RU2665676C1 - Method of free delayed plasty of skin autografts in traumatic skin detachments - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, particularly to traumatology and orthopedics. Cut off the exfoliated skin, remove from it subcutaneous fat tissue, preserve the skin at a temperature of +4 °C in physiological saline. Apply a vacuum dressing of the Suprasorb CNP Easy Dress system from Lohmann&Rauscher with a negative alternating pressure of 80–125 mmHg for 1–3 days. Patient is taken out of shock, the traumatic wound is prepared for transplantation, excising adipose tissue and necrotic muscles, and performing autoplasty. In this case, before the plastic, the graft is reworked, the lower layers of the dermis are cut by 0.1–0.2 mm with dermatome. Apply scalpel drainage punctures on the transplant for the entire thickness of 2–5 mm every 2–5 cm. After plasty, a vacuum bandage of the Suprasorb CNP Easy Dress system from Lohmann&Rauscher is applied to the transplant and a constant uniform negative pressure of 50 mmHg is applied on a full-length autograft for a period of 3–4 days.EFFECT: method allows to avoid decompensation of a condition of the patients who are in a shock, perform delayed plastic surgery on a viable wound, shorten treatment period for patients with severe traumatic skin detachments by creating conditions for a quick, more secure engraftment, create optimal conditions for engrafting a full-layer autograft, reduce purulent complications, do not use donor skin sites, achieve a better cosmetic result.1 cl, 7 dwg, 2 ex

Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used when performing skin autoplasty.

11.24.2019, it will be 150 years since Jacques Reverden made the first free skin graft - 3 by 4 mm in size on a granulating wound. During this period of time, various types of free skin transplantation onto wounds of various origins have been developed. It is generally recognized that a full-layer free skin autograft is superior in quality to a split autograft (Zolton J. Skin transplant. - Budapest, 1984. - 304 p.). Reverden's apprentice, Russian surgeon Yu.Yu. Janelidze wrote: “Thin grafts have advantages: the donor site heals quickly; easy to take large sizes; almost always takes root. The disadvantages of plastic thin grafts are: cosmetically defective; wrinkles; in some places it cannot protect the underlying tissues. ”

Thick (full-layer) grafts have advantages: the cosmetic effect is superior to that obtained with a thin graft; in appearance it is very close to normal skin; tendency to contracture is minimal; transplanted to the entire thickness of the skin serves as sufficient protection for the underlying tissues, there is no soldering of the transplanted bone graft, which makes it possible to perform reconstructive operations on bone tissue, without the threat of necrosis of the transplanted skin graft.

To date, in clinical practice, with traumatic skin detachment, plastic is used with a full-layer (thick) free graft according to Krasovitov, which is an analogue of our invention (V.M. Krasovitov. Primary plastic surgery with torn flaps of the skin / V.M. - Krasnodar, 1947. - 87 p.).

The technology of surgery - plastic surgery with a full-layer skin flap according to Krasovitov is that only on the first day after the injury, the full-layer skin flap peeled off at the time of the injury is cut off at the border with intact tissues, primary surgical treatment of the traumatic wound is performed at the site of the formed skin defect with thorough excision of adipose tissue and a wound toilet with solutions of antiseptics, after which the adipose tissue is excised on the transplant and the toilet with its anti solutions eptikov next stage produce drainage punctures graft with a scalpel in the entire thickness in a staggered manner, the drainage holes in the graft located at a distance of 2.0-2.5 cm, after which the graft donor site replantiruyut for fixing it to the border seams intact tissues.

The main drawback of plastic graft according to Krasovitov is:

- the inability to perform plastic surgery according to Krasovitov in patients in a state of traumatic shock due to the duration and trauma of surgical intervention - the operation can lead to decompensation of the patient's condition and death;

- the inability to perform plastic surgery according to Krasovitov’s patients, not only with traumatic skin detachment, but also with crushing of muscle tissue, which is typical for severe open fractures of the extremities, skin transplantation into necrotic muscles inevitably leads to transplant necrosis.

- small chances of engraftment of a thick transplant in trauma patients (Dzhanelidze Yu. Yu. Free skin grafting. - Medgiz. - M., 1952. - 70 p.).

Failures in plastic surgery with a full-layer skin flap are due to poor blood supply to quickly necrotic adipose tissue, infection, poor blood supply to the wound bed (Krasovitov V.M. Primary plastic surgery with torn flaps of the skin / V.M. Krasovitov. - Krasnodar Regional Book Publishing. - Krasnodar, 1947. - 87 s; B.V. Parin, B.V. Skin plastics for traumatic injuries / B.V. Parin. - M.: Medgiz, 1943. - 44 p.).

As the closest analogue, the method of surgical treatment of deep skin defects was adopted (Sergeev K.N., Zhaglin A.V. Use of the system for treating wounds with negative pressure of patients with complicated bone injury // Wounds and wound infections. Journal named after Professor B.M. Kostyuchenko. 2014. No. 2). The implementation of the method of surgical treatment of a skin defect is as follows. After the revision of the wound (the bottom of the wound is the muscles of the anteroposterior and anteroposterior surfaces of the shoulder and forearm), a traumatic opening of the fascial cases is noted, there are no signs of ongoing bleeding. In the operating room, surgical treatment of the wound, layer-by-layer suturing was performed. According to urgent indications, surgical treatment of the wound of the left upper limb was performed, the ligatures were removed from the wound and sutured fascial cases. A necrectomy and fixation of the fracture by a blocked intramedullary pin were performed. At the final stage, negative pressure therapy (NPWT) was started using sterile disposable VivanoMed Foam Kit (L) kits in a continuous mode of 120 mmHg using S 042 NPWT / VivanoTec apparatus. At the first stage, the exposure of vacuum therapy was 48 hours, after which repeated surgical treatment was performed with economical necrectomy and a vacuum dressing was applied. The vacuum dressing changes 4 times in 2-3 days. When granulation is formed, after 10-12 days, autodermoplasty is performed with a split perforated skin graft. To protect and prevent graft displacement, the wound is covered with an Atrauman Ag non-traumatic wound dressing and stabilized by a VivanoMed Foam Kit (L) vacuum dressing in an alternating mode of 80-120 mm Hg, the exposure of the vacuum-assisted dressing was 96 hours. At the first change of dressing after autodermoplasty, the graft was well fixed to the wound. The second revision on the 7th day - a good engraftment of the autograft was noted. The total treatment period was 30 days.

The disadvantages of this method are:

- long-term preparation of the wound for autoplasty;

- failure to use a full-layer graft and, as a result, an incomplete functional result;

- collection of donor site from healthy skin.

Tasks:

- to improve the method of treatment of full-layer skin detachment in patients in a state of shock;

- improve and accelerate the engraftment and adaptation of a full-layer skin autograft.

The essence of the proposed method of treatment is the following: - before delayed grafting, the graft is reprocessed, dissecting the lower dermis by 0.1-0.2 mm with a dermatome, and after grafting, the Suprasorb CNP Easy Dress vacuum dressing from Lohmann & Rauscher is applied to the graft to ensure a constant uniform negative pressure of 80 mmHg. on a full-layer autograft for a period of 3-4 days.

EFFECT: method allows: avoiding decompensation of the state of patients in shock; produce delayed plastic surgery on a viable wound; reduce the treatment time for patients with severe traumatic skin detachments by creating conditions for a quicker, more guaranteed graft engraftment; create optimal conditions for the engraftment of a full-layer autograft due to excision from the nutria of the dermis by 0.1-0.2 mm before autoplasty; apply VAK therapy providing uniform pressure on the transplant; reduce purulent complications due to the use of VAC therapy; do not use donor skin by preserving a full-layer autograft; to achieve the best cosmetic result due to plastic surgery with a full-layer graft as opposed to performing plastic surgery with split grafts.

According to this method, in clinical conditions GBUZ "Research Institute - Regional Clinical Hospital No. 1 named after Professor S.V. Ochapovsky ”of the Ministry of Health of the Krasnodar Territory operated on 2 patients with polytrauma in 2017.

Example 1. Patient D., 24 years old, was admitted to LLP No. 1 GBUZ "NII KKB No. 1 named. prof. S.V. Ochapovsky ”01/24/2017 with a diagnosis of: Severe combined trauma (polytrauma), chest, abdomen, limbs; multiple fractures of the ribs (6, 7, 8, 9) on the left, complicated by small hemothorax (up to 300 ml) and intense pneumothorax; rupture of the spleen, ongoing bleeding into the abdominal cavity, hemoperitonem - 1200 ml; open fracture of the proximal tibia metaphysis on the left, traumatic detachment of the skin of the left tibia. Traumatic shock 2-3 tbsp .; AIS-ISS polytrauma severity index - 29 points. The prognosis for life is dubious.

After examination, the diagnosis, 30 minutes after hospitalization, surgical treatment was started against the background of intensive therapy.

First of all, the life-threatening consequences of the injury were eliminated:

- active drainage of the pleural cavity on the left;

- removal of the spleen, hemostasis, reinfusion of blood poured into the abdominal cavity.

Due to the unstable condition of the patient and the high probability of decompensation of the condition and lethal outcome when performing traumatic surgical interventions on the limbs, it was decided to apply the technology of staged treatment of open bone fracture of the proximal metaphysis of the lower leg and traumatic detachment of the skin of the left lower leg, the type of damaged limb is shown in Fig. one.

At the first stage, the most minimally traumatic surgical intervention was performed: PCF of open fracture wounds in a reduced volume (Fig. 3):

- cut off a detached full-layer skin graft at the border with intact tissues (Fig. 2);

- performed hemostasis, toilet wounds with antiseptic solutions;

- a vacuum dressing was applied on the Suprasorb CNP Easy Dress system of Lohmann & Rauscher with a negative pressure of 125 mm Hg, (Fig. 36), which helps to maintain the vitality of the exposed bone, which is the bottom of the wound;

- a core external fixation apparatus (ANF) has been applied to stabilize the fracture (Figure 3a).

Subsequent manipulations with the graft (cut off flap) were performed after transferring the patient to the intensive care unit:

- thoroughly dissected adipose tissue, produced a toilet with antiseptic solutions (Fig. 4);

- wrapped the autograft in sterile wipes moistened with physiological saline and placed in a sterile sealed plastic bag in a refrigerator with a temperature of + 4 ° C.

2 days after receiving the injury and taking the patient out of shock (achieving relative stabilization of the condition), without the threat of decompensation of the patient's condition, the second stage of treatment was performed - repeated surgical treatment of an open fracture wound (Fig. 5), during which:

- subcutaneous fatty tissue, non-viable muscle tissue were excised (Fig. 5),

- a wound toilet was made with antiseptic solutions, the wound was sown for microflora;

- the lower layers of the dermis were additionally excised with a dermatome on the transplant by 0.1-0.2 mm and draining skin punctures were made over its entire thickness;

- then transplantation was performed into the skin defect zone and fixed with sutures (Fig. 6a);

- Then they applied the vacuum dressing of the Suprasorb CNP Easy Dress system from Lohmann & Rauscher providing a uniform pressure of 50 mm. Hg for a full-layer autograft for a period of 4 days (Fig. 6b). Removing the vacuum dressing after 3 days, the beginning of graft adaptation is noted.

14 days after the injury, the immediate result of treatment was fixed - graft engraftment was 100% (Fig. 7).

Example 2. Patient S., 30 years old, was admitted to LLP No. 1 GBUZ "Research Institute KKB№1 named. prof. S.V. Ochapovsky "02/02/2017 with a diagnosis of combined trauma, chest, abdomen, limbs; multiple fractures of the ribs (3, 4, 5) on the left; liver rupture, an open fracture of the middle third of the tibia on the left, traumatic detachment of the skin of the left tibia; AIS-ISS polytrauma severity index - 36 points. The prognosis for life is dubious.

After examination, formulation of the diagnosis, 20 minutes after hospitalization, surgical treatment was started. At the first stage, the most minimally traumatic surgical intervention was performed: PCR of open fracture wounds in a reduced volume: a peeled full-layer skin graft was cut off at the border with intact tissues; performed hemostasis, wound toilet with antiseptic solutions; Lozmann & Rauscher Suprasorb CNP Easy Dress vacuum dressing was applied with a negative pressure of 125 mmHg, which helps to maintain the vitality of the bare bone, which is the bottom of the wound; - superimposed rod apparatus of external fixation (ANF) in order to stabilize the fracture.

Subsequent manipulations with the graft (cut off flap) were performed after the patient was transferred to the intensive care unit: they thoroughly dissected the adipose tissue, made a toilet with antiseptic solutions; wrapped the autograft in sterile wipes moistened with saline and placed in a sterile sealed plastic bag in a refrigerator with a temperature of + 4 ° C. 2 days after the injury and taking the patient out of shock (achieving relative stabilization of the condition), without threatening to decompensate the patient's condition, the second stage of treatment was performed - repeated surgical treatment of the open fracture wound, during which: subcutaneous fatty tissue, non-viable muscle tissue were excised; a wound toilet was made with antiseptic solutions, the wound was sown for microflora; the lower layers of the dermis were additionally excised with a dermatome on the transplant by 0.1-0.2 mm and draining skin punctures were made over its entire thickness; then transplantation of the graft into the area of the skin defect was performed and fixed with sutures; - Then they applied a vacuum bandage to the Suprasorb CNP Easy Dress system from Lohmann & Rauscher providing uniform pressure of 50 mm Hg. for a full-layer autograft for a period of 4 days. Removing the vacuum dressing after 2 days, the beginning of graft adaptation is noted. 18 days after the injury, the nearest treatment result was fixed - graft engraftment was 100%.

Claims (1)

The method of free delayed plasty with a skin autograft in case of traumatic skin detachment, in which detached skin is cut off, subcutaneous fat is removed from it, the skin is preserved at + 4 ° C in physiological saline, a Lozmann & Rauscher Suprasorb CNP Easy Dress vacuum dressing is applied to the wound with negative variable pressure of 80-125 mm Hg for 1-3 days, the patient is taken out of shock, a traumatic wound is prepared for transplantation, excising adipose tissue and necrotic muscles, autoplasty is performed, characterized in that the graft is re-treated before plastic surgery, the lower layers of the dermis are excised by 0.1-0.2 mm with a dermatome, apply drainage punctures on the graft with a scalpel to the entire thickness of 2-5 mm every 2-5 cm, after plastic surgery, apply the Suprasorb CNP Easy Dress system from Lohmann & Rauscher to the graft and ensure a constant uniform negative pressure 50 mmHg on a full-layer autograft for a period of 3-4 days.

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