How to treat a ligature fistula. Ligature fistula postoperative scar

Hello Olga Vladimirovna.

Only a qualified surgeon in a medical institution can process and treat (if necessary) a ligature fistula. Despite the fact that this is not the first time you have encountered this problem, and, as it may seem to you, you already know perfectly well what you are dealing with, it is highly not recommended to carry out any independent manipulations with the fistula. Self-treatment of affected tissues and any other self-treatment is always fraught with inflammation and the introduction of an additional infection.

Again and again a tubercle appears - this is nothing more than a section of a thread (ligature). If you decide not to go to the doctor, but just wait until the suture comes out on its own, and the pus breaks out and the patient gets better, then you are at great risk. The fact is that the lack of medical intervention in this process is fraught with the development of complications (suppuration of neighboring areas, the development of phlegmon, etc.).

The appearance of ligature fistulas occurs for the following reasons:

The suture material (ligature) was initially infected.
The infection was introduced during surgical intervention when removed inguinal hernia.
Infection of the wound tissues occurred due to improper processing of the seam or non-compliance with hygiene and sanitation measures (this is a direct error of the doctor).

Precautions and Risk Factors

If the doctor has not established the cause, but simply excised the fistula from time to time, then this will not lead to any positive results. If the source of infection is not removed, is it possible to hope for a normal process of tissue regeneration? Naturally not! It is possible that the doctor does not sufficiently comply with the rules of sanitation and subsequent processing of the suture.

In addition, the patient's age can also play an important role, because a 70-year-old man's immunity is already weakened and cannot fully perform the functions that were originally assigned to him. But it is the state immune system largely determines the success of the healing process of postoperative sutures and the absence of the risk of complications.

Treatment and prevention of ligature fistulas

You mention the excision of the fistula - this method of treatment is referred to as surgical (more radical). At surgical treatment it is extremely important to remove the infected ligature from the fistula, which does not resolve. The presence of suture material in the wound can cause subsequent fistula formation. By the way, the laser excision technique has been widely used recently. This device is more accurate and reliable, because it eliminates the human factor, and for the patient himself, the procedure for removing the ligature with a laser is more gentle.

However, if the reason for the regular formation of a fistula is an infection (I remind you that, based on your description, the doctor has not established the cause), then conservative treatment is used to eliminate the infection, and not the fistula itself. If the focus of inflammation is removed, then the fistula will close on its own. At conservative treatment antibacterial and anti-inflammatory drugs, antiseptics, as well as immunomodulating drugs and vitamin complexes are used (the importance of the immune system is discussed above).

Effective preventive postoperative measures include strict adherence to the rules of antiseptic treatment of the wound. If we talk about the measures that should have been applied by the surgeon before the operation, then it is important to say about:

careful preparation of the wound before suturing;
checking the suture material for sterility;
the use of high-tech suture materials and the rejection of the use of non-absorbable threads.

Sincerely, Natalia.

If you know that all types of fistulas are divided into congenital, acquired, and artificially created, then the ligature fistula of the postoperative scar will belong to the latter category. Therefore, it can occur anywhere if there has been a surgical intervention, after which inflammation has developed from the suture surgical material itself - the ligature. And there is absolutely no difference which thread was used (synthetic, natural, absorbable or not). Sometimes the cause of a fistula is the negligence of medical personnel, but it happens that the body itself rejects foreign material.

Conservative treatment of ligature fistula of postoperative scar

As a rule, the pathological process that has begun makes itself felt even before the patient is discharged home. Unfortunately, not everyone is attentive to their condition after the operation and certainly strives to be discharged from the hospital as soon as possible. After all the worries about the upcoming surgical procedures, a slight redness in the suture area seems like such a trifle. However, only at the first signs of fistula development and the initial stage of suppuration, its conservative treatment is possible.

An experienced surgeon himself will determine that the healing process of the suture has deviations and will take timely action. Firstly, the site of inflammation is carefully examined, dead tissue is removed so that the wound heals faster. This is done in several stages with constant treatment of the seam with an antiseptic solution. Secondly, threads are removed in parallel, the endings of which appeared on the surface.

Medical treatment is prescribed:

antibiotics (, Ceftriaxone, Norfloxacin, Levofloxacin);
local antiseptics in the form of powders and water-soluble ointments (Levomikol, Trimistin);
enzymes that dissolve dead cells.

Popular Vishnevsky ointments and synthomycin-based ointments are contraindicated due to their fatty base.

Surgical excision of the ligature fistula

It is much worse if the fistula is on the internal organs. Or outside, but the inflammation has gone too far. In this case, there are two options for drastic measures:

removal of suture material without dissection of the fistula through its hollow channel;
complete excision of the fistula in order to remove the ligature and flush the wound from suppuration.

Ligature fistula, the treatment of which is carried out both conservatively and surgically, is subjected to medical institution quartz treatment or exposure to ultrasound. Ultrasonic control allows you to make sure that all threads are removed without residue.

Treatment of ligature fistula at home

There are a lot of unconventional methods of treating various kinds of fistulas, but you should not rely on the ability to quickly cope with inflammation from the remnants of the ligature if they are not previously removed by dissecting the place of suppuration. If you miss the time, trying to fight with improvised means at home, then the process can be aggravated up to sepsis. When the focus of inflammation is correctly removed in the hospital, the doctor himself will probably give advice on what simple procedures can be done at home to speed up the closure of the wound.

For example:

A salt bandage is applied to the ligature fistula as an antiseptic as a prevention of re-inflammation, it helps even if it was not possible to release all the threads during dissection. Concentration saline solution is made at the rate of 1 tsp per glass of hot boiled water.
You can wash the fistula site with hot enough salty water, make lotions or.
Treatment of a ligature fistula with Dimexide is also quite common at home. This is a cheap universal concentrate, from which a 50% -90% aqueous solution can be prepared for lotions. Demixid has the ability to draw out all the impurities from a festering wound.

overlay surgical sutures- the last stage of the intracavitary operation. The only exceptions are operations on purulent wounds, where it is necessary to ensure the outflow of the contents and reduce inflammation in the surrounding tissues.

Sutures are natural and synthetic, absorbable and non-absorbable. Expressed inflammatory process at the suture site can lead to the release of pus from the incision.

The outflow of serous fluid, thickening and swelling of tissues indicates such a pathological phenomenon as a ligature fistula of a postoperative scar.

Why does a ligature fistula appear after the operation

A ligature is a thread used to tie blood vessels. By applying a suture, doctors try to stop bleeding and prevent its occurrence in the future. Ligature fistula is an inflammatory process at the site of wound stitching.

It develops due to the use of material contaminated with pathogens. The pathological element is surrounded by a granuloma - a seal that consists of different tissues and cells:

The ligature thread is also part of the granuloma. Its suppuration is dangerous for the development of an abscess.

It is clear that the main reason for the formation of a ligature fistula lies in the infection of the suture material. The development of an unfavorable process is provoked by various factors:

Avitaminosis.
Syphilis.
Tuberculosis.
General condition and age of the patient.
Hospital infection (streptococcus, staphylococcus aureus).
Oncological diseases involving protein depletion.
High immune reactivity of a young organism.
Rejection of the thread by the body due to individual intolerance to the material.
Wound infection due to lack of antiseptic treatment.
Metabolic disease ( diabetes, obesity).
Localization of the operated area (belly in women after caesarean section, paraproctitis).

Ligature fistulas occur in any part of the body and in all types of tissues. As for the time of their appearance, there are no exact forecasts here. In some patients, the problem occurs after a week or a month, but it also happens that the fistula bothers a year after the operation.

Symptoms of a ligature fistula

The following symptoms help to identify a fistula on a scar after surgery:

In the first days after the operation, the area thickens, swells, and causes pain when palpated. The skin surrounding the wound turns red, the local temperature rises.
A week later, when pressing on the seam, serous fluid and pus are released.
Body temperature rises to 37.5 - 39°C.
The behavior of the fistula is unpredictable - the passage can spontaneously close and reopen later.

Only a second operation helps to completely get rid of the canal. What a ligature fistula looks like can be seen in the photo.

Outwardly, it is a deep wound with inflamed skin around the edges. Interestingly, the fistula can form completely different from where the incision was made. Physicians are aware of cases when inflammation developed for a long time inside the patient's body, but the person himself understood that he was sick only when a small hole appeared on the body, from which purulent-serous fluid oozed.

A fistula is a hollow channel inside the body, a kind of link between organs and the external environment. It can also be an articulation of the internal cavity and an oncological neoplasm. The channel, which looks like a tube, is lined with epithelium from the inside. Pus comes out through it. In advanced cases, bile, urine, feces come out of the fistula.

Postoperative fistulas are divided into several types:

Full. Features two outlets. This structure promotes rapid healing.
Incomplete. The fistula has one exit inside abdominal cavity. In such conditions, the pathogenic flora multiplies rapidly and enhances the inflammatory process.
Tubular. A properly designed canal releases purulent, mucous and fecal masses.
labial. The fistula fuses with muscle and dermal tissue. It can only be removed by surgery.
Granulating. Fistula overgrows granulation tissue, the surface of the surrounding skin looks hyperemic and edematous.

In the ICD-10, the ligature fistula is listed under the code L98.8.0.

Most often, ligature fistulas are formed at the places where the silk thread is applied. To avoid this problem, modern doctors use a material that does not require the removal of sutures and through a short time dissolves on its own.

Diagnosis and treatment of ligature fistula on the scar

Ligature fistula is diagnosed during the examination of the postoperative wound. For a complete study of the suspicious area, the patient is sent for ultrasound and fistulography. This is a kind of x-ray with the use of a contrast agent. The picture clearly shows the location of the fistulous canal.

Treatment of ligature fistula provides for an integrated approach. Patients are prescribed different groups of drugs:

Enzymes chymotrypsin and trypsin.
Antiseptics for local treatment.
Antibiotics SSD - Norfloxacin, Ampicillin, Ceftriaxone, Levofloxacin.
Water-soluble ointments - Levomekol, Levosin, Trimistin.
Fine powders - Baneocin, Gentaxan, Tyrozur.

Enzymes and antiseptics are injected into the fistulous canal and surrounding tissues. Substances act within 3-4 hours, so the problem area is treated several times a day. With abundant expiration of purulent masses, it is forbidden to use Vishnevsky's liniment and synthomycin ointment. They clog the channel and delay the outflow of pus.

In order to relieve inflammation, the patient is sent to physiotherapy. Wound quartzing and UHF therapy improve blood and lymph microcirculation, reduce swelling and neutralize pathogenic flora. The procedures provide a stable remission, but do not contribute to a complete recovery.

Complications of a ligature fistula: abscess, phlegmon, sepsis, toxic-resorptive fever and eventration - prolapse of organs due to purulent fusion of tissues.

A non-closing ligature fistula is treated by surgical treatment of a complicated postoperative wound. The site is disinfected, anesthetized and dissected to completely remove the suture material. The cause of the fistula is also excised along with adjacent tissues.

To stop the bleeding, an electrocoagulator or hydrogen peroxide (3%) is used, otherwise the flashing of the vessel will provoke the formation of a new fistula. The surgeon's work is completed by washing the wound with an antiseptic (Chlorhexidine, Decasan or 70% alcohol), applying a secondary suture and organizing drainage in the treated area.

AT postoperative period the drainage is washed and the dressing is changed. With multiple purulent leaks, antibiotics are used, Diclofenac, Nimesil and ointments - methyluracil or Troxevasin. Minimally invasive methods of fistula removal, for example, through ultrasound, are ineffective.

Almost every surgical intervention ends with closing the wound with surgical sutures, with the exception of only operations performed for purulent wounds, where, on the contrary, conditions are created for a normal outflow of purulent contents and a decrease in infiltration (inflammation) around the wound.

Surgical sutures can be of both synthetic and natural origin, as well as those that dissolve and do not dissolve in the body after some time.

Sometimes it happens that a pronounced inflammatory process occurs at the site of their application, serous (cherry color), and then purulent discharge, and this is a reliable indicator that a fistula has formed after the operation and its rejection by the body has begun. It is important to understand that the postoperative fistula is a manifestation of the abnormal course of this period and requires further treatment.

Causes of the appearance of a ligature fistula after surgical interventions

The accession of an infection that has entered the wound through the sutures (insufficient observance of the cleanliness of the wound, insufficient observance of antiseptics during the operation);
Rejection by the body due to allergic reaction on the thread material.

Also, the following factors influence the occurrence of a ligature fistula in the postoperative period:

It is interesting that ligature fistulas:

Occur in any part of the body;
In different layers of the surgical wound (skin, fascia, muscle, internal organ);
Do not depend on the time frame (occur in a week, month, year);
Have different clinical manifestations(rejection of sutures by the body with further healing or prolonged inflammation with suppuration of the wound without healing);
Occur regardless of the material of the surgical thread;

Manifestations

The first days in the projection of the surgical wound there is a thickening, redness, slight swelling, soreness and an increase in local temperature.
After one week, serous fluid begins to come out from under the sutures, especially when pressed, and later pus.
In parallel with this, the body temperature rises to (37.5-38);
Sometimes the inflamed fistulous passage closes on its own, but reopens after a while;
A complete cure occurs only after a subsequent operation and elimination of the cause.

Complications arising from ligature fistula

Abscess - cavity with pus
Phlegmon - the spread of pus through the subcutaneous fat
eventration - loss internal organs due to purulent fusion of the surgical wound
Sepsis - with a breakthrough of purulent contents into the cavity of the abdomen, chest, skull
Toxic-resorptive fever- a severe temperature reaction of the body to the presence of a purulent focus in the body.

Diagnostics

It is possible to diagnose a ligature fistula during a clinical examination of the wound in the dressing room. It is also a prerequisite to perform an ultrasound examination of the surgical wound, which is done to identify possible purulent streaks or abscesses.

If diagnosis is difficult due to the deep location of the fistula, fistulography is used. The essence of the latter is the introduction of a contrast agent into the fistulous tract, followed by radiography. The picture clearly shows the location of the fistula.

Treatment

Before treating a fistula, it is necessary to understand that in most cases there will be no cure without surgical intervention and its long existence will only aggravate the course of the disease. Also, with a ligature fistula, treatment should be comprehensive, with the obligatory use of:

local antiseptics:
- water-soluble ointments: levomikol, trimistin, levosin
– finely dispersed powders: tyrosur, baneocin, gentaxan
broad-spectrum antibiotics - ceftriaxone, norfloxacin, levofloxacin, ampicillin
enzymes that dissolve dead tissue - trypsin and chymotrypsin.

These antiseptics and enzymes must be injected both into the fistulous tract itself and into the local tissues surrounding it several times a day, since their activity lasts no more than 4 hours.

It is necessary to know that with abundant discharge of pus from the fistula, it is strictly forbidden to use fatty ointments (Vishnevsky, synthomycin), as they clog its channel and thereby disrupt the outflow of pus.

Also, in the phase of inflammation, physiotherapeutic procedures can be actively used, namely quartzing of the wound and UHF therapy. The latter significantly reduce swelling and the spread of infection due to improved blood and lymph microcirculation and a detrimental effect on microorganisms. Such measures do not guarantee a complete recovery, but can only cause a stable remission.

To the question: “what to do with a fistula that does not close?” one can only answer that this is a guaranteed indication for surgical intervention. The treatment of a ligature fistula by surgery is the “gold standard”, because only through surgical treatment can the cause of constant suppuration be eliminated.

The course of the operation for the ligature fistula

Treatment of the surgical field with antiseptics (alcoholic solution of iodine) three times;
In the projection of the surgical wound and under it, an anesthetic is injected (2% lidocaine solution, 0.5-5% novocaine);
For the convenience of searching, a dye (brilliant green and hydrogen peroxide) is introduced into the fistulous tract;
The wound is incised with the removal of all suture material;
The cause that caused the fistula is located and removed with the tissues surrounding it;
Bleeding is stopped only with the help of an electrocoagulator or 3% hydrogen peroxide, flashing the vessel is strictly prohibited, as this can re-cause a fistula;
After the bleeding stops, the wound is washed with antiseptic solutions (chlorhexidine, 70% alcohol, decasan) and closed with secondary sutures with mandatory active drainage.

In the postoperative period, periodic dressings are carried out with washing of the drainage, which, in the absence of a purulent discharge, is removed. If there are indications (extensive phlegmon, multiple purulent streaks), the patient receives:

antibiotics
anti-inflammatory drugs (- dicloberl, )
ointments that stimulate healing processes (methyluracil, troxevasin)
drugs can also be used at the same time plant origin, especially those that are rich in vitamin E (, aloe).

It is important to note that the operation for the ligature fistula is most effective in its classical form, namely with a wide incision and adequate revision. All slightly invasive techniques (using ultrasound) in this case show not high efficiency in the fight against this disease.

It should also be noted that self-treatment in the case of a ligature fistula of a postoperative scar is not permissible, since everything will still end with surgery, followed by surgical treatment, but time will be lost and life-threatening complications may develop.

Prognosis after surgery and prevention

In many cases surgical treatment ligature fistula is effective, but there are cases when the human body in every possible way rejects all surgical threads, even after multiple repeated operations. With self-treatment of a fistula, the prognosis is not favorable.

Prevention of the appearance of a fistula in most cases is not possible, since the infection can penetrate the seam even under the most aseptic conditions, not to mention the rejection reaction.

- this is a pathological course surrounded by an inflammatory infiltrate in the area of a non-absorbable suture thread, which was used for suturing tissues during various surgical interventions. Prone to relapsing course. It is manifested by the presence of a seal, in the center of which there is a small hole with a scanty serous-purulent discharge. The skin around the lesion has a purple-bluish or dark color. A ligature fistula is diagnosed based on symptoms, a history of surgery, fistulography data, and ultrasound. Treatment is curettage of granulations and removal of ligatures or excision of the fistula.

ICD-10

L98.8 Other specified diseases of skin and subcutaneous tissue

General information

Ligature fistula is a fairly common complication. Occurs in 5% of patients undergoing various surgical interventions. It is significantly more often diagnosed after surgical manipulations on the hollow organs of the abdominal cavity and small pelvis (conditionally aseptic operations), which is due to an increased likelihood of infection of surrounding tissues, even with strict adherence to the rules of asepsis and antisepsis. The prevalence of this complication after gynecological interventions is 8.9%, hernia repair - 9.5%, operations for gastric ulcer and duodenal ulcer - 7.8%. The ligature can be located both superficially and at a considerable depth. Due to the tendency to recurrence, pathology often causes long-term disability. Aggravates the course of the underlying disease.

The reasons

The reason for the development of a ligature fistula is a rejection reaction foreign body- thread used for suturing deep and superficial tissues during surgery. Usually, pathological passages occur when non-absorbable threads are rejected. More often in the fistula, silk threads are found, somewhat less often - lavsan and kapron. Despite the fact that catgut is an absorbable thread, there are references in the literature to catgut ligature fistulas. The disease is almost never caused by Vicryl or Prolene threads. Provoking factors include:

Infection. Pathogenic microorganisms penetrate the suture area as a result of suppuration of the surgical wound, which may be due to the non-sterility of the surgical field and instruments, violation of medical recommendations, the addition of a hospital infection, a change in reactivity or exhaustion of the body, etc. If the rules for sterilization of the suture material are violated, infectious agents may be on the thread at the time of tissue suturing.
Immune rejection reaction. Occurs in response to the introduction of a foreign body, the likelihood of occurrence depends on individual immunological characteristics. The thread is not covered by the capsule, but becomes a target for immune cells that recognize it as a foreign antigen.
Stitching of a hollow organ. It is observed when the entire wall of the organ is accidentally captured and the thread exits into its lumen. Upon contact with the non-sterile contents of the organ, the thread becomes infected, pathogenic microbes spread along its entire length and give rise to a focus of inflammation.

Pathogenesis

Usually, over time, a layer of scar connective tissue forms around non-absorbable threads, the threads are encapsulated. With the development of a purulent-inflammatory process, encapsulation does not occur, an abscess forms around the thread. Subsequently, the cavity of the abscess is opened in the area of the postoperative scar, phenomena acute inflammation decrease due to the constant outflow of content. The thread may remain in place or migrate along the pathological course.

When the thread comes out on its own or is surgically removed, the cause of inflammation disappears, the fistula closes. Otherwise, the inflammation acquires a recurrent character, may be complicated by a secondary infection. Fistulas can be both single and multiple, formed in the area of the threads used to suture superficially located tissues, or in the depth of the wound, for example, in the abdominal cavity. In the latter case, there is a possibility of involvement of internal organs in the purulent-inflammatory process.

Symptoms of a ligature fistula

Pathology can occur both in the early and late postoperative period. Sometimes fistulas form several years after the intervention. During the formation of an abscess, local and general signs of purulent inflammation are revealed. There are pains, the localization of which is determined by the location of the infected thread. Weakness, weakness, fever may be noted. Then, a painful induration appears in the projection of the postoperative scar. The skin over the site of inflammation acquires a purple or cyanotic hue. A few days later, the abscess spontaneously erupts. A small fistula is formed, from which a meager serous-purulent discharge is released. Inflammatory phenomena decrease, intoxication syndrome disappears. Subsequently, the fistula usually periodically closes and opens until the thread is removed or spontaneously discharged.

Complications

Most dangerous complication ligature fistula is a secondary infection with the spread of a purulent process. Depending on the location of the ligature, the formation of superficial and deep abscesses and streaks, damage to nearby organs is possible. With purulent fusion of tissues, eventration of the internal organs is sometimes noted. The secondary infectious process, in turn, can be complicated by sepsis. In severe cases, there is a risk of death.

Due to leakage of a fistula discharged in the area of the external opening, dermatitis often develops. soft tissues around the fistula become edematous, thicken, the skin acquires a purple-bluish color, over time a hyperpigmentation area is formed, a cosmetic defect is formed in the scar area. With an unsuccessful attempt to extract a deeply located ligature, in some cases, damage to surrounding tissues and internal organs is observed.

Diagnostics

Diagnosis and treatment is carried out by specialists who performed the operation. Due to the increased likelihood of the formation of ligature fistulas after interventions with the opening of hollow organs, pathology is most often detected by gynecologists and abdominal surgeons, somewhat less often by urologists, even less often by thoracic surgeons, traumatologists, neurosurgeons and other specialists. The diagnosis is usually not difficult due to the typical history (presence of surgical intervention) and the location of the fistula in the area of the postoperative scar. The main task is to determine the depth of the fistula and the configuration of the fistulous tract, to identify other factors that affect the tactics of treatment. The list of diagnostic measures includes:

Inspection. Produced in a dressing room. The doctor evaluates the amount and nature of the discharge, notes changes in the surrounding tissues, and examines the fistulous tract with a clamp. With a slight tortuosity of the pathological course and the location of the ligature above the aponeurosis, this technique usually does not present any difficulties. Sometimes the thread can be removed during a diagnostic study. With a significant tortuosity of the fistulous tract or its penetration under the aponeurosis, the method is used with caution, trying not to disturb the demarcation shaft and not damage the internal organs.
visualization techniques. The classic way to determine the depth and shape of the fistula is fistulography. A contrast agent is injected into the fistula, then images are taken in different projections, on radiographs, the cavity and passages are displayed as dark areas. AT last years for the same purpose, ultrasound is sometimes prescribed. Fistulous tracts are visualized as hypoechoic structures with a hyperechoic contour, nodes - as rounded hyperechoic structures.

Treatment of ligature fistulas

At the initial stage, dressings are usually performed, physiotherapeutic measures are prescribed, but the effectiveness of conservative methods is low, which forces specialists in the field of general surgery to resort to invasive manipulations. If the ligature thread does not come off on its own, they try to remove it with a clamp, but this technique has several disadvantages, since the doctor has to act blindly, which increases the risk of complications. At the same time, scraping of granulations is performed for better wound healing.

In the specialized literature, there are references to the extraction of ligatures under ultrasound control, which makes it possible to prevent accidental perforation of the wall of the pathological passage. With the long-term existence of fistulas, the presence of streaks and fistulous passages of complex shape, deep location of the ligatures, the fistula is excised. The disadvantage of this method is the need for a large-scale surgical intervention in the area of scar tissue.

Forecast and prevention

The prognosis for ligature fistulas is usually favorable for life and conditionally favorable for recovery. In most cases, recovery is observed, however, to eliminate the pathology, repeated open manipulations or surgical interventions are often required. It is possible to successfully remove the ligature with a clamp in 65% of patients, while 21% of patients subsequently experience a relapse. The prevalence of purulent-inflammatory complications after excision of fistulous passages reaches 30%, 17% of patients require repeated operations.

Prevention consists in carefully ensuring sterility during operations, proper processing of threads, the use of suture material, which gives fewer complications, and adequate antibiotic therapy in the postoperative period. Patients must strictly follow the doctor's recommendations: do not remove the bandage, do not wet the wound, take prescribed drugs, etc.