Infections in abdominal surgery. Surgical treatment of peritonitis. Who is an abdominal drain suitable for?

Clinical practice indicates that in some cases surgical intervention have to drain abdominal cavity.

This method is used to bring out liquid contents that accumulate in hollow organs, wounds and abscesses.

The procedure provides the creation of favorable conditions for the recovery of the body after surgery.

Purpose of the procedure

Surgical methods of treatment of the abdominal organs are always accompanied by the risk of serious complications.

To avoid negative consequences, it is necessary to carefully prepare for the operation. Equally important is postoperative care for the sick.

Upon completion of the operation, the cavity is sanitized and drained to drain intra-abdominal fluid or pus.

Drainage is effective tool rehabilitation of the patient after surgical treatment of purulent or fecal peritonitis, as well as other diseases.

In some cases, this method is used in preventive purposes to avoid recurrence of the pathology.

The accumulation in the abdominal cavity of biological fluids, which are called effusion or exudate, is considered a sign that the body is leaking inflammatory process.

Actually, as a result of inflammation of the peritoneum, effusion is released. These fluids contain dead cells, minerals and pathogenic microbes.

If you do not take measures to remove them, then inflammation will develop.

To date, drainage is considered the most effective method, which creates favorable conditions for healing and recovery of the body after surgery.

Drainage methods

Sanitation of the abdominal cavity is carried out after any surgical intervention. Most effective way for this, drainage is considered.

To date, the following types of drainage are available to the attending physician:

1. physiological;
2. surgical.

With physiological drainage of the abdominal cavity, laxatives are used.

The prescribed medications increase intestinal motility, thereby contributing to the removal of fluid from the body.

For the procedure to bring the expected result, the patient must be in a supine position.

The lower part of the body must be raised in order to evenly redistribute the fluid over the peritoneal area.

Experts have long known that the accumulation of fluid occurs in certain spaces of the abdominal cavity.

If this substance is not removed in a timely manner, then it will serve as the basis for the development of inflammation. In such cases, surgical drainage is used.

The method involves the use of special tubes that are inserted into the cavity and ensure the outflow of fluid to the outside.

At the same time, it is necessary to ensure that the patient is located in such a way that the fluid does not stagnate in the sinuses and pockets, but flows out of the abdominal cavity.

Most often, this is a semi-sitting position, in which excess internal pressure is created.

Clinical practice proves that drainage should be carried out not only after abdominal operations, but also after laparoscopy.

In each case, the success of the procedure is determined by the following conditions:

• drainage method;
• drain tube orientation;
• the quality of antibacterial drugs.

Each of these factors has a certain impact on ensuring the timely and complete outflow of exudate.

AT emergency situations temporary use of improvised means is allowed, but this should not be taken as a rule.

Drainage Requirements

Currently technical means for drainage of the abdominal cavity are represented by a wide range of products.

The list includes the following items:

• tubes made of rubber, plastic and glass;
• graduates glove made of rubber;
• catheters and soft probes;
• gauze and cotton swabs.

An important condition for the procedure is to ensure the sterility of the instrument. Sanitation of the abdominal cavity ensures the elimination of infectious foci.

If sterility is violated during the installation of tubes, then the probability of recurrence of the pathology increases dramatically. The most vulnerable place in this regard is the point of contact between the tube and the skin.

According to the current methods, drainage is recommended for laparoscopy of the abdominal cavity.

After surgery to eliminate a certain pathology, it is very important to ensure the outflow of purulent residues.

Practice shows that rubber tubes become clogged with pus very quickly and do not perform their functions.

The diameter of the tube is selected in the range from 5 to 8 mm, depending on the installation location.

Today, new drainage devices have appeared that are gradually replacing the usual tubes.

Drainage installation

In order for the drainage of the abdominal cavity to bring the expected results, it is very important to determine the site for the installation of the drainage.

The place of accumulation of fluid depends on the type of pathology and anatomical features sick. Given these circumstances, the appropriate area for drainage is determined by the attending physician.

Over the years, the practice has been to place tubes in front of the lower wall of the diaphragm or at the anterior wall of the stomach.

After the installation site is determined, a simple but responsible procedure is performed. The insertion site of the tube is thoroughly disinfected with an antiseptic solution.

After antiseptic treatment, a small incision is made in the wall of the abdominal cavity, a clamp is inserted into this incision, and a drainage tube is inserted into the cavity through the clamp.

It is very important to securely fix the clamp so that it does not fall out when the patient moves.

Similarly, drainage is established during laparoscopy. After that, it is necessary to ensure effective drainage.

When the tube has fulfilled its functions, it is carefully removed. It must first be squeezed to prevent infection from entering the abdominal cavity.

Indications for drainage

Abdominal drainage procedure is not medical procedure. It is performed to ensure the recovery and rehabilitation of the patient after surgical treatment.

Infectious diseases of the internal organs are not always amenable to therapeutic methods treatment.

To avoid severe complications or lethal outcome performing surgical operations.

The peculiarity of the surgical method of treatment is that the underlying pathology is eliminated.

While the recovery and rehabilitation of the body require a long period of time, and not only time, but also certain actions.

First of all, it is necessary to remove the biological fluid from the abdominal cavity, the remains of which are located in different places.

Removal is performed by drainage after operations for various reasons. It can be acute appendicitis, chronic pancreatitis or cholecystitis.

A stomach ulcer is most effectively treated with a surgical method, intestinal obstruction too. In each case of surgical intervention, it is necessary to carry out drainage at the final stage.

The installed drainage significantly limits the freedom of movement of the patient. This limitation has to be put up with and endured so that recovery occurs in accordance with the prognosis.

The abdominal cavity is considered the most vulnerable organ in human body for microbes and viruses.

When draining, this must be remembered and all sterility requirements must be met.

Introduced short review Literature on the evolution of methods of sanitation of the abdominal cavity with general peritonitis. It is known that the most important component of the complex treatment of acute widespread peritonitis is the sanitation of the abdominal cavity, the quality of which largely determines the dynamics of the development of the pathological process, as well as the need for subsequent treatments of the abdominal cavity. The methods of drainage of the abdominal cavity, tamponade in case of bleeding and purulent processes, peritoneal dialysis, laparostomy, program relaparotomy are considered. Emphasis is placed on low-traumatic methods, including the use of modern equipment. It is shown that in recent decades, with the development of minimally invasive surgery, wide application in the diagnosis and treatment of widespread peritonitis found laparoscopic technology.

laparoscopy

laparostomy

peritonitis

1. Alieva E.A. New method sanitation and drainage of the abdominal cavity in experimental diffuse purulent peritonitis // Pathological Physiology and experimental therapy. - 2005. - No. 1. - S. 20-22.

2. Alieva E.A., Isaev G.B., Hasanov F.D. Ways to improve the effectiveness of postoperative sanitation of the abdominal cavity with diffuse purulent peritonitis (experimental clinical study) // Annals of Surgery. - 2008. - No. 5. - P.57-59.

3. Anisimov V.F., Palamarchuk V.F. Comparative evaluation drainage from rubber and from polyvinyl alcohol // Experimental Surgery and Anesthesiology. - 1963. - No. 4. - P.19-20.

4. Askerkhanov G.R., Guseinov A.G., Zagirov U.Z. Programmed relaparotomy for peritonitis // Surgery. - 2000. - No. 8. - P.20-23.

5. Ashfarov R.A., Davydov M.I. Abdominal drainage and lavage, decompression and lavage hollow organs gastrointestinal tract in the treatment of peritonitis // Surgery. - 2001. - No. 2. - P.56-59.

6. Babadzhanov B.D., Teshaev O.R., Beketov G.I. New approaches to the treatment of postoperative peritonitis. Vestnik khirurgii im. I.I. Grekov. - 2002. - No. 4. - P.25-28.

7. Bagdasarova E.A., Abagyan A.E., Ivannikov V.A. Semi-open laparostomy in the treatment of patients with generalized peritonitis // Annals of Surgery. - 2004. - No. 1. - P.61-65.

8. Bondarev G.A. The use of low frequency ultrasound in complex treatment peritonitis in experiment and clinic: Abstract of the thesis. dis. … cand. honey. Sciences. - M., 1981. - 23 p.

9. Briskin A.S., Savchenko Z.I., Khachatryan N.N. Abdominal sepsis, role antibiotic therapy// Surgery. - 2002. - No. 4. - P.69-74.

10. Briskin B.S., Khachatryan N.N. Treatment of severe forms of widespread peritonitis // Surgery. - 2003. - No. 8. - P.56-60.

11. Briskin B.S., Khachatryan N.N., Savchenko Z.I. Some aspects of the treatment of severe forms of widespread peritonitis // Surgery. - 2000. - No. 2. - P.17-21.

12. Bulynin V.I., Glukhov A.A. A new method of sanitation of the abdominal cavity // Ex Consilio. - 1998. - No. 1. - P. 28-41.

13. Valuyskikh Yu.V., Perkin E.M. The method of gas-liquid sanitation of the abdominal cavity with widespread purulent peritonitis // Kazansky medical journal. - 2008. - No. 1. - P. 93-95.

14. Gelfand B.R., Protsenko D.N., Ignatenko O.V. Syndrome of intra-abdominal hypertension (literature review) // Surgery. Appendix to Consilium medicum. - 2005. - No. 7. - P.1.

15. Gelfand E.B., Gologorsky V.A., Gelfand B.R. Clinical characteristics of abdominal sepsis in surgical patients // Infection and antimicrobial therapy. - 2000. - No. 1. - P.3-11.

16. Glukhov A.A., Zhdanov A.I., Andreev A.A. The method of parietal-cavitary sanation of the intestine in the complex treatment of acute widespread peritonitis. Vestnik khirurgii im. I.I. Grekov. - 2004. - No. 2. - P. 41-45.

17. Dudanov I.P., Mezhenin A.M., Sharshavitsky G.A. Evaluation of the effectiveness of drainage of the abdominal cavity. Vestnik khirurgii im. I.I. Grekov. - 2001. - No. 1. - P.63-66.

18. Evdokimov V.V. Pathogenetic criteria for the diagnosis and complex treatment of widespread peritonitis with the inclusion of lymphological methods // Surgeon. - 2007. - No. 5. - P.21-32.

19. Kirshina O.V. Place and possibilities of laparostomy in the complex treatment of patients with peritonitis: Abstract of the thesis. dis. … Dr. med. Sciences. - M., 1999. - 58 p.

20. Koreyba K.A., Ibatullin I.A., Stroitelev I.A. Clinical and anatomical rationale for the prevention of damage to the neurovascular bundles of the anterior abdominal wall with median laparotomy and drainage of the postoperative wound // Kazan Medical Journal. - 2001. - No. 5. - P. 328-330.

21. Cueto J., Diaz O., Rodriguez M. The efficacy of laparoscopic surgery in the diagnosis and treatment of peritonitis. Experience with 107 cases in Mexico City // Surg. Endosc. - 1997. - Vol.11, No. 4. - P.366-370.

The treatment of patients with widespread forms of peritonitis is a complex, unresolved problem in surgery. Despite the undoubted progress in medicine, mortality in peritonitis remains high. The main role in this is played by ineffective surgical sanitation of the purulent-inflammatory focus in the abdominal cavity, ongoing peritonitis or late admission of patients to the hospital.

Death of patients in postoperative period most often occurs due to the ongoing inflammatory process in the abdominal cavity. One of the main components of the complex treatment of acute widespread peritonitis is the sanitation of the abdominal cavity, the quality of which largely determines the dynamics of the development of the pathological process, as well as the need for subsequent treatments of the abdominal cavity.

Abdominal cavity drainage remains one of the first and most common sanitation methods to date. In 1881, J. Mikulicz developed a tamponade method for bleeding and purulent processes. It has now been proven that the use of tampons for peritonitis is not only ineffective, but also dangerous due to the development of such complications as the formation of intra-abdominal abscesses, bleeding, progression of peritonitis, and fistula formation.

The inserted tampon is saturated with exudate during the first 2-3 hours and turns into a “plug” that clogs the “hole” in the abdominal wall. The use of tampons can only be justified by stopping bleeding, in case of ineffectiveness or absence of other hemostatic methods. Its use is also possible in order to delimit an indelible source of peritonitis from the free abdominal cavity.

Since then, many different drainage devices have been proposed in order to improve drainage efficiency. Currently, silicone drains are widely used, since they are flexible, durable and do not cause decubitus ulcers of the intestinal wall during a long stay in the abdominal cavity. Functionally, the action of drains is limited by a time interval, since they do not have biological inertness and quickly separate from the abdominal cavity as a result of the processes of adhesion formation and fibrin overlays. Experimental studies show that drainage of the abdominal cavity, regardless of the number of drainage tubes and active aspiration, does not always contribute to adequate sanitation. In conditions of widespread peritonitis, in almost 80% of cases, within 12-24 hours after laparotomy, the drainage tubes lose their patency.

Of the two main methods, active and passive drainage, most surgeons prefer the latter. It is believed that the negative pressure in the drainage system during active drainage contributes to the obstruction of the drainage holes by adjacent tissues and organs.

Discussions are still ongoing about the methods of drainage, the material and form of drainage, the method of its implementation, the frequency of use and indications. There is also no consensus on the need for drainage of the abdominal cavity with peritonitis. The use of various drainage devices cannot always adequately evacuate toxic exudate from the abdominal cavity and prevent further intoxication of the body and the development of early postoperative complications. A common way to sanitize the abdominal cavity to date is washing it with antiseptic solutions (1-1.5% hydrogen peroxide, furacillin solution at a dilution of 1:5000, 0.5% dioxidine solution, sodium hypochlorite, ozonized solutions, etc.). As a rule, from 4 to 6 liters of solution are used to wash the abdominal cavity. Some authors believe that up to 10 liters are needed. The question of the amount of solutions used remains debatable.

Mandatory requirement sanitation is the removal of fibrin plaques, since under them remains pathogenic microflora. Conventional lavage of the abdominal cavity does not always fully satisfy this requirement.

More than 100 years ago, H. Nolan and J. Price proposed washing the abdominal cavity in the postoperative period - "peritoneal lavage". Two methods have been proposed: flow-through (continuous) and fractional (intermittent). The indications for peritoneal dialysis were the presence of fibrinous or purulent peritonitis, in which, after intraoperative sanitation of the abdominal cavity, there remained a large number of fibrin overlays, which could not be removed immediately. The authors of this technique believed that in the process of washing the abdominal cavity, its mechanical cleaning occurs, the solution used prevents the adhesive process, the formation of intra-abdominal abscesses.

By changing the composition of the solution, it is possible to influence water-salt exchange, create high concentration antibiotics in the abdomen. To achieve these effects, heparin, streptokinase, enzymes, and other substances were added to the solution. In the process of applying this technique, it was revealed and negative impacts on the patient's body, which subsequently served as a reason for refusing peritoneal dialysis. These include the spread of infection in the abdominal cavity, uncontrolled loss of proteins with dialysate, the development of hypervolemia, respiratory and heart failure as a result of a tense hydroperitoneum, the toxic effect of antibiotics, renal failure, impaired natural conditions in the abdominal cavity, contributing to the delimitation of inflammation, the formation of intra-abdominal abscesses.

In 1928, Jean Louis Faure improved and applied the laparostomy method proposed by J. Mikulicz, formerly known as “ open belly, fenestration of the abdominal cavity, closed evisceration, open method for the treatment of peritonitis, open management of the abdominal cavity. There are two types of laparostomy - closed evisceration, the laparotomy wound is not sutured, but internal organs delimited by napkins or film. In the second type, the abdominal cavity remains open, and various frame devices are sewn into the edges of the wound (zippers, fasteners, ventrophiles, an apparatus for bringing the edges of the wound together, etc.).

The widespread use of laparostomy occurred in the 50s of the last century, due to the possibility of dynamic revision and sanitation of the abdominal cavity. Indications for laparostomy were the terminal stage of widespread peritonitis in the phase of multiple organ failure, postoperative peritonitis, eventeration into a purulent wound, peritonitis with phlegmon of all layers of the anterior abdominal wall, anaerobic peritonitis.

Along with the advantages of this method, there are also disadvantages that limit the scope of laparostomy. An open abdominal cavity leads to large fluid losses, disorders of all types of metabolism, the formation of intestinal fistulas, the formation of a massive adhesive process abdominal cavity, the formation of extensive defects in the anterior abdominal wall, requiring repeated surgical intervention, the addition of superinfection.

In 1987 M.I. Kuzin proposed the method of program relaparotomy. Its essence lies in the fact that after the completion of the operation, only the skin is sutured. Indications for program relaparotomy are emerging abscesses of the abdominal cavity, massive overlays of fibrin and devitalized tissues that cannot be removed at once, postoperative peritonitis, uncertainty about the viability of organs, peritonitis with the spread of the inflammatory process to the retroperitoneal tissue, intra-abdominal hypertension syndrome. The disadvantages of the method are operating trauma as a result of repeated intervention, purulent complications abdominal cavity and anterior abdominal wall, fistula formation, high risk intra-abdominal bleeding.

Minirelaparotomy has the least invasiveness, when 1-2 sutures are removed from the edges of the wound and the abdominal cavity is examined using the “sharpening catheter” method.

In recent decades, with the development of minimally invasive surgery, laparoscopic technologies have found wide application in the diagnosis and treatment of widespread peritonitis, which allow:

1. Sanitize the abdominal cavity, correct the location of the drains, control the condition of the intestinal sutures and anastomoses, the possibility of suturing in case of a hollow organ defect.
2. Perform puncture and drainage of intra-abdominal abscesses.
3. Stopping bleeding using hemostatic polymer materials, carry out clipping, coagulation, flashing of vessels.
4. Dissect formed and emerging adhesions between the abdominal organs.
5. Treat the peritoneum and abdominal organs with ultrasound in an antiseptic solution or laser irradiation abdominal cavity.

There are mainly two types of laparoscopic debridement: the mechanical effect of the washed solution (hydropressive debridement, BRYUSAN Malkova) and physical factors (ultrasonic treatment, laser irradiation).

Indications for programmed sanitation: the duration of the disease is more than 24 hours, if the source of peritonitis is pathology colon, expressed inflammatory changes parietal and visceral peritoneum, accompanied by massive, dense imposition of fibrin, exudate with the presence of feces, fluid retention after peritoneal lavage, bile leakage, as well as all cases requiring visual dynamic control.

The disadvantages of laparoscopic sanitation are the impossibility of adequate sanitation of the abdominal cavity with massive bacterial contamination, with massive fibrinous overlays, poor visibility in the presence of paralytic intestinal obstruction, the inability to perform nasointestinal intubation.

Thus, currently widely used improved methods of drainage, open and closed management of the abdominal cavity, the introduction of laparoscopic technologies in the complex treatment of patients with advanced forms of peritonitis have a number of disadvantages, and the use of any treatment option is sometimes debatable. The search for new, highly effective methods of treatment is still promising, especially in present stage development of medical technologies.

Reviewers:

Smolkina A.V., Doctor of Medical Sciences, Professor of the Department of Hospital Surgery, Faculty of Medicine named after A.I. T.Z. Biktimirova Ulyanovsk State University”, Ulyanovsk.

Rubtsov O.Yu., Doctor of Medical Sciences, Professor of the Department of Faculty Surgery, FSBEI HPE “Mordovia State University. N.P. Ogaryov, Saransk.

Bibliographic link

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 normal functioning 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 perform the operation correctly and provide qualified postoperative care. Therefore, after performing a surgical intervention, debridement and drainage of the abdominal cavity is often performed in order to remove fluid.

The use of such procedures during surgery, including laparoscopy, can 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 destruction 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 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.

The development of postoperative complications is associated with insufficient sanitation. If exudate remains after its implementation, there is high probability 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, meet Negative consequences in the form of ventral hernias, suppuration postoperative wounds or their prolonged healing, secondary infection of the abdominal cavity.

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. When running processes, the probe must be in the stomach constantly, during the entire preoperative period, during the operation and 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 0.25% solution of novocaine into the region of the celiac trunk, the root of the mesentery of the transverse colon, small and sigmoid intestines and under the parietal peritoneum, which ensures a reduction in the need for narcotic analgesics, eliminates reflex vascular spasm, which creates conditions for 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. Need to pay Special attention at this point in the 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. Commonly used saline, chlorhexidine solution. 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 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 primary departments jejunum (also possible with endovideosurgical technique).

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

Adequate anesthesia.

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

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.

Novocaine blockade of reflexogenic zones.

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Optimal access to all parts of the abdominal cavity is provided by a median laparotomy, since, depending on the localization of the focus, the wound of the abdominal wall can be expanded up or down. If widespread peritonitis is detected during an operation performed from a different incision, then you should switch to a median laparotomy.

Injected up to 100.0 ml 0.5% solution of novocaine in the region of the celiac trunk, the root of the mesentery of the transverse colon, thin and sigmoid colon This ensures a reduction in the need for narcotic analgesics, eliminates reflex vascular spasm, which creates conditions for an earlier recovery of peristalsis.

3. Elimination or reliable isolation of the source of peritonitis

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 cases, the volume 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.

Washing reduces the content of microorganisms in the exudate below a critical level (10 5 microbial bodies in 1 ml), thereby creating favorable conditions for the elimination of infection. Tightly fixed fibrin deposits are not removed due to the risk of deseration. Removal of exudate by rubbing with gauze wipes due to trauma to the serous membrane is unacceptable.

Wash fluid should be isotonic. The use of antibiotics does not make sense, since short-term contact with the peritoneum cannot have the proper effect on the peritoneal flora.

Most antiseptics have a cytotoxic effect, which limits their use. Electrochemically activated sodium chloride solution (0.05% sodium hypochlorite) is deprived of this drawback, it contains activated chlorine and oxygen, therefore it is especially indicated in the presence of anaerobic flora. Some clinics use ozonized solutions.

in toxic and terminal stages peritonitis, when intestinal paresis acquires an independent clinical significance conduct nasogastrointestinal intubation of the small intestine with a vinyl chloride probe.

The length of intubation is 70-90 cm distal to the ligament of Treitz. The large intestine, if necessary, is drained through the anus.

AT rare cases to carry out the probe, a gastro-, or jejuno-, or appendicostomy is applied.

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.

6. Drainage of the abdominal cavity is carried out with PVC or rubber tubes, which are brought to the purulent focus and brought out in the shortest way.

On Fig. A variant of drainage of the abdominal cavity with destructive appendicitis, unrestricted local peritovitis. Options for drainage of the abdominal cavity with widespread and general peritonitis [from. VC. Gostishchev "Operative purulent surgery", M. Medicine, 1996], for lavage.

7. The suturing of the laparotomic wound is carried out with the drainage left in the subcutaneous fatty tissue.

Treatment of residual infection is related to the method of completion of the operation. These are different methods of dealing with residual (residual) infection, related to the methods of drainage of the abdominal cavity, or, more precisely, the methods of removing exudate and other infected and toxic contents from the abdominal cavity.

1. Sewing the wound tightly without drainage, hoping that the peritoneum itself will cope with the remaining infection. can be used only for local non-delimited serous peritonitis with a non-critical level of bacterial contamination, in the absence of the risk of abscesses and infiltrates. Under these conditions, the body itself can suppress the infection or with the help of antibiotic therapy.

2. wound closure with passive drainage. Drainages are also used for local administration of antibiotics.

3. sewing with drains for washing (lavage) flow and fractional. The method is practically not used due to the difficulty of correcting protein and electrolyte disorders and reducing efficiency after 12-24 hours of use.

4. convergence of the edges of the wound (semi-closed method) with the installation of drains at rear wall br.pol., for dorsoventral lavage with aspiration of the flowing fluid through the median wound.

5. approaching the edges of the wound with various devices with repeated revisions and sanitation. We use the term planned debridement. The indication for use is the presence of a pronounced adhesive process when severe forms purulent-fibrinous peritonitis with sub- and decompensation of vital functions important organs. The number of revisions is from 2-3 to 7-8. Interval from 12 to 48 hours.

6. open method (laparostomy according to N.S. Makokha or Steinberg-Mikulich) in order to drain exudate through the wound covered with tampons with ointment. When changing tampons, it is possible to observe the condition of the intestinal loops adjacent to the wound. It should be used in the presence of multiple unformed intestinal fistulas, extensive suppuration of the wound or phlegmon of the abdominal wall.

GENERAL TREATMENT.

Antibacterial therapy

The most adequate regimen of empirical antibiotic therapy (until microbiological verification of the pathogen and determination of its sensitivity to antibiotics) is a combination of synthetic penicillins (ampicillin) or cephalosporins with an aminoglycoside (gentamicin or vancocin) and metronidazole. This combination is valid for almost the entire spectrum. possible pathogens peritonitis.

upon receipt bacteriological analysis appropriate combination of antibiotics

Routes of administration:

1) local (intra-abdominal) - through irrigators, drains (dual purpose of drainage).

a) intravenous

b) Intra-arterial (intra-aortic, into the celiac trunk, into the mesenteric or omental arteries)

c) Intramuscular (only after restoration of microcirculation)

d) Intraportal - through the recanalized umbilical vein in the round ligament of the liver.

e) Endolymphatic. Anterograde - through a microsurgical catheterized peripheral lymphatic vessel on the back of the foot or depulpated inguinal lymph node. Retrograde - through the chest lymphatic duct. Lymphotropic interstitial - through the lymphatic network of the lower leg, retroperitoneal space.

immune therapy.

Of the drugs that improve the immunoreactive properties of the body, immunoglobulin, antistaphylococcal g-globulin, leukocyte mass, antistaphylococcal plasma, leukinferon - a complex of human interferons and cytokines are used.

The use of pyrogenal, decaris (levamisole), prodigiosan, thymalin and other “weakened immunity stimulants” in malnourished patients is contraindicated in the opinion of many authors.

Corrective therapy in the postoperative period

Adequate pain relief.

Along with traditional methods of treating pain with narcotic analgesics, prolonged epidural analgesia with local anesthetics, acupuncture analgesia, and electroanalgesia are used.

Balanced infusion therapy.

The total amount of fluid administered to the patient during the day is the sum of the physiological daily requirements (1500 ml / m 2), water deficit at the time of calculation and unusual losses due to vomiting, drainage, increased sweating and hyperventilation.

Prevention and treatment of multiple organ failure syndrome

The pathogenetic basis for the development of PON syndrome is hypoxia and cell hypotrophy due to impaired respiration, macro- and microhemodynamics.

The prevention and treatment measures for MODS are:

Elimination of infectious-toxic source.

Removal of toxins by methods of efferent surgery.

Ensuring adequate pulmonary ventilation and gas exchange (often prolonged mechanical ventilation).

Stabilization of blood circulation with the restoration of BCC, improvement and maintenance of the work of the heart. Normalization of microcirculation in organs and tissues.

Correction of protein, electrolyte, acid-base composition of blood.

Parenteral nutrition.

Recovery of gastrointestinal function

The most effective way to restore gastrointestinal motility is to decompress the intestine with a transnasal probe, followed by its lavage.

Normalization nervous regulation and restoration of intestinal muscle tone is achieved by replenishing protein and electrolyte disorders. After that, it is possible to use anticholinesterase drugs (prozerin, ubretide), ganglion blockers (dimecoline, benzohexonium).

With PON, the use of forced diuresis, hemodialysis, plasmapheresis, hemofiltration through the organs of the pig (liver, spleen, lungs), mechanical ventilation, HBO is indicated.

HBO is able to stop all types of hypoxia that develop in peritonitis, promotes an accelerated decrease in bacterial contamination of the peritoneum, and enhances the motor-evacuation function of the intestine.

Hemosorption, lymphosorption, plasmapheresis and other methods of detoxification cannot be considered as independent methods of treating peritonitis that provide significant advantages.

Emphasis should be placed on the prevention of endotoxemia using methods to combat residual infection ( surgical methods and antibiotic therapy).

Most low rates lethality is achieved with the use of planned laparosanations (20%).

According to inst. Them. Vishnevsky in the treatment of a homogeneous group of patients with peritonitis of appendicular origin with closed drainage years = 24%, with staged washing 12%. The frequency of abscesses during dialysis and drainage = 27 and 26.6%, with staged washing - 4%. The frequency of sepsis during staged washing is 12.2%, while drainage and lavage are the same - 31%.