Laparocentesis in the diagnosis of closed abdominal injuries. Laparocentesis: indications and technique for performing Gastric lavage with a thick probe

Indications. This procedure is carried out for diagnostic and therapeutic purposes.

For diagnostic purposes: to detect the presence of blood in abdominal cavity if it is impossible to perform laparoscopy or ultrasound of the abdominal organs.

For therapeutic purposes: evacuation of ascitic fluid.

Contraindications. 1. Intestinal obstruction.

2. Pregnancy.

3. Violation of blood clotting: hemophilia, thrombocytopenia, DIC syndrome etc.

4. Availability inflammatory diseases anterior abdominal wall: pyoderma, furuncle, phlegmon, etc.

Technique. The position of the patient on the back. Before performing the manipulation, the bladder should be emptied or a Foley catheter should be inserted into it.

diagnostic test. After treatment of the anterior abdominal wall with an antiseptic, local anesthesia is performed, for which a needle with a syringe is injected at a point located along the midline of the abdomen in the middle of the distance between the navel and the pubic joint and anesthetized in layers, deep into the peritoneum. A scalpel is used to make an incision on the skin up to 1-1.5 cm and on the aponeurosis of the rectus abdominis muscle. Through this incision, a trocar is used to puncture the peritoneum and penetrate into the abdominal cavity. The stylet of the trocar is removed, and a rubber or polyvinyl chloride tube is inserted through its tube in the direction of the small pelvis - a “groping catheter”. A small amount (5-10 ml) of a sterile liquid is injected through a “balling catheter” with a syringe, and then this liquid is aspirated. If there is blood or bile in the abdominal cavity, the aspirated fluid will be mixed with blood or bile, which is an indication for emergency surgery. In the absence of impurities in the aspirated fluid, the catheter is left in the abdominal cavity for a day or two as a control drainage.

Therapeutic puncture. The technique of the therapeutic puncture is the same as for the diagnostic test. After the PVC tube is inserted through the trocar tube, the trocar tube is removed, and ascitic fluid freely flows through the drainage left in the abdominal cavity. In order to avoid a sharp drop in intra-abdominal pressure, which can lead to a collaptoid state of the patient, it is necessary to periodically pinch the tube for 2-3 minutes. At the end of the evacuation of ascitic fluid, the tube can be removed and the skin wound sutured with a silk ligature or the tube can be left in the abdominal cavity for 3-4 days to control and evacuate the accumulated fluid.

Complications. 1. Perforation of the intestine or Bladder.

2. Injury to the epigastric or mesenteric vessels with intra-abdominal bleeding.

3. Development of arterial hypotension during or after manipulations.

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CT scan

Rice. 53-3. Spiral X-ray computed tomography. Retroperitoneal hematoma.

Rice. 53-4. Spiral computed tomogram. Rupture of the left kidney. Hemorrhages are seen in the perisplenic space and the left perirenal space; there is no perfusion of the upper pole of the left kidney. The blood flow is carried out only in a small segment of the back of the left kidney.

In addition, the method allows visualization of vascular structures and ducts of various organs using contrasting. At the same time, in seriously ill patients who cannot hold their breath, artifacts may appear that make interpretation difficult and increase the time for examining patients.

When organizing emergency research, it is necessary to be guided by the following basic principles:

• Almost all patients with brain damage need urgent X-ray CT to diagnose trauma, its complications and evaluate the effectiveness of treatment. internal organs and skeleton.
• Contraindications to urgent CT are reduced to a sharp violation of the vital functions of the body and the presence of profuse bleeding, requiring immediate surgical intervention.
• When the patient's condition stabilizes, delayed x-ray CT is necessary to study the state of organs and structures that are not visualizable by other research methods or are not available for revision during an emergency operation.
• Emergency X-ray CT should be performed as quickly as possible; it should not interfere with the implementation of therapeutic measures.
• The information obtained during the emergency CT scan must be compared with clinical, laboratory and instrumental data, which will make it possible to determine the most rational treatment tactics.

Selective angiography

Laparocentesis and laparoscopy

In doubtful cases, with a satisfactory condition of the wounded and unexpressed symptoms of a penetrating wound of the abdomen and pelvis, or, conversely, in a serious condition of the victim, combined injuries of various anatomical regions, when clinical manifestations damage to the organs of the abdominal cavity or pelvis is mild, diagnostic laparoscopy can be performed, and if it is impossible to perform it, diagnostic laparocentesis can be performed. The information content of these methods is very high.

Laparocentesis technique

Rice. 53-5. Scheme of introducing a trocar into the abdominal cavity during laparocentesis.

The stylet is removed and a catheter is inserted into the abdominal cavity, which is sequentially passed into the right and left hypochondrium, iliac regions and into the cavity of the small pelvis. Aspiration through the catheter of blood, intestinal contents, bile or urine indicates damage to the corresponding organs of the abdominal cavity or pelvis. If pathological contents are not obtained from the abdominal cavity, up to 1 liter of sterile 0.9% sodium chloride solution is injected through the catheter into the abdominal cavity, which is then aspirated. If the color of the aspirated solution is not changed, it is advisable to leave the catheter in the abdominal cavity for up to 12 hours for subsequent monitoring of the nature of the contents coming through the catheter, on the basis of which one can judge the presence or absence of blood or the contents of hollow organs in the abdominal cavity. Upon receipt of blood, bile, intestinal contents or urine, an urgent laparotomy is indicated to stop bleeding or repair damage to internal organs. At the same time, slightly blood-stained aspirated fluid against the background of damage to the pelvis or spine, as well as in the presence of retroperitoneal hematoma, is not an indication for laparotomy, but requires additional diagnostic measures.

It must be borne in mind that laparocentesis and laparoscopy have relative contraindications in cases of previously performed surgical interventions on the abdominal organs. Unfortunately, laparocentesis is not very informative in case of damage to the retroperitoneal organs and the formation of retroperitoneal hematomas: it cannot be used to exclude injuries to the dome of the diaphragm, the posterior surface of the liver, the posterior wall of the stomach and pancreas. In addition, the introduction of air into the abdominal cavity for laparocentesis in cases of thoracoabdominal injuries can dramatically worsen breathing, and fractures of the pelvic bones or spine limit the rotation of the body necessary for a more thorough revision of the abdominal cavity.

Videolaparoscopy

• victims with a closed abdominal injury who, after complex diagnostics doubtful indications for surgical intervention remained - the presence of free fluid in the abdominal cavity with an estimated volume of less than 500 ml, fuzzy peritoneal symptoms;
• sick with open injury abdomen in the presence of multiple (more than five) wounds of the anterior abdominal wall with cold steel and the absence of clinical and instrumental data on the nature of these injuries (penetrating or not), the purpose of videolaparoscopy is to revise the parietal peritoneum;
• if it is impossible to conduct a revision of the wound channel throughout during the primary surgical treatment of the wound and the absence of clinical and instrumental data for penetrating nature (the purpose of the study is revision of the parietal peritoneum);
• with a proven penetrating wound of the abdominal wall without clinical and instrumental signs of damage to the abdominal organs.

Videolaparoscopy is contraindicated in respiratory and hemodynamic disorders. Insufflation of gas into the abdominal cavity under these conditions further worsens the patient's condition, and the lack of sufficient pneumoperitoneum makes it impossible to fully revise the abdominal organs. It is not advisable to perform it with peritonitis, the presence of free gas in the abdominal cavity, with hemoperitoneum with a volume of more than 500 ml (according to the clinical picture of intra-abdominal bleeding and ultrasound data), that is, with symptoms indicating trauma to a hollow organ or significant damage to parenchymal organs, which requires a wide median laparotomy. Excludes the implementation of a full-fledged mini-invasive revision of the abdominal organs and adhesive disease. The imposition of pneumoperitoneum is absolutely contraindicated in cases of suspected diaphragmatic rupture, as this will lead to the rapid development of a tension pneumothorax and the death of the victim.

The introduction of the laparoscope trocar is carried out in the same way as with laparocentesis. After the introduction of the trocar, the stylet is removed and the optical tube is inserted, connected by a light guide to the illuminator. The pneumoperitoneum required for the study is applied by introducing air, carbon dioxide or nitrous oxide through a special valve on the trocar, or the abdominal cavity is additionally punctured in the left iliac region with a special Veress needle included in the laparoscopic set.

To carry out a detailed examination of the abdominal organs allows changing the position of the patient on the operating table. In the position on the left side, you can examine the right lateral canal with the caecum and the ascending part of the colon, the right half of the colon, and the liver. The gland in this position is shifted to the left side. When the patient is positioned on the right side, the left lateral canal with the descending colon becomes available. In patients with combined trauma, the position on the operating table is often forced, which makes it difficult to examine the abdominal organs in detail. In case of fractures of the pelvic bones, as a rule, large retroperitoneal and preperitoneal hematomas bulging into the abdominal cavity are detected. It is possible to examine a non-enlarged damaged spleen in rare cases. The conclusion about her injury is made by indirect signs - flow and accumulation of blood in the left lateral canal.

Bleeding from a damaged liver is more easily detected, since most of this organ lends itself well to inspection, but tears of the posterior surface of the liver are not visible. The diagnosis of rupture in these cases is based on the accumulation of blood in the right subhepatic space and the right lateral canal. The blood level at the border of the small pelvis indicates a rather large blood loss (more than 0.5 l). The presence of blood only between the loops of the intestine can be with a blood loss of less than 0.3-0.5 liters. Light yellow fluid in the abdominal cavity raises the suspicion of damage to the intraperitoneal part of the bladder. To clarify the diagnosis, it is necessary to introduce a solution of methylthioninium chloride (methylene blue) into the bladder cavity. When a colored solution appears (after 5-10 minutes) in the abdominal cavity, the diagnosis of damage to the bladder wall becomes obvious. The presence of cloudy fluid in the abdominal cavity raises the suspicion of damage to the intestine.

Diagnostic laparotomy

Diagnostic laparotomy is indicated:

• with suspicion of ongoing intra-abdominal bleeding;
• in cases where it is impossible to exclude damage to the intra-abdominal organs in a patient with a concomitant injury in a serious condition, despite a detailed examination, including ultrasound, laparocentesis, laparoscopy;
• in a satisfactory condition of the patient, when an active examination performed within 2-3 hours (including special methods), does not resolve doubts about damage to the abdominal organs;
• with penetrating wounds identified during the primary surgical treatment of wounds.

Inspection of the abdominal cavity and retroperitoneal space is carried out consistently and carefully. Immediately after opening the abdominal cavity, the detected blood is quickly aspirated into a pre-prepared sterile container with a preservative for subsequent reinfusion. When removing blood, it is necessary to establish the source of bleeding as soon as possible, immediately stop it with finger pressure and apply a temporary hemostatic clamp. First of all, an audit of the liver, spleen and mesentery of the intestine is performed. massive, life threatening the bleeding has a clear source and must be stopped immediately. After a temporary stop of bleeding, the stomach is sequentially examined, including its posterior wall. To do this, they penetrate into the stuffing bag through the gastrocolic ligament, which allows you to examine the pancreas. Next, the intestines, bladder, retroperitoneal space, kidneys, and diaphragm are sequentially audited.

When gastric or intestinal contents are found in the abdominal cavity, the entire intestine is examined, starting from the duodenal-intestinal fold, gradually and carefully removing loop after loop for revision. The area of ​​the intestine where wounds or hematomas are found is temporarily closed with napkins fixed with a soft clamp.

Depending on the findings, surgical interventions are performed on damaged organs. The laparotomy ends with a thorough sanitation of the abdominal cavity, draining it through separate incisions-punctures on the anterior abdominal wall with silicone double-lumen tubes. If there are no indications for abdominal tamponade, the surgical wound is sutured tightly.

In addition to the diagnostic methods described, some other methods are used in clinical practice for limited indications - dynamic scintigraphy, MRI, etc.

A.S. Ermolov

Indications: early diagnosis of closed abdominal injuries, acute inflammatory diseases of the abdominal organs and postoperative complications.

Technique. Laparocentesis is performed in the ward or in the dressing room, depending on the severity of the patient's condition. The puncture was made in places of the most pronounced pain and muscle protection, as well as dullness of percussion sound. More often it is the lower quadrants of the abdomen. Under local anesthesia(10-20 ml 0.5- 2% novocaine solution) on the border of the outer and middle third of the line connecting the navel and the upper anterior spine ilium, with a pointed scalpel we dissect the skin, subcutaneous tissue and aponeurosis (with mild subcutaneous adipose tissue), through this incision with a length of I - 2 cm we pass a trocar with an inner diameter of the tube 4 mm (a larger diameter is possible - up to 1 cm) and with rotational movements we pierce the abdominal wall. The trocar can be inserted at an angle of either 45° or 90° to the abdominal wall.

After removing the stylet through the tube of the trocar into the abdominal cavity, we introduce "grooving" catheter, for which we use an elastic plastic tube with 3 - 4 side holes at the end. By aiming it into one or another area of ​​the abdominal cavity, we carry out a test aspiration of the pathological contents with a syringe. If blood, exudate or other pathological contents are aspirated and the source of damage or inflammation can be determined with certainty by their color, smell and transparency, the patient is performed a laparotomy. If there is a difficulty in assessing the contents from the abdominal cavity, then we conduct its laboratory study (density, Rivalt reaction, protein, leukocytes, erythrocytes, diastasis, bile pigments, hematocrit, hemoglobin, etc.). With a "dry puncture", up to 500 ml of isotonic sodium chloride solution with novocaine is injected into the abdominal cavity, followed by aspiration and laboratory examination of the contents. The "groping" catheter with a negative puncture in some patients is left in the abdominal cavity for up to 3-5 days. for repeated aspiration in case of appearance of pathological contents in the abdominal cavity, as well as for timely recognition of late (two-phase) ruptures of parenchymal organs - the liver and spleen. We establish dynamic monitoring for patients with periodic laboratory, radiological and other necessary studies. If the clinical picture, which is decisive in the diagnosis, does not completely exclude acute surgical pathology, we undertake a laparotomy. Complications: infection and damage to the abdominal organs.

Sigmoidoscopy.

Indications.

1.mucous, purulent, bloody issues from the rectum.

2. tenesmus.

3. discomfort in the rectum.

4. hemorrhoids.

5. cracks.

6. diarrhea.

3. persistent constipation.

9. colitis.

10-diagnosis of dysentery and dynamic monitoring of the course of recovery of di-

11.operations: removal of polyps, cauterization. dissection of constrictions, biopsy. Methodology: the most favorable knee-elbow position. If, for some reason (severe general weakness, shortness of breath, pain, joint damage), the patient cannot be given the indicated position, then he is laid on his side (preferably on the left) with a raised pelvis and

to belly hips.

Technique. The introduction of a sigmoidoscope, starting from the anus and ending with the rectal knee of the sigmoid colon, i.e. for 30-35 cm, consists of 4 phases. 1. A tube with a mandrin, slightly warmed up and lubricated at the lower end with petroleum jelly, is inserted 4-5 cm into the intestine in a horizontal direction with careful, rare rotational movements. After that, the mandrin is removed, the lighting system is turned on, and the outer hole of the tube is closed. eyepiece or magnifying glass. Further advancement of the whale tubes is performed with an illuminated field of view, after eye control.

2. The tube is inserted over the next 5-6 cm in an upward direction. 3. The tube is given an almost horizontal position and moving it forward, they reach the entrance to the sigmoid colon, which is located at a distance of 11-13 cm from the anus.

4. When the endoscopic tube is inserted into the rectosigmoid flexure, it is advanced further at an angle downwards.

After the tube has been inserted to the maximum possible depth, it is immediately withdrawn back, and at this time a more thorough examination of the anal canal is carried out, because. in the first phase of the introduction, the tube passes through it closed by an obturator.

Complications: perforations: straight and sigmoid colon, injury to the intestinal wall, bleeding.

Rectal examination in diagnostics acute diseases abdominal organs. Technique.
Interpretation of the obtained results.

Finger research is carried out methodically and systematically. The index finger in a medical glove is liberally lubricated with petroleum jelly, applied with a soft surface of the distal phalanx to the center treated with petroleum jelly

anus. Carefully, rather slowly, sometimes rotationally, a finger is inserted into the anus to the entire depth of the anal canal, immediately assessing its patency. Then note the tone of the sphincters of the anus, their extensibility and elasticity, and proceed to a direct examination of the walls of the anal canal, using

fingers roughly determine the upper edge of the anal canal, and first the level of the scallop line is specified - the transition of the skin part of the anal canal to the mucous membrane. From this border, you should move your finger on average

1.5 cm, which corresponds to the upper edge of the muscular ring of the anus.

The most important stage of the approximate digital examination of the rectum is the examination of its ampullar section. With an average finger length (7-8 cm), the entire lower ampullar section of the rectum is well accessible for palpation. It is taken into account that the upper edge of the lower part of the ampoule of the rectum in men coincides with the bottom of the Douglas pouch, and in women it is 1–2 cm above the transitional fold of the peritoneum, it is possible to palpate the seminal vesicles located above the prostate gland, the bladder triangle in men, the cervix and parts of the body of the uterus in women. In addition, pararectal tissue is palpated through the lateral and posterior walls of the intestine, then the prostate gland is felt through the anterior wall of the intestine in men.

The depth of the study can be increased by 2 cm, if strongly pressed soft tissues perineum with the examined hand.

Acute intestinal obstruction.

Balloon-like expansion of the ampulla of the rectum and gaping of the anus due to the weakening of the tone of the sphincter of the rectum.

Abscess of the recto-uterine cavity (Douglas space).

With a digital examination of the rectum, the writing of its anterior wall is determined, a sharp pain on palpation of this area. Sometimes here you can palpate a compaction of a doughy consistency.

Ischiorectal paraproctitis.

Soreness and thickening of the intestinal wall above the rectal-anal line, smoothness of the folds of the mucous membrane of the rectum on the side of the lesion.

Acute retrorectal paraproctitis.

Sharply painful bulging of the posterior wall of the rectum.

overlay surgical suture(nodal, continuous, U-shaped)

nodal: the skin is sutured together with subcutaneous fatty tissue for its entire thickness and muscles.

1.the distance between the seams should not exceed 2cm

2. there must be complete contact of the opposite edges of the wound

Z.vkol and vykol needles on both sides should be at the same distance from the edges of the wound

4. The knot is tied on the side of the wound.

Continuous: used for suturing the peritoneum, operations on the stomach and intestines.

1. in one corner of the wound, the edges of the peritoneal incision are stitched with a long catgut thread

2. the short end of the thread is tied to the main thread

Z. then both edges of the peritoneum are stitched with stitches (the assistant holds the thread taut with his fingers, intercepting it as the peritoneum is stitched)

4. Having approached the opposite corner of the wound, the last stitch is not tightened, but a loop is formed and tied to the end of the thread.

Overlay technique continuous seam.

U-shaped: impose on the muscle, especially dissected perpendicular to the course of the fibers, because nodal sutures can be cut through - the knots are tied loosely, only until the edges of the muscle come together.

Leukocyte index of intoxication (according to Kalf-Kalif)

Reflects the degree of endogenous intoxication.

Normally 0.65-1.5. average - 1.0

LII= ( S + 2P + 3Yu + 4Mie) * (Pl + 1)

(M+L) * (E+1)

LII= ( S+2P+3Yu+4Mie)

C-segmented neutrophils

P-stab

myelocytes

Pl - plasma cells

M - monocytes

L-lymphocytes

E eosinophils

Treatment of the surgeon's hands

Spasokukotsky-Kochergin method:

1.) Hands are washed with a brush and soap in running water, especially in the area of ​​the periungual spaces, interdigital folds and palms. Water should flow from the hands to the elbows.

2.) Then they are washed with gauze napkins in warm 0.5% ammonia solution successively in 2 basins for 3 minutes. in everyone.

3.) The surgeon moves into the operating room. The sister opens the bix, where there is underwear for the surgeon. The last one takes a napkin from above, wipes his hands: first the fingertips, then the hands and forearms.

4.) Another napkin is taken from the bix, on which the sister pours 96% alcohol. Within 2 minutes. the surgeon treats the brushes with alcohol.

The method is quite effective: 0.5% ammonia solution has the property of degreasing the skin. However, the solution must be prepared anew each time.

Hand treatment with pervomour: pervomur - a mixture of hydrogen peroxide and formic acid. It has a high bactericidal activity (in 0.5% solution of E. coli and Staph, aureus die in 30 seconds).

1.) Hands are washed with warm tap water and soap without a brush for 1 minute. 2.) Thoroughly dry hands with a dry, clean towel. 3.) Treat hands for 1 min. in a basin with solution pervomura. 4.) Dry hands with a sterile towel. After treatment, put on sterile gowns and gloves. In one basin with 5 liters of working solution, at least 15 people can disinfect their hands. In isolated cases, transient itching and dry skin are observed.

Hand treatment with chlorhexidine:(gibitan) - has a pronounced bactericidal effect on the majority of Gr + to Gr- bacteria, but does not affect the growth of Proteus, viruses and spores.

Forming microorganisms.

1.) Hands are washed in warm running water with soap without a brush.

2.) Within 3 min. hands are washed with a napkin in a basin with 0.5% alcohol or 1% water

3.) Wipe hands dry with a sterile towel. After cleaning the hands, put on a sterile gown and gloves. Additional processing of hands is not required. In one basin, without changing the solution, the hands of 15-20 people can be treated. Chlorhexidine causes a quick transition-dashuk> stickiness of hands. Iodine and an iodine-containing antiseptic cannot be used when using chlorhexidine because of the risk of dermatitis. Diocide Hand Treatment:

1.) Diocide solution 1:5000 in boiled, heated to 40-50 degrees, water is poured into a basin and hands are washed with a sterile gauze napkin for 3 minutes.

2.) After washing, wipe the hands with a sterile towel and within 2 minutes. treated with 96% alcohol.

Iodine is not used to avoid dermatitis. After the operation, it is recommended to burn the hands with fat to eliminate dry skin. The bactericidal effect of the solution lasts up to 3 months.

Currently, the classical methods of preparing the surgeon's hands for surgery have been abandoned, because they take a lot of time.

very efficient and fast way is the treatment with iodophor (iodopyrone-polyvinylpyrrolidone, povidone-iodine-betadine) and hexachlorophene in a soap-like solution (shampoo) for 3-5 minutes. both cleansing and disinfection of the skin of the hands are achieved at the same time.

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INTERCOSTAL BLOCK

Indications. Rib fractures, especially multiple ones. Technique. The position of the patient is sitting or lying down. The introduction of novocaine is carried out along the corresponding intercostal space in the middle of the distance from the spinous processes to the scapula. The needle is directed to the rib, and then slide down from it to the area of ​​passage of the neurovascular bundle. Enter 10 ml of 0.25% novocaine solution. To enhance: the effect is added to 10 ml of novocaine 1.0 ml of 96 ° alcohol (alcohol-novocaine blockade). It is possible to use a 0.5% solution of novocaine, then 5.0 ml is injected.

PARAVERTEBRAL BLOCK

Indications. Rib fractures, pronounced pain radicular syndrome (degenerative-dystrophic diseases of the spine).

Technique. At a certain level, a needle is inserted, stepping back 3 cm a hundred
ronu from the line of spinous processes. The needle is advanced perpendicularly
skin until it reaches the transverse process of the vertebra, then the end of the needle
slightly shifted upwards, advanced 0.5 cm deep and injected
5-10 ml of 0.5% novocaine.

ROOT BLOCK

Indications. It is carried out as the final stage of all traumatic surgical interventions on the abdominal organs as a means of preventing postoperative intestinal paresis.

Technique. AT the root of the mesentery, gently under the sheet of peritoneum, so as not to damage the vessels, inject 60-80 ml of a 0.25% solution of novocaine.

SHORT PENICILLIN-NOVOCAINE BLOCK

Indications. Used for limited inflammatory processes(furuncle, inflammatory infiltrate, etc.)

Technique. Around the inflammatory focus, departing from its visible border, novocaine with an antibiotic is injected from different points into the subcutaneous tissue, also creating a pillow under the focus. Usually injected 40-60 ml of 0.25% novocaine solution.

1. Stop bleeding from femoral artery. Technique.

the abscessed artery is pressed against the horizontal branch of the pubic bone immediately below the pupartite ligament in the middle of the distance between the anterior-superior iliac spine and the pubic joint. Pressing is done with 2 thumbs with a thigh girth or clenched into a fist, fingers of the right hand, enhancing their action with the left hand. If these measures are ineffective, especially in obese people, you can use the following technique: the assisting person presses the artery in a typical place with the knee of the left leg. You can also apply a tourniquet, i.e. perform a circular pull on the thigh above the site of bleeding with a mandatory tissue pad. The tourniquet is applied for no more than 2 hours, and in winter up to 1 hour. To stop bleeding, increased flexion in hip joint(i.e. above the wound), fixing a strongly bent joint in this position with bandages

2. Stopping bleeding from the popliteal artery. Technique.
Stopping bleeding from the popliteal artery is achieved by maximum flexion lower limb in-
knee joint. In order to fix the limb in this position, a belt is additionally applied.

3. Stop bleeding from the iliac artery. Technique.

It is achieved by strong pressing of the trunk of the iliac artery proximal and distal to the injury site.
You can also apply the imposition of a clamp in the wound on the bleeding vessel. It should be remembered that this may cause injury to a nearby organ, so you need to try to stop the bleeding by pressing the vessel:

fingers, and then apply a clamp directly to the bleeding vessel, after draining the wound from the blood.

4. Stop bleeding from the subclavian artery. Technique.

The subclavian artery is pressed in the supraclavicular fossa to the 1st rib in the place where it passes above it between the scalenus muscles. When the patient is lying on his back (the person assisting is facing the victim), his head is taken away from the place of pressing, with 4 fingers they cover the back of the neck and press the artery with the thumbs.

5. Stop bleeding from the common carotid artery. Technique.

General carotid artery pressed against the transverse processes of the cervical vertebrae, in the middle of the inner edge of the sternocleidomastoid muscle. When the patient is lying on his stomach (providing assistance is from the back of the victim), turn his head in the opposite direction to the wound. Thumb hands are placed on the back of the neck, and the carotid artery is pressed with the rest of the fingers.

Diagnosis of strangulated hernias, tactics of rendering medical care on the prehospital stage.
Infringement of the hernial contents occurs, as a rule, after straining, sudden physical exertion, coughing, vomiting, etc. Most characteristics hernia incarcerations are:

1 - sharp pain,

3 - irreducibility of a previously reducible hernia,

4 - no transmission of cough shock.
Objective state. The patient is pale, severe tachycardia, a decrease in blood pressure may develop a picture of pain
shock. Percutere: in case of infringement of the intestinal loop - tympanitis, in later dates(due to the accumulation of hernial water) - dullness of percussion sound. On auscultation above the site of infringement, there is an increase in peristaltic noises.

Urgent care. Emergency hospitalization in the surgical department, where an urgent operation is to be performed. Any attempts to reduce a strangulated hernia are prohibited due to the possibility of a number of complications (rupture of the intestine, peritonitis). Transportation on a stretcher in a prone position.

The most widely used for detecting free blood and pathological contents in the abdominal cavity is laparocentesis- diagnostic puncture of the anterior wall of the abdomen.

Laparocentesis has almost a century of history. The first attempts to puncture the abdominal cavity were made in 1880: they pierced the abdominal wall with a trocar if a perforated stomach ulcer was suspected.

With a closed abdominal injury, laparocentesis for diagnostic purposes was first performed by J. Dixon in 1887, which made it possible to establish a rupture of the gallbladder. In 1889 G.F. Emery diagnosed a traumatic rupture of the common bile duct by laparocentesis.

The most widely laparocentesis for abdominal injuries began to be used in the 50-60s of the twentieth century, first abroad, and then in our country.

The experience of domestic and foreign surgeons in the use of laparocentesis for the diagnosis of open and closed abdominal injuries shows that it is simple and safe with strict observance of the technique.

Laparocentesis is ancillary instrumental method diagnosis of injuries of the abdominal organs. The indications for this method are as follows:

1. Fuzzy clinical picture of damage to one or another abdominal organ.

2. Severe concomitant trauma of the skull with loss of consciousness, when damage to the abdominal organs can be suspected by the type and mechanism of injury (fall from a height, road injury).

3. Combined spinal injury, chest, fractures of the pelvic bones, when there is a clinical picture simulating an "acute abdomen".

4. A state of severe alcohol intoxication with symptoms of alcohol intoxication and suspicion of damage to the abdominal organs.

Relative contraindications to laparocentesis are previous operations on the abdominal organs. Laparocentesis is not recommended near the bladder, various palpable tumor formations and enlarged parenchymal organs.

The examination is carried out in the operating room with strict adherence to the rules of asepsis and antisepsis, as in laparotomy.

Laporacentesis can be performed in the intensive care unit if all the conditions for an emergency operation are available, while simultaneously performing anti-shock measures.

Trainingpatient for examination. Starting the examination of the patient, one can never exclude the need for subsequent laparoscopy. Before the examination, it is necessary to catheterize the bladder, rinse the stomach, if the patient's condition allows.

Techniquelaparocentesis. In the position of the patient on the back, under local anesthesia with 0.25-0.5% novocaine solution at a point 2-2.5 cm below the navel in the midline of the abdomen or on the left at the level of the navel, 2-2.5 cm away from it , using a large skin surgical needle, a silk ligature is carried out (silk, nylon or lavsan No. 6 or 8). In this case, it is necessary to capture the aponeurosis of the anterior wall of the vagina of the rectus abdominis muscle.

At an average distance between the injection and injection of the needle, an incision up to 1 cm long is made during the ligature. The abdominal wall is pulled up by the ligature as high as possible in the form of a sail, after which the abdominal wall is punctured through the skin incision with a trocar.

The trocar is passed at an angle of 45° to the anterior abdominal wall from front to back towards the xiphoid process.

To puncture the abdominal wall during laparocentesis, a trocar is used, which is attached to a laparoscopic set of domestic production. After removing the stylet through the casing of the trocar into the abdominal cavity in the direction of the small pelvis, side canals, left and right subdiaphragmatic spaces, a “groping” catheter is inserted. At the same time, the contents of the abdominal cavity are constantly aspirated using a 10- or 20-gram syringe.

Interpretation of laparocentesis data. Detection of pathological contents during laparocentesis (blood more than 20 ml; blood with urine or feces; cloudy dark brown, greenish-gray or other color liquid) is an undoubted indication for urgent surgery.

If during laparocentesis the contents from the abdominal cavity are not obtained, then the result of laparocentesis is regarded as negative (“dry puncture”).

The accuracy of diagnosis during laparocentesis is directly dependent on the amount of fluid present in the abdominal cavity. To obtain contents from the abdominal cavity, it is necessary that it be at least 300 - 500 ml. Experimental studies showed that in the presence of fluid in the abdominal cavity with a volume of 500 ml, 78% of positive punctures are observed, with 400 ml - 71%, with 300 ml - 44%, with 200 ml - 16%, with 100 ml - 2%, with 50 ml - 0.

To improve the diagnostic capabilities of laparocentesis with its negative result, some scientists suggest repeated laparocentesis, but this increases the preoperative period, and late diagnosis is known to be dangerous. Other scientists suggest through a catheter inserted into the abdominal cavity during laparocentesis, inject up to 1000 ml of isotonic sodium chloride solution or Ringer-Locke solution at the rate of 25 ml per 1 kg of the patient's body weight and, after aspiration, examine the resulting contents using a microscopic or biochemical method (diagnostic peritoneal lavage ).

The criteria for a positive assessment of diagnostic peritoneal lavage during laparocentesis are:

1) hematocrit in the washing liquid is above 1-2%, which corresponds to 20-30 ml of blood per 1000 ml of washing liquid;

2) the number of erythrocytes over 1000000, and leukocytes over 500 in 1 mm? washing liquid. This technique allows you to identify a small amount of blood (up to 30-50 ml), which usually accumulates in the posterior abdominal cavity.

When receiving blood during laparocentesis ( positive result) often have to decide whether the bleeding has stopped or not. In some cases, even if there is a large amount of blood in the peritoneal cavity (750-3000 ml), bleeding may stop spontaneously. The facts of such a stop of bleeding in case of damage to the abdominal organs are known to doctors involved in emergency surgery.

To detect ongoing bleeding, the Ruvelois-Gregoire test is used. Laparocentesis in the diagnosis of ongoing or stopped bleeding makes it possible not only to take anti-shock measures and thereby reduce the risk of subsequent surgery, but also to determine the order in which patients are sent to the operating room for urgent surgery.

Blood mixed with urine, obtained by aspiration during laparocentesis and determined by smell, always indicates intra-abdominal damage to the bladder. Blood mixed with feces indicates damage to the intestines. Turbid dark brown, greenish-gray or other color liquid with fibrin flakes aspirated from the abdominal cavity during laparocentesis also indicates damage to hollow organs.

The reliability of the results of laparocentesis depends not only on the method of its implementation, but also on the correct interpretation of the data obtained.

In the periodical press there are works in which the authors note the difficulties of interpreting the data of laparocentesis when extracting fluid from the abdominal cavity, slightly stained with blood. Weak pink staining may indicate bleeding of a hematoma from the retroperitoneal space. However, as our experience shows, the blood fluid obtained during laparocentesis does not always indicate the presence of only a retroperitoneal hematoma. An additional thorough examination of the abdominal organs after laparocentesis by laparoscopy revealed mesenteric ruptures in patients. small intestine, areas of deserosis of the small and large intestine, extraperitoneal ruptures duodenum, tears of the capsule of the liver and spleen. These laparoscopic findings were confirmed by subsequent surgery. During laparotomy, 50-250 ml of blood was found in the abdominal cavity, and it accumulated mainly in the posterior parts of the abdominal cavity or the small pelvis.

If sanic fluid is found in the abdominal cavity, we recommend that laparoscopy be performed without fail, and in the absence of conditions for its implementation, leave control drainage in the abdominal cavity for 48-72 hours or more for repeated aspiration of peritoneal exudate, blood or injected isotonic sodium chloride solution.

Leaving the control catheter in the abdominal cavity after receiving blood fluid during laparocentesis allowed us to diagnose damage to internal organs in 8 patients, but the preoperative period increased from 8 to 12 hours, which adversely affected the postoperative period.

At present, sufficient experience has been accumulated in the use of laparocentesis, and there is no longer any need to prove its value in the diagnosis of unclear cases of injuries of the abdominal organs. The vast majority of authors have established the simplicity, safety and information content of its results during aspiration of pathological contents from the abdominal cavity.

However, like any method of examination, laparocentesis is not without drawbacks. So, in 4.5% of cases, laparocentesis turned out to be false-negative, according to our data, in 9% of cases.

The reason for false-negative results sometimes lies in the fact that the catheters, when passed into the abdominal cavity through the trocar casing, slide over the surface of the intestinal loops and the greater omentum directly under abdominal wall and do not always fall into the sloping places of the abdominal cavity, where fluid mainly accumulates during pathological conditions. Due to the low elasticity of rubber and polyethylene catheters and low controllability, they do not always move in the directions that they are given when passing through the trocar casing.

In case of damage to the internal organ, delimited by an extensive adhesive process and not communicating with the abdominal cavity, hemoperitoneum or outflow of intestinal contents from the damaged intestine by a “groping” catheter may not be detected.

It should be borne in mind that with subcapsular lesions of parenchymal organs, the results of laparocentesis will be negative, which, unfortunately, complicates the choice of indications for surgery. Sometimes a rubbing catheter or guided probe becomes clogged with a blood clot, making examination difficult or giving a false negative result.

A small amount of blood (up to 20 ml) during laparocentesis and diagnostic peritoneal lavage can lead to false positive results. According to our data, this is observed in 3.3% of cases, and according to other scientists - in 4.5%. This is explained by the incorrect puncture of the abdominal wall, as well as the flow of blood from the preperitoneal hematoma during a fracture of the pelvic bones.

Thus, laparocentesis is a fairly simple and objective research method with high diagnostic reliability. At the same time, it should be borne in mind that if there is a discrepancy between the clinical picture and the results of laparocentesis, aspiration from the abdominal cavity of the blood fluid, "dry puncture", as well as when receiving a small amount of blood, it is necessary to perform laparoscopy in order to avoid diagnostic errors.

Laparocentesis is a puncture of the anterior abdominal wall in order to detect or exclude the presence of pathological contents: blood, bile, exudate and other fluids, as well as gas in the abdominal cavity. In addition, laparocentesis is performed to establish a pneumoperitoneum before laparoscopy and some x-ray studies, for example, for diaphragmatic pathology.

Indications for laparocentesis

• - Closed abdominal trauma in the absence of reliable clinical, radiological and laboratory signs of damage to internal organs.
• - Combined injuries of the head, trunk, limbs.
• - Polytrauma, especially complicated traumatic shock and coma.
• - Closed trauma of the abdomen and combined trauma in persons in a state of alcoholic intoxication and narcotic stunning.
• - Uncertain clinical picture acute abdomen as a result of the introduction of a narcotic analgesic at the prehospital stage.
• - Rapid fading of vital functions in concomitant trauma, unexplained by injuries to the head, chest and extremities.
• - Penetrating wound of the chest with a probable injury to the diaphragm (knife wound below the 4th rib) in the absence of indications for emergency thoracotomy.
• — Impossibility to exclude a traumatic defect of the diaphragm by X-ray contrast examination of the wound channel (vulneography) and examination during primary surgical treatment chest wall wounds.
• - Suspicion of perforation of a hollow organ, cysts; suspicion of intra-abdominal bleeding and peritonitis.

By look and laboratory research fluid obtained during laparocentesis (admixture of gastric, intestinal contents, bile, urine, increased content of amylase), damage or disease of a certain organ can be assumed and an adequate treatment program can be developed.

Unreasonable diagnostic for a false acute abdomen negatively affects the patient's condition. in a victim with polytrauma, it can be life-threatening, as it inhibits diaphragmatic breathing and increases hypoxia. In urgent abdominal surgery, postoperative aspiration pneumonitis, delirium and intestinal eventration are observed, especially in the group of persons who were in a state of alcoholic intoxication. Therefore, laparocentesis is preferable.

The issue of conducting diagnostic laparocentesis should be approached individually, taking into account the specifics of the clinical situation. If there is a reserve of time, laparocentesis is preceded by a detailed history taking, a thorough objective examination of the patient, laboratory and radiodiagnosis. In critical situations, with unstable hemodynamics, there is no time reserve for performing a standard diagnostic algorithm. Laparocentesis can quickly confirm damage to the abdominal organs. The speed, simplicity, rather high information content of laparocentesis, the minimum set of tools are its advantages in the event of a massive influx of victims.

Contraindications for laparocentesis

- severe flatulence, adhesive disease of the abdominal cavity, postoperative ventral - due to the real danger of injuring the intestinal wall.

Method of laparocentesis

Currently, the method of choice for laparocentesis is trocar puncture, which is usually performed under local infiltration anesthesia in the midline 2 cm below the navel. With a pointed scalpel, an incision is made up to 1 cm of the skin, subcutaneous tissue and aponeurosis. Two trunnions capture the umbilical ring and raise the abdominal wall as much as possible to create a safe space in the abdominal cavity when the trocar is inserted. G.A. Orlov (1947) studied the topography of the internal organs of the abdominal cavity on the Pirogovo cuts of corpses during traction for the aponeurosis in the navel zone during laparocentesis. Loops of the small intestine, ascending and descending colon shift towards the midline. In the abdominal cavity, a space is formed without internal organs from 8 to 14 cm high under the point of application of the thrust. The height of the cavity between the abdominal wall and the viscera gradually decreases with distance from this point.

The trocar is introduced into the abdominal cavity with a moderate force of rotational movements at an angle of 45° towards the xiphoid process. The stylet is removed. A silicone tube with side holes is advanced through the trocar sleeve to the intended site of fluid accumulation - a “groping” catheter, and the contents of the abdominal cavity are aspirated. With its help, it is possible to detect the presence of a liquid with a volume of more than 100 ml. If there is no fluid during laparocentesis, from 500 to 1200 ml of isotonic sodium chloride solution is injected into the abdominal cavity with a drip system. The aspirated solution may contain blood and other pathological impurities. Some have a negative attitude to peritoneal lavage, believing that in case of intestinal trauma, it leads to widespread microbial contamination of the abdominal cavity during laparocentesis.

A positive iodine test testifies to a traumatic defect, gastric and duodenal ulcer (Neimark, 1972). To 3 ml of exudate from the abdominal cavity add 5 drops of 10% iodine solution. Dark, dirty-blue coloration of the exudate indicates the presence of starch and is pathognomonic for gastroduodenal contents. With a pronounced acute abdomen and the absence of aspirate, it is advisable to leave the tube after laparocentesis in the abdominal cavity for 48 hours in order to detect possible appearance blood and exudate.

An elastic “groping” catheter, when it encounters an obstacle (planar commissure, bowel loop), may twist and not penetrate into the studied area of ​​the abdomen. The diagnostic set for laparocentesis is deprived of this disadvantage, which includes a curved trocar and a spiral metal “groping” probe with a curvature approaching the curvature of the lateral channels of the abdominal cavity. A diagnostic metal probe with holes is advanced with its beak forward, sliding along the parietal peritoneum of the anterior-lateral wall of the abdomen, then along the peritoneum of the lateral canal. During laparocentesis, they examine typical places fluid accumulations: subhepatic and left subdiaphragmatic space, iliac fossae, small pelvis. The position of the metal probe in the abdominal cavity is determined by palpation at the moment of pressure from the inside on the abdominal wall with the working end of the instrument.

Reliability and complications of laparocentesis

Laparocentesis is not informative for injuries of the pancreas, extraperitoneal parts of the duodenum and large intestine, especially in the first hours after injury - a false negative result of the study. After 5-6 or more hours after injury to the pancreas, the likelihood of detecting exudate with a high content of amylase increases.

Accumulation of exudate and blood abdominal pockets, delimited from the free cavity by the walls of organs, ligaments and adhesions, is also not detected by laparocentesis.

Extensive retroperitoneal hematomas, for example, due to fractures of the pelvic bones, are accompanied by bleeding through the peritoneum of a bloody transudate. It is possible for blood to enter the abdominal cavity from the wound canal of the abdominal wall when the trocar is inserted through the muscles in the iliac region. The erroneous conclusion of laparocentesis about intra-abdominal bleeding should be considered as a false positive result. Thus, the diagnostic possibilities of laparocentesis with a "groping" catheter have a certain limit. In cases of inconclusive data obtained during diagnostic laparocentesis in patients with concomitant injuries, and an alarming clinical picture of an acute abdomen, it is necessary to raise the question of emergency laparotomy.

Diagnostic pneumoperitoneum used in laparocentesis differential diagnosis relaxations, true hernias, tumors and cysts of the diaphragm, subdiaphragmatic formations, in particular, tumors, cysts of the liver and spleen, pericardial cysts and abdominal mediastinal lipomas. The study is carried out on an empty stomach, the colon is cleaned with enemas. Usually, the puncture of the anterior wall of the abdomen is performed with a standard thin needle with a mandrin or a Veress needle along the outer edge of the left rectus muscle at the level of the navel, as well as at the Kalk points.

Facilitates the puncture of arbitrary tension in patients with the abdominal press. The layers of the abdominal wall are overcome with a needle gradually, with jerky movements. The penetration of the needle through the last obstacle - the transverse fascia and the parietal peritoneum - is felt as a dip. After removing the mandrin, you should make sure that there is no blood flow through the needle. It is advisable to introduce 3-5 ml of novocaine solution into the abdominal cavity. The free flow of the solution into the cavity and the absence of reverse current after the syringe is disconnected indicates the correct position of the needle. With the help of an apparatus for intracavitary injection of gases, 300-500 cm3, less often 800 cm3 of oxygen are injected into the abdominal cavity. Gas moves in the free abdominal cavity depending on the position of the patient's body. X-ray examination is performed an hour after the imposition of pneumoperitoneum. In the vertical position, the gas propagates under the diaphragm. Against the background of a layer of gas, the peculiarities of the position of the diaphragm and pathological formation, their topographic relationship with adjacent organs of the abdominal cavity are clearly visible.

It is believed that an accidental needle puncture of the intestine during laparocentesis, as a rule, does not have fatal consequences. The results of the study in the experiment of the degree of danger of percutaneous puncture of the abdominal cavity: a puncture of the intestine with a diameter of 1 mm was sealed after 1-2 minutes.