This invention relates to a surgical closure that can be repeatedly opened and closed, especially for the abdominal wall. More particularly the invention relates to a surgical closure having fabric of plate-like securing elements that can be tightly but detachably connected to the body tissue and has a closure which can be repeatedly opened and closed.
Such a surgical closure is known, for example, from German Patent 34 44 782. This surgical closure is used especially as a temporary closure for the abdominal cavity, preferably for postoperative treatment of peritonitis.
Peritonitis, as a secondary form that develops as a result of a perforation of a hollow organ or as a postoperative complication, still has, even today, a high lethality. With increasing incidence, it represents a central surgical problem.
The abdominal cavity is subject to a physiological, regulated fluid stream that drains mainly by small openings in the peritoneal diaphragm underside. In this way, bacteria are fed by the lymph tracts to the systemic defense mechanism. The absorption capacity of the intraperitoneal fluid is increased by the mobility of the diaphragm and intraperitoneal pressure. During peritonitis, this drainage is blocked by the pathophysiological development of fibrin and bacteria and circulation is hindered by fibrin-induced adhesions. The defense system is disrupted and a rise in bacterial counts, or their toxins and fibrin, results. If the progression of peritonitis is not stopped promptly, a pathophysiological cascade gets started whose dynamics constantly grow and, after a certain point, can no longer be stopped.
To cleanse the abdominal cavity, washing with physiological saline solution is already done during the operation until the wash fluid stays clear. With this mechanical cleansing, bacterial counts, fibrin, dead tissue, toxins and also residual blood (even hemoglobin promotes the start of an infection) are to be removed as completely as possible, to provide, along with surgical removal of septic focus, an optimal condition for healing.
In the postoperative phase, in which the fate of the patient is mainly determined, it is decisive to recognize a worsening of the condition as early as possible, and optionally, to remove the cause (e.g., correction of an inadequate suture after oversewing a gastric ulcer) and, by effective lavage, if possible from the first postoperative day forward, to make sure conditions are clean (blood that reappears, fibrin and bacteria are to be rinsed away).
In postoperative lavage, the strategy of the open abdomen with periodic washing and the wash treatment with a closed abdomen are known.
This so-called open abdomen is made possible by the sliding splint closure and by the snap closure as a temporary closure for the abdominal cavity, with the advantages that repeated intra-abdominal accessibility is guaranteed and the technician, during each washing, can be convinced of the success of the removal of septic focus, and thus, can control the course of peritonitis. In doing so, postoperative, intra-abdominal adhesions can be detached and coatings of fibrin can be removed. The typical drainage complications are eliminated. (Plugging of drainage for the abdominal wall, blockage or obstruction of drainages, infection sources.) A relaparotomy is no longer necessary.
Here, the drawback is that right after the operation, washing cannot be performed and no continuous washing is possible. But then, periodic washing is relatively frequent and also a burden for the patient, when the patient is in critical condition. Periodic washing must be prepared carefully; it is performed in the operating room (the abdomen is open during washing) and under general anesthesia. The advantages of the principle of peritoneal dialysis must be done without, since previous temporary abdominal cavity closures do not close the abdomen tightly. The wash effect remains limited, since a desired intra-abdominal pressure is not maintained, and the wash fluid flows, preferably, only in preformed wash channels. Further, after the temporary closure of the abdominal wall, part of the wash fluid oozes into the bed which, in addition to being another source of infection, means ineffective washing, additional burden for the patient, and considerable additional expense for the nursing staff. Patients with an open abdomen belong, at that time, to the most care-intensive patients. If a so-called snap closure or sliding splint closure, as a temporary abdominal cavity closure, is infolded, another drawback comes to bear. Once cut and infolded, adaptation to the tension conditions of the abdominal wall is no longer possible. But, because of edematous swelling of inner organs during the course of peritonitis, the tension of the abdominal wall can increase considerably, with the danger that the sutures tear out. On the other hand, the edges of the incision must be brought together again gradually to the final suture of the abdominal wall later, during the healing phase in which the swelling of the inner organs decreases. Further, the typical complications of snap closures must be taken into account (constriction, tenaculum). There is no particular edge structure to infold into the fascia, so that only the individual sutures provide support. They are often not secure and tear out easily.
Continuous peritoneal lavage with a closed abdomen offers the advantage that an effective washing treatment can be started immediately after the operation, and thus, the purpose of the usual Redon suction drainage can be replaced considerably more effectively. The latter has a weak suction capacity, suctioning only right at the spot where it lays. Further, it easily becomes clogged and misleads to the assumption that the incision area has already been suctioned empty. With the sealed system, an intraperitoneal pressure can be built up and dosed. In doing so, the wash fluid (possibly with antibiotic added) also reaches the critical "atmospheric corners" of the abdomen. But not only are wash channels created, as when seepage through without pressure occurs. Fewer fibrin-induced adhesions are formed, since the abdomen contents "swim" and fibrin (among other things) is effectively washed out (thus, simultaneous ileus prophylaxis).
Peritoneal dialysis is possible. With it, an increase in the retention values (creatine, urea, potassium) with a threat of renal failure can conceivably be halted simply by using a commercially available dialysis fluid as the wash fluid. The patient can easily be dialyzed, without having to be put into the expensive program of hemodialysis. The associated drawbacks are also eliminated, as they can sometimes occur during the handling of blood volume. Washing can be taken over by a machine according to a desired program; thus, clear relief for the nursing personnel is possible. A chamber count of the leukocytes in the wash fluid makes it possible to monitor simply the response of the peritonitis. A judgment of the efflux can conceivably be performed simply by inspection (cloudiness, fibrin or blood admixtures). Wash fluid sensors to determine the resistance of bacteria can be removed by the catheter at any time, just as other substances can be administered (e.g., electrolytes, protein, heparin). The drawback here is that the abdomen is no longer accessible and thus no direct visual monitoring exists any more, which is important, when the efflux changes pathologically or the clinical condition of the patient worsens. Packing and infection source of the drainage passage points, as well as clogging or obstruction of the drainages represent typical complications. If the abdomen must be accessed again, a relaparotomy must be performed.
Despite promising starts, the strategy of the closed abdomen has not been able to be used in practice, since the drawbacks predominate.