obstruction caused by adhesive processes.

After the procedure, there are negative consequences in the form of ventral hernias, suppuration postoperative wounds or their prolonged healing, secondary infection of the abdominal cavity.

Quite difficult and ambiguous is the question of choosing the optimal treatment, and first of all surgical tactics. The principle of radical surgical treatment is based on the complete, adequate and early elimination or delimitation of all the main, additional and potential sources (foci) of endogenous intoxication, both microbial and dysmetabolic. At the next stage of surgical treatment, the implementation of peritoneal lavage and sanitation of the abdominal cavity provides, although not in all cases, a sufficient decontamination and detoxification effect. Treatment and prevention of re-infection is achieved by a reasonable choice of one or more methods: peritoneal lavage with antiseptics in flow or fractional mode; programmable (staged) revision and sanitation of the abdominal cavity, laparostomy.

Simultaneous sanitation of the abdominal cavity on the operating table.

After removing the source of peritonitis, an important step in the operation is the removal of pathological exudate from the abdominal cavity in order to maximize the decontamination of the surface of the parietal and visceral peritoneum. To date, the most common and recognized method of intraoperative sanitation by almost all surgical schools remains the washing of the abdominal cavity using an antiseptic solution.

After draining the abdominal cavity using an electric suction and gauze wipes, its sanitation begins with washing with a 0.5% heated solution of chlorhexidine, a 1:5000 solution of furacilin or sodium hypochlorite at a concentration of up to 1200 mg / l. As a rule, about 4-6 liters of solution are spent on adequate sanitation of the abdominal cavity. In the later stages of peritonitis, when a large amount of effusion accumulates in the abdominal cavity, the volume of fluid for washing increases to 8-10 liters. Washing continues until the liquid becomes clear. An obligatory component of sanitation is the removal of fibrin layers from the loops of the intestine and peritoneum, since fibrin films contain the same number of microorganisms as peritoneal exudate, both in qualitative and quantitative terms.

In recent years, in order to increase the effectiveness of the antimicrobial effect of intraoperative sanitation, a number of authors propose, in addition to including antibiotics in the solution for washing, using ultrasound treatment of the abdominal cavity. Furacilin solution is used as the sound medium, water solution chlorhexidine, furagin solution or broad-spectrum antibiotics.

It should be noted that although one-stage sanitation of the abdominal cavity on the operating table is a basic element of treatment, with widespread peritonitis, it must necessarily turn into one of the options for prolonged sanitation.

Methods of prolonged sanitation of the abdominal cavity:

To date, the surgeon has only four options for completing surgery:

traditional drainage of the abdominal cavity with blind suture of the laparotomic wound and massive postoperative antibiotic therapy

flow or fractional peritoneal lavage

prolonged (programmed) relaparotomy

laparostomy

The first two methods today have lost their paramount importance and preference is given to the last two.

Treatment of severe forms of peritonitis is a complex task that requires an integrated approach.

Already in the case of local peritonitis or the reactive phase of widespread (diffuse) peritonitis, the treatment program includes measures determined by the characteristics of the body's response to the inflammatory process and the presence of concomitant diseases. If we are talking about the peritoneal form of abdominal sepsis, then therapeutic measures begin in the intensive care unit, continue during anesthesia, surgery, and then in the postoperative period.

Tasks of intensive care in abdominal sepsis :

1) recovery in terms of volume and content of the internal environment of the body. In severe abdominal (peritoneal) sepsis, the loss of intracellular fluid reaches 15–18 %, which is the maximum permissible value. Without eliminating cellular dehydration, it is impossible to count on the correction of metabolic disorders. Therefore, the need to introduce large amounts of low-concentration polyon solutions (up to 100-150 ml per 1 kg of body weight) determines to a large extent the content of infusion therapy on the first day of treatment. At the same time, the elimination of cellular dehydration must be rationally combined with the replenishment of the BCP, the restoration of ion-electrolyte, colloid-osmotic and acid-base relationships.

2) elimination of tissue hypoxia. In this regard, along with infusion-transfusion therapy, recovery is of particular importance. external respiration using modern equipment and auxiliary ventilation modes.

3) detoxification . Controlled hemodilution with forced diuresis is combined here with the rational use of extracorporeal detoxification methods, and the greatest intensity of this group of activities falls on the postoperative period, when measures to eliminate the sources of endotoxicosis have already been implemented.

4) restoration and maintenance of plastic and energy potential . These activities are also carried out in the postoperative period. The development of peritonitis is accompanied by massive catabolism. The body's needs for energy and plastic resources increase dramatically. On average, patients with peritonitis should receive at least 2500–3000 kcal per day. Early enteral tube feeding is promising.

The central and most important role in a comprehensive treatment program for widespread (diffuse) purulent peritonitis belongs to surgical intervention.

Preoperative preparation at The vast majority of patients should not exceed 1-3 hours. At the same time, taking into account individual differences depending on the age of patients, body weight, the presence of concomitant diseases, the general scheme of preoperative preparation should include:

Jet (in the presence of cardiopulmonary insufficiency - drip) intravenous administration of low-concentrated polyionic crystalloid solutions in an amount of up to 1000-1500 ml, preferably under the control of CVP;

The introduction of 400-500 ml of colloidal solutions to replenish the volume of the circulating fluid;

Intravenous use of broad-spectrum antibiotics;

Correction of central and peripheral hemodynamics.

The need for intravenous antibiotics in the preoperative period is determined by the inevitable mechanical destruction during surgical intervention of biological barriers delimiting the area infectious process and natural intra-intestinal biocenosis. Therefore, surgery for peritonitis should be performed against the background of creating a therapeutic concentration of antibacterial drugs in the blood and tissues.

The subclavian vein is always catheterized. This provides a high rate of infusion, the ability to control CVP. It is advisable to catheterize the bladder to measure hourly diuresis as an objective criterion for the effectiveness of infusion therapy. Be sure to empty the stomach with a tube. At running processes the probe must be in the stomach constantly, during the entire preoperative period, during the operation and for some time after it (until the restoration of the peristalsis of the stomach and intestines).

Preoperative preparation begins immediately after the diagnosis is established and ends in the operating room, successively moving into the anesthetic management of the operation. Surgery for widespread (diffuse) peritonitis is always performed under multicomponent general anesthesia With artificial ventilation lungs.

Surgery with widespread (diffuse) peritonitis, it provides for the following main tasks:

Elimination or reliable isolation of the source of peritonitis;

Intraoperative sanitation and rational drainage of the abdominal cavity;

Creation of conditions for prolonged sanitation of the peritoneal cavity in the postoperative period;

Drainage of the intestine, which is in a state of paresis;

Creation of favorable conditions for influencing the main pathways of resorption and transport of toxins (according to special indications);

Closure of the laparotomic wound.

Most rational access with widespread peritonitis - median laparotomy, providing the possibility of a full revision and sanitation of all parts of the abdominal cavity. If widespread peritonitis is detected during an operation performed from a different incision, then you should switch to a median laparotomy.

After opening the peritoneum as completely as possible pathological content is removed: pus, blood, bile, stool etc. This can be done most fully and less traumatically with the help of an electric pump. Particular attention is drawn to the places of accumulation of exudate: subdiaphragmatic spaces, lateral channels, the cavity of the small pelvis.

Then a thorough revision of the abdominal organs to identify the source of peritonitis. This stage may be preceded by the introduction of 150–200 ml of a 0.25% solution of novocaine into the region of the celiac trunk, the root of the mesentery of the transverse colon, small and sigmoid colon and under the parietal peritoneum, which ensures a reduction in the need for narcotic analgesics, reflex vascular spasm is eliminated, which creates conditions for an earlier recovery of peristalsis.

To eliminate the source of peritonitis, the simplest and fastest method is used. In the reactive phase, it is possible to carry out radical operations (gastric resection, hemicolectomy), since the probability of anastomotic failure is negligible. In toxic and terminal surgery, the scope of the operation should be minimal: appendectomy, suturing of the perforated hole, resection of the necrotic area of ​​the gastrointestinal tract with the imposition of an entero- or colostomy, or delimitation of the focus from the free abdominal cavity. All reconstructive operations are transferred to the second stage and performed in more favorable conditions for the patient. At the same time, it is necessary to measure the volume of intervention with the severity of the patient's condition and not expand the operation, striving in all cases to radically eliminate the underlying disease that caused peritonitis.

The next step in the operation is sanitation of the abdominal cavity. It is necessary to pay special attention to this moment of intervention. Its inferiority cannot be filled by any efforts in the postoperative period. Sanitation consists in an additional revision after eliminating the source of infection and carefully removing exudate and pathological contents from the abdominal cavity, and when the process is extended to all its departments. H The best method of intraoperative debridement is repeated washing of the abdominal cavity with sterile solutions. Usually physiological saline, chlorhexidine solution are used. Washing reduces the content of microorganisms in the exudate below the critical level (10 5 microbial bodies in 1 ml), creating favorable conditions for the elimination of infection. Sanitation is carried out in a gentle way, without eventration of intestinal loops. Heated to a temperature of 35–38 ° C, the solution is poured into the abdominal cavity in such an amount that the loops of the intestines float in it. After washing the abdominal cavity, the solution is removed using an electric suction. Washing is carried out to "clean water". Solid particles of food masses, feces, fibrin films, etc. carefully removed with tweezers or a tupfer soaked in novocaine solution. Tightly fixed fibrin deposits are not removed due to the risk of deseration. For sanitation of the abdominal cavity is usually used from 4 to 8 liters of solution.

Then the question of drainage of the small intestine. It is indicated for severe signs of paralytic ileus. Identification during operations of sharply stretched contents of the loops of the small intestine, with flabby cyanotic walls covered with fibrin, with dark spots of subserous hemorrhages, should be considered the basis for draining the intestinal tube.

Decompression of the small intestine can be quite effectively carried out by nasogastric drainage with a Muller-Ebott probe. At the same time, emptying and prolonged drainage of the initial part of the jejunum (50–70 cm from the ligament of Treitz) is of particular importance, where the contents pose the greatest threat to the development of endotoxicosis. It is important to make sure that the proper drainage of the stomach is complete. The drainage is kept in the jejunum for 3-4 days and removed after the intestinal contents stop flowing through it (with mandatory control of the patency of the probe!) And the appearance of intestinal noise during auscultation. In the postoperative period, a probe correction of the enteral environment is performed, including decompression, intestinal lavage, enterosorption, and early enteral nutrition. This reduces the permeability of the intestinal barrier to microflora and toxins, leading to an early restoration of the functional activity of the gastrointestinal tract. The large intestine, if necessary, is drained through the anus. In the event that the drainage of the intestinal tube is associated with the dissection of adhesions caused by previous operations, the small intestine is drained throughout, and the probe is stored for 7-8 days. Only under this condition can it perform a frame function and eliminate the risk of developing adhesive intestinal obstruction in the immediate and long-term postoperative period.

The final stage of surgical intervention is rational drainage of the abdominal cavity (Figure 1).

Picture 1– Scheme of drainage of the abdominal cavity with diffuse peritonitis

Task for creation of conditions for full sanitation of the abdominal cavity in the postoperative period solved in different ways depending on the specific conditions. An effective method of postoperative sanitation of the abdominal cavity is its irrigation with a solution of antiseptics (previously widely used solutions with antibiotics, as shown by meta-studies, have no advantages over conventional antiseptics, but at the same time contribute to the development of antibiotic resistance!). For this purpose, through the punctures in the right and left hypochondria in the transverse direction, a drainage tube with a diameter of 3-4 mm with multiple perforations is inserted along the part that is in the abdominal cavity. Both withdrawn ends of the tube serve for drip (better) or fractional (worse) introduction of the solution into the abdominal cavity. If necessary, another tube is introduced in a similar way below the level of the first tube, at a distance of 10-15 cm.

In order to remove the accumulated fluid, a two-lumen drainage tube is inserted into the pelvic cavity through an incision in the inguinal region on the left or right, providing the possibility of active aspiration with the introduction of flushing fluid through the nipple channel. The patient is laid horizontally and the head end of the bed is raised. If necessary, additional drainage of the lateral channels of the peritoneum is also carried out with double-lumen tubes through additional punctures of the abdominal wall. Attempts to carry out postoperative sanitation of the abdominal cavity through several nipple drains introduced into various sections between the intestinal loops or into the lateral channels of the peritoneum turned out to be ineffective. After a few hours, small closed cavities form around such microdrainages, which limit the contact of solutions with the peritoneum.

The primary operation is being completed with widespread peritonitis and a fully performed sanitation of the abdominal cavity suturing the wound of the abdominal wall . In the presence of severe intestinal paresis or pronounced signs of inflammation of the visceral and parietal peritoneum, only the skin with subcutaneous tissue. This, firstly, prevents the harmful effects of an increase in intra-abdominal pressure in the first days after the operation, and secondly, it makes it possible to perform a repeated programmable sanitation of the abdominal cavity in a day or two if the surgeon is not satisfied with the sanitizing measures during the first operation. Sometimes, for this purpose, provisional sutures are applied to the abdominal wall or a locking device with a “zipper” is fixed on it, which is not quite accurately referred to as the imposition of a “laparostomy”.

true laparostomy, when the abdominal wall is not sutured, and the intestinal loops are covered with ointment swabs, or when the treatment of an open abdominal wound is carried out in chambers with an abacterial environment, can only be used in exceptional cases(in the presence of multiple unformed intestinal fistulas, anaerobic peritonitis or phlegmon of the abdominal wall).

When similar situations develop secondarily as a result of repeated events leading to the formation of a wound of the abdominal wall with fixed edges, the bottom of which is intestinal loops, they must be isolated from direct contact with the external environment. For this purpose, after short-term preparation with sanitizing dressings with water-soluble ointments, the intestinal loops are covered with a split perforated (dermotome) free autoskin flap. The damage from the false ventral hernia of the abdominal wall formed as a result of such a technique is “compensated” by preventing the death of the patient from widespread peritonitis or from the formation of multiple small intestinal fistulas.

In recent years, due to the development endovideosurgical technologies it became possible to carry out with their help a programmed or indicated repeated sanitation of the abdominal cavity after surgery for widespread peritonitis, without resorting to relaparotomy. The special elevators available for this purpose make it possible to avoid the need for massive gas insufflation into the abdominal cavity and successfully perform revision and sanitation of various parts of the abdominal cavity.

Ensuring good nutrition in the catabolic phase of the postoperative period provides for the introduction, along with modern technologies of parenteral nutrition, of methods early enteral nutrition with the help of special nutritional formulations and the simultaneous introduction of digestive enzymes. If tube feeding is not possible (the location of the source of peritonitis in the upper floor of the abdominal cavity), enterostomy can be used for these purposes in the initial sections of the jejunum (it is also possible using endovideosurgical technique).

Great importance in the postoperative period is given to measures to correct impaired immunity.

Adequate anesthesia.

Along with traditional methods of pain syndrome treatment with the help of narcotic and non-narcotic analgesics, prolonged epidural analgesia with local anesthetics, acupuncture analgesia, electroanalgesia are used.

One of the central places in the complex treatment of peritonitis and endogenous intoxication in the postoperative period is detox therapy. Modern methods of detoxification are divided into two groups: intracorporeal and extracorporeal.

To intracorporeal include: enteral detoxification, hemodilution, forced diuresis, peritoneal dialysis, enterosorption, indirect electrochemical blood oxidation. To extracorporeal detoxification methods include: hemodialysis, hemofiltration, plasmapheresis, hemosorption, plasmasorption, lymphosorption, quantum blood therapy, xenosplenoperfusion.