Edema of the postoperative suture
Operative gynecology> Wound postoperative complications
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With wound complications it is necessary to collidedaily, since their frequency (among all others) is the highest. The risk of their occurrence increases in the presence of complicated circumstances: hypovolemia, metabolic disorders, high operative traumatism, purulent-inflammatory processes, poor-quality suture material.
All wounds heal on general biologicalregularities with a difference in the duration and severity of the inflammatory reaction, as well as the nature of the repair. Two phases of the wound process are distinguished: hydration and dehydration.
The first phase is characterized by hyperemia, exudation, edema and leukocyte infiltration. In connection with the prevalence of hydrogen and potassium ions in the wound, the phenomena of acidosis are expressed.
Thanks to phagocytes and proteolytic enzymes, the wound is released from dead tissues, decay products, bacteria and toxins, which creates back-up sources for regeneration.
In the second phase, edema and hyperemia decrease, the woundfilled with granulation and epithelization begins. Morphologically it is manifested by filling the wound with a blood clot with inflammation cells (leukocytes, lymphocytes, macrophages, plasma cells). In aseptic conditions, the inflammatory reaction lasts up to 3-4 days and corresponds to the catabolic process.
In the wound slit already from the second day fibrin is exposedorganization, begins the development of granulation tissue, the formation of capillaries and the growth of fibroblasts. On the 3rd-4th day, the edges of the wound are already connected by a gentle layer of connective tissue, and on the 7-9th day a scar is formed, the organization of which takes place 2-3 months. Disappear pain, hyperemia and temperature reaction.
Wound healing worsens with hypovolemia, hypoproteinemia,metabolic disorders (diabetes mellitus), hypocoagulation, hypo- and avitaminosis. The wound process is influenced by many factors. So, corticosteroids (cortisone, etc.) in small doses suppress the inflammatory reaction, and mineralocorticoids (aldosterone) - strengthen.
Thyroid hormones stimulate regenerativeprocesses, showing anti-inflammatory and anti-edematous effect. Reduction of the duration of the first phase - hydration is promoted by proteinases (trypsin, chemopsin, chemotripsin, ribonuclease) due to their necrotic, anti-edematous and anti-inflammatory action. Similarly, inhibitors of proteolytic enzymes and kallikrein-kinin system, zinc preparations.
Antibiotics in large doses reduce the nonspecificreactivity of the organism, thereby slowing the healing of postoperative wounds, but, suppressing the vital activity of the microflora, promote the acceleration of the inflammation phase, activate regenerative processes.
Positive effect on the course of the reparative process various physiotherapeutic procedures. For this purpose, the UHF, IMP (pulsed magnetic field), UFO, and laser effects are shown.
Regenerative processes and wound healing breaksinfection. It always takes place in postoperative wounds. Particularly rapid multiplication of microorganisms occurs 6-8 hours after the operation, which is facilitated by proteinolytic and hydrolytic enzymes released during the destruction of cells, which create favorable conditions for the development of wound infection. A purulent wound contains many microorganisms with scraps of tissue.
The exudative-alterative process in ittightened for more than 3 -4 days, can capture surrounding tissues. The opening of the wound and the creation of the possibility of a free outflow of the separable contribute to the elimination of these negative phenomena. The second phase of the wound process (wound healing) in conditions of infection is characterized by the formation of a granulation tissue covering the bottom and side walls, gradually performing the entire wound. First, the loose granulation tissue gradually thickens, undergoing fibrinous and cicatricial degeneration. The cessation of the growth of granulations with abundant wound secretion testifies to unfavorable effects on the wound process, stopping the processes of epithelialization and slowing the healing of the wound and its scarring.
Therefore, in view of the foregoing,postoperative period should actively use all the circumstances that contribute to the rapid healing of the wound and eliminate factors that hinder this process.
Implications of the wound process are seromas, inflammatory infiltrates, suppuration of the wound, ligature fistula and event.
The formation of seromy is a cluster in the woundthe cavity of serous effusion of straw color, which is associated with the intersection of a large number of lymphatic vessels, when a significant detachment of adipose tissue from the aponeurotic layer is produced. Treatment consists in evacuation of the accumulated fluid when one of the seams is removed with draining the wound and applying pressure bandages (a small load on the wound), using physiotherapy procedures. There is a danger of suppuration of the wound.
Inflammatory infiltrates are more often formed incorpulent women operated on for purulent inflammatory processes, using suture material with high tissue reactivity (thickening of cellulose with thick catgut). Morphologically, the infiltration is the impregnation of the surrounding tissues (by 5-10 cm) with the transudate, which means the elongation of the hydration phase. The process develops gradually, by the 3-5th day of the postoperative period.
There is a feeling of pain and raspiraniya in the wound area, the swelling of the tissues over the sutures. There is a slight hyperemia of the skin around the wound, subfebrile temperature, leukocytosis.
In the treatment, timely intervention is important, up tosuppuration of the wound, which consists in removal of several stitches (through 1 - 2), revision of the probe and drainage of the wound after evacuation of its contents. Physiotherapeutic procedures (UV, laser), restorative measures (immunomodulators, vitamins), correction of hematological and water-electrolyte disturbances are shown). Often, infiltrates are suppressed.
Suppuration postoperative wound is more common inpurulent-inflammatory processes, peritonitis, as well as inaccuracies with violation of aseptic and antiseptic rules during the operation and during the management of the postoperative period, with a decrease in the resistance of the organism to infection.
Infection of wounds can be due to exogenous and endogenous sources of microorganisms (materials, personnel, contact infection from the abdominal cavity) or hematogenous way.
The focus of suppuration is more often localized in the subcutaneousfiber with the spread of the process to some or all of the area of postoperative sutures. Less often, pus can accumulate in the intercellular or sub-panic region.
Clinically, suppuration of the wound manifests itself already withsecond day with the maximum development of symptoms by 4-6 days. It is characterized by local (edema, hyperemia, pain) and general symptoms of intoxication (fever, ESR, leukocytosis). With deep (under the aponeurosis) localization of the process, local symptoms may not be expressed, which makes diagnosis difficult. Especially difficult is the complication of infection with cavitary wound infection (B.proteus vulgaris, B.pyocyaneus, B.putrificum, etc.), as well as anaerobes. Infection is also possible with a conditionally pathogenic flora, which is especially characteristic of recent times. Anaerobic infection is characterized by early (2-3 days) onset and rapid flow with maximum severity of general and local symptoms.
Treatment includes general and local effects. Surgical treatment of a suppurative postoperative wound is performed, in which, along with a wide opening, necrotic tissues are excised and conditions are created for the outflow of the necrotic tissue to be separated and rejected. Repeated surgical treatments are required with elimination of formed pockets and fouling by adequate drainage. It is important to wash the wound with antiseptic solutions. The introduction of antibiotics into the wound is used.
It is necessary to treat the wounds with ultrasound, laser.
There are two methods of treatment of festeringpostoperative wound: closed with irrigation with antiseptic solutions and active aspiration through special drainage and open until complete self-healing or overlapping of secondary seams.
Indications for the open method treatment of purulent postoperative wounds are the presence of deep pockets and swells,extensive foci of tissue necrosis, pronounced inflammatory changes, as well as the presence of an anaerobic process. Initially, measures are taken to limit and eliminate inflammatory tissue changes, to local use of drugs with anti-inflammatory, antibacterial and osmotic actions using physiotherapeutic procedures. Hypertensive solutions of salts, proteolytic enzymes, antiseptics, antibiotics are widely used.
The combined effect of these agents is possessed by ointments onwater-soluble polyethylene oxide base, 5% dioxidine ointment. It is not recommended to use ointments on a fat basis (emulsions of synthomycin, balsamic liniment according to AV Vishnevsky, etc.). They prevent the outflow of the necrotic masses to be separated and rejected, rendering only a weak antibacterial effect. These agents are effective in the second phase of the wound process, when the regeneration processes begin. The healing of wounds with this open control results in secondary healing.
He is helped by preparations of vegetable origin (rose hips, sea buckthorn, Kalanchoe), other agents (solcoseryl-jelly, lyfuzol, etc.). The healing process can be delayed up to 3-4 weeks.
To accelerate it is used technique of superimposing secondary seams. They are shown after a complete cleansing of the wound fromnecrotic masses and pus and the emergence of islands of granulation tissue. This can take place only 1 week after the initial surgical treatment of the wound (primary-delayed suture), 2 weeks after the wound is covered with granulations prior to scarring (early secondary suture) or 3-4 weeks later, when the scar process is expressed and economical excision of tissues is made (late secondary seam). When superimposed primary-delayed and early secondary seams, active drainage of the wound should be carried out in order to avoid recurrence of suppuration. Suturing of the wound is tightly justified with the application of late secondary sutures.
The closed method of treatment of suppurating postoperative wounds involves their primary surgical treatment with suturing and draining.
Among the methods of active drainage of attention deserves the reception of N.N. Konshina (1977).
The essence of it is that through the woundone through tube or two on the sides, contacting in the center of the wound. The tubes have many holes in the walls. Through one end of the tube (or through the upper of the two), an antiseptic solution is added for rinsing, and through the other end (or through the lower one at two) is withdrawn. In this case, a constant, then periodic (at the discretion) irrigation of the wound is possible. Aspiration of the wound detachable is achieved better by using a special vacuum device connected to the lower tube (or using a syringe).
Active washing, as well as the use ofThis antibiotic and antiseptic disturbs the conditions for life and reproduction in the wound of microorganisms. This technique of active drainage is indicated for the application of primary-delayed and early secondary sutures. As the wound is cleansed, conditions are created for its regeneration and healing.
In parallel with local impacts general measures are carried out in the treatment of purulentpostoperative wounds. These include antibacterial therapy, the use of funds to increase the nonspecific resistance of the body and the activity of immune mechanisms, correction of metabolic and water-electrolyte abnormalities, as well as functional disorders of various organs and systems.