CC BY
39
UDC 616-089
COMPARATIVE ANALYSIS OF ENDOVIDEOSURGERY AND OPEN SURGERY
FOR DAMAGED DIAPHRAGM
S.A.Gadzhiev, A.P.Uhanov
Yaroslav-the-Wise Novgorod State University, ukhanov@mail.natm.ru
We have carried out comparative analysis of endovideosurgery and traditional interventions for damaged diaphragm. We indicated that thoracoscopic and laparoscopic procedures are less traumatic resulting in easier course of postoperative period, the number of postoperative complications decreased in 5 times.
Keywords: diaphragm injury, endovideosurgery, thoracoscopy, laparoscopy
Проведен сравнительный анализ эндовидеохирургических и традиционных вмешательств при повреждениях диафрагмы. Указывается, что торакоскопические и лапароскопические операции отличаются меньшей травматичностью, в результате чего значительно легче протекает послеоперационный период, количество послеоперационных осложнений снижается в 5 раз.
Ключевые слова: повреждения диафрагмы, эндовидеохирургия, торакоскопия, лапароскопия
Diagnosis and treatment of the diaphragm injury is one of the unsolved problems of emergency surgery as during peaceful and war time [2,7-9]. This is explained not only by the severity of trauma and simultaneous injury of the impermeability of the two cavities, but also by the continuing high rate of diagnostic and therapeutic-tactical errors.
Choice of preoperative preparation, rational surgical approach, postoperative intensive care are still controversial. Difficulties of early diagnosis are caused by variety of clinical picture, the severity of patients’ condition, the lack of specific symptoms of diaphragm injury, combined injuries of the chest and abdominal cavities [1,6].
Endovideosurgery is promising direction for improving of treatment results in patients with diaphragm injury [35]. Thoracoscopy and laparoscopy allow not only to clarify the localization of the injury, its severity, developing complications, but also to solve the problems of surgical tactics. In addition videosurgery methods make it possible to combine diagnostic and therapeutic manipulations.
Endovideosurgery has been used in 92 patients with rupture of diaphragm. In 81 patients the rupture was stitched with continuous suture, in 11 — in addition to suture we used netted transplant. Videoscopic intervention started with thoracoscopy in 53 (57.6%) patients and with laparoscopy in 39 (42.4%) patients. The sequence was determined by analysis of clinical manifestations, results of X-ray and ultrasound examinations of chest and abdomen. Damage of the left part of diaphragm was found in 51 (55%) cases, of the right part — in 41 (45%) cases. Stitching of rupture has been started with muscular real part taking the entire thickness of the muscle, but not more than 1 cm from the edge of the rupture. It is necessary to make sure that the stitching has not damage the phrenic nerve. The tendon part of diaphragm has been stitched in the same way.
Comparative analysis of immediate results of treatment of thoracoabdominal injuries by traditional and en-dovideosurgical ways has been carried out to study the effectiveness of endovideosurgery. Although such comparison is nominal because of different severity of patients’ condition and organ damage, still research materials allowed to identify comparable groups of patients, to analyze the results of their treatment and to come to certain conclusions.
Endovideosurgery as the final stage of operation has been used in 71 cases, as one of the stages of operation — in 79 patients. Frequency of using of this method, as experience grew, increased. So if at the beginning of research such interventions have been singular, recent years this method has taken strong position in the arsenal of treatment programs in this category of patients. When analyzing the outcomes of patients with thoracoabdominal injuries with rupture of the diaphragm, it becomes apparent that the main advantages endovideosurgery are essential minimizing of the severity of surgical aggression, respiratory and septic, including wound, complications, as well as less traumatizing of internal organs and reducing the probability of adhesion formation.
To study the effect of operative approach on the incidence of complications treatment outcomes of 2 groups of patients matched by sex, age, nature of injury and severity of the condition have been analyzed. Group of patients operated endovideosurgically contained 48 patients (basic group), in the traditional way — 53 patients (control group).
All patients have undergone comparable preoperative preparation and the extent of examinations. Antibiotic therapy has been started during the preoperative (used third generation cephalosporins or ciprofloxacin) and, if necessary, continued after the operation. All patients have undergone operation under multicomponent endotracheal anesthesia within 1-3 hours after admission. The duration of each phase of videoscopic operation was 52 minutes on average, the traditional one — 78 minutes.
In order to assess the damage during surgery and the response of the body to surgical aggression using different methods of surgical treatment comparative analysis and statistical processing of the following parameters: terms of treating in the intensive care department after surgery, the duration of antibacterial and infusion therapy, temperature reaction, the severity of pain, the dynamics of changes in leukocyte counts in postoperative period and the basic biochemical parameters as well as terms of normalization of function of gastrointestinal tract.
The most expensive stage of hospital treatment of patients is the terms of intensive care in the intensive care unit. So, if the cost of treating a patient in the surgical department is 254 rubles a day, cost of treating in the intensive care is 1,550 rubles (according to the tariffs of the territorial fund for 2009).
The indications for placement of patients in the intensive care unit are considered to be severity of blood loss and the necessity to normalize the functions of the respiratory and cardiovascular systems after the anesthetic depression, the severity of the surgery, severe concomitant diseases, accompanied by compromising the functions of various organs and systems.
55.2% of patients who were operated endovideo-surgically were transferred to the surgical department up to 6 hours after their admission to the intensive care unit, 31% of patients were in the department at least 12 hours and only 13.8% — from 12 to 24 hours. The total number of bed-days spent by patients undergoing surgery en-dovideosurgically in intensive care unit was 72 days (taking onto account that any admission of patient to the intensive care unit, regardless of the duration, is considered as one bed-day). The average duration of treatment in intensive care unit was 1.5 days.
Transfer of patients to specialized department up to 6 hours after traditional operations was unable. 15.4% of patients have been transferred to surgical department in 6-12 hours, 46.2% — in terms from 12.5 to 24 hours, 23.1% — in more than a day. 15.4% of patients have been in the intensive care unit more than 2 days. The total number bed-days spent by patients operated in the traditional way in intensive care unit was to 186, with average rate of staying in intensive care unit was 3.5 days. Thus, the real cost of treatment in the intensive care unit for 1 patient operated endovideosurgically was 2325 rubles, in traditional way — 5,225 rubles.
The duration of infusion therapy in group of patients operated in the traditional way was 4.5 days at average. After 3-5 days patients operated in traditional way were transferred to full enteral nutrition; after endovideosurgically intervention duration of infusion therapy was 2.5 days at average and patients were transferred to full enteral nutrition on 2nd-3rd days.
One of the cardinal symptoms that point to positive changes in the patient's condition after surgery on the abdominal organs is the appearance of peristalsis. Average terms of active peristalsis and consequently the possibility of taking solid foods after surgery in the basic group was 1.8 ± 0.29 days. In the control group active peristalsis appeared on 3.4 ± 0.21 days at average (p < 0.05).
Duration of antibiotic therapy was established on the basis of the temperature reaction, the dynamics of leukocyte counts, enteroparesis and availability of various postoperative, more often — respiratory, complications. Duration of antibiotic therapy for videoscopic interventions was 3.5 days at average.
The necessity of changing of the antibiotics did not occur and all patients were given antibiotics that initially have been used. After traditional intervention antibacterial therapy lasted 8.5 days at average. In 7 patients due to the ineffectiveness of the applied therapy, expensive antibiotics from the reserve group have been prescribed.
A comparative analysis of the results of endovide-osurgical and open surgery in patients with injuries of the diaphragm has been performed. We compared the following indicators: complications and deaths, the average period of hospitalization (Table).
Comparative characteristics of results of endovideosurgical and traditional treatment in patients with diaphragm injuries
Indicator Basic group (n=48) Control group (n=53)
Postoperative complications (n, % M±m) 3 (6.3 ± 0.3%) 18 (34.0±2.4%) P < 0.05
Postoperative lethality (n, % M±m) — 3 (5.7 ± 0.2%) P < 0.05
Average bed-days (days, M±m) 6.5 ± 0.3 10.5±0.4 P < 0.05
Complications after endovideosurgical interventions were observed in 3 (6.3%) patients. After the traditional operations various complications occurred in 20 (34.0%) patients; with 3 of them have undergone repeated surgeries (because of abdominal abscess and eventration).
After endovideosurgical intervention deaths have not been observed, whereas after the traditional operations 3 patients have died (5.7%).
Positive moments of minimally invasive endovide-osurgical interventions, such as the lack of significant trauma chest or abdominal wall and organs of chest or abdominal cavity lead to more rapid postoperative rehabilitation of patients accompanied by statistically significant reduction of the period of hospitalization. The average duration of hospital treatment after videoscopic intervention was 6.5 days, while after traditional operations — 10.5.
Thus, videodcopic intervention in trauma of the chest and abdomen with rupture of the diaphragm performed according to indications have obvious advantages over traditional operations. It is less traumatic surgery that results in relatively easier postoperative period, the number of postoperative complications is reduced in more than 5 times. Material costs for the treatment of patients are much lower in endovideosurgical intervention. In addition, terms of medical and social rehabilitation of patients operated with
videoscopic way are almost 2 times less than in the group of patients who have undergone traditional intervention.
Conclusions
Diaphragm injury is observed in 11.1% of patients with chest and abdominal traumas, including 8.2% of patients with closed and 18.8% of patients with penetrating thoracoabdominal injuries.
Compared to other severe injuries of the chest or abdominal cavities diagnostic value of X-ray and ultrasound of diaphragm injuries is low. Direct signs of damage of diaphragm (bowel loops in the pleural cavity) have been detected only in 3 persons (2%) with closed injury and 2 patients (1.4%) with open one. In this regard using of en-dovideosurgical diagnosis is crucial as it allows to diagnose injury of diaphragm in 100% of patients during thoracoscopy and in 95.2% of patients during laparoscopy.
In 34.6% of patients with diaphragm injury operation can be performed endovideosurgically, while in 31.1% of patients — with using of mini-invasive videoscopic intervention in combination with open surgery methods. Overall, in 65.7% of patients with various injuries of diaphragm surgery can be performed either endovideosur-gically or with combination of minimally invasive surgery with the traditional method of cavitary operating.
Videoscopic interventions in case of trauma of the chest and abdomen with rupture of the diaphragm performed according to indications have obvious advantages over traditional operations. They are expressed in less traumatic surgery, resulting in significantly lighter flows postoperative period; the number of postoperative complications is reduced by more than 5 times. In addition, the timing of medical and social rehabilitation of patients operated videoscopic way, almost 2 times less than in the group of victims who have been subjected to traditional interventions. It is less traumatic surgery that results in relatively easier postoperative period, the number of postoperative complications is reduced in more than 5 times. In addition, the timing of medical and social rehabilitation of patients operated video-scopic way, almost 2 times less than in the group of victims who have been subjected to traditional interventions.
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