Provides sympathetic innervation to the stomach. Non-permanent arteries of blood supply to the stomach. Anatomy and structure

Greatest distribution for detection in the abdominal cavity free blood and received pathological contents laparocentesis- diagnostic puncture of the anterior abdominal wall.

Laparocentesis has almost a century-old history. The first attempts to puncture the abdominal cavity were made in 1880: they pierced the abdominal wall with a trocar when a perforated gastric ulcer was suspected.

With a closed abdominal injury, laparocentesis for diagnostic purposes was first performed by J. Dixon in 1887, which made it possible to establish a rupture of the gallbladder. In 1889 G.F. Emery diagnosed a traumatic rupture of the common bile duct using laparocentesis.

Laparocentesis for abdominal injuries began to be used most widely in the 50-60s of the twentieth century, first abroad, and then here.

The experience of domestic and foreign surgeons in the use of laparocentesis for the diagnosis of open and closed abdominal injuries shows that it is simple and safe with strict adherence to the technique.

Laparocentesis is auxiliary instrumental method diagnostics for injuries of the abdominal organs. Indications for the use of this method are as follows:

1. Unclear clinical picture of damage to one or another abdominal organ.

2. Severe combined trauma of the skull with loss of consciousness, when the type and mechanism of injury suggests damage to the abdominal organs (fall from a height, road traffic injury).

3. Combined spinal injury, chest, fractures of the pelvic bones, when a clinical picture simulating an “acute abdomen” is observed.

4. State of being strong alcohol intoxication with phenomena alcohol intoxication and suspected damage to abdominal organs.

A relative contraindication to laparocentesis is previous surgery on the abdominal organs. Laparocentesis is not recommended to be performed near the bladder, various palpable tumor formations and parenchymal organs that are increased in size.

The examination is carried out in the operating room with strict adherence to the rules of asepsis and antisepsis, as with laparotomy.

Lapocentesis can be performed in intensive care unit subject to all conditions for emergency surgery, while simultaneously performing anti-shock measures.

Preparationpatient for examination. When starting to examine a patient, one can never exclude the need for subsequent laparoscopy. Before examination, catheterization should be performed. bladder, rinse the stomach if the patient’s condition allows.

Techniquelaparocentesis. With the patient in the supine position, under local anesthesia with a 0.25-0.5% novocaine solution at a point 2-2.5 cm below the navel midline abdomen or on the left at the level of the navel, 2-2.5 cm away from it, using a large skin surgical needle, a silk ligature (silk, nylon or lavsan No. 6 or 8) is inserted. In this case, it is necessary to capture the aponeurosis of the anterior wall of the rectus abdominis vagina.

At the middle distance between the injection and puncture of the needle, when carrying out the ligature, an incision up to 1 cm long is made. The abdominal wall is pulled up by the ligature as high as possible in the form of a sail, after which the abdominal wall is punctured through the skin incision with a trocar.

The trocar is passed at an angle of 45° to the anterior abdominal wall from front to back towards the xiphoid process.

To puncture the abdominal wall during laparocentesis, a trocar is used, attached to a domestically produced laparoscopic kit. After removing the stylet through the trocar casing in abdominal cavity a “groping” catheter is inserted in the direction of the small pelvis, lateral canals, left and right subdiaphragmatic space. In this case, the contents of the abdominal cavity are constantly aspirated using a 10- or 20-gram syringe.

Interpretation of laparocentesis data. Detection of pathological contents during laparocentesis (blood more than 20 ml; blood in urine or feces; cloudy dark brown, greenish-gray or other colored liquid) is an undoubted indication for urgent surgery.

If during laporacentesis no contents are obtained from the abdominal cavity, then the result of laparocentesis is regarded as negative (“dry puncture”).

The diagnostic accuracy of laparocentesis is directly dependent on the amount of fluid present in the abdominal cavity. To obtain contents from the abdominal cavity, it is necessary that there be at least 300 - 500 ml. Experimental studies have shown that in the presence of fluid in the abdominal cavity with a volume of 500 ml, 78% of positive punctures are observed, with 400 ml - 71%, with 300 ml - 44%, with 200 ml - 16%, with 100 ml - 2%, with 50 ml - 0.

To increase the diagnostic capabilities of laparocentesis when its result is negative, some scientists propose repeated laparocentesis, but this increases the preoperative period, and late diagnosis is known to be dangerous. Other scientists suggest injecting up to 1000 ml through a catheter inserted into the abdominal cavity during laparocentesis. isotonic solution sodium chloride or Ringer-Locke solution at the rate of 25 ml per 1 kg of the patient’s body weight and, after aspiration, examine the resulting contents using a microscopic or biochemical method (diagnostic peritoneal lavage).

The criteria for a positive assessment of diagnostic peritoneal lavage during laparocentesis are:

1) hematocrit in the washing fluid is higher than 1-2%, which corresponds to 20-30 ml of blood per 1000 ml of washing fluid;

2) the number of erythrocytes is over 1,000,000, and the number of leukocytes is over 500 per 1 mm? washing liquid. This technique allows you to identify a small amount of blood (up to 30-50 ml), usually accumulating in the posterior abdominal cavity.

When obtaining blood during laparocentesis ( positive result) you often have to decide whether the bleeding has stopped or not. In some cases, even if there is large quantity blood in the peritoneal cavity (750-3000 ml), bleeding may stop spontaneously. The facts of such stopping of bleeding in case of damage to the abdominal organs are known to doctors involved in emergency surgery.

To detect ongoing bleeding, the Rouvilois-Gregoire test is used. Laparocentesis in the diagnosis of ongoing or stopped bleeding makes it possible not only to carry out anti-shock measures and thereby reduce the risk of subsequent surgery, but also to determine the order of referral of patients to the operating room for urgent surgery.

Blood mixed with urine obtained by aspiration during laparocentesis and identified by smell always indicates intra-abdominal bladder damage. Blood mixed with feces indicates damage to the intestines. Cloudy dark brown, greenish-gray or other colored fluid with fibrin flakes aspirated from the abdominal cavity during laparocentesis also indicates damage to the hollow organs.

The reliability of the results of laparocentesis depends not only on the technique of its implementation, but also on correct interpretation the data obtained.

There are works in the periodical press in which the authors note the difficulties of interpreting laparocentesis data when extracting fluid faintly stained with blood from the abdominal cavity. A faint pink color may indicate a hematoma leaking from the retroperitoneum. However, as our experience shows, sanguineous fluid obtained during laparocentesis does not always indicate the presence of only a retroperitoneal hematoma. An additional thorough examination of the abdominal organs after laparocentesis using laparoscopy made it possible to identify mesenteric ruptures in patients small intestine, areas of deserosis of the small and large intestine, extraperitoneal ruptures duodenum, tears of the capsule of the liver and spleen. These laparoscopic findings were confirmed by subsequent surgery. During laparotomy, 50-250 ml of blood was found in the abdominal cavity, and it accumulated mainly in the posterior parts of the abdominal cavity or pelvis.

If sanguineous fluid is detected in the abdominal cavity, we recommend that laparoscopy be performed, and if there are no conditions for its implementation, control drainage should be left in the abdominal cavity for 48-72 hours or more for repeated aspiration of peritoneal exudate, blood, or the injected isotonic sodium chloride solution.

Leaving the control catheter in the abdominal cavity after obtaining sanguineous fluid during laparocentesis allowed us to diagnose the injury in 8 patients internal organs, but at the same time the preoperative period increased from 8 to 12 hours, which adversely affected the postoperative period.

Currently, sufficient experience has been accumulated in the use of laparocentesis and there is no longer a need to prove its value in diagnosing unclear cases of damage to the abdominal organs. The vast majority of authors have established the simplicity, safety and informativeness of its results during aspiration of pathological contents from the abdominal cavity.

However, like any examination method, laparocentesis is not without its drawbacks. Thus, in 4.5% of cases laparocentesis turned out to be false negative, according to our data - in 9% of cases.

The reason for false negative results is sometimes that catheters, when inserted into the abdominal cavity through the trocar casing, slide along the surface of the intestinal loops and greater omentum directly under the abdominal wall and do not always enter the sloping areas of the abdominal cavity, where fluid mainly accumulates during pathological conditions. Due to the low elasticity of rubber and polyethylene catheters and low controllability, they do not always move in the directions they are given when passing through the trocar casing.

If an internal organ is damaged, delimited by a large adhesive process and not communicating with the abdominal cavity, hemoperitoneum or leaked intestinal contents from the damaged intestine may not be detected by a “groping” catheter.

It should be borne in mind that in case of subcapsular injuries of parenchymal organs, the results of laparocentesis will be negative, which, unfortunately, complicates the choice of indications for surgery. Sometimes the rummaging catheter or steerable probe becomes clogged with a blood clot, making the test difficult or giving a false negative result.

A small amount of blood (up to 20 ml) during laparocentesis and diagnostic peritoneal lavage can lead to false-positive results. According to our data, this is observed in 3.3% of cases, and according to other scientists - in 4.5%. This is explained by improper puncture of the abdominal wall, as well as leakage of blood from the preperitoneal hematoma during a fracture of the pelvic bones.

Thus, laparocentesis is quite simple and objective method studies with high diagnostic reliability. At the same time, it should be taken into account that if there is a discrepancy between the clinical picture and the results of laparocentesis, aspiration of sanguineous fluid from the abdominal cavity, “dry puncture”, as well as when obtaining a small amount of blood, it is necessary to perform laparoscopy to avoid diagnostic errors.

Indications. This procedure is carried out with diagnostic and therapeutic purpose.

For diagnostic purposes: to detect the presence of blood in the abdominal cavity if it is impossible to perform laparoscopy or ultrasound of the abdominal organs.

For therapeutic purposes: evacuation of ascitic fluid.

Contraindications. 1. Intestinal obstruction.

2. Pregnancy.

3.Blood clotting disorders: hemophilia, thrombocytopenia, DIC syndrome and so on.

4.Availability inflammatory diseases anterior abdominal wall: pyoderma, boil, phlegmon, etc.

Technique. Position the patient on his back. Before performing the procedure, you should empty your bladder or install a Foley catheter in it.

Diagnostic test. After treating the anterior abdominal wall with an antiseptic, local anesthesia, for which an injection is made with a needle and syringe at a point located along the midline of the abdomen in the middle of the distance between the navel and the pubic symphysis and anesthetized in layers, deep to the peritoneum. Using a scalpel, an incision is made in the skin up to 1-1.5 cm and in the aponeurosis of the rectus abdominis muscle. Through this incision, a trocar is used to puncture the peritoneum and penetrate into the abdominal cavity. The trocar stylet is removed, and a rubber or polyvinyl chloride tube is inserted through its tube in the direction of the small pelvis - a “groping catheter”. A small amount (5-10 ml) of sterile liquid is injected through the “groping catheter” using a syringe, and then this liquid is aspirated. If there is blood or bile in the abdominal cavity, the aspirated fluid will be mixed with blood or bile, which is an indication for emergency surgical intervention. If there are no impurities in the aspirated fluid, the catheter is left in the abdominal cavity for a day or two as control drainage.

Therapeutic puncture. The technique for performing a therapeutic puncture is the same as for a diagnostic test. After inserting a polyvinyl chloride tube through the trocar tube, the trocar tube is removed, and ascitic fluid flows freely through the drainage left in the abdominal cavity. To avoid sharp fall intra-abdominal pressure, which can lead to a collapsed state of the patient, it is necessary to periodically clamp the tube for 2-3 minutes. Once the evacuation of ascitic fluid is completed, the tube can be removed and the skin wound sutured with a silk ligature, or the tube can be left in the abdominal cavity for 3-4 days to control and evacuate the accumulated fluid.

Complications. 1. Perforation of the intestine or bladder.

2. Injury to the epigastric vessels or mesenteric vessels with intra-abdominal bleeding.

3. Development arterial hypotension during or after performing manipulations.

Laparocentesis is a puncture of the anterior abdominal wall in order to detect or exclude the presence of pathological contents: blood, bile, exudate and other liquids, as well as gas in the abdominal cavity. In addition, laparocentesis is performed to establish pneumoperitoneum before laparoscopy and some x-ray examinations, for example, regarding pathology of the diaphragm.

Indications for laparocentesis

• — Closed abdominal injury in the absence of reliable clinical, radiological and laboratory signs of damage to internal organs.
• — Combined injuries to the head, torso, and limbs.
• — Polytrauma, especially complicated traumatic shock and coma.
• — Closed abdominal injury and combined injury in persons under the influence of alcohol and drug stun.
• — Uncertain clinical picture acute abdomen as a result of the administration of a narcotic analgesic at the prehospital stage.
• — Rapid decline of vital functions with combined trauma, unexplained by injuries to the head, chest and limbs.
• — Penetrating chest injury with a possible injury to the diaphragm (knife wound below the 4th rib) in the absence of indications for emergency thoracotomy.
• — Inability to exclude a traumatic defect of the diaphragm by X-ray contrast examination of the wound canal (vulneography) and examination during primary surgical treatment chest wall wounds.
• — Suspicion of perforation of a hollow organ, cyst; suspicion of intra-abdominal bleeding and peritonitis.

By appearance and laboratory research fluid obtained during laparocentesis (admixture of gastric and intestinal contents, bile, urine, increased amylase content) can suggest damage or disease of a certain organ and develop an adequate treatment program.

Unreasonable diagnostic tests for a false acute abdomen have a negative impact on the patient’s condition. in a victim with polytrauma, it can be life-threatening, as it inhibits diaphragmatic breathing and increases hypoxia. In urgent abdominal surgery, postoperative aspiration pneumonitis, delirium and intestinal eventration are observed, especially in the group of people who were intoxicated. Therefore, laparocentesis is preferable.

The decision to perform diagnostic laparocentesis should be approached individually, taking into account the specifics of the clinical situation. If there is time reserve, laparocentesis is preceded by a detailed history taking, a thorough objective examination of the patient, laboratory and radiology diagnostics. In critical situations, with unstable hemodynamics, there is no time reserve for performing the standard diagnostic algorithm. Laparocentesis can quickly confirm damage to abdominal organs. The speed, simplicity, fairly high information content of laparocentesis, and a minimal set of instruments are its advantages in the event of a mass admission of victims.

Contraindications to laparocentesis

- severe flatulence, adhesive disease of the abdominal cavity, postoperative ventral - due to the real danger of injury to the intestinal wall.

Laparocentesis technique

Currently, the method of choice for laparocentesis is trocar puncture, which is usually performed under local infiltration anesthesia in the midline 2 cm below the umbilicus. Using a pointed scalpel, make an incision of up to 1 cm in the skin, subcutaneous tissue and aponeurosis. The umbilical ring is grasped with two pins and the abdominal wall is raised as much as possible to create a safe space in the abdominal cavity when the trocar is inserted. G.A. Orlov (1947) studied the topography of the internal organs of the abdominal cavity using Pirogov’s cuts of corpses when pulling on the aponeurosis in the navel area during laparocentesis. Loops of the small intestine, ascending and descending colon shift towards the midline. A space is formed in the abdominal cavity without internal organs with a height of 8 to 14 cm under the point of application of traction. The height of the cavity between the abdominal wall and the viscera gradually decreases with distance from this point.

The trocar is inserted into the abdominal cavity with moderate force and rotational movements at an angle of 45° towards the xiphoid process. The stylet is removed. A silicone tube with side holes - a “groping” catheter - is advanced to the suspected site of fluid accumulation through the trocar sleeve and the contents of the abdominal cavity are aspirated. With its help, it is possible to detect the presence of liquid with a volume of more than 100 ml. If there is no fluid during laparocentesis, 500 to 1200 ml of isotonic sodium chloride solution is injected into the abdominal cavity by drip system. The aspirated solution may contain blood and other pathological impurities. Some have a negative attitude towards peritoneal lavage, believing that in case of intestinal trauma it leads to widespread microbial contamination of the abdominal cavity during laparocentesis.

A positive iodine test indicates a traumatic defect, gastric and duodenal ulcers (Neimark, 1972). To 3 ml of exudate from the abdominal cavity add 5 drops of 10% iodine solution. The dark dirty blue color of the exudate indicates the presence of starch and is pathognomonic for gastroduodenal contents. In case of severe acute abdomen and the absence of aspirate, it is advisable to leave the tube after laparocentesis in the abdominal cavity for 48 hours in order to detect possible appearance blood and exudate.

When an elastic “groping” catheter encounters an obstacle (planar adhesion, loop of intestine), it may become twisted and not penetrate into the area of ​​the abdomen being examined. Deprived of this drawback diagnostic kit for laparocentesis, which includes a curved trocar and a spiral-shaped metal “groping” probe with a curvature approaching the curvature of the lateral canals of the abdominal cavity. A diagnostic metal probe with holes is moved forward with its beak, sliding along the parietal peritoneum of the anterolateral abdominal wall, then along the peritoneum of the lateral canal. During laparocentesis they examine typical places fluid accumulations: subhepatic and left subphrenic space, iliac fossae, small pelvis. The position of the metal probe in the abdominal cavity is determined by palpation at the moment of pressure from the inside on the abdominal wall with the working end of the instrument.

Reliability and complications of laparocentesis

Laparocentesis is not informative for injuries of the pancreas, extraperitoneal parts of the duodenum and colon, especially in the first hours after injury - a false negative result of the study. 5-6 or more hours after pancreatic injury, the likelihood of detecting exudate with high content amylase.

The accumulation of exudate and blood in the abdominal pockets, delimited from the free cavity by the walls of organs, ligaments and adhesions, is also not detected by laparocentesis.

Extensive retroperitoneal hematomas, for example, due to fractures of the pelvic bones, are accompanied by bloody transudate leaking through the peritoneum. It is possible for blood to enter the abdominal cavity from the wound canal of the abdominal wall when a trocar is inserted through the muscles in the iliac region. The erroneous conclusion of laparocentesis about intra-abdominal bleeding should be considered as false positive result. Thus, the diagnostic capabilities of laparocentesis with a “groping” catheter have a certain limit. In cases of inconclusive data obtained during diagnostic laparocentesis in victims with associated injuries, and alarming clinical picture acute abdomen, it is necessary to raise the question of emergency laparotomy.

Diagnostic pneumoperitoneum during laparocentesis it is used for differential diagnosis relaxations, true hernias, tumors and cysts of the diaphragm, subdiaphragmatic formations, in particular tumors, cysts of the liver and spleen, pericardial cysts and abdominal-mediastinal lipomas. The study is carried out on an empty stomach, the colon is cleaned with enemas. Typically, a puncture of the anterior abdominal wall is performed with a standard thin needle with a mandrel or a Veress needle along the outer edge of the left rectus muscle at the level of the navel, as well as at the Calque points.

Relieves puncture of arbitrary tension in patients with abdominal pain. The layers of the abdominal wall are overcome with a needle gradually, with jerking movements. The penetration of the needle through the last obstacle - the transverse fascia and the parietal peritoneum - is felt as a failure. After removing the mandrin, you should make sure that there is no blood flow through the needle. It is advisable to inject 3-5 ml of novocaine solution into the abdominal cavity. Free flow of solution into the cavity and absence reverse current after disconnecting the syringe indicates correct position needles. Using a device for intracavitary injection of gases, 300-500 cm3, less often 800 cm3, of oxygen is injected into the abdominal cavity. Gas moves in the free abdominal cavity depending on the position of the patient's body. X-ray examination performed an hour after the application of pneumoperitoneum. IN vertical position gas spreads under the diaphragm. Against the background of the gas layer, the features of the position of the diaphragm and pathological formation, their topographic relationships with adjacent abdominal organs.

It is believed that accidental puncture of the intestine with a needle during laparocentesis, as a rule, does not have fatal consequences. The results of an experimental study of the degree of danger of percutaneous puncture of the abdominal cavity: a puncture of the intestine with a diameter of 1 mm was sealed after 1-2 minutes.

The article was prepared and edited by: surgeon

Indications for laparocentesis

IN outpatient settings an incision-puncture of the anterior abdominal wall (laparocentesis) is performed primarily for the evacuation of ascitic fluid in patients with cirrhosis of the liver of various origins; in surgical hospitals - for diagnostic purposes when closed injuries abdomen to detect bleeding into the abdominal cavity, as well as during laparoscopy.

Technique for performing lacentesis

At ascites the patient usually sits; in other cases, the intervention is performed with the patient lying on his back. The intestines and bladder are first emptied. Local infiltration anesthesia with a 0.5% novocaine solution is used. Laparocentesis is often carried out along the midline of the abdomen, midway between the navel and pubis.

Using a pointed scalpel, an incision-puncture is made slightly wider than the diameter of the trocar on an anesthetized and antiseptic-treated area of ​​the anterior abdominal wall. The skin and superficial fascia are dissected. You should not forcefully “pierce” the abdominal wall with a scalpel, since after overcoming significant skin resistance, the scalpel can then easily slide deeper, penetrate the abdominal cavity and damage the adjacent loops of intestine. The task consists of a measured incision-puncture of almost only the skin. A trocar with a stylet is inserted into the resulting wound and, with rotational movements, it is moved relatively freely through the fascia, muscles and parietal peritoneum, penetrating into the abdominal cavity. The aponeurosis of the white line of the abdomen at this level is weakly expressed.

The trocar stylet is removed. If ascitic fluid flows out in a stream, then the trocar tube is in the abdominal cavity. The outer end of the tube is tilted down and advanced another 1-2 cm into the abdominal cavity so that its proximal end does not move into the abdominal cavity. soft fabrics abdominal wall during a relatively long-term manipulation of ascitic fluid removal. In this position, the tube is held by the cannula with your fingers. The liquid flows into the basin along an oilcloth (film) pre-tied to the lower part of the patient’s abdomen in the form of an apron. Asepsis is mandatory. The manipulation is carried out wearing sterile gloves.

The liquid is released without forcing, focusing on general state sick. For supporting stable pressure in the abdominal cavity, the assistant gradually tightens the patient’s stomach with a towel. Upon completion of the evacuation of ascitic fluid, the trocar tube is removed and one suture is placed on the wound of the abdominal wall and gauze bandage. It is advisable to “suture the abdomen in a towel” with some tension in order to maintain the intra-abdominal pressure familiar to the patient.

In the hospital, to diagnose intra-abdominal bleeding or determine the nature of the existing exudate, laparocentesis is performed and a “groping” catheter is inserted into the abdominal cavity through a trocar tube, through which the contents are sucked out with a syringe (Fig. 71). If it does not enter the syringe, then 200 ml of isotonic sodium chloride solution is injected into the abdominal cavity and the liquid is aspirated again. The color and smell of this liquid can indicate hemorrhage into the abdominal cavity or damage to a hollow organ. To perform laparoscopy - a visual examination of the abdominal cavity through a trocar tube, a special endoscopic device - a laparoscope - is inserted.

Rice. 71. Laparocentesis for evacuation of ascitic fluid and for diagnostic purposes. a - insertion of a trocar into the abdominal cavity; b - insertion of a “groping” catheter through the trocar tube; c - obtaining pathological contents of the abdominal cavity in a syringe.

Minor surgery. IN AND. Maslov, 1988.