RU2529412C2 - Method for preperitoneal block following median postoperative ventral hernioplasty - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to abdominal surgery and anaesthesiology, and can be used where it is necessary to anaesthetise after the prosthetic hernioplasty for median postoperative ventral hernias. That is ensured by placing an endoprosthesis under the aponeurosis, a polyvinylchloride catheter is placed into the formed spaced around the periphery of a postoperative wound in the form of an oval above the endoprosthesis plane at 2.5-3 cm from its edges. Along its full length, the catheter has multiple side holes. Single openings are created in a projection of a lower corner of the wound, and the catheter ends are brought out onto the skin. An inlet of the catheter is attached to a local anaesthetic dosage device by means of a cannula. That is followed by a controlled prolonged irrigation with 2.5% Ropivacaine 20 ml every 6-8 hours during 2-3 days.

EFFECT: method enables the adequate postoperative anaesthesia, as well as the length of the postoperative intestinal distention by providing the uniform controlled administration of the local anaesthesia solution.

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Description

The invention relates to medicine, namely to surgery and anesthesiology. The method can be used in herniology if anesthesia is necessary, after prosthetic hernioplasty with median postoperative ventral hernias.

A known method of standard anesthesia using opioid narcotic analgesics.

However, in the early stages of the postoperative period, the administration of narcotic analgesics is undesirable, taking into account the side effects: nausea, vomiting, dynamic paresis of the gastrointestinal tract, inhibition of the respiratory center, addiction and physical dependence. (Alyautdinov R.N. Pharmacology. - M.: Medicine, 2004. - 197 p.).

A known method of analgesia after prosthetic hernioplasty, including with median ventral hernias, including the introduction of local anesthetics into the area of the surgical wound for analgesia. (V.A. Oskretkov, V.A. Gankov, S.P. Bubechikov Prosthetic hernioplasty of inguinal hernias // Endoscopic surgery - 2008. - No. 4. - P.18-20). But this method of pain relief is carried out only for the operation itself, without taking into account pain relief in the postoperative period, since a single administration of a local anesthetic has a limited effect due to its short duration of action.

A known method of blocking nociceptive afferent fibers of the peritoneum by continuous infusion of local anesthetic through a multiport catheter installed by the surgeon at the end of the operation (Beaussier M. Continuous preperitoneal infusion of ropivacaine provides effective analgesia and accelerates recovery after colorectal surgery. Anesthesiology. - 2007. - Vol.107 (3. ). - P. 461-468).

The reasons that impede the achievement of the technical result when using the above method include the fact that one catheter is installed in one anatomical region in a small space, which restricts tissue infiltration by a local anesthetic and does not allow to create a local anesthetic depot, thereby not providing adequate analgesia. In addition, the use of a combination of narcotic analgesics (morphine) does not allow to fully assess the effectiveness of the perperitoneal blockade.

A known method of drainage of the wound, where one tube is laid along the bottom of the wound to ensure the most uniform outflow, which accordingly implies uniform irrigation of the wound (Theory and practice of local treatment of purulent wounds (the problem of drug therapy) // Dotsenko B.M., Kiev, Health, 1995, pp. 121-123).

The proposed wound irrigation using a similar tube will have a weak effect, since tissue infiltration with anesthetic is assumed only in a limited area.

The most reliable method selected as a prototype is the known method of preperitoneal blockade in the postoperative period, which includes the formation of left and right throughout the laparotomy wound, at a distance of 1.5-2 cm from its edges, catheters are installed in the tunnel having several holes. Through installed catheters, a local anesthetic is injected into the peritoneal space every 3 hours for 3 days (RF patent No. 2400259 C1, 09/27/2010).

However, this method has its drawbacks.

1. This method does not ensure uniform distribution of the anesthetic, since a single bolus injection of fluid through an open system, which does not take into account the diameter of the perforated holes and the diameter of the catheter itself, which does not give uniform irrigation and involves the release of fluid only through the nearest (first) or largest hole available in this handset.

2. An open system increases the risk of infection of a postoperative wound.

3. Uncontrolled injection of local anesthetics into the peritoneal space can lead to overdose and undesirable side effects of anesthetics.

The objective of the present invention is to increase the efficiency of the method of preperitoneal blockade in patients after prosthetic hernioplasty of the median postoperative ventral hernias, which consists in the fact that controlled uniform irrigation of local anesthetic is carried out, which provides adequate analgesia and reduces the number of postoperative complications, and also promotes early activation of the patient.

The invention is illustrated by drawings, where:

figure 1 - presents the image of the median wound on the anterior abdominal wall;

figure 2 - side wound after implantation of a mesh endoprosthesis,

where 1 is a postoperative wound, 2 is a perforated catheter, 3 is a catheter cannula (catheter inlet), 4 is a dosing device for administering anesthetic, 5 is a barometer for measuring the pressure of the preperitoneal tissue, 6 is a catheter cannula (catheter outlet), 7 - subcutaneous fatty tissue, 8 - the outer aponeurotic layer of the anterior abdominal wall of the abdomen, 9 - the rectus abdominis muscle, 10 - the mesh endoprosthesis, 11 - the peritoneal space, 12 - the peritoneum.

The stages of the operation are presented in the photo, where:

Photo 1. The uniform distribution of the brilliant green solution with a multi-hole catheter is shown.

Photo 2. Installation of the conductor on the stylet in the surgical wound.

Photo 3. The process of installing a catheter in the preperitoneal tissue.

Photo 4. The process of removing the second end of the catheter to the skin.

Photo 5. A multi-hole catheter is installed in preperitoneal tissue, the wound is sutured.

The method is carried out in the following way, after the main stage of hernia repair with the installation of an endoprosthesis 10 between the peritoneum and the muscle-aponeurotic layer in the formed preperitoneal space 11 around the wound circumference in the form of an oval 1 over the plane of the endoprosthesis 10, a polyvinyl chloride catheter 2 is installed at a distance of 2.5-3 cm from its edges having all along multiple side openings. Moreover, in the projection of the lower corner of the wound 1, separate punctures are performed on both sides and the ends of the catheter are brought out to the anterior abdominal wall. The inlet of the catheter is connected to the device, dosing the introduction of local anesthetic using cannula 3. Through the dispenser 4, a controlled prolonged irrigation of 2.5% ropivacaine solution of 20 ml is carried out every 6-8 hours for 2-3 days. At the same time, through a barometer 5, which is connected by means of a cannula 6 with the outlet of the catheter, if necessary, the pressure in the preperitoneal tissue is measured. The catheter is fixed in several places with absorbable interrupted sutures to the endoprosthesis. During implantation (installation) of the mesh endoprosthesis, the peritoneum exfoliates from the muscle-aponeurotic layer for 6-8 cm in all directions. As a result, a prepertial space will be created where an anesthetic solution depot is formed, which allows not only effective local local anesthesia, but also gives the effect of conductive analgesia.

Clinical example

Patient A.B., 58 years old, was admitted to the 1st Surgical Department of GAUZ GKB No. 7 of Kazan on September 25, 2012. at 8 h in a planned manner with a diagnosis of Large postoperative ventral hernia. Upon admission, the patient complained of tumor-like protrusion in the area of the postoperative scar, pain during exercise over the tumor-like protrusion. In 2005, he underwent surgery for a knife wound with the removal of a colostomy. In the same year, a recovery operation was performed: closure of the colostomy. Subsequently, a postoperative ventral hernia developed. In this connection, he sought medical help and was hospitalized in the surgical department No. 1 GAUZ GKB No. 7 of Kazan in a planned manner.

On examination, the general condition of the patient is satisfactory. The skin is moist, physiological in color. Pulse satisfactory filling 76 beats per minute. Blood pressure 130/80 mm Hg

The tongue is moist, clean, not coated. The abdomen is moderately painful and tense in the area of hernial protrusion, which is determined by straining and in a horizontal position in the area after the surgical scar. The hernial protrusion freely falls into the abdominal cavity, the skin above it is not changed, with no signs of pinching up to 15 cm in size. The patient was diagnosed with a large postoperative ventral hernia and surgical treatment was indicated as planned. Laboratory tests are within normal limits. There are no contraindications to surgical treatment. A hernia repair with a polypropylene implant is planned.

Operation 09/26/12. 9 h 00 min -11 h 20 min. Hernia repair. In lay plastic with a polypropylene implant. Under intubation anesthesia, two bordering incisions with excision of the postoperative scar and a hernial sac was isolated. The hernia gate is 15 cm long and 10 cm wide. The peritoneum is separated from the deep leaf of the aponeurosis of the rectus abdominis muscle. A polypropylene mesh implant is fixed preperitoneally, under the aponeurosis, and a catheter is installed along the circumference of the wound in the formed space at a distance of 3 cm from the edges of the wound, which has many openings for local anesthesia throughout. The cannula (external opening) was brought to the anterior abdominal wall. The catheter was fixed to the endoprosthesis with absorbable suture material. The edges of the aponeurosis are sutured by interrupted sutures. Layered seams on the wound. Aseptic dressing.

Postoperative diagnosis: Large postoperative ventral hernia.

In the postoperative period, an extended local analgesia of 2.5% ropivacaine 20.0 ml every 6 hours was performed through a cannula (catheter inlet) every 6 hours using an anesthetic dosing device for 2 days. The postoperative period was uneventful, smooth. The patient received complex pathogenetic therapy. The patient in the postoperative period did not complain of pain, the analgesic effect was achieved. Intestinal paresis resolved on day 2.

The postoperative wound healed by primary intention. In satisfactory condition, the patient was discharged October 9, 2012 under the supervision of a surgeon at the place of residence.

Thus, the proposed method of preperitoneal blockade in the postoperative period provides an even distribution of local anesthetic in the preperitoneal tissue, and thereby achieves adequate postoperative analgesia, reduces the number of postoperative complications, shortens the time of postoperative intestinal paresis, which leads to early activation of the patient, as well as refusal to use narcotic analgesics.

We conducted a study in which the results of surgical treatment of 77 patients with large and giant postoperative hernias were analyzed. Patients, depending on the method of anesthesia, were divided into two groups. In the comparison group (first), methods traditional for the clinic were used. In the main group, the method of postoperative analgesia developed by us was tested. In our work, we used all three options for fixing the endoprosthesis for plastic closure of the hernia gate: onlay, inlay, sablay.

In both groups, the Numerical rating scale (NRS) was used to assess pain intensity. NRS consists of 11 points from 0 (no pain) to 10 (the most severe pain you can imagine).

The main group consisted of 26 (34%) patients who, for the purpose of prolonged local analgesia and prevention of wound complications, installed a polyvinyl chloride catheter in the prepperitoneal tissue, around the circumference of the surgical wound above the endoprosthesis. Through the dispenser, prolonged controlled irrigation of the wound with a 2.5% ropivacaine solution is carried out: 20 ml every 6-8 hours for 2-3 days.

The comparison group consisted of 51 (66%) patients who were prescribed nonsteroidal anti-inflammatory drugs and narcotic analgesics for pain relief.

The criterion for the effectiveness of the analgesia was the intensity of the pain syndrome, expressed in points by NRS. Observations showed that the average level of pain in patients of the main group was 3.81 ± 0.40 points. The pain level in the comparison group was 5.3 ± 0.40 points.

As the research results showed, preperitoneal irrigation with ropivacaine with saline solution provides adequate postoperative analgesia, reduces the number of postoperative complications, reduces the length of hospital stay, and the rejection of narcotic analgesics reduces intestinal paresis and, accordingly, the risk of developing abdominal compression syndrome.

Claims (1)

A method of preperitoneal blockade after prosthetic hernioplasty of median postoperative ventral hernias, including the introduction of local anesthetics into the preperitoneal space using a catheter, characterized in that after installing under the aponeurosis of the endoprosthesis in the formed space around the circumference of the postoperative wound in the form of an oval above the endoprosthesis plane, 2 cavities are set to 2 , 5-3 cm from its edges, having throughout the whole multiple side openings, while in projection on the lower side of the wound, separate punctures are performed on both sides and the ends of the catheter are brought out to the skin, the inlet of the catheter is connected to a dosing device of local anesthetic using a cannula and a controlled prolonged irrigation of 2.5% ropivacaine solution of 20 ml is carried out every 6-8 hours for 2 -3 days.

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