Intestinal injury at combined abdominal injury

INTESTINAL INJURY AT COMBINED ABDOMINAL INJURY

(Literature review)

Khaidarov Numonjon Buron ugli., Mustafakulov Ishnazar Boynazarovich.,

Karabaev Khudoiberdi Karabaevich., Khursanov Yokubjon Erkin ugli.,

Dzhuraeva Zilola Aramovna., Umedov Khushvakt Alisherovich.,

Ergashev Akobir Fakhriddinovich,

Zhumanov Khusniddin Alisher ugli., Shomurodov Hamza Rashidovich.

Samarkand State Medical Institute (rector-prof. Rizaev Zh.A)

Samarkand branch of the RSCEMP (Director - T.Ph. Yangiev B.A.)
In recent years, there has been a steady increase in injuries throughout the world. Technogenic and natural disasters, local military conflicts, transport and industrial accidents in 50-60% of all injuries lead to combined and multiple damage to organs and systems of the human body, and, as a consequence, to high sanitary losses in the first hours and days [1, 2,5,11,16,22,26,]. Concomitant injury is a simultaneous injury to two or more of the seven anatomical regions of the body by one traumatic agent. Among the causes of deaths from injuries, the share of concomitant traumatic injuries accounts for more than 60%, although they account for 8-10% of inpatients with injuries [3,4,6,7,20].

The share of abdominal injuries accounts for 1.5 to 36.5% of peacetime injuries, but their frequency and severity continue to grow [10,21,24]. According to A.N. Tulupov. (2015), in severe concomitant trauma, abdominal injuries are present in almost 30% of victims. Due to the severity of damage to internal organs and difficulties in diagnosis, such an injury is characterized by a high rate of complications and mortality, which, according to various authors, ranges from 25 to 65%. According to Shapot Yu.B. (1990) and Afonina A.A. (1998), with an isolated injury of one abdominal organ, the lethality ranges from 5.1 to 20.4%, and with a combined injury - from 18.3 to 64% [8,13,18,19,25].

Closed abdominal injuries are accompanied by a large number of complications and high mortality due to difficulties in diagnosis and frequent combination with injuries of other organs and systems [12,17,27]. A special problem is the diagnosis and treatment of concomitant closed abdominal trauma accompanied by shock. Hospital mortality in this variant of the pathology ranges from 17.3 to 72.7% [14.28]. Over the past 5 years, the mortality rate from road accidents in Russia has increased by 65%, and the death toll, according to the traffic police, reaches 33-35 thousand people per year [9,15,16,23,25].

The intestine is the most frequently damaged organ as when closed­that trauma to the abdomen, and with injuries. During the Great Patriotic War­During the war among those wounded in the stomach, injuries to the hollow organs were found in 83.8%. Although for the pro­the past century, lethality in case of intestinal damage and decrease­was increased from 100 to 5%, which was largely facilitated by the use of antibiotics in the early stages, but among the hospitalized­bathrooms against the background of general peritonitis, it is 30-50%. Mortality remains high in case of gunshot wounds only­stand up intestines - from 11 to 31%; it should be borne in mind that damage­large intestine in local wars of the last decade­are found in 38-41% of the wounded [18,19]. ...

These are only the immediate results of the treatment. How many­Most people remain disabled! It should be noted that the literature­These data are difficult to compare, since many authors do not carry out a differentiated analysis of the outcome of trauma, taking into account the etiological­factor, the severity and level of intestinal damage, the presence of associated injuries, the timing of surgery. [17.21].

So, some surgeons damage mesentery of any severity is identified with intestinal trauma; other­Some of these include only such damage to the mesentery, in which the nutrition of the regional section of the intestine is disturbed, resulting in its necrosis or development of enteritis with scarring is possible, respectively­the segment of the intestine, mortality is reported in 17% of cases­teas. Among the analyzed contingent, 63% were injured­those in which only wall hematoma was revealed during laparotomy intestine or mesentery, rupture of the serosa of the intestine, i.e. trauma, in which­the swarm even the need for surgical intervention is debatable; if we take into account only the victims in whom the integrity of all layers of the intestinal wall was violated and with the separation of the mesentery­ki, then the lethality would have been 50%. The number of postoperative complications is high - 40-70%, the recognition and correction of which­rykh represent significant difficulties. [6.9].

One of the formidable complications is the failure of the sutures of the sutured bowel wound and interintestinal anastomoses. Especially often (up to 50%), suture failure develops after suturing­non-shooting wounds of the colon, which is due to underestimation of the contusion zone. Complications such as paralytic and adhesions that usually accompany peritonitis are not uncommon.­bowel movement, abdominal abscesses, eventration.

An urgent problem for peace and, especially, military surgery­treatment of rectal injuries remains, which is due to the increasing frequency and severity of injury, the complexity of choosing the optimal surgical tactics, a large number of­the number of complications and high mortality. [8.23].

Among the early postoperative complications, life threatens­are peritonitis, phlegmon of pelvic tissue, sepsis. In the long term, osteomyelitis of the pelvic bones, stricture of the anal canal, impaired function often lead to disability.­tions of the anal press. [15.25].

Diagnosis of bowel injury is based on the recognition­nii wound peritonitis, the clinic of which is not always clear yes­the same with an isolated abdominal injury and, moreover, combined, especially against the background of shock and acute blood loss. It should be borne in mind that the clinic of colon trauma is less pronounced and extended over time. These circumstances­tions are the reason for late appeal and untimely surgical intervention.

According to [17.21]. in the first 3 hours of admission­25% of victims with closed trauma and 85.3% - with intestinal injuries. And yet, it is the clinical manifestations that form the basis of diagnosis. Almost all victims note abdominal pain. The pain may be local in nature and then spread­getting hurt all over the abdomen, which is usually combined with increased bullets­sa. Vomiting, reflexively at first­character, soon becomes one of the signs of intoxication­onny syndrome. The tension of the muscles of the anterior abdominal wall is detected in 81.8% of the victims. However, this sign can also be in situations where there is only a contusion of the abdominal wall. As for the Blumberg-Shchetkin symptom, it occurs no more often than in 35% of victims[1,3,24]....

A digital examination through the rectum allows early detection of irritation of the parietal layer of the peritoneum, and the detection of blood in the rectum usually indicates its damage.

Auscultation of the abdominal cavity is also advisable - the absence of intestinal murmurs occurs in 64.3% of patients with rupture of all layers of the intestine or injury to the intestine. Pathogno­A common symptom is the detection of free air in the abdominal cavity by percussion or, more reliably, with the help of­genological research. However, this symptom againit occurs only in 25% of patients with damage to the small intestine and 40% - in the large intestine.

Of the instrumental research methods, laparocentesis is widely used. However, the resolving diagnostic ability of laparocentesis in isolated intestinal injury, even if lavage of the abdominal cavity with subsequent microscopic examination is used.­pia centrifugate, does not exceed 70%.

At the same time, there are reports on the specificity of enzymatic markers contained in the fluid aspirated from the abdomen.­cavity during lavage, depending on the damaged organ; in particular, when the intestine is damaged, the level of alkaline phosphatase produced by the mucous membrane of the small and large intestines increases.

Laparoscopy is undoubtedly a more informative research method.­giving. However, there is a danger of not detecting all the damage even during surgery. To avoid that­any mistake, it is necessary to carefully examine all parts of the intestine­nickname, including those located retroperitoneally. When detecting pro­no wound of the ascending or descending intestine should be mobilized by dissecting the transitional fold of the peritoneum, the corresponding segment of the intestine and, in order to exclude the through nature of the wound, examine the posterior wall of the intestine.

When recognizing damage to the retroperitoneal rectum, the presence of complaints such as pain in the perineum, rivers­tal bleeding, tenesmus, sometimes dysuric phenomena. The diagnosis is clarified by digital examination of the rectum and sigmoidoscopy - without preliminary preparation.­no-contrast study, including vulnerography. [9,18,23].

With trauma of the small intestine in most patients, surgical intervention consists in suturing wounds in the transverse direction­lining with single seams. In conditions of peritonitis, N.I. Pirogov's suture is used, in which the first row of sutures passes through­pink, muscular and submucosal layers without suturing the mucous membrane, ensuring close contact of the edges of the afterbirth­her.

Small bowel resection is performed according to the following indications­yam: crushing of the segment; the presence of multiple wounds in a small area, the suturing of which would lead to deformation or narrowing of the intestine; detachment of the mesentery or significant damage to it with the development of an extensive hematoma; doubts about sufficient­normal blood supply to the intestinal segment; necrosis of the intestinal loop that has fallen out through the wound of the abdominal wall; with a gunshot wound - poured­whose wall defect is greater than the semicircle of the intestine, and the side-to-side anastomosis is more reliable, although functionally less beneficial than the end-to-side anastomosis­netz "

Resection of the distal ileum is often complicated by the failure of the sutures of the small bowel anastomosis. Therefore, in emergency situations, ileoascendoanastomosis is safer, applying ileoceco- or ileoascendoanastomosis­the brain, the end of the terminal section of the ileum is not sutured, but leads to the abdominal wall and through it intubates the intestine to the interintestinal anastomosis.

If necessary, resection of the distal iliac intestines against the background of severe peritonitis or extreme severity of the victim's condition, due to multiple injuries to the­ganov, blood loss, it is considered acceptable to be limited to the terminal ileostomy; ileostomy is recommended to be supplemented with intestinal intubation­Nick with polyvinyl chloride during resection of the ileum in conditions of general peritonitis, a U-shaped enterostomy is formed. The essence of the operation is to resect the damaged lesion.­the intestine, after which a side-to-side or end-to-side anastomosis is applied between the adductor gut and the excretory gut disconnected over 12-16 cm, the end of which extends to the anterior abdominal wall in the right iliac region. [1.6].

The management of colon injuries is much more complicated. According to the majority of surgeons, the improvement in the results of treatment of colon injuries is due primarily to a decrease in the number of primary reconstructive surgeries. [11,15].

Undoubtedly, this is facilitated by the timeliness of the intervention­state and highly effective antibacterial therapy. Fresh stab-cut wounds are subject to suturing - no later than 6-8 hours after injury, in the absence of an array­contamination of the abdominal cavity, severe blood loss or life­non-threatening associated injuries and the size of the wound should not exceed half the circumference of the intestinal tubes­Ki. Some surgeons limit the time for initial restoration of colon passage to as little as two hours. [27].

With a gunshot wound to the mobile sections of the colon­ki it is recommended to cross it at the site of injury and bring both ends to the anterior abdominal wall in the form of a stoma. In case of injury to the fixed (mesoperitoneally located) parts of the intestine­after excision of the edges, the wound is sutured with a two-row suture and the damaged area is turned off by imposing a full proximal­colostomy, and the retroperitoneal space in the area is damaged­the intestine is drained with double-lumen drains or a single-lumen tube with a diameter of at least 1 cm. [5.8].

With the localization of the wound in the ascending colon­After its suturing, it is necessary to remove the ileum 25 cm from the ileocecal angle in the form of a loop or terminal ileostomy. The end ileostomy is easier to care for. Cecostomy is unsuitable for these purposes, since it does not interfere with the passage of the intestinal­held and, in addition, paracolostomy wasps often occur­falsehoods. [4,7,24].

With a difficult-to-predict outcome of primary reconstructive surgery, a compromise solution is extraperitonization of the damaged segment of the intestine. [8.17].

Undoubtedly safer for gunshot wounds, the rim­Noah intestine two-stage intervention. Even timely ears­Shot wounds of the colon in 38% of affected wasps­falsely inconsistent sutures, which is due to the presence of a zone of primary traumatic necrosis within up to 2 cm from the edges of the wound, and the zone of molecular concussion reaches 9 cm. [13,14].

Therefore, most surgeons consider the primary restoration of the passage to be advisable only if the right flank is damaged. intestines, namely hemicolectomy with the imposition of an ileotransverzoan-stomosis, and in case of injury to other sections - a colostomy at the wound site­niya, resection of a segment of the intestine with the removal of both ends of the intestine, or obstructive resection - a Hartmann-type operation.

However, there are messages whose authors prefer the primary­new restoration of intestinal continuity out of 74 victims with a gunshot wound to the colon sutured the wound 50, made a bowel resection with a primary anastomosis 15, a Hartmann-type operation - only 9; mortality with­put 12% [fifteen]. The author considers the early admission of victims to the hospital and stable hemodynamics to be an indispensable condition for restoring the integrity of the intestine, the volume of intervention also depends on the degree of contamination of the abdominal cavity, the severity of associated injuries­denium. And yet, in a later post, re­recommends colonic anastomoses to be applied as rarely as possible, moreover, with an additional proximal colostomy. The same way­tics adheres, according to which primary colonic anastomoses are accompanied by a failure­sutures in 66.4% and mortality in 71.4% of cases. [23.24].

In case of ruptures of the colon, the indications for the imposition of a colostomy should be wider than for penetrating stab-cut wounds, since with the contusion-compression mechanism it is closed­that injury, as with gunshot wounds, it is not always possible to determine with certainty the true area of ​​damage to the intestinal wall.

Tactics for rectal injuries depends on many factors: where the wound is located in relation to the peritoneum (internal­ri-, extraperitoneal or simultaneous damage to both parts of the intestine), to the lumen of the intestine (penetrating, non-penetrating wound­it is important to take into account the depth of the wound, the nature of the wound (rupture, stab-cut, gunshot­noe, barotrauma, etc.); the severity of damage to the anal sphincter; the presence of associated injuries - most often the bladder, urethra, pelvic bones; the degree of contamination of the perineal wound; races­the extent of the inflammatory process along the pararectal cell­chatke; the time elapsed since the injury, as well as the state of­suffering. [16.18].

With extraperitoneal lesions of the rectum, it produces­Primary surgical treatment of the perineal wound, excision of the edges of the intestinal wound and its closure with a double-row suture, devulsion of the anus, drainage of the pararectal and presacral cellular tissue space with double-lumen or several silicone tubes, which makes it possible to conduct after­the operational period of flowing washing with solutions of anti­septic tanks. Some surgeons also consider it necessary to apply a pet­left sigmostomy, especially with gunshot wounds to the intestine, localized above the pelvic diaphragm. Most surgeons disconnect the rectum from the passage after suturing pain­large bowel defects, with a through wound or simultaneous damage to the bladder, when it is also necessary to impose an epicystostomy, significant destruction of the obturator­that, as well as with late hospitalization, when an infected bowel wound is not sutured. [15.22].

In case of extraperitoneal lesions of the rectum, combined with fractures of the pelvic bones, a loop sigmoidostomy should also be formed, and the rectum should be rinsed out on the operating table for the prevention of osteomyelitis of the pelvic bones.

It is also necessary to introduce prophylaxis­tic dose of antigangrenous serum and timely­the importance of broad-spectrum antibiotics.

With late hospitalization of the victims, in addition to creating a colostomy, drainage of the pelviorectal tissue is shown.­th space by wide pararectal incisions. Artificially superimposed fecal fistulas for­cover in terms of 1.5 to 6 months...