RU2692463C2 - Method for liver wounds closure - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to surgery, and can be used for closing liver wounds in hepatic injuries. Method involves performing liver wounds inspection, stopping bleeding from hepatic wound by electric coagulation, measuring wound depth, cutting a mesh prosthesis from an esphil standard polypropylene mesh, length of prosthesis is comparable to length of wound, width is sum of two sizes of wound depth and four centimetres. Mesh prosthesis is laid on the wound bottom so that the edges of the mesh prosthesis are located from the wound edge in the distal directions by 2 cm. Healing of liver wound together with mesh prosthesis with U-sutures atraumatic needle, non-absorbable suture of size 0. Suture is started from the upper angle of the wound at distance of 2 cm in the distal direction from the wound edge, thread advance from top to bottom through polypropylene mesh, through capsule and hep parenchyma to entire depth of liver with needle prick-out in bed of liver wound through polypropylene mesh. Needle is then drawn from the bottom of the liver wound through the polypropylene mesh, through the parenchyma, the liver capsule, through the polypropylene mesh, needle prick-out at the upper angle of the wound at distance of 2 cm in the distal direction from the wound edge on the opposite side. Further, from the exit point of 1.5 centimetre thread in the caudal direction, the U-suture is continued in the reverse order with the thread exit from the opposite side of the wound. U-shaped sutures are applied by the above method along the entire length of the wound. Interval of sutures 1.5 centimetres. Wound edges are brought together by tightening U-shaped sutures until haemorrhage stops. Abdominal cavity is drained. Laparotomic wound is closed in layers.EFFECT: method enables preventing suture cutting, reliably matching liver tissue, providing reliable haemostasis with minimizing bleeding risk in the early postoperative period, minimizing the risk of developing intrahepatic abscesses in the late postoperative period, that is higher clinical effectiveness.1 cl, 2 dwg

Description

The invention relates to medicine, namely to surgery, can be used for suturing wounds of the liver in liver damage.

A known method of suturing wounds of the liver with its traumatic injuries (Patent RU No. 2459589, publ. 27.08.2012, IPC: AV 17/04). The method is as follows. First, deep U-shaped sutures are placed under the wound bottom over the entire length of the wound. To do this, they retreat from the lower edge of the wound by 1-1.5 centimeters and, using a round atraumatic needle, pierce the parenchyma of the organ, passing one end of the thread under the bottom of the wound, with a shot to the opposite side, at a distance of 1-1.5 centimeters from the upper edge wounds. Then the other end of the thread is carried out in a similar way, departing from the first injection at a distance of 1-1.5 cm. Stepping back from the first deep U-shaped seam at a distance of 1-1.5 centimeters, they impose subsequent similar deep U-shaped seams under the bottom of the wound, over its entire length.

The ends of the threads are not pre-connected to each other. Then impose surface U-shaped seams 1/3 the depth of the wound from the surface in the opposite direction. Having retreated from the upper edge of the wound by 0.5-0.8 centimeters, from the side of the deep u-shaped sutures, in the middle of the distance between the first deep U-shaped sutures, the organ parenchyma is punctured with a round atraumatic needle, holding one end of the thread to 1/3 of the wound depth from the surface, with a shot to the opposite side at a distance of 1-1.5 centimeters from the bottom edge of the wound, under the loop of a deep U-shaped seam. Then the other end of the thread is carried out through the middle of the distance between the punctures of the second deep U-shaped suture, departing from the upper edge of the wound by 0.5-0.8 centimeters, using a round atraumatic needle, pierce the parenchyma of the organ,

making a thread at 1/3 of the wound depth from the surface, with a shot to the opposite side at a distance of 1-1.5 centimeters from the bottom edge of the wound, under the loop of a deep U-shaped seam. Through the middle of the distance between the punctures of the subsequent deep U-shaped seams, the subsequent surface U-shaped seams are placed at 1/3 of the wound depth from the surface, over its entire length. After all the stitches are applied, all the ends of the threads of the deep U-shaped seams are simultaneously connected to each other, and on the other hand, all the ends of the threads of the surface U-shaped seams. Depending on the length of the wound impose several stitches. According to this method of suturing wounds of the liver with its traumatic injuries with the use of opposing U-shaped sutures, the eruption of the liver parenchyma by the thread is not excluded, which may contribute to the development of bleeding.

The above method has significant drawbacks:

1. It is not excluded the eruption of the liver parenchyma by thread, which contributes to the development of bleeding.

2. During the eruption of the liver tissue parenchyma, the formation of intrahepatic hematomas is possible, followed by abscess formation of hematomas.

The objective of the invention is to create a method of suturing wounds of the liver, preventing the eruption of the liver parenchyma, preventing the development of bleeding and the formation of intrahepatic hematomas.

The task is achieved by the method of suturing wounds of the liver, including revision of the liver wound, stopping bleeding from the liver wound by electrocautery, measuring the depth of the wound, cutting out the mesh prosthesis from the polypropylene mesh esfil standard, the length of the denture is comparable to the length of the wound, laying the mesh prosthesis in the bottom of the wound, stitching the wound the liver, together with the mesh prosthesis U-shaped

suture with an atraumatic needle, non-absorbable thread Prolen size 0. The seam starts from the top angle of the wound at a distance of 2 cm in the distal direction from the wound edge, advancing the thread from top to bottom through the polypropylene mesh, through the capsule and the liver parenchyma to the full depth of the liver wound, with the needle punctured the bed of the liver wound through a polypropylene mesh. Then the needle is carried out from the bottom of the wound of the liver through the polypropylene mesh, through the parenchyma, the liver capsule, through the polypropylene mesh, the needle pokes out at the upper corner of the wound at a distance of 2 centimeters from the wound edge on the opposite side. Further, a distance of 1.5 centimeters from the exit point of the thread in the caudal direction, the U-shaped seam is continued in reverse sequence, with the exit of the thread on the opposite side of the wound. Impose U-shaped seams in the above way along the entire length of the wound. The interval between the seams is 1.5 centimeters. They pull together the edges of the wound by tightening the U-shaped stitches until the bleeding stops, tying the stitches together. Drain the abdominal cavity. The laparotomic wound is sutured in layers.

The novelty of the invention:

- We cut out the mesh prosthesis from the polypropylene mesh Esfil standard, the length of the prosthesis is comparable to the length of the wound.

- Stitching the liver wound together with the mesh prosthesis with U-shaped sutures with an atraumatic needle, not absorbable Prolene thread size 0. The seam starts from the top angle of the wound at a distance of 2 cm distal from the wound edge, advancing the thread from top to bottom through the polypropylene mesh, through the capsule and the liver parenchyma to the entire depth of the wound of the liver, with a needle poked into the bed of the liver wound through a polypropylene mesh. Then the needle is carried out from the bottom of the wound of the liver through the polypropylene mesh, through the parenchyma, the liver capsule, through the polypropylene mesh, the needle pokes out at the upper corner of the wound at a distance of 2 centimeters from the wound edge on the opposite side. Farther away from the point of exit of the thread 1.5 cm in the caudal direction, the U-shaped seam continues

reverse sequence, with the release of the thread on the opposite side of the wound.

The set of essential features of the invention, allows to obtain a new technical result:

Prevent the eruption of sutures, reliably match liver tissue, ensure reliable hemostasis while minimizing the risk of bleeding in the early postoperative period.

To minimize the risk of developing intrahepatic abscesses in the late postoperative period, i.e. increase the effectiveness of treatment.

The invention is illustrated by the schematic diagrams in FIG. one; FIG. 2

FIG. 1 is a schematic representation of the method in the frontal plane after applying U-shaped seams. FIG. 1 shows:

1 - liver wound;

2 - polypropylene mesh;

3 - U-shaped seam;

FIG. 2 final form after tightening and tying seams.

The method is as follows.

Perform upper-middle, middle-middle laparotomy. Mobilize the liver. A revision of the liver wound is performed, the bleeding from the liver wound is stopped by electrocautery, the depth of the wound is measured, the mesh prosthesis is cut out of the esfil standard polypropylene mesh, the length of the prosthesis is comparable to the length of the wound. Lay the mesh prosthesis on the bottom of the wound. Liver wound is stitched together with mesh prosthesis with U-shaped sutures with an atraumatic needle, not absorbable Prolene thread, size 0. The seam starts from the top angle of the wound at a distance of 2 centimeters in the distal direction from the wound edge, advancing the thread from top to bottom through the polypropylene mesh, through the capsule and parenchyma liver full depth

wounds of the liver, with a needle poked out into the bed of the wound of the liver through a polypropylene mesh. Then the needle is carried out from the bottom of the wound of the liver through the polypropylene mesh, through the parenchyma, the liver capsule, through the polypropylene mesh, the needle pokes out at the upper corner of the wound at a distance of 2 centimeters from the wound edge on the opposite side. Further, a distance of 1.5 centimeters from the exit point of the thread in the caudal direction, the U-shaped seam is continued in reverse sequence, with the exit of the thread on the opposite side of the wound. Impose U-shaped seams in the above way along the entire length of the wound. The interval between the seams is 1.5 centimeters. They pull together the edges of the wound by tightening the U-shaped stitches until the bleeding stops, tying the stitches together. Drain the abdominal cavity. The laparotomic wound is sutured in layers.

Example.

Patient K., 44 years old, was taken by the pumping squad to the Guryev regional hospital on 05/14/14 with a diagnosis of a stab wound to the anterior abdominal wall. The prescription is about 30 minutes. Alcohol intoxication. General condition of moderate severity. Body temperature 36.3 oC. Conscious, inadequate, not oriented in time and place. The skin is a normal color. Subcutaneous fatty tissue is moderately developed. Peripheral lymph nodes are not enlarged. Osteo-articular system without signs of pathology. Nasal breathing free. Thorax regular shape, symmetrical. Percussion pulmonary sound. Auscultatory harsh breathing in all departments, no wheezing. NPV 16 per minute. Heart sounds are clear, rhythmic heart rate 84 per minute satisfactory filling, tension. Blood pressure 90 \ 60 torr. Tongue dryish, clean. The belly of the correct form, symmetrical, does not swell. In the projection of the xiphoid process, the wound is 4 * 0.8 cm with moderate bleeding.

Complete blood count: Er — 4.3 × 10 12 / L; Hb - 120 g / l; L - 14.1 × 10 9 / l.

Coagulogram: PTI-90%; fibrinogen 4.0 g / l; O / b - 70 g / l; creatinine

 - 96 mmol / l; ALT - 15; ACT - 20; sugar - 4.6.

Urinalysis: beats. weight - 1002, protein - neg, L - 25-30 in p / sp .;

When performing the primary surgical treatment of wounds, the penetrating nature of the injury was established. Considering the penetrating nature of the injury, surgical treatment was carried out for health reasons.

Under endotracheal anesthesia, an upper-midline, mid-midline laparotomy was performed, in the abdominal cavity up to 800 ml of blood, clots, sanitized, during the inspection, the left liver lobe was wounded in the vertical direction of 6 * 1.5 * 2.5 cm, s continued bleeding. There is no other pathology in the abdominal cavity. Considering the intraoperative finding, it is recommended to perform a wound closure of the liver. Partially stop bleeding from a liver wound by electrocautery. Given the significant size of the liver wound, it was decided to close the skin using the Esfil standard polypropylene mesh. A mesh prosthesis measuring 6 * 11 centimeters is cut. The mesh is laid in the liver wound. Sewing a liver wound together with a mesh prosthesis with U-shaped sutures with an atraumatic needle, not absorbable thread, prolene of size 0. The suture is 2 centimeters distal from the wound's upper corner distal from the wound edge, advancing the thread downwards through the polypropylene mesh, through the capsule and the liver parenchyma the entire depth of the wound of the liver, with the needle poked out into the bed of the wound of the liver through the polypropylene mesh. Then a needle was passed from the bottom of the liver wound through a polypropylene mesh, through the parenchyma, liver capsule, through a polypropylene mesh, and a needle popped out at the upper wound angle at a distance of 2 centimeters from the wound edge on the opposite side. Further, a distance of 1.5 centimeters from the exit point of the thread in the caudal direction, the U-shaped seam was continued in reverse order, with the exit of the thread on the opposite side of the wound. Superimposed U-shaped seams above method along the entire length of the wound. The interval between the seams is 1.5 centimeters. The convergence of the edges of the wound, tightening the U-shaped seams, the bleeding is stopped, the seams are tied.

Drainage of the small pelvis through contraception. Layer-by-layer suturing of a laparotomy wound. Rubber graduate. Aseptic dressing.

P / o diagnosis: penetrating stab wound of the abdominal cavity, complicated by injury of the left lobe of the liver. Hemoperitoneum. Hemorrhagic shock 1 degree. Alcohol intoxication. The duration of the operation is 1 hour and 10 minutes.

Drainage tube from the abdominal cavity removed on the 2nd day. Meals from the 3rd day. An ultrasound examination in the postoperative period revealed no pathological foci of fluid.

The stitches were removed on the 9th day, wound healing by first intention.

Discharged from the hospital after 9 days.

At the control examination after 3 months no complaints, postoperative scar without features. At the control examination after a year no complaints, postoperative scar without features.

The claimed method allowed to minimize postoperative complications, reduce the time of rehabilitation, i.e. increase the effectiveness of treatment.

Claims (1)

The method of suturing wounds of the liver, including measuring the depth of the wound of the liver, cutting out the mesh prosthesis from the polypropylene mesh esfil standard, the length of the prosthesis is comparable to the length of the wound, then putting the mesh prosthesis on the bottom of the wound, stitching the liver wound together with the mesh prosthesis with U-shaped sutures with an atraumatic needle with non-absorbable thread Prolene size 0, the seam starts from the top corner of the wound at a distance of 2 centimeters in the distal direction from the edge of the wound, advancing the thread from top to bottom through a polypropylene mesh, through a capsule and a pair liver nikhima to the entire depth of a liver wound with a needle punctured into the liver wound bed through a polypropylene mesh, then a needle is passed from the bottom of the liver wound through a polypropylene mesh, through the parenchyma, liver capsule, through a polypropylene mesh, a needle wolves at the upper wound angle at a distance of 2 centimeters from the edges of the wound from the opposite side, further from the place of the exit of the thread 1.5 cm in the caudal direction, continue the U-shaped seam in reverse sequence with the release of the thread from the opposite side of the wound, impose U-shaped seams above in a known manner along the entire length of the wound, the interval between the seams is 1.5 centimeters, they bring the wound edges together, tightening the U-shaped seams until the bleeding stops, fasten the seams.

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