Operations for acute paraproctitis

The operation for acute and chronic paraproctitis is somewhat different. As a rule, an operation in the acute form of proctitis is necessary for vital signs and is carried out without preparation in two stages:

• cleansing of the purulent cavity;
• excision of the passage from the cavity to the rectum.

The easiest way is to cleanse the crypts (a crypt is a depression on the surface of an organ) filled with pus in the subcutaneous or submucosal layer. With a visual and rectoscopic examination, they can be seen - around the anus, you can see an abscess translucent through the skin or feel a fluctuation.

With the high professionalism of the surgeon-paraproctologist, both stages are carried out on the same day. If the doctor is not confident in his abilities, then both stages are carried out with an interval of 1-2 weeks. During this time, the crypt is completely cleared, begins to heal, but you can still find the exit hole.

With insufficiently professionally performed surgery for resection of the course immediately after opening the abscess, there is a high probability of recurrence of the pathology.

Description of the stages of the operation

1. The stage of opening and releasing pus from the abscess in the rectum is performed using epidural or local anesthesia, since the most relaxed anal sphincter is required during surgery. With subcutaneous paraproctitis, the surgeon makes an external semicircular incision around the anus in the place where the cavity is palpated or visualized. The doctor dissects all the bridges that separate the cavity of the crypt, cleans and rinses it with a disinfectant solution and drains to release the exudate.
2. The second stage is the detection and resection of the duct that connects the pocket and the rectal cavity. With the help of a probe inserted into the cavity of the crypt, a duct is found and its exit into the intestine. Then the course is excised. Seams are not applied. When an abscess is localized in the submucosal layer, access to it is made from the rectal cavity. The doctor inserts a rectal mirror into the intestine and finds a protrusion that forms a purulent cavity. A needle is inserted into it, and if pus appears during puncture, then the abscess is opened, cleaned and drained through the anus to the outside.

The most difficult type of surgery is surgery for pus in the crypt, localized in the following area:

• sciatic-rectal;
• behind the rectum;
• pelvic-rectal.

The exact localization of the abscess is difficult, since the crypts are located in the deep layers of the tissues. They are detected during instrumental examination - using CT or MRI. Then the abscess is opened with percutaneous or intra-intestinal access. If the abscess is localized in space outside the sphincter, then the approach to the cavity and resection of the canal is performed percutaneously.

If the inflamed crypt is located deep in the tissues behind the anal sphincter, then access is from the inside of the rectum. In this case, a partial dissection of the sphincter ring can be performed. The removal of the stroke is done with the help of a ligature.

With this method, a ligature thread is inserted inside the fistulous passage, the ends are removed from the sphincter and from its outer side, and the thread is tied into a ring. Every day the thread is tightened, gradually dissecting the sphincter.

This method avoids the risk of recurrence of the pathological process as a result of insufficiency of the fistulous tract and insolvency of the anal sphincter. It is believed that in the intervals between tightening the ligature, the wound gradually scars and when the anal sphincter is completely cut through with a thread, a thin scar is formed that does not affect the obturator function.

Operations for chronic paraproctitis

Chronic paraproctitis usually occurs as a result of self-resolution - spontaneous opening of the abscess, as well as an unsuccessful operation. There is a possibility that even after a successful surgical intervention, a relapse of the disease may occur.

The operation for chronic paraproctitis is complicated by the fact that the fistulous passages may not be single and tortuous. The fistulous tract may have 2 openings opening at both ends of the canal, or one. In order to determine the localization of the course, a dye is injected into the wound, if necessary, radiography is performed with a radiopaque substance.

After establishing the location, number and type of the fistulous passage, it is eliminated by the following methods:

• dissection;
• excision;
• with the help of ligation;
• laser ablation;
• filling with collagen thread.

In the first two cases, the operation is performed from the rectum itself with wound closure, partial or complete. With a deeper location of the passages, they are dissected by the ligature method or resected along the course with an incomplete dissection of the sphincter.

If the fistula was opened into the intestinal cavity, then after its removal, plastic surgery is performed, closing the wound surface with a flap of mucous tissue or sealing the wound with collagen glue, applying a stapler suture.

The latest treatments

A method of clipping the internal fistula opening using a special clip with shape memory, which tightens the edges of the opening, is under investigation. The "clipOTIS" method in the study of effectiveness allowed to completely cure 90% of patients with chronic paraproctitis.

If the course is uncomplicated, then the operation can be performed by laser ablation, introducing the light guide into the fistulous tract and “soldering” it with laser radiation. When conducting clinical studies on the effectiveness of laser ablation of the fistulous tract, a successful operation was performed in 72% of cases, and when the fistula opening was closed with a flap, this percentage increased to 89%.

Filling the cavity of the passage with a collagen thread is carried out if the course is straight and uncomplicated. The xenograft is made from lyophilized porcine intestinal tissue. The graft is replaced with the patient's own tissues 3 months after insertion into the canal. This method is called "Fistula plug" and has been used successfully for about 20 years.

The advantage of minimally invasive methods and percutaneous access is the preservation of the integrity and functions of the anal sphincter and a shorter rehabilitation period.

The result of the operation depends not only on the professionalism of the surgeon, but also on the postoperative period.

Therapy during the rehabilitation period

The main methods of therapeutic influence during the rehabilitation period of the patient are drug treatment. Antibiotic therapy is carried out under the supervision of the attending physician to prevent infection of the wound surface and prevent recurrence of the disease.

In the postoperative period, the patient experiences severe pain caused by treatment and dressing. Therefore, the patient is prescribed analgesics.

After the intervention, the patient stays in the hospital for several days. During this period, defecation is not recommended so as not to introduce an infection into the wound. To do this, the patient is kept on a slag-free diet with food that is quickly and completely digested.

A few days later, the patient is given an enema. If healing occurs without complications, then the patient is discharged home, where he independently continues to treat and dress the wound. The actions consist of washing the wound with disinfectant solutions, treating with hydrogen peroxide and applying a sterile wipe with a regenerating ointment.

Treatment of paraproctitis after surgery consists mainly in the prevention of infection, which is achieved by maintaining the hygiene of the urogenital area and preventing violations of the act of defecation.

Both constipation and diarrhea are dangerous for the patient's condition. Therefore, it is very important to follow a diet with a sufficient introduction of fermented milk products to normalize the microflora and speed up metabolic processes, baked apples rich in pectin, and a large amount (about 5 liters) of liquid.

To speed up healing, take sitz baths with a decoction of medicinal plants. It takes a long time to heal festering wounds. From surgery to complete healing sometimes takes more than a month.

With simple superficial operations, the rehabilitation period is 1.5-2 weeks. Due to the secretion of ichor and possible insufficiency of the anal sphincter, the patient has to use diapers or pads for some time. With a successful operation, the discharged fluid becomes less and less over time, and at the end of the rehabilitation period, the outflow stops.

Table of contents of the subject "Treatment of Pancreatitis. Acute Cholecystitis.":

Surgery for acute pancreatitis. Surgical technique for acute pancreatitis.

Surgical intervention regarding infected or non-infected pancreatic necrosis has no significant differences and consists in the removal of necrotic tissues. (We hope that you do not have too many reasons for operations with sterile pancreatic necrosis?)

Key questions of the operational manual:
Time - early or late operation.
Access - through or retroperitoneal.
Technique - resection of the gland or removal of necrotic tissue (necrectomy).
Completion of the operation - closed or open (laparostomy) maintenance.
Postoperative management - with or without prolonged irrigation of the pancreatic bed.
Repeated operation - planned or urgent.

You can reach the necrosis zone through the frontal, transperitoneal access or extraperitoneally - through an incision in the side wall. The latter will protect the abdominal cavity from contamination and reduce the number of wound complications, but this "blind" technique is fraught with a high risk of damage to the colon and retroperitoneal hemorrhage.

In addition, this access makes it difficult exposure of the pancreas and necrectomy. We prefer a long transperitoneal transverse incision (chevron-shaped) that provides sufficient access to the entire abdominal cavity. A midline laparotomy also provides adequate access, but manipulation can be difficult with the small bowel present, especially when reoperations are planned or if a laparostomy is needed.

Extraperitoneal accesses become important in those rare cases when the process is localized in the region of the tail, the left parts of the gland or in the region of the head on the right. Most often, these accesses are used to remove necrotic fat sequesters during subsequent reoperations.

Your main goals for the operation:
- Evacuate necrotic and infected substrates.
- Draining toxic process products.
- Prevent further accumulation of these products.
- Avoid damage to neighboring organs and vascular structures.

We emphasize that infected pancreatic necrosis is fundamentally different from other types of surgical infection you encounter, as this necrosis is prone to progression despite obviously adequate clearance of necrotic tissue and drainage of the omental sac.

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Surgery for acute pancreatitis

How is surgery performed for acute pancreatitis?

• What operations are performed in case of a disease
• How is surgery performed
• Possible Complications

Most often, people with this disease are prescribed conservative treatment. Surgery for acute pancreatitis is prescribed when therapy does not help, and the state of health worsens. Surgical intervention is also indicated in the case of a combination of the disease with cholecystitis and the development of peritonitis. Concomitant ailments of the abdomen may also require surgical treatment.

About the disease in a few words

The development of inflammation in the pancreas is called acute pancreatitis. If the patient is left without treatment, then this condition often ends in death. Therefore, urgent medical attention is needed.

Acute pancreatitis usually develops in people who like to drink hard and often. About 60% of patients with this pathology are alcoholics. In the rest of the patients, the disease was caused by such diseases as:

• pathology of the bile ducts of a hypertensive nature;
• cholecystitis of various forms (acute and chronic);
• ailments associated with stones in the biliary tract.

There are a number of other causes of acute pancreatitis. They are much less common. It:

The main digestive processes take place in the duodenum. The contents of the biliary tract, pancreatic juice enter the same organ. These fluids contain enzymes that break down food. They can also break down living tissue. But in the pancreas, enzymes are not in an active state, and therefore are not terrible for her. They are activated when they enter the intestines in contact with bile. In acute pancreatitis, bile enters the pancreas, where it combines with enzymes and activates them. The body starts to break down. And bile enters the gland due to various pathological processes in the body.

This disease develops rapidly. The human condition is deteriorating rapidly. An ambulance was called to immediately deliver the patient to the hospital. The clinical manifestations of pancreatitis vary in different patients, but the main ones are as follows:

• colic, encircling the entire abdomen, radiating to all organs (sometimes it seems that the shoulder blades, ribs and other parts of the body hurt);
• vomiting, which has frequent urges, does not bring relief, with impurities of bile and blood;
• dehydration syndrome, characterized by dryness of the oral cavity and mucous membranes, rapid heartbeat;
• intoxication syndrome, in which there is no temperature in the first days of the development of the disease;
• dyspeptic syndrome, in which the abdomen swells, gases form in the abdomen.

The patient undergoes therapeutic or surgical treatment, depending on the indications.

Back to index

Patients undergo several types of surgical treatment, depending on the indications. Operations can be assigned as follows:

1. Emergency. They are carried out at the very beginning of the development of the disease. It can be the first hours and days. Patients with enzyme-induced peritonitis and acute pancreatitis, which began due to obstruction of the duodenum, are urgently operated on.
2. Detachable. They are prescribed in the case when the dead tissues of the pancreas begin to be torn away from the organ. The doctor operates on the patient approximately one and a half to two weeks after the onset of the disease.
3. Planned. The surgeon begins to operate on the patient only when the acute inflammation in the pancreas has ceased. Before the operation, the patient is carefully examined so that the recurrence of the attack does not begin.

Operations are performed with concomitant diseases.

If the pathology in the gland is due to stones, then an operation is performed to remove them. For this, the walls of the bile duct and gland are dissected. Stones are removed. Tissues dissected prior to stone extraction are sutured.

If a cyst has formed in the pancreas, then an operation is performed to remove it. Together with it, a part of the gland itself is excised. If the cyst has grown too much, then the entire organ is resected along with the neoplasm. Modern methods of treatment involve more gentle surgical treatment, in which the cyst cavity is drained.

For malignant tumors in the pancreas, resection is the only correct choice of treatment.

Modern medical institutions offer surgery using robotic medical equipment. This increases the level of surgical intervention, and reduces possible complications after surgery.

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The operation for acute pancreatitis is carried out by two methods:

1. With the use of laparotomy, in which the surgeon cuts the walls of the abdominal cavity and lumbar to get to the focus of the disease. This method is used when purulent foci appear in the form of abscesses, cysts, with the spread of infection in tissues, with peritonitis. Such an operation is also indicated for unsatisfactory results from treatment by other methods.
2. Minimally invasive methods, which include laparoscopy and puncture intervention with drainage, for which small punctures are made in the walls of the abdominal cavity. This type of surgery is performed to install a drain when removing effusion and infected fluids. Sometimes laparoscopy is performed as a preliminary step before laparotomy.

The patient is prepared in a special way before the operation. The first condition for its implementation is fasting. Acute pancreatitis requires the patient to refuse food and as a first aid during an attack. An empty stomach and intestines are necessary to reduce the risk of postoperative complications, which can develop from infection of the abdominal cavity with the contents of the digestive tract and vomit, which is possible with anesthesia.

On the day of the operation, in addition to fasting, a cleansing enema and premedication are done. The patient is given medication to relieve anesthesia. They are able to reduce secretion by the glands and prevent possible allergies. Such medications include tranquilizers, sleeping pills, antihistamines, analgesics and more. During the operation, the patient is on artificial lung ventilation.

Surgery usually goes like this:

1. Distal resection. With it, the body of the pancreas and its tail are removed. It is carried out for those patients who do not have all the gland affected.
2. subtotal resection. In addition to the tail and body, part of the head of the organ is also removed. There are several sites located close to the duodenum 12. Such surgical treatment is prescribed for those patients who have almost the entire gland affected.
3. Necrosequestrectomy. During the operation, an ultrasound machine and fluoroscopy are used. Drainage is placed on formations with liquid in the gland and the contents are removed. Then, with the help of larger drainage pipes, rinsing and vacuum suction are done. Shallow drains are then placed to help the wound heal at a slow pace.

Methods of carrying out operations are determined by the doctor.

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After surgery for acute pancreatitis, complications may occur in the form of multiple organ failure, pancreatogenic or septic shock.

There are also long-term consequences, that is, those that occur after a while: pseudocysts, pancreatic fistulas, chronic pancreatitis, diabetes mellitus, dyspepsia.

In the postoperative period, the patient needs special nutrition. In the first two days hunger is shown. Then tea, pureed liquid vegetarian-type soups, boiled cereals, steamed protein omelet, cottage cheese, crackers are gradually introduced. Nothing else can be done in the first postoperative week.

Then the patient begins to take a diet that is prescribed to all patients with ailments of the digestive system. Physical activity is determined by the attending physician. It depends on the course of the operation and on the condition of the patient.

Surgical treatment of acute pancreatitis

6-12% of patients undergo surgical treatment of acute pancreatitis. Indications for surgery in acute pancreatitis are: 1) pancreatogenic enzymatic peritonitis; 2) destructive pancreatitis; 3) the failure of conservative treatment within 36-48 hours, manifested in the growth of enzyme intoxication, the appearance of symptoms of diffuse peritonitis; .4) combination of acute pancreatitis with destructive cholecystitis; 5) complicated acute pancreatitis (purulent pancreatitis, abscess of the omental bursa, perforation of the abscess into the omental bursa or into the abdominal cavity, retroperitoneal phlegmon, arrosive bleeding, obstructive jaundice).

Due to the severity of the patient's condition and trauma, surgical treatment for acute pancreatitis is carried out after stabilization of body functions. Operations are divided into early, late and delayed operations.

Early surgical interventions are performed in the first 7-8 days after the onset of the disease: with peritonitis, a combination of acute pancreatitis with destructive cholecystitis, the failure of conservative therapy.

Late operations are performed 2-4 weeks after the onset of the disease, which coincides with the sequestration, melting and abscess formation of necrotic lesions of the pancreas and retroperitoneal tissue.

Delayed operations include operations performed during the period of subsiding or relief of an acute process in the pancreas (a month or more after an attack of acute pancreatitis). They are aimed at preventing subsequent relapses of acute pancreatitis.

The volume of surgical treatment of acute pancreatitis depends on the severity and prevalence of the purulent-necrotic process in the pancreas, the presence or absence of delimitation of purulent-destructive foci from healthy tissues, the degree of inflammatory changes in the abdominal cavity, and concomitant diseases of the biliary system. This is determined during laparoscopy, translaparotomic revision of the abdominal cavity and pancreas.

With pancreatogenic enzymatic peritonitis, established during laparoscopy, laparoscopic drainage of the abdominal cavity is indicated, followed by peritoneal dialysis and infusion of medicinal substances. The essence of laparoscopic drainage consists in bringing under the control of a laparoscope microirrigators to the omental opening and the left subdiaphragmatic space and thicker drainage through a puncture of the abdominal wall in the left iliac region into the small pelvis. According to embodiments, the infusion of the abdominal cavity can be fractional and constant (as in the treatment of patients with peritonitis). The composition of dialysis solutions includes antiseptics (1:5000 solution of furacilin; 0.02% chlorhexidine solution), antiproteases, antibiotics, cytostatics, glucose solutions (10-40%), Ringer-Locke, Darrow, etc. Peritoneal dialysis allows you to effectively remove toxic and vasoactive substances. However, it is advisable only when using 6-30 liters of dialysate per day and only in the first 48-72 hours after the onset of the disease. The method is not appropriate for biliary pancreatitis, fatty pancreatic necrosis.

Infusion of medicinal substances into the abdominal cavity is used for moderate pancreatogenic pancreatitis (there is no or a small amount of serous, hemorrhagic exudate in the abdominal cavity). It consists in introducing into the abdominal cavity up to 4 times a day 200-300 ml of an infusate containing 100-150 ml of a 0.25% solution of novocaine, 100 ml of Ringer-Locke solution, Darrow, isotonic sodium chloride solution, antibiotics, protease inhibitors, cytostatics.

In the surgical treatment of acute pancreatitis, the pancreas becomes available for examination after dissection of the gastrocolic ligament. To assess the state of the posterior surface of the body and the tail of the pancreas, the peritoneum covering it is dissected along the lower edge to the left of the midline of the body, and the head is dissected along the descending knee of the duodenum (according to Kocher), followed by mobilization of the gland. At the same time, parapancreatic tissue is examined.

If an edematous form of pancreatitis is detected during laparotomy, the tissue surrounding the gland is infiltrated with a solution of novocaine (0.25-0.5% - 100-200 ml) with antibiotics, protease inhibitors, and cytostatics. Additionally, a microirrigator is introduced into the root of the mesentery of the transverse colon for subsequent infusions of novocaine, antienzymatic drugs and other agents 3-4 times a day. Drainage is supplied to the omental opening through a puncture in the right hypochondrium. A cholecystostomy is placed.

Patients with pancreatic necrosis with large foci of necrosis (2-3), having a well-defined demarcation shaft, are shown to perform pancreatonecrosequestrectomy in combination with pancreatic abdominization, drainage of the omental sac, retroperitoneal space and abdominal cavity, decompression of the biliary tract (cholecystostomy or external drainage of the common bile duct). As a rule, the operation is performed on the 3-5th week of the disease, i.e., with a clear delimitation of non-viable tissues, their rejection and encapsulation. Residual cavities after necrosequestrectomy should be well drained, which is achieved by the predominant use of the flow dialysis method with active aspiration.

Abdominization of the pancreas - mobilization (isolation) of its body and tail from parapancreatic fiber - is aimed at preventing the spread of enzymes and decay products to the retroperitoneal tissue, as well as delimiting the necrotic process in the pancreas and omental sac.

The omental bag is more often drained according to the methods of A. A. Shalimov, A. N. Bakulev, A. V. Martynov.

According to the method of A. A. Shalimov, one drain is brought to the head of the pancreas through the omental opening or the hepatogastric ligament from a puncture of the abdominal wall in the right hypochondrium. The second drainage is located in the region of the tail of the gland and is removed through the gastrocolic ligament and counter-opening in the left hypochondrium. A modification of the method is the use of one long tube with many holes (through drainage), which provides not only adequate drainage of the stuffing box, but also allows it to be replaced if necessary.

The method of A. N. Bakulev - A. A. Shalimov consists in suturing the gastrocolic ligament to the edges of the laparotomy incision in its upper third with drainage and tampons brought to the pancreas.

Retroperitoneal drainage in the surgical treatment of acute pancreatitis is performed in the left lumbar region. To do this, the left bend and the initial section of the descending colon are mobilized (the transitional fold of the peritoneum is dissected, as well as the diaphragmatic-colonic ligament and peritoneum along the lower edge of the pancreas). Then the posterior surface of the pancreas is bluntly mobilized and drainage is brought to it through the counter-opening in the lumbar region (the method of A.V. Martynov - A.A. Shalimov). The drainage is located in front of the prerenal fascia, below the spleen and posterior to the angle of the colon. When draining according to A.V., Martynov - A.A. Shalimov, drainage through the left side channel should be avoided, since in this case conditions are created for enzymatic leakage along the side channel.

Often the necrotic lesion of the pancreas in the postoperative period continues to progress. In addition, areas of necrosis may not always be detected during the operation. In some cases, this necessitates relaparotomy.

In order to improve the results of treatment of patients with pancreatic necrosis, a method of dynamic pancreatoscopy has been developed. Its essence lies in the fact that after dissection of the gastrocolic ligament, revision of the pancreas, necrosequestrectomy, drainage of the omental sac, parapancreatic tissue, bringing the greater omentum to the pancreas, a laparostomy is formed with preliminary fixation of the edges of the colonic ligament to the parietal peritoneum. In the postoperative period, with an interval of 1-3 days, a revision of the pancreas, retroperitoneal space is performed and, if necessary, additional removal of necrotic tissues.

For surgical treatment of patients with pancreatic necrosis, the method of programmed lavage of the abdominal cavity (laparostomy) with periodic revision of the pancreas, necrosequestrectomy and washing of the abdominal cavity can also be used.

In the case of focal fat or hemorrhagic necrosis without a clear delimitation of foci, drainage of the omental sac or abdominal cavity is performed in combination with or without pancreatic abdominalization; omentopancreatopexy.

In patients with extensive necrosis of the pancreas, resection of the affected part or pancreatectomy is performed. Resection is indicated in the case of isolated involvement in the process of these sections of the pancreas or disseminated lesions of the entire pancreas with small focal areas of necrosis, purulent pancreatitis. The operation eliminates the entry of toxins into the blood and lymph, prevents subsequent vascular erosion, the formation of abscesses and cysts. However, in 30-50% of cases, the operation fails to establish the true prevalence of pancreatic necrosis, which leads to the progression of purulent-necrotic complications in the postoperative period. In addition, with a favorable outcome of the disease, a significant proportion of patients develop exo- or endocrine insufficiency.

Pancreatectomy is performed in patients with total pancreatic necrosis. When it is performed, a small area of ​​the pancreas remains in the duodenum. Complication of pancreatic necrosis by necrosis of the duodenal wall is an indication for total duodenopancreatectomy. The disadvantage of both pancreatic resection and pancreatectomy is the trauma and associated high postoperative mortality.

With widespread hemorrhagic pancreatic necrosis and the impossibility of performing a radical operation, cryodestruction of the pancreas is performed. During cryodestruction, areas of pancreatic necrosis are exposed to ultra-low temperatures (-195 ° C with an exposure of 1-2 minutes). In the future, they are replaced by connective tissue, which prevents autolysis. According to the area of ​​performance, cryodestruction is divided into total, proximal and distal.

The combination of acute pancreatitis with the pathology of the gallbladder and biliary tract involves the performance of appropriate operations both on the pancreas and on the biliary system: cholecystectomy, choledocholithotomy with external drainage of the biliary tract, cholecystostomy, In patients with organic diseases of the major duodenal papilla to resolve intraductal hypertension and prevent progression of destructive changes in the gland, endoscopic papillosphincterotomy or transduodenal papillosphincterotomy (plasty) is performed. In case of inflammatory or functional disorders of the major duodenal papilla, methods of decompression of the pancreatic duct are used that are not accompanied by the destruction of the structure of the sphincter of Oddi - one-stage or prolonged decompression by deep catheterization of the main pancreatic duct, followed by active aspiration of the pancreatic secretion.

To eliminate the enzymatic destruction of acinar cells, the complex of surgical treatment of acute pancreatitis also includes intraductal sealing of its excretory system. It involves the introduction into the main duct of the gland through its mouth both endoscopically and during laparotomy of various adhesive compositions based on organosilicon compounds - silicones, pancreasil, etc. with the addition of antibiotics, cytostatics.

The volume of surgical treatment of acute pancreatitis is expanding in case of development of its complications. So, with purulent complications, an abscess of the pancreas, retroperitoneal phlegmon is opened with sequestrectomy, sanitation and drainage of the omental sac and abdominal cavity.

When compressed by an inflammatory infiltrate of the duodenum, a gastroenteroanastomosis is applied. With necrosis of the wall of the stomach and duodenum, the initial section of the jejunum due to melting of the pancreas and suppuration of cysts, wall defects are sutured, the intestine is intubated nasogastrically or through a gastrostomy for at least 50 cm distal to the perforation site. In the postoperative period, enteral nutrition is carried out through the drainage. The deep location of the drainage prevents the retrograde flow of the injected solutions and mixtures to the level of the intestinal wall defect and the expulsion of the probe. With necrosis of the colon, a double-barreled unnatural anus is formed proximal to the defect.

In case of arrosive bleeding, the operation includes ligation of the bleeding vessel with adequate drainage of the lesions, resection of the pancreas in some cases with splenectomy, ligation of the bleeding vessels throughout. In critical situations, tight tamponade of the site of arrosion is acceptable.

In the postoperative period, complex conservative treatment of acute pancreatitis is carried out.

Mortality in surgical treatment of patients with destructive forms of acute pancreatitis reaches 50-85% and 98-100% in case of fulminant course of the disease.

surgeryzone.net

Surgery for pancreatitis, surgical (surgical) treatment of the pancreas

Published: October 15, 2014 at 10:28 am

Acute pancreatitis is an inflammation of the pancreas that causes damage and destruction of its tissues. Why does this inflammation occur? The reason is diseases due to which the outflow of juice from the pancreas is disturbed, and intra-current pressure increases.

The medical history of pancreatitis can begin with a disease of the stomach, gallbladder and duodenum, as well as spasms of the pancreatic sphincters, its tumor, reverse reflux of juice, obstruction of the ducts, and impaired blood circulation in the gland. This disease can be triggered by injuries, infections, toxins and allergens. An acute attack sometimes occurs as a reaction to alcohol, fatty and protein foods in large quantities.

Pancreatitis is a life-threatening disease for the patient, so the task of doctors is not only to alleviate pain in the patient, but also to prevent serious complications. Therefore, in some cases, surgical treatment, that is, surgery, is required. But doctors resort to surgery for this disease only in extreme cases, because any surgical intervention, including in such an important organ as the pancreas, cannot do without consequences.

If the diagnosis of "acute pancreatitis" is established, the patient is hospitalized in the surgical department, where he is prescribed the necessary treatment. This takes into account the history of the disease, the presence of complications and other factors in the development of the disease.

In the necrotic and interstitial form of the disease, conservative therapy is usually prescribed, that is, without surgery. But in some cases of interstitial pancreatitis, surgery is the first line of treatment. In the case of purulent-necrotic pancreatitis, surgical treatment cannot be avoided, since the operation is the only way to save the patient from the problem.

Surgery of the pancreas is a necessary method of treatment that can be applied according to certain indicators even at an early stage, with a delay for a certain period. Indications for surgical intervention may be severe pain, progression of the disease, obstructive jaundice, stones in the gallbladder and bile ducts.

If the doctor decides to perform an operation on the pancreas, then it is carried out on the second day after intensive preparation for surgery. The goal of surgical treatment of pancreatitis is to eliminate pain, preserve the natural functions of the pancreas, free the body from toxic decay products and prevent complications (fistulas, pseudocysts, purulent complications, pancreatic pleurisy and ascites).

A surgical operation makes the pathological process stable, that is, it slows down the progression of the disease, but, unfortunately, it cannot completely eliminate inflammation in the pancreas. A good result of surgical intervention for pancreatitis is considered to be a decrease in pain on the 2nd-3rd day after surgery, an increase in the amount of urine, and an improvement in blood flow.

With the localization of inflammation during surgery, a resection (removal of part) of the pancreas is performed. In some cases, the spleen is also removed. If pancreatitis is small-focal, foci of necrosis are additionally removed. With extensive tissue damage, the glands remove the most affected areas in order to reduce the intoxication of the body with decay products and enzymes.

Surgical treatment of pancreatitis is contraindicated in patients with a progressive drop in blood pressure, persistent shock, no urine output, increased enzyme levels, high glucose levels in the urine (more than 140 mg%), and the inability to restore blood volume in the body.

The standard approach to the treatment of this disease involves conservative tactics, which usually prove to be very effective. However, in 15-20% of patients with acute pancreatitis, signs of purulent-destructive pathology in the pancreas may be observed, which indicates the need for surgical intervention. Usually these signs appear on the 7-14th day after the exacerbation of the disease.

Diagnostic signs of purulent pancreatitis:

• worsening of the general condition of the patient, persistence or increase in fever;
• palpation reveals a dense infiltrate in the parapancreatic region;
• shift to the left in the leukocyte formula;
• hyperglycemia;
• on x-ray - cavities with gas content;
• on ultrasound - cavities with fluid content.

Indications for surgery for pancreatitis

Based on the history of the disease, an audit of the entire parapancreatic region and maximum sanitation is carried out - drainage of all abscesses. If necessary, a limited necrosequestrectomy may be performed. In case of violation of the supply of bile to the duodenum, the medical history shows the need, directly during the operation, to determine the advisability of cholecystostomy. At the same time, radical surgical interventions are best avoided due to the severe general condition of the patient; surgical treatment of cholelithiasis and other diseases of the gallbladder is best postponed until later. One should not strive for a single opening of all abscesses of the pancreas because of the risk of heavy bleeding.

In most patients, there is a gradual maturation of purulent cavities in the retroperitoneal space, which may require bursostomy, planned sanitation of the pancreas in dynamics. The issue of tightly suturing the abdominal cavity with fixation of the bursostomy remains controversial. The patient's postoperative medical history provides for regular washing of the retroperitoneal space. If necessary, after 1-2 days, a repeated planned sanitation of the foci of suppuration is performed. An extensive purulent lesion in severe cases may require up to 8-10 repeated planned surgical interventions of this type. Drainage near the pancreatic tissue is performed through the lumbar region.

Mortality in acute purulent pancreatitis is about 9-10%. The usual conservative tactics in most cases is quite effective. Surgery is required in 15-20%. In almost 50% of cases, the acute form of the disease degenerates into a chronic one.

zhkt.guru

Surgical treatment of acute pancreatitis at the stage of exacerbation of the disease

The pancreas is the organ responsible for two essential functions: the production of insulin and the secretion of most of the digestive enzymes. Inflammation of this organ is called pancreatitis. Digestive enzymes found in cells under normal conditions have an inactivated state. But the impact of various factors can lead to their activation, and then the process of digestion of the pancreatic parenchyma, as well as the body's own tissues, starts. Due to inflammation of the gland, as well as the release of digestive enzymes into the blood, the body is affected by severe intoxication. In recent years, there has been an increase in the incidence of this disease. Specialists may prescribe medical or surgical treatment for acute pancreatitis.

What are the causes of the development of the disease

1. Cholelithiasis;
2. Alcohol intoxication;
3. Injuries;
4. Diseases of the duodenum;
5. Hereditary metabolic disorders, connective tissue diseases.

In some cases, postoperative pancreatitis may be observed, the cause of which is operations performed on the organs of the digestive system, such as resection of the stomach, interventions performed on the duodenum, removal of the gallbladder. Such a violation (enzymopathy) develops due to local pathologies of the tissues of the gland, which can be caused by compression or other type of injury during the operation. This is a kind of response of the body to such a "hard" effect on its tissues.

Clinical picture of acute pancreatitis

In acute pancreatitis, the symptoms depend on the form of the disease, the period of its development, and how severe the systemic reaction of the body to inflammation. For the initial period of the disease, patients complain of incessant sharp pains localized in the epigastric region and radiating to the back, that is, girdle. In addition, repeated vomiting and nausea are observed. A person may feel severe pain, both in the right and in the left side of the abdomen. There is no clear connection between pain and the process localized in the pancreas. Alcoholic pancreatitis can cause pain 12-48 hours after intoxication. With cholecystopancreatitis (biliary), pain can make itself felt after a heavy meal. Acute pancreatitis can occur without pain, but there is a pronounced systemic reaction syndrome up to impaired consciousness, but such cases are very rare. This disease poses a serious danger to humans. The patient's condition can further aggravate the complications of acute pancreatitis. It:

• Retroperitoneal phlegmon;
• Diffuse peritonitis;
• Cyst, pseudocyst of the pancreas;
• Abscess;
• Diabetes;
• Thrombosis of the vessels of the abdominal cavity;
• Fistulas.

Usually, treatment for acute pancreatitis takes place in a hospital setting, in no case should one hesitate to contact a specialist, since the disease is fraught with very serious consequences.

How is the diagnosis established?

Modern diagnosis of acute pancreatitis is carried out using a survey that includes:

• General blood test, which allows to detect the presence of an inflammatory process;
• Biochemical blood test, which reveals an increased level of gland enzymes;
• Urinalysis, urine amylase is evidence of pancreatitis;
• Pathologies of the pancreas, as well as changes in other organs of the abdominal cavity, are detected using ultrasound;
• EGDS (gastroscopy);
• radiography;
• ERCP (endoscopic retrograde cholangiopancreatography);
• Fecal analysis.

If the patient is shown medical treatment of acute pancreatitis, then it is necessarily accompanied by a starvation diet. Pain relief is provided by the use of analgesics. It is also prescribed intravenous drip of colloidal or saline solutions and taking drugs - inhibitors of proteolytic enzymes that block enzyme activity.

The indication for surgical treatment of acute pancreatitis is

1. The combination of pancreatitis with destructive cholecystitis in acute form;
2. Inability to drain the abdominal cavity by means of laparoscopy;
3. Pancreatogenic peritonitis;
4. Complications of the disease.

Surgical intervention

The tactics of surgical treatment of acute pancreatitis depends on how deep anatomical changes the pancreas itself has undergone. The main method of treatment is laparoscopy, the use of which eliminates unreasonable laparotomy. With the help of this method, drainage is provided, the most effective treatment, and the indication for pancreatitis surgery - laparotomy is justified.

Types of intervention

• Drains are installed and peritoneal lavage dialysis is performed to remove vasoactive and toxic substances.
• Resection of the pancreas - eliminates the possibility of bleeding and erosion of blood vessels, as well as the formation of an abscess.
• Operation of "multiple stoma" (Lawson).

It should be noted that operations for acute pancreatitis do not always exclude the risk of purulent complications. In some cases, repeated surgical intervention is required, which can threaten a person's life.

is among the most common proctological pathologies. The process of inflammation affects the tissues surrounding the rectum. Since its treatment in the acute period necessarily requires surgical intervention, patients with this diagnosis try to find out as many details about it as possible.

Paraproctitis occurs in most cases in men, in about 60-70%. In terms of prevalence, it is put in 4th place after hemorrhoids, anal fissures and colitis. The disease according to the activity of the inflammatory process is chronic and first detected (acute).

Surgery for acute paraproctitis is almost always required, but many are afraid to go under the knife. To make sure of its necessity and benefits, it is better to look at the photo of the buttocks before and after paraproctitis surgery.

Photos before and after paraproctitis surgery

For older children and adults, as a preoperative preparation, sitz warm baths are prescribed 2 times a day for 3-5 days before surgery. If a fistula has formed, then its course is washed with a solution of furacilin or rivanol.

On the day of the operation, cleansing enemas are done, and in the evening the day before, with an antiseptic solution. The diet should contain dairy products. You need to exclude meat, legumes, some vegetables. It is necessary to follow a diet after paraproctitis surgery.

If the course of the disease is acute, then patients it is necessary to undergo a course of antibacterial and anti-inflammatory therapy. After the inflammation subsides, surgery should be performed as soon as possible to avoid recurrence.

In cases such as old age, weakened immunity, severe illness, it is not always possible to perform an operation. Therefore, they try to improve the condition with conservative treatment, only after that to operate.

There are times when conservative methods give good enough results to postpone surgery.

Operation progress

After all preparations have been made, an operation is prescribed, which lasts no more than 30 minutes. Anesthesia is used only sacral or epidural. The operation for the treatment of paraproctitis involves two steps: excision of the abscess or opening and draining the abscess.

To understand how long paraproctitis heals after surgery it is necessary to take into account the age and individual characteristics of the organism.

An urgent operation to open an acute paraproctitis is performed only if there are indications for that. The procedure cannot be performed if the tissues around the site of the surgical incision are inflamed and if the location of the anal sinus is unknown.

Surgery for acute paraproctitis usually lasts no more than 30 minutes

The operation for acute paraproctitis can go in three ways:

• First open the abscess, drain it, then excise the sinuses and purulent passage into the rectum. This option is appropriate if the course is located inside the external sphincter and if only the subcutaneous layer is affected.
• With an intersphincteric inflammatory process, an abscess is opened, the contents are drained, excise the anal sinus and produce a sphincterotomy.
• With trans- and extrasphincteric paraproctitis an abscess is cut, purulent masses are removed, crypts are excised, a ligature is applied for drainage. As a result of such an operation, a good outflow of content appears.

Most often, a multi-stage operation is performed, which involves several stages. At the first, the abscess is opened and the contents are removed. At the next stage, after about 5-7 days (depending on tissue healing), the anal sinus and glands are removed. The technique of opening subcutaneous paraproctitis depends on the nature of the inflammation.

After operation

Treatment of acute paraproctitis after surgery includes complex therapy. If there are no complications and healing is normal, then the patient is allowed to go home after a few days.

Healing itself after an uncomplicated operation lasts up to 10 days, and a purulent wound heals completely only within 4 weeks.

Almost always, antiviral and antibiotics are prescribed to avoid the inflammatory process. Cleansing enemas with drugs are also required. It is necessary to constantly apply ointments to the wound for healing.

If stool retention occurs after 2-3 days, then cleansing enemas are used. After each trip to the toilet, you need to treat the wound: sitz baths and a new dressing.

Photo, paraproctitis before and after surgery

According to reviews and photos, paraproctitis before and after surgery is very different. With the steady observance of all the prescriptions of doctors, it can be cured quite quickly.

It is recommended to follow a specific diet after paraproctitis surgery to help the intestines recover. At least 5 glasses of liquid should be drunk daily. Exclude from the diet salty, sour, spicy, beans, raw fruits and vegetables, pastries and alcoholic / carbonated drinks.

Nutrition after paraproctitis surgery, what you can eat:

• semolina and rice porridge on the water;
• steamed meatballs;
• baked apples;
• boiled vegetables;
• compote;
• dairy products;
• boiled fish and meat, passed through a meat grinder;
• protein omelet.

Complications after surgery

Recurrence of paraproctitis after surgery is possible, but it depends only on individual qualities and other concomitant diseases . However, possible complications due to factors such as:

• severe intoxication;
• untimely appeal to a specialist for help;
• the postoperative period was carried out incorrectly;
• there are severe comorbidities;
• wrong operation.

At the first signs of paraproctitis, you should consult a doctor

Acute peritonitis- one of the most dangerous diseases of the abdominal organs, which is an extremely significant and complex problem in emergency surgery. That is why the treatment of purulent peritonitis is difficult for practical surgery.

According to different authors, acute peritonitis occurs in 3.1% - 43.1% of the total number of patients hospitalized in surgical hospitals, and mortality in the development of various forms of acute peritonitis remains at a high level and ranges from 9.2% to 71.7 %.

At present, the main provisions of the complex treatment of acute peritonitis are as follows: adequate preoperative preparation in order to stabilize hemodynamic and electrolyte disorders, unload the upper gastrointestinal tract.

Multicomponent emergency surgical intervention, including the following steps:

• choice of method of anesthesia;
• wide laparotomy, removal of exudate and elimination of the source of peritonitis;
• thorough sanitation of the abdominal cavity;
• decompression of the gastrointestinal tract;
• selection of the operation completion method;
• multipurpose postoperative.

To date, the feasibility and necessity of preoperative preparation for acute peritonitis has been proven and is not a subject of discussion. The duration and volume of preoperative preparation depend on the cause of peritonitis and the stage of the course. In cases of acute peritonitis of the reactive stage, short-term preparation is used (1-2 hours), patients with acute peritonitis of the toxic and terminal stages are subject to longer preoperative preparation (from 2 to 6 hours or more).

The presence of internal bleeding determines the indications for emergency emergency surgery against the background of massive fluid transfusion. The whole complex of preoperative measures for acute peritonitis can be divided into diagnostic and treatment-corrective stages.

Diagnostic stage of preoperative preparation

It includes, in addition to the diagnosis of peritonitis, the identification of concomitant pathology and the degree of violation of vital functions (respiratory, cardiac activity, excretory, etc.), as well as the identification of the degree of homeostasis disturbance. It is necessary to monitor the dynamics of arterial and central venous pressure, as well as to perform electrocardiography and some hemodynamic tests (for example, Stange, Gencha, Motta, Baraja, etc.), which is a fairly informative study of cardiac activity.

Therapeutic and corrective

Therapy in the preoperative period can be represented as the following scheme:

• fight against pain syndrome;
• decompression of the stomach and, if possible, the colon;
• elimination of metabolic acidosis;
• correction of disorders of cardiovascular activity;
• correction of water and electrolyte balance with compensation for fluid deficiency under the control of diuresis;
• correction of anemia;
• elimination of microcirculation disorders;
• correction of protein disorders;
• antibacterial therapy;
• therapy aimed at improving the functions of parenchymal organs (primarily the liver and kidneys);
• antienzymatic therapy;
• direct medical preparation before surgery (premedication).

Severe functional disorders of organs and systems explain the need for a serious attitude to the method of anesthesia. In this situation, preference is given to general anesthesia, tracheal intubation with artificial lung ventilation and good muscle relaxation of the abdominal wall. Epidural anesthesia is very effective both at the stage of the operation and in the postoperative period.

Currently, regarding the surgical approach in acute peritonitis, the opinion of the absolute majority of surgeons is single-median laparotomy. During the operation, additional incisions may be necessary to prevent infection of the abdominal cavity.

After opening the abdominal cavity, one of the important points of the operation is the implementation of novocaine blockade of reflexogenic zones. In severe forms of acute peritonitis, it is recommended to carry out a total prolonged retroperitoneal neurovegetative blockade according to Bensman. Since the 90s in Ukraine, the laparoscopic method of treating peritonitis has been used and finds more and more supporters, aimed at eliminating its source, sanitizing and draining the abdominal cavity. There are two types of endoscopic interventions for this pathology: radical laparoscopy and diagnostic laparoscopy with conversion to laparoscopically assisted minilaparotomy.

In the postoperative period, according to indications, planned relaparoscopies and sanitation of the abdominal cavity are performed with an interval of 2-3 days.

Laparoscopic operations have become the main ones for gynecological and pancreatogenic peritonitis. Then, after evaluating the exudate, if the amount of effusion is large enough, the abdominal cavity should be freed as much as possible from the pathological fluid using an electric suction or gauze swabs, and only after that proceed with a phased examination of the organs in order to identify the source of peritonitis.

After identifying the source of the pathological process, they begin to reliably eliminate it with the help of the least traumatic and easily performed surgical procedure. If it is not possible to remove the source of peritonitis, it should be reliably delimited with tampons from the free abdominal cavity. The third option for eliminating the source of peritonitis is its drainage, the indication for which is an unremovable purulent-necrotic focus in the abdominal cavity and the spread of a purulent-necrotic process to the retroperitoneal tissue.

After removal of the source of peritonitis, the main goal is the maximum decontamination of the surface of the parietal and visceral peritoneum. To date, the most common and recognized method of intraoperative one-stage sanitation by almost all surgical schools remains washing the abdominal cavity with antiseptics and antibiotic solutions. At the same time, in the literature there are also negative opinions about intraoperative lavage of the abdominal cavity due to the fear of infection spreading through it. In patients with fecal peritonitis, the abdominal cavity is additionally washed with 500 ml of a 0.25% solution of novocaine with the addition of hydrogen peroxide.

The atomic oxygen formed when hydrogen peroxide comes into contact with the peritoneum suppresses both anaerobes and residual infection. The use of physical methods of sanitation of the abdominal cavity is also effective. In recent years, a number of authors have suggested using ultrasonic low-frequency cavitation with the URSK-7N-18 apparatus. A solution of furacilin, an aqueous solution of chlorhexidine, a solution of furagin or broad-spectrum antibiotics is used as a sound medium. Ultraviolet irradiation of the abdominal cavity, laser irradiation of the abdominal cavity, evacuation of the abdominal cavity, jet-ultrasonic treatment with antiseptics, exposure to the abdominal cavity with a pulsating jet of antibiotics also have a positive effect. Recently, a certain place in the treatment of widespread purulent peritonitis is given to ozone. Ozonated solutions with an ozone concentration of 3-4 mg/l have a bactericidal, fungicidal, virocidal effect and improve blood circulation.

The positive results of the use of the physiotherapeutic flow of argon plasma in acute peritonitis are also described. At one time there was a period of enthusiasm for detergents for the purpose of mechanical treatment of the abdominal cavity. However, the use of surfactants is now recognized as an anachronism. One of the leading pathogenetic mechanisms for the development of endogenous intoxication is liver damage in common forms of peritonitis and, in particular, inhibition of the monooxygenase system (MOS) of the organ. In this regard, simple electrochemical systems are used using various oxygen carriers - indirect electrochemical blood oxidation. One of such oxygen carriers is sodium hypochlorite (NaClO), obtained by indirect electrochemical oxidation from isotonic sodium chloride solution in EDO-4, EDO-3M devices. However, it must be said that, although in acute peritonitis one-stage sanitation of the abdominal cavity on the operating table is the basic element of treatment, it should “transition” into one of the options for prolonged sanitation.

An important step in the treatment of acute peritonitis is intraoperative decompression of the gastrointestinal tract. In various cases, both nasointestinal intubation and ostomy can be used for this purpose.

Currently, there are several options for completing the operation for acute peritonitis. According to most authors, the most preferred option for completing the operation, especially in cases of advanced forms of the disease, is peritoneostomy, which is a rather highly effective means of achieving recovery in this extremely difficult category of patients. Thanks to peritoneostomy, intra-abdominal pressure can be regulated, trauma to the tissues of the surgical wound is reduced, microcirculation of soft tissues is prevented, which contributes to the prevention of purulent complications, and makes it possible not to use expensive materials and devices. Traditional drainage of the abdominal cavity with several drains with a blind suture of the laparotomic wound and massive postoperative antibiotic therapy is often used. The methods of flow, fractional and combined peritoneal lavage are described. Prolonged relaparotomy and deaf suturing of the laparotomic wound without drainage are used much less frequently. There is a method of separate autonomous micro-irrigator strip drainage of the abdominal cavity, according to which each area, sinus, canal and bag of the abdominal cavity must be drained separately with a micro-irrigator (for subsequent administration of dialysate) and a wide rubber strip (for outflow of exudate). In the literature, one can find a description of the method of aspiration drainage according to A.I. Generalov with appendicular peritonitis, according to which drainage is carried out through an additional puncture and suturing the surgical wound tightly, which avoids suppuration of the main wound and the development of eventrations.

The method of planar sorption drainage of the abdominal cavity according to Mikulich-Makokha with VNIITU-1 hemosorbent in combination with regional lymphotropic therapy is described. This method, due to the effect of lymphosanation (as evidenced by benign hyperplasia of the regional lymph node due to an increase in the areas of the cortical and medulla, cortical and medullary sinuses, T- and B-dependent zones), contributes to the activation of local immunity, increased drainage, transport and detoxification functions lymphatic region and allows to reduce the time of suturing the abdominal cavity with its open management, improve the results of treatment and reduce the mortality rate of patients.

Multi-purpose postoperative therapy is aimed at correcting homeostasis by intravenous and intra-arterial infusions of protein, electrolyte and hemodynamic drugs, antibacterial, immunocorrective and detoxification therapy using extracorporeal detoxification methods (hemosorption, lymphosorption, plasmapheresis, oxygenation of autologous blood and hyperbaric oxygenation, ultrafiltration, ultraviolet and laser irradiation of blood , extracorporeal connection of xenospleen and xenoliver) and quantum therapy, enterosorption, ultrasound, external abdominal hypothermia, reflexology, mechanical ventilation, treatment aimed at restoring bowel function, as well as preventing postoperative complications from vital organs and systems.

Good results in the treatment of acute peritonitis are observed with the introduction of antibacterial drugs directly into the lymphatic channel. An effective way to correct homeostasis disorders in acute peritonitis can be complex therapy using 400 ml of a 1.5% solution of Reamberin with the addition of ex tempore 1 ml of a 0.005% solution of imunofan, as well as 10 ml of pentoxifylline. In the treatment of acute peritonitis, low-intensity laser radiation can be used. There are two main pathogenetic directions of action of photon energy in patients with peritonitis: stimulation of the motor function of the gastrointestinal tract and optimization of the processes of reparative regeneration of the peritoneum. In clinical practice, domestic installations of infrared laser radiation "Uzor" and "RIKTA" with a wavelength of 890 nm, a pulse repetition rate of 50 and 150 Hz, and an average radiation power of 5 and 3 mW, respectively, are used. The most favorable terms for the use of laser exposure: the first or second day after the operation. The exposure for each field of laser exposure is 1 minute. Irradiation is carried out from four fields: the right iliac region, the right mesogastric region, the epigastric region and the left mesogastric region. Usually, 2-3 sessions of irradiation performed daily are enough for a course of laser therapy.

Despite the large number of treatment options for acute peritonitis, mortality in this disease remains high. Therefore, the search for new approaches and methods for the treatment of peritoneal disease remains extremely relevant and in the future will improve the effectiveness of therapy, increase the frequency of favorable outcomes, reduce the frequency of complications, reduce economic costs, and facilitate treatment control.