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SKIN PLASTY AREA OF THE PERINEUM OF PATIENTS AFTER REPEATED NECRECTOMY, AIMED AT COMBATING THE ANAEROBIC INFECTIONS OF PATIENTS WITH ACUTE
PARAPROCTITIS
Sergatskiy K.I.,
PhD, senior lecturer of Surgery Department of Medical institute of PSU.
Nikoisky V.I.,
MD, Prof., professor of Surgery Department of Medical institute of PSU.
Budachev S.A.
Student of 5 course of Medical institute of PSU.
Medical Institute, Penza State University, Russian Federation
ABSTRACT
Acute paraproctitis of anaerobic etiology is one of life-threatening diseases. During anaerobic extensive soft tissue infections primary task is saving the patient's life. After elimination of of anaerobic infections and stabilization of the patient, we must eliminate postoperative perineal skin defects. There are two clinical observations of successful perineal skin plasty in patients who underwent anaerobic paraproctitis. If there is the remaining flap of skin of a scrotum at the root of penis, then authors recommend the use of this flap to form neoskrotum. If there is the total absence of the skin of a scrotum and penis after acute anaerobic abscess, then we should perform a modified operation of B.A.Vitsin, with the installation of subcutaneous expander for penis skin plasty. Demonstrated results of plastic surgery confirm the correctness of the chosen surgical interventions.
Keywords: Acute anaerobic paraproctitis, plastic of the perineum, plastic of the scrotum
Introduction
The problem of the treatment of acute paraproctitis is actual [1, 2]. Acute paraproctitis is the most common pathology in practice emergency surgery of proctology and amount to 20-40% of patients in the structure proctologic diseases [3, 4]. Acute anaerobic paraproctitis etiology refers to the number of life-threatening diseases, mortality rate of 15-40%, while the generalization of the process is 80% [5, 6].
Acute paraproctitis with anaerobic etiology refers to the number of life-threatening diseases, mortality rate is 15-40%, while the generalization process it reaches 80%.
We present two clinical cases autoplasty area of the perineum of patients with acute anaerobic paraproctitis.
Clinical observation №1.
Patient F., 48 years old. He addressed to the Penza regional clinical hospital N.N. Burdenko 26.09.14 with complaints of pain in the anus, of the perineum, worse during defecation, increasing weakness, hyperthermia up to 39.5 ° C, the presence of dense painful education, occupying the entire perianal area and the area of a scrotum.
History of the disease: he got sick two weeks ago, when endured ligation of hemorrhoids for chronic hemorrhoid in one of the nonstate clinics. On admission during the inspection we found a massive painful infiltration, tissue swelling perineal area on the right and left of the anus up to 20 cm in diameter, the skin over which the hyperemic, hot to the touch, the scrotum to the root of the penis swollen, painful during palpation, scrotal skin and perianal region with areas of wet necrosis (picture №1).
On inspection, the tonus the sphincter raised, rectal wall is sharply painful over on the left and upper semicircles. We suspected acute anaerobic paraproctitis complicated with putrid-necrotic phlegmon of the soft tissues of the perineum, of a scrotum.
The general analysis of blood revealed leukocytosis (19.2 * 109/ l), increased ESR (43 mm / h), a sharp offset leukocyte formula to the left.
After a short preoperative preparation urgently patient was operated: under general anesthesia we performed opening of acute bilateral putrefactive ischi-orectalis paraproctitis, opening putrefactive necrotic cellulitis tissue of the perineum, the scrotum (picture №2), necroectomy, sanitation, drainage ischiorectalis areas.
Pic. 2. Patient F.: opening putrid-necrotic phlegmon of the perineum, scrotum (intraoperative photo).
In the bacterial seeding smear, which we took from the wound after the opening of an acute paraproctitis, we found the culture of gram-negative rods Proteus mirabilis.
Conservative therapy in the postoperative period include antibiotics, anesthesia, daily dressings (often with the participation of an anesthesiologist).
During extended dressings we found a single subcutaneous tissue necrosis, the pelvic floor muscles, and perform necrectomy. The latter extended ligation performed 2.10.14.
17.10.14 in satisfactory condition the patient was discharged to continue treatment on an outpatient basis at the surgeon for dressings. General view of the peri-neal wounds at discharge is shown in picture №3.
Pic. 3. Patient F. : appearance post-operative wounds at discharge.
Subsequent hospitalization 20.10.14. During inspection of the perineal area, we found that the skin of the scrotum decreased in the form of folds partially preserved at the root of the penis. The testicles are covered with granulations with fibrin. Tissues in the perineum is infiltrated, inactive, bleed easily on palpation.
The next day, the patient is treated in a planned way. The first step we made revision of a skin graft, which was at the root of the penis. The size of the flap is recognized as enough to perform one-stage plastic of
the scrotum. Then, with technical difficulties, we conducted dissection of scar crosspieces, the relative mobility of the testes was reached, that allowed to hide it under the skin graft. The edges of the skin graft was sewn together. Neoscrotum was formed. The newly formed cavity of of the scrotum drained by Redon's method. In the postoperative period we performed liga-tion, prophylactic antibiotic therapy and the syndromic therapy. General view of the perineum 10 days after performing reconstructive plastic surgery is shown in picture №4. During the dressings removed drainage.
Skin sutures are removed, the patient was discharged in satisfactory condition on the 11th day after the operation under the supervision and continued treatment at the surgeon as an outpatient. We recommended inspection of coloproctologist after 1-1,5 months for addressing the need for radical surgery, aimed at excising fistula pararectal, if it will available.
Patient did not visit the proctologist. He was called on the phone to monitor remote results after 1.5 years from the date of plastics. Inspection Date - 25/04/2016. Remote plastic cosmetic effect is shown in picture
Pic. 5. Patient F.: appearance of scrotum after 1,5 years from the date of implementation ofplastic surgery.
We got the complaints about the periodic minor sanies from wounds in the anal area, diagnosed in-tersphincteric posterior rectal fistula (picture №6). A
planned surgery is recommended._
Pic. 6. Patient F.: appearance of perianal area after 1.5 years from the date of implementation of reconstructive and plastic surgery. The arrow indicates the external opening of the fistula of the rectum.
Clinical observation 2.
Patient Z., 34 years old. He addressed to the Penza regional clinical hospital N.N. Burdenko 12.10.13. with complaints about the presence of scarring in the perineum area, lack of sexual activity, discomfort during urination. From the anamnesis: he was treated at the Central Regional Hospital of the Penza region on 06.08.13 to 07.10.13 with the diagnosis of acute anaerobic a paraproctitis. Putrid-necrotic phlegmon of the perineum, scrotum. He suffered a series of operations
aimed at combating anaerobic infection. The last surgery was about 1 month ago. It performed the testicles displacement into the subcutaneous tissue on the left and right inner thigh, and displacement the penis into the subcutaneous tissue over the pubis (the first stage of the operation B.A. Vitsin).
On examination: the testicles are moved under the skin of the inner thighs, penis stowed in a subcutaneous tunnel over the pubis (picture №7).
Pic. 7. Patient Z.: appearance of the perineum admission.
Pic. 8. Patient Z.: The preoperative markings in front of the first stage of reconstructive and restorative surgery.
After the pre-marking (picture №28) during the first the thighs, at the same stage performed the implantation phase of the operation we conducted plastic of the scro- of expander in the right iliac region subcutaneously to
Pic. 9. Patient Z. : appearance after the formation of the cavity of the scrotum (intraoperative photograph). The
arrow shows the expander implant area.
After removal of sutures, the patient was discharged to outpatient treatment.
11.11.2013 After a gradual increase in the volume of the skin expander implant area, the newly formed of wound healing scrotum (picture №10) and preoperative
marking (picture №11) is made of plastic skin of the penis displaced skin graft on a stem with the anterior abdominal wall from the zone of the previously installed expander (picture №12).
Pic. 10. Patient Z.: appearance after first stage of reconstructive surgery after 2 months.
Pic. 11. Patient Z.: preoperative markings reconstructive surgery.
Pic. 12. Patient Z.: appearance after penis skin plasty (intraoperative photograph).
The patient was discharged into 12 days after the Inspection Date 27.01.2014. Long-term results is last stage of reconstructive surgery. He was inspected shown in picture №13. by doctor after 2.5 months after the last intervention.
Pic. 13. Patient Z. : appearance after 2.5 months of the year since the implementation the second stage of
reconstructive and plastic surgery.
The patient has no specific complaints. Erectile and sexual function was restored. Inconveniences during urination didn't mark.
Later, in the conversation with a patient by phone, we learned that in early 2016 the patient became the father!
Conclusion.
1. After aggressive interventions in the presence of common postoperative defects of the skin of the perineum in patients after acute anaerobic paraproctitis advisable to perform plastic surgery.
2. If there is remaining flap of skin of the scrotum at the root penis after acute anaerobic paraproctitis expedient to use this flap to form neoscrotum.
3. In the absence of the skin of the scrotum and penis after acute anaerobic paraproctitis expedient to implementation of the modified transaction B.A. with Vitsin installing subcutaneous expander for penis skin followed by plastics.
References
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