Modern aspects of prevention of postoperative adhesive process of an abdominal cavity of
of Butchers A. D., Lipatov V. A., Bezhin A. I.
Concerning an adhesive illness annually in surgical offices it is treated by 1% operated earlier sick, intestinal impassability develops at 50 - 75% of patients with development of an adhesive illness, conservative treatment of an adhesive illness is ineffective, after operations for an adhesive illness recurrence of a disease makes 32 - 71%, the lethality at adhesive intestinal impassability makes 13 - 55%, well-tried remedies of prevention of postoperative adhesive process of an abdominal cavity still are absent (Zhenchevsky R. A., 1989; Kurguzov O. P., Kuznetsov N. A., Artyukhina E. G., 1990; Vorobyov A. A., Geburashvili A. G., Pisarev E. E., 1998; Filenko B. P., 2000).
Biologically expedient reaction of an organism directed to localization of pathological process of an abdominal cavity often becomes an etiology which can lead to such terrible complication as adhesive intestinal impassability.
To this day in literature most of authors are uniform in opinion that the major etiopatogenetichesky factor of a disease is damage a mezoteliya of a peritoneum and an inflammation with prevalence of its proliferative phase. Also postoperative paresis of intestines and an immunological component is considered the important moment (Cherenko M. P., 1988; Zhenchevsky R. A., 1989; Makshanov I. Ya., Karpik A. I., Polynsky A. And, 1992; Osipov V. I., 1992;; Thompson, J., 1998; Hooker GD, Taylor BM, Driman DK, 1999).
Considering these literatures and data of own researches, only observance of the principles of the sparing relation to a peritoneum is represented to us insufficient during operation as in some cases the deserozirovaniye and death of peritonealny mezoteliotsit cannot be avoided. In this regard and most of authors, and we, consider rational application of the additional resources allocated for prevention of development of postoperative solderings. When studying literature we found a tendency of the last years: it is considered that the most perspective principle providing high preventive effect is application of the means separating wound surfaces (Osipov V. I., 1992; DiZerega G. S., 1994; Alponat A, Lakshminarasappa SR, Yavuz N, Goh PM, 1997; Baykal A, Onat D, Rasa K, Renda N, Sayek I., 1997, DiZerega G. S., 2001). Similar “barrier“ prophylactics, we will dare to classify by an aggregate state (fig. 1).
In the course of studying of literature we found various prophylactics of adhesive process which consist in introduction to an abdominal cavity of the gases, liquid polymers, films, membranes and devices creating a barrier between wound surfaces that interferes with an adgeziogenez. The most perspective use of solutions of the dextrans and membranes consisting of the cellulose air (methyl cellulose, sodium - carboxymethylcellulose) possessing high biological inertness in the field is considered (Onat D, Rasa K, Renda N, Sayek I., 1997; Baykal A, Onat D, Rasa K, Renda N, Sayek I., 1997). However solutions of dextrans quickly eliminirut from an abdominal cavity that demands their repeated introduction, and a film, are the mechanical irritant capable to cause aseptic reaction both from damaged, and from a healthy peritoneum. In this regard we consider perspective intra belly use of viscous indifferent substances for the purpose of prevention of postoperative adhesive process of an abdominal cavity. In available literature us ways of prevention of formation of postoperative solderings by means of intra belly introduction of gels are not revealed
As a prophylactic we used 3% gel of methyl cellulose water-soluble. This preparation possesses high biological inertness (Hemp A. And., etc., 1986; Razinkov S. P., Hemp A. And.; Lazarev A. I., 1987; Razinkov S. P., 1998; Pankrusheva T. A., Surina L. V., Medvedev O. A. 1997), protects a peritoneum from drying, possesses electroinsulating properties (prevents migration and adhesion of an epiploon to a wound surface). The way is approved on model of adhesive process of an abdominal cavity. In aseptic conditions to two series of rats - males of the line the Vistar (on 30 animals in everyone) was reproduced adhesive process by traumatizing a peritoneum. And the first group was control, and the second skilled - after modeling of adhesive process by an animal of this group deserozirovanny sites of a peritoneum were processed by 3% methyl cellulose gel. Animals were brought from experiment for the 14th days by overdose of a radio anesthesia. Before removal from experience the general condition was estimated, the general clinical blood test was made. Rats were exposed to autopsy, careful studying of abdominal organs, an assessment of expressiveness of adhesive process visually and about the help of a technique of semantic differential. The parietal peritoneum and abdominal organs were exposed to histologic research on the standard technique with fixing in neutral formalin, filling in paraffin, coloring of cuts hematoxylin - eoziny, on Wang - to Gizon, impregnation by silver according to Foote and coloring with the help CHIC - reactions. Results of researches are processed statistically (average sizes, Styyudent`s criterion, associativity coefficient are calculated, Hee`s methods - a square, linear regression and correlation are used).
Statistically reliable differences of the general state, indicators of clinical blood test and indexes of a leykotsitarny formula between control and skilled groups us are not revealed. The control group of soldering took place at all animals, expressiveness of adhesive process by method of semantic differential made 3,39±0,18 points. In experimental group only at four animals the epiploon podpaivaniye to a median postoperative hem took place, and expressiveness of adhesive process by method of semantic differential made only 0,02±0,001.
At histologic research at animals of the first group the morphological organization of solderings corresponded to the term of removal of an animal from experiment. The basis of neogenic fabric was made by a mature collagenic network with insignificant amount of elastichesky fibers. The cellular structure is poor, presented generally by fibroblasta and fibrotsita. The parietal and visceral peritoneum of animals of the first series is thickened, is fibrozno changed. In the field of soyedinitelnotkanny unions dystrophy of a muscular layer of intestines decides on the phenomena of disintegration of muscle fibers. This phenomenon is noted also at parietal edge of solderings. To this term of an union have well expressed vascular network which already has the ordered structure.
In the second series the peritoneum morphology from area of defect was studied. On the gistostruktura the peritoneum did not differ from intact. Only in separate preparations focal fields of fibrosis were defined, inflammation signs in a peritoneum of animals of the second series are noted.
Thus, use of gel of methyl cellulose authentically effectively reduces probability of postoperative adhesive process of an abdominal cavity in experiment (P