Who is recommended for abdominal drainage? Drainage of the abdominal cavity: what is it, indications, complications, method Obstruction of the drainage tube complications of the abdominal cavity.

103. Principles and technique of drainage abdominal cavity. Drainage of the joints. Drainage-microirrigators for the introduction of medicines.

Drainage can be passive, based on the independent outflow of the contents, and active, when the outflow is carried out under the action of a vacuum created in the drainage system.

Drains should be treated like insurance - they are cheap and easy to install during surgery, but they become very expensive when complications develop. A drain placed close to the anastomotic suture line will help prevent leakage peritonitis and external fistula formation without surgery. Drainage, through which there is no discharge, should be removed, since it only serves as an entrance gate for infection. If the drainage is functioning, it is better to remove it, gradually tightening it so that the drainage channel heals from the inside. If the drainage is in the cavity of the abscess, you can not remove it until this cavity closes. In this case, continuous aspiration is recommended. Drainages, which are installed to protect against suture failure, can be kept for 7 to 10 days.

Drainage is carried out both for the evacuation of the contents found during the operation, and for prophylactic purposes (installation of the so-called control drainage). In the latter case, the end of the drainage tube is placed near the sutures placed on the stomach, intestine or any other internal organ. In the event of failure of the sutures, the contents of the hollow organ are released through the drainage to the outside. Reliable drainage and delimitation of the process make it possible to do without repeated surgical intervention.

When draining the abdominal cavity, care should be taken, since a significant rarefaction in the drainage (300 mm of water column) can cause circulatory disorders and perforation of the intestinal wall. Drainages for aspiration of the contents of the abdominal cavity are removed on the 3rd - 8th day.

Drainages placed for outflow are removed only after the cessation of the release of pathological contents.

The control drains placed to the area of ​​the seams are removed on the 7th - 8th day, when it becomes clear that the divergence of the seams has not occurred.

In some cases, in the soft tissues and cavities of the body, the surgeon leaves microirrigators or drains for the introduction of drugs - antibiotics or antiseptics.

Microirrigators are soft tubes made of polymeric materials with a diameter of 1 to 5 mm, the outer ends of which are tied with silk thread. Medicinal preparations are administered through a puncture with a needle of these tubes, carefully observing the rules of asepsis. The introduction of antibiotics in irrigators is continued until the inflammatory process subsides, after which the irrigators are removed.

Drainage tubes designed for the outflow of pathological contents from the pleural, abdominal and retroperitoneal cavities are made of elastic materials.

104. Drainage of hollow organs. Indications. Gastrointestinal and rectal probes.

Unlike drainage of the abdominal and pleural cavities, drainage of the gastrointestinal tract solves the following problems:

 are created favorable conditions for the healing of anastomoses, intra-intestinal hypertension is eliminated - microcirculation is restored.

 liberation of the gastrointestinal tract from toxic contents, organization of enteral nutrition through it. Long bowel tubes are placed before or during surgery to decompress distended and congested small intestine, with recurrent intestinal obstruction and peritoneal carcinomatosis. For these purposes, Miller-Abbott, Cantor, Johnston or Baker-Nelson probes are used. Probes are installed only with preserved peristalsis. Aspiration through a long intestinal tube is carried out in intermittent mode with a small vacuum. To maintain patency, the probe is periodically washed. Removing a long probe cannot be done at once. Every hour, they are removed by 15 cm, and only when the tip of the probe reaches the stomach, it is removed completely.

Drainage of hollow organs

Active drainage consists in pumping out the contents of the stomach using a large syringe with a capacity of 200 cm3 (Janet's syringe) put on the outer end of the probe or using a special suction.

AT clinical practice quite often it is necessary to resort to the introduction of various tubes - probes, catheters into the hollow organs in order to evacuate the contents for therapeutic or diagnostic purposes. As a rule, probing is carried out through natural openings: mouth, nasal passages, anus, urethra, etc., probing through artificial (surgical) fistulas is less often performed.

When starting probing, it is necessary to clearly understand the goals of manipulation, the anatomical structure and features of the functioning of the organ, anticipate possible complications and know how to treat them. Special attention should be paid to the impeccable observance of the rules of antiseptics. When carrying out the manipulation, one should try to cause the patient as little pain as possible, in some cases even resorting to additional anesthesia.

Enemas. This is a therapeutic or diagnostic effect, which consists in the retrograde introduction of a liquid substance into the colon.

Gas removal from the intestines. With atony, incision of the intestine in its lumen accumulates a large number of gases formed as a result of ongoing processes of decay and fermentation. Most often this occurs with peritonitis and after abdominal surgery. Excessive accumulation of gases causes pain, makes breathing difficult, and makes you feel worse. 08d.ru Under normal conditions, gases exit under the action of peristalsis through the anus. After operations, a spasm of sphincters occurs and intestinal motility is disturbed, preventing the passage of gases. When introduced into anus rubber tube, gases escape due to increased intra-intestinal pressure, even in the absence of peristalsis. A gas tube is usually placed after a laxative enema or microclyster with glycerin.

catheterization Bladder . The introduction of a catheter into the urethra (urethra) is carried out for:

evacuation of urine in violation of independent urination;

washing the bladder;

obtaining urine from the bladder for laboratory testing.

catheterization contraindicated with acute inflammation of the urethra (inevitable infection of the bladder), with damage to the urethra, with spasm of the sphincter of the bladder. For catheterization, soft (rubber or plastic) and hard (metal) catheters are used.

Gastric tubes:

Used for aspiration of contents and gastric lavage, as well as for enteral nutrition.

Enlarged side openings provide efficient passage of liquid.

Probes with conductor (mandrin) are offered.

Rectal probes:

Used as a gas outlet tube, as well as for the introduction medicines and rectal drainage. Enlarged side openings provide efficient passage of liquid.

The lumen does not overlap when twisting.

The specially treated surface reduces the need for lubricants.

Colored funnel connectors allow quick identification of product diameter and can be used with all standard adapters.

Materials:Tubes: Medical grade PVC, phthalates free.

Acute peritonitis- one of the most dangerous diseases abdominal organs, which is an extremely significant and complex problem in emergency surgery. That is why the treatment of purulent peritonitis is difficult for practical surgery.

According to different authors, acute peritonitis occurs in 3.1% - 43.1% of the total number of patients hospitalized in surgical hospitals, and mortality in the development of various forms acute peritonitis remains at a high level and ranges from 9.2% to 71.7%.

At present, the basics complex treatment acute peritonitis are as follows: adequate preoperative preparation in order to stabilize hemodynamic and electrolyte disorders, unload the upper gastrointestinal tract.

Multicomponent emergency surgical intervention, including the following steps:

• choice of method of anesthesia;
• wide laparotomy, removal of exudate and elimination of the source of peritonitis;
• thorough sanitation of the abdominal cavity;
• decompression of the gastrointestinal tract;
• selection of the operation completion method;
• multipurpose postoperative.

To date, the feasibility and necessity of preoperative preparation for acute peritonitis has been proven and is not a subject of discussion. The duration and volume of preoperative preparation depend on the cause of peritonitis and the stage of the course. In cases of acute peritonitis of the reactive stage, short-term preparation (1-2 hours) is used, patients with acute peritonitis of the toxic and terminal stages are subject to longer preoperative preparation (from 2 to 6 hours or more).

The presence of internal bleeding determines the indications for emergency emergency surgery against the background of massive fluid transfusion. The whole complex of preoperative measures for acute peritonitis can be divided into diagnostic and treatment-corrective stages.

Diagnostic stage of preoperative preparation

It includes, in addition to the diagnosis of peritonitis, the identification of concomitant pathology and the degree of violation of vital functions (respiratory, cardiac activity, excretory, etc.), as well as the identification of the degree of homeostasis disturbance. It is necessary to monitor the dynamics of arterial and central venous pressure, as well as to perform electrocardiography and some hemodynamic tests (for example, Stange, Gencha, Motta, Baraja, etc.), which is a fairly informative study of cardiac activity.

Therapeutic and corrective

Therapy in the preoperative period can be represented as the following scheme:

• fight against pain syndrome;
• decompression of the stomach and, if possible, the colon;
• elimination of metabolic acidosis;
• correction of disorders of cardiovascular activity;
• correction of water and electrolyte balance with compensation for fluid deficiency under the control of diuresis;
• correction of anemia;
• elimination of microcirculation disorders;
• correction of protein disorders;
• antibacterial therapy;
• therapy aimed at improving the functions of parenchymal organs (primarily the liver and kidneys);
• antienzymatic therapy;
• direct medical preparation before surgery (premedication).

Severe functional disorders of organs and systems explain the need for a serious attitude to the method of anesthesia. In this situation, preference is given to general anesthesia, tracheal intubation with artificial lung ventilation and good muscle relaxation of the abdominal wall. Epidural anesthesia is very effective both at the stage of the operation and in the postoperative period.

Currently, regarding the surgical approach in acute peritonitis, the opinion of the absolute majority of surgeons is single-median laparotomy. During the operation, additional incisions may be necessary to prevent infection of the abdominal cavity.

After opening the abdominal cavity with one of important points operation is the implementation of novocaine blockade of reflexogenic zones. At severe forms acute peritonitis, it is recommended to carry out a total prolonged retroperitoneal neurovegetative blockade according to Bensman. Since the 90s in Ukraine, the laparoscopic method of treating peritonitis has been used and finds more and more supporters, aimed at eliminating its source, sanitizing and draining the abdominal cavity. There are two types of endoscopic interventions for this pathology: radical laparoscopy and diagnostic laparoscopy with conversion to laparoscopically assisted minilaparotomy.

In the postoperative period, according to indications, planned relaparoscopies and sanitation of the abdominal cavity are performed with an interval of 2-3 days.

Laparoscopic operations have become the main ones for gynecological and pancreatogenic peritonitis. Then, after evaluating the exudate, if the amount of effusion is large enough, the abdominal cavity should be freed as much as possible from the pathological fluid using an electric suction or gauze swabs, and only after that proceed with a phased examination of the organs in order to identify the source of peritonitis.

After identifying the source of the pathological process, they begin to reliably eliminate it with the help of the least traumatic and easily performed surgical procedure. If it is not possible to remove the source of peritonitis, it should be reliably delimited with tampons from the free abdominal cavity. The third option for eliminating the source of peritonitis is its drainage, the indication for which is an unremovable purulent-necrotic focus in the abdominal cavity and the spread of a purulent-necrotic process to the retroperitoneal tissue.

After removal of the source of peritonitis, the main goal is the maximum decontamination of the surface of the parietal and visceral peritoneum. To date, the most common and recognized method of intraoperative one-stage sanitation by almost all surgical schools remains washing the abdominal cavity with antiseptics and antibiotic solutions. At the same time, in the literature there are also negative opinions about intraoperative lavage of the abdominal cavity due to the fear of infection spreading through it. In patients with fecal peritonitis, the abdominal cavity is additionally washed with 500 ml of a 0.25% solution of novocaine with the addition of hydrogen peroxide.

The atomic oxygen formed when hydrogen peroxide comes into contact with the peritoneum suppresses both anaerobes and residual infection. The use of physical methods of sanitation of the abdominal cavity is also effective. AT last years a number of authors suggest using ultrasonic low-frequency cavitation with the URSK-7N-18 apparatus. A solution of furacilin, an aqueous solution of chlorhexidine, a solution of furagin or broad-spectrum antibiotics is used as a sound medium. Ultraviolet irradiation of the abdominal cavity, laser irradiation of the abdominal cavity, evacuation of the abdominal cavity, jet-ultrasonic treatment with antiseptics, exposure of the abdominal cavity to a pulsating jet of antibiotics also have a positive effect. Recently, a certain place in the treatment of widespread purulent peritonitis is assigned to ozone. Ozonated solutions with an ozone concentration of 3-4 mg/l have a bactericidal, fungicidal, virocidal effect and improve blood circulation.

Described and positive results application of physiotherapeutic flow of argon plasma in acute peritonitis. At one time there was a period of enthusiasm for detergents for the purpose of mechanical treatment of the abdominal cavity. However, current use is superficial active substances recognized as an anachronism. One of the leading pathogenetic mechanisms development endogenous intoxication is liver damage in common forms of peritonitis and, in particular, inhibition of the monooxygenase system (MOS) of the organ. In this regard, simple electrochemical systems are used using various oxygen carriers - indirect electrochemical blood oxidation. One of such oxygen carriers is sodium hypochlorite (NaClO), obtained by indirect electrochemical oxidation from isotonic sodium chloride solution in EDO-4, EDO-3M devices. However, it must be said that, although in acute peritonitis, one-stage sanitation of the abdominal cavity on the operating table is the basic element of treatment, it should “transition” into one of the options for prolonged sanitation.

An important step in the treatment of acute peritonitis is intraoperative decompression of the gastrointestinal tract. AT various occasions for this purpose, both nasointestinal intubation and stoma can be used.

Currently, there are several options for completing the operation for acute peritonitis. The most preferred option for the end of the operation, according to most authors, especially in advanced forms of the disease, is peritoneostomy, which is quite high. effective tool allowing to achieve recovery of this extremely difficult category of patients. Thanks to peritoneostomy, intra-abdominal pressure can be regulated, trauma to the tissues of the surgical wound is reduced, microcirculation of soft tissues is prevented, which contributes to the prevention of purulent complications, and makes it possible not to use expensive materials and devices. Traditional drainage of the abdominal cavity with several drains with a blind suture of the laparotomic wound and massive postoperative antibiotic therapy is often used. The methods of flow, fractional and combined peritoneal lavage are described. Prolonged relaparotomy and deaf suturing of the laparotomic wound without drainage are used much less frequently. There is a method of separate autonomous micro-irrigator strip drainage of the abdominal cavity, according to which each area, sinus, canal and bag of the abdominal cavity must be drained separately with a micro-irrigator (for subsequent administration of dialysate) and a wide rubber strip (for outflow of exudate). In the literature, one can find a description of the method of aspiration drainage according to A.I. Generalov with appendicular peritonitis, according to which drainage is carried out through an additional puncture and suturing the surgical wound tightly, which avoids suppuration of the main wound and the development of eventrations.

The method of planar sorption drainage of the abdominal cavity according to Mikulich-Makokha with VNIITU-1 hemosorbent in combination with regional lymphotropic therapy is described. This method, due to the effect of lymphosanation (as evidenced by benign hyperplasia of the regional lymph node due to an increase in the areas of the cortical and medulla, cortical and medullary sinuses, T- and B-dependent zones), promotes the activation of local immunity, enhances the drainage, transport and detoxification functions of the lymphatic region and reduces the time for suturing the abdominal cavity with its open management, improves treatment outcomes and reduce patient mortality rates.

Multi-purpose postoperative therapy is aimed at correcting homeostasis by intravenous and intra-arterial infusions of protein, electrolyte and hemodynamic drugs, antibacterial, immunocorrective and detoxification therapy using extracorporeal detoxification methods (hemosorption, lymphosorption, plasmapheresis, oxygenation of autologous blood and hyperbaric oxygenation, ultrafiltration, ultraviolet and laser irradiation of blood , extracorporeal connection of xenospleen and xenoliver) and quantum therapy, enterosorption, ultrasound, external abdominal hypothermia, reflexology, mechanical ventilation, treatment aimed at restoring bowel function, as well as prevention postoperative complications from vital organs and systems.

Good results in the treatment of acute peritonitis are observed with the introduction antibacterial drugs directly into the lymphatics. An effective way to correct homeostasis disorders in acute peritonitis can be complex therapy using 400 ml of a 1.5% solution of Reamberin with the addition of ex tempore 1 ml of a 0.005% solution of imunofan, as well as 10 ml of pentoxifylline. In the treatment of acute peritonitis, low-intensity laser radiation can be used. There are two main pathogenetic directions of action of photon energy in patients with peritonitis: stimulation motor function gastrointestinal tract and optimization of the processes of reparative regeneration of the peritoneum. In clinical practice, domestic installations of infrared laser radiation "Uzor" and "RIKTA" with a wavelength of 890 nm, a pulse repetition rate of 50 and 150 Hz, and an average radiation power of 5 and 3 mW, respectively, are used. The most favorable terms for the use of laser exposure: the first or second day after the operation. The exposure for each field of laser exposure is 1 minute. Irradiation is carried out from four fields: the right iliac region, the right mesogastric region, the epigastric region and the left mesogastric region. Usually, 2-3 sessions of irradiation performed daily are enough for a course of laser therapy.

Despite the large number of treatment options for acute peritonitis, mortality in this disease remains high. Therefore, the search for new approaches and methods for the treatment of peritoneal disease remains extremely relevant and in the future will improve the effectiveness of therapy, increase the frequency of favorable outcomes, reduce the frequency of complications, reduce economic costs, and facilitate treatment control.

Clinical practice suggests that in some cases, after surgical intervention have to perform drainage of the 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 a risk serious complications.

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

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

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

In some cases, this method is used as a preventive measure 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 an inflammatory process is taking place in the body.

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, with the help of which favorable conditions are created 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.

In 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 internal organs are not always amenable to therapeutic methods of treatment.

To avoid serious complications or death, surgical operations are performed.

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.

Gastric ulcer most effectively treated 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.

Treatment at the European Clinic for Surgery and Oncology severe patients with somatic and cancer. Every patient gets the best medical care at the level of Western standards, and even if it is impossible to radically solve the problem, everything possible is done to improve the well-being of a person and prolong his life.

One of the serious complications of many diseases is ascites, which is sometimes very resistant to conservative treatment and in this case it is necessary to resort to invasive manipulations.

Ascites provokes severe respiratory failure and pain in the abdominal cavity and, therefore, it must be disposed of.

Doctors of the European clinic have mastered the most modern methods treatment of ascites and people admitted here can count on a quick normalization of their condition not only in relation to the underlying disease, but in all existing complications.

Ascites formation

A small amount of fluid is contained in the abdominal cavity healthy person, but it is constantly deleted through the system lymphatic vessels. If the volume of ascites does not exceed 500 ml, then it is subjectively not felt in any way. In a number of diseases, its production is so intense that the amount of fluid can exceed 10 liters. Then they talk about tense ascites.

Such ascites can form in heart failure, when the heart has difficulty pumping the available blood volume, for example, against the background of post-infarction cardiosclerosis or myocarditis.

In this situation, the emphasis in treatment is on stimulating the work of the myocardium through cardiac glycosides and reducing venous return, which is possible with the appointment of nitrates, diuretics, ACE inhibitors and etc.

Portal hypertension due to cirrhosis inevitably leads to ascites. The stroma of the liver is reborn, connective tissue growths appear in it and this leads to a violation in the portal vein system. Preference is given to the treatment of the underlying disease and punctures of the abdominal cavity are performed, diuretics are given under the control of blood pressure.

Sometimes, kidney disorders can also provoke ascites. The main mechanism of development in this case is associated with the loss of protein and changes in oncotic pressure in the bloodstream. Renal pathology should be treated.

Peritoneal carcinomatosis and other types of cancer in the abdominal cavity can provoke the formation of an effusion, sometimes reaching very large volumes.

Conservative therapy gives only a slowdown in the process and temporary relief. To get rid of cancer, a surgical operation is required, and if the patient is not operable, then a puncture of the abdominal wall is made to remove the resulting fluid.

In addition to the surgical operation, the oncological process can be influenced by radio irradiation and chemotherapy.

Invasive treatments for ascites

The puncture of the abdominal cavity is usually carried out with a large accumulation of ascitic fluid. The process is usually carried out in a treatment room. It is carried out by the attending physician, and the nurse assists.

The puncture of the anterior abdominal wall is not carried out in case of a pronounced adhesive process, bloating, with injuries and purulent-inflammatory reactions in the abdominal cavity. The manipulation itself is performed using a metal trocar, which consists of a stylet and a tube with a valve.

There are many different designs of such equipment, but the main idea is that the stylet is inserted into the tube, and after penetration into the abdominal cavity, the stylet is removed and the proximal exit of the tube communicates with the abdominal cavity.

The area of ​​the proposed puncture is first infiltrated with 1% novocaine or 2% lidocaine. After the anesthesia has worked, a small incision of the skin and subcutaneous aponeurosis is made 2-3 cm below the navel. Then a trocar is installed in this place and a puncture of the anterior abdominal wall is made.

When the stylet reaches the abdominal cavity, it is removed and the tube is advanced another 2-3 cm so that it does not rest against soft tissues during the procedure.

After that, a valve is opened on the tube and the ascitic fluid is drained. Part of it is sent to laboratories for cytological analysis of the sediment. The process of exiting the liquid is carried out very carefully and slowly.

With large ascites, no more than one liter is removed in 5 minutes, so as not to cause severe decompression of the intra-abdominal vessels and loss of consciousness.

Simultaneously with the release of ascitic contents, the doctor's assistant squeezes the outside of the abdomen with a long towel in order to compensate for the loss of intra-abdominal pressure.

The patient (if health permits) spends the entire procedure in a sitting position, leaning slightly forward, which makes it possible to more effectively remove the contents. In this case, the assistant can support him from behind by the shoulders or with the help of a stretched towel.

Possible complications of laparocentesis

It is impossible to allow air to be sucked into the abdominal cavity, as this provokes mediastinal emphysema, in which gas infiltrates the tissue in the abdominal and thoracic cavities.

Another complication of this procedure is the traumatization of blood vessels of various calibers, damage to the intestines, peritonitis, phlegmon of the abdominal wall.

If the patient cannot sit, the puncture is done in the supine or lateral position.

For one procedure it is forbidden to remove more than 10 liters of liquid.

Laparocentesis is not always effective and is often done under ultrasound guidance. Sometimes, with the rapid re-formation of ascitic fluid, a drain is installed, which is connected to the proximal tube of the trocar, and for some time the fluid may continue to exit.

There is a clamp on the drain, which prevents air from being sucked in when the liquid does not pour out.

The drainage is 25 cm long and runs in the lateral canal of the abdominal cavity, descending into the small pelvis, which allows the maximum volume of ascitic discharge to be removed.

The use of the Redon system in ascites

In the West, the so-called Redon system is used, which, in fact, is also a drainage with an adjustable valve for the exit of liquid.

The meaning of such a system is to help patients with constant formation of ascitic fluid in inoperable cancer producing effusion.

Installing a drain is technically similar to a puncture. An incision is also made on the abdomen and a puncture of the anterior abdominal wall under ultrasound control.

Then the plastic drainage itself is installed, the outer end of which is fixed to the skin with sutures and adhesive tape. At the outer skin end there is a tap that allows you to drain the liquid and close it when there is no liquid - to seal the abdominal cavity.

Aspiration of ascites during surgery

The success of emergency surgery largely depends on the use of adequate methods of drainage of the abdominal cavity.

General principles of drainage of the abdominal cavity

The concept of rational drainage of the abdominal cavity includes a set of techniques that ensure unhindered outflow of fluid from the abdominal cavity. First of all, we mean ensuring the outflow of pus in peritonitis - the primary task of treating any purulent process.

Successful drainage of the abdominal cavity is possible only under the following conditions: the drainage must be in places where fluid accumulates, be passable. It is installed in the sloping areas of the abdominal cavity and some of its pockets, and the patient is recommended a position in bed that contributes to the best drainage. With peritonitis, as a rule, an elevated position is shown, in some cases, a position on the side, back is required. It is more difficult to ensure the patency of the drainage. For drainage purposes, the introduction of rubber tubular drains, as well as drains made of synthetic materials, is widespread.

All drainages from improvised material have a drawback - they become impassable in the next day. Insufficient outflow is facilitated not only by blockage of the drainage lumen, but also by adhesions and plugs of fibrin (pus) that form in the abdominal cavity around the inserted tubes.

Detection during surgery of destructive changes in the appendix with the presence of purulent effusion, especially in patients with a pronounced subcutaneous fat layer, as well as in elderly and debilitated patients, is an indication for drainage of the abdominal cavity. If only local peritonitis is found during appendectomy, a single silicone or tube-glove drainage through the appendicular incision in the right iliac region is sufficient. If a large amount of serous fluid has accumulated in the abdominal cavity during catarrhal appendicitis, the introduction of a microirrigator for the instillation of antibiotics is indicated.

In cases where an appendicular abscess is opened, capillary bleeding from the appendix bed cannot be stopped, the tip of the appendix has come off, there is no confidence in sufficient ligation of the mesentery of the appendix, it is advisable to introduce a gauze swab. The gauze swab should be removed for 5-7 days, preferably in stages. On 3-4 days it is pulled up (the beginning of mucus), and after 2-3 days it is completely removed. Instead, a strip of glove rubber is introduced, which prevents premature gluing of the edges of the wound and a delay in the depth of its discharge.

Drainage of the abdominal cavity in acute cholecystitis

In operations performed for acute cholecystitis, cholecystopancreatitis (cholecystectomy, cholecystostomy or extended operations on the extrahepatic biliary tract), drainage of the subhepatic space is always required. Our experience shows that through the counter-opening in the right hypochondrium, tubular-glove drainage should be brought into the subhepatic space to the omental opening. In this case, it is advisable to use the Spasokukotsky method. They take an obliquely cut tube up to 20 cm long with one side hole at a distance of 2-3 cm from the lower end. The lower section is brought to the omental opening, and the side window - to the stump of the cystic duct and the gallbladder bed. If it is necessary to drain the biliary tract, the corresponding tube of internal drainage is removed through a puncture of the abdominal wall above the tube-glove drainage.

Operations on the liver with injuries, after opening abscesses and other manipulations should be completed with drainage of the subhepatic space and the right lateral peritoneal canal with tubular-glove graduates, which often have to be combined with gauze swabs due to possible bleeding or, if necessary, delimitation of the process.

Drainage of the abdominal cavity in acute pancreatitis

With pancreatic necrosis and purulent pancreatitis, there is a need for drainage in order to remove purulent or enzyme-rich exudate, bring antibiotics to the focus, and carry out flow irrigation of the omental bag. It is possible to drain the pancreatic bed and the omental bag by dissecting the gastrocolic, hepatogastric ligaments, transverse mesentery colon or lumbotomy in the left or right lumbar region.

Dissection of the gastrocolic ligament allows for a detailed examination of the pancreas, to isolate the drainage from the free abdominal cavity by suturing the sheets of the ligament to the parietal peritoneum of the anterior abdominal wall. A tubular-glove drainage is brought to the bed. Only in case of violation of the integrity of the lesser omentum and extensive leakage into the subhepatic space, it is necessary to carry out drainage with the opening of the gastrohepatic ligament. Lumbotomy is indicated for extensive retropancreatic leakage, deep focal changes posterior surface of the pancreas, retroperitoneal necrosis.

Abdominal drainage for ulcers

During operations for a perforated ulcer, drainage of the right lateral canal with a tube-glove drainage through a counter-opening in the right iliac region is indicated, where the outflowing contents most often flow, the removal of which does not exclude inflammation of the peritoneum. In this case, you should also introduce a microirrigator into the right hypochondrium (the most likely source of infection) for the administration of antibiotics. Sometimes it is necessary to install drainage in the pelvic cavity (through the counter-opening in the right iliac region).

Drainage of the abdominal cavity after

After resection of the stomach according to Billroth-2 and in the absence of confidence in the reliability of the closure of the stump, especially in patients with acute gastrointestinal bleeding, along with its transnasal drainage, tube-glove drainage is brought to the stump through the counteropening in the right hypochondrium.

Drainage of the abdominal cavity with intestinal obstruction

During operations for acute obstruction intestinal drainage of the abdominal cavity is not required if there is no peritonitis; if present, drainage is carried out according to the general rules.

Drainage of the abdominal cavity after removal of the spleen

After removal of the spleen in case of its rupture, the left subdiaphragmatic space should be drained with tubular-glove drainage through the counter-opening located in the outer section of the left hypochondrium.

Drainage of the abdominal cavity after hemicolectomy

The area of ​​anastomosis after resection of the left half of the colon should be extraperitoneated and drained with glove-tube drainage in order to prevent peritonitis in case of insufficient sutures.

Drainage of the abdominal cavity with peritonitis

With general peritonitis, it is advisable to wash the abdominal cavity during surgery (lavage), which provides the most effective cleansing of purulent exudate without significant damage to the peritoneal mesothelium. With diffuse peritonitis, the unaffected sections of the abdominal cavity are preliminarily isolated with gauze wipes and sterile towels. The inflammatory process cannot be eliminated by a one-time sanitation, therefore, rational drainage acquires postoperative period paramount importance.

With general purulent peritonitis, regardless of the cause of its occurrence, drainage is carried out from 4 points with silicone or tubular glove drainages. Counter-openings are applied in both subcostal and iliac regions. Drainages are introduced into the subdiaphragmatic, subhepatic spaces and into both lateral canals. In this case, the drainage, carried out through the left lateral canal, is immersed in the small pelvis.

If the source of peritonitis was acute purulent pancreatitis, additional drainage is installed in the cavity of the lesser omentum. In case of general peritonitis caused by a breakthrough of an abscess of the retroperitoneal space, along with drainage from 4 points, tubular-glove drainage is brought to the focus in the retroperitoneal space and removed posteriorly. The need for such drainage occurs in appendicitis with a retroperitoneal location of the appendix, pancreatitis, suppuration of retroperitoneal hematomas, pyonephrosis, paranephritis. Drainage in these cases is usually brought through the counter-opening in the lumbar region. In case of breakthrough of intra-abdominal abscesses after their sanitation, tubular-glove drainage is introduced into the abscess cavity.

With diffuse peritonitis that does not spread to the upper floor of the abdominal cavity, instead of drainage in both hypochondria, the introduction of microirrigators is acceptable. A solution of antibiotics injected through thin tubes into the space under the diaphragm will drain into ground floor abdominal cavity, and the outflow is carried out through tubular-glove drainages introduced into the iliac region. If diffuse peritonitis is caused by acute cholecystitis, perforated gastric ulcer, or duodenum, drains are introduced into the subhepatic space and into both lateral canals (through the iliac region).

With peritonitis limited to the pelvic area, tubular-glove or other drainages are introduced through counter-openings in the iliac regions and through the lateral channels of the peritoneum are carried out to the bottom of the pelvis. With delimited extensive pelvic abscesses, it is advisable for women to introduce drainage by posterior colpotomy, and for men - through the rectum.

The tubular drainage element, which is also used for introducing antiseptics into the abdominal cavity, as already mentioned, must be removed on the 3-4th day, while the remaining glove drainage is only tightened during these periods. If at the same time no outflow of fluid is observed, then the glove drainage is removed for 6-7 days, if the discharge continues to flow through the drainage, it is replaced with a new one and left in the abdominal cavity until it stops functioning completely. A patient with a drained abdominal cavity needs careful dynamic monitoring, since the drainage itself can become a source of additional complications (intestinal obstruction, bedsores).

N. N. Kanshin recommends active drainage of purulent wounds and cavities. He developed two versions of the method based on the introduction of a double-lumen TMMK drainage tube into a purulent cavity or into a sutured festering wound, which is then used for washing with prolonged aspiration. Depending on the size of the purulent cavity, 1, 2, 3 drainage tubes and more of an original design are installed. A drip infusion is connected to the microchannel (a weak solution of an antiseptic, water sterilized by boiling), and an aspiration apparatus is connected to a wide channel. The pus sucked in through the side openings into a wide channel is mixed with the washing liquid and evacuated into a collection jar. Aspiration can be carried out using a modernized aquarium vibrocompressor or L.L. Lavrinovich's apparatus with an adjustable level of vacuum. The method is effective in the treatment of residual and delimited abscesses, including subdiaphragmatic, appendicular, interintestinal. The author also proposed a simplified aspiration-flushing method for the treatment of suppurative processes, carried out in the absence of factory-made two-channel tubes, using improvised materials.

Drainage for bladder injuries

In case of injuries and injuries of the abdominal cavity with damage to the bladder or deep parts of the urethra, with accidental injuries of the bladder (for example, during hernia repair with a sliding hernia), it becomes necessary to drain the perivesical space through the obturator opening due to possible urine leakage (drainage according to Buyalsky) . This well-known drainage is not always used for indications in general surgical, especially small, hospitals. According to indications, such drainage is performed on both sides and must be supplemented with the imposition of a cecostomy.

It is not necessary to list all the situations of emergency surgery that require drainage of the abdominal cavity, the introduction of tampons and microirrigators. Actions should be regulated by knowledge of their purpose and specific pathology.

The outflow through standard silicone or tube-glove drainages occurs from sloping sections under the action of gravity. Where possible and appropriate, an aspiration-flushing method should be used to treat purulent cavities using factory-made double-lumen silicone tubes or a simplified technique. A tampon in abdominal surgery is used only in extreme cases for the purpose of hemostasis and for the formation of delimiting adhesions. The microirrigator is used only for the introduction of medicinal substances. Drainages, tampons and micro-irrigators are removed through counter-openings.