TREATMENT OF EXTENSIVE ABDOMINAL WALL DEFECTS N MINE-BLAST WOUND USING THE METHOD OF DOSED EXPANSION OF SOFT TISSUES

TREATMENT OF EXTENSIVE ABDOMINAL WALL DEFECTS N MINE-BLAST WOUND USING THE METHOD OF DOSED EXPANSION OF SOFT TISSUES

Pyatakov S.N., Zavrazhnov A.A., Pyatakova S.N., Soldatov A.A.

Surgery chair No.1, faculty of skills upgrading and professional retraining, Kuban State Medical University, Krasnodar, Russia,
City Hospital No.4, Sochi, Russia

Objective – to show the possibility and efficiency of using the technique of dosed tissue expansion in treatment of an extensive defect of the anterior abdominal wall in the patient with a severe mine-blast wound.
Materials and methods. The dosed expansion of soft tissues is a method of gradual tissues stretching with increasing square of the cutaneous-subcutaneous-muscular flap. The authors’ method of dosed expansion and the original dermotension device were used during the treatment of the patient.
Conclusion. The clinical case of the treatment of the abdominal wall mine-explosive wound showed that the offered method and the dermotension device allowed the successful closure of an extensive wound defect in the anterior abdominal wall with use of local tissues, resulting in significant reduction of hospital stay and achievement of the optimal functional outcome.

Key words: mine-blast wounds; extensive defects of soft tissues; dosed expansion of soft tissues

The mine blast pathology is a multifactorial injury that appears as the resultof the joint effect: 1) the blast (explosive) wave; 2) gas jet; 3) various wounding shells; 4) flame; 5) toxic products of burning that cause severe injuries in the region of immediate influence on tissues and in the whole body. The mine-blast injury is the impact of explosive substances in the region of direct affection from blast wave. Organ and tissue injuries can have the organic or/and functional pattern, depending on the blast strength, distance and presence of barriers [1-4].
The wound process has some features relating to mine-blast injuries. These features are determined by concomitant and multiple characteristics of injuries with combined influence of adverse factors, acute massive blood loss, common contusion of the heart and the lungs, early traumatic toxicosis [1]. All these features create some conditions for appearance of extensive regions of secondary traumatic necrosis and promote the increasing incidence of local (abscess, phlegmon, the wound leaks) and generalized (sepsis, severe sepsis, septic shock) forms of infectious complications.
The modern approach to treatment of patients with extensive soft tissue defects of mine-explosive origin means the early closure of the wound surface that is impossible without radical primary and/or secondary surgical preparation and skin plastic surgery [1, 5-11]. Moreover, surgical preparation of the pathologic region can increase the wound defect, but early skin plastic surgery for a contaminated wound can be accompanied by higher proportion of postsurgical non-infectious and infectious complications [1, 12, 13].
Among the various techniques for wound closure, the evident advantages (relative simplicity, functional sufficiency, cosmetic effect) are associated with skin plastic surgery with local tissues. The success of such surgery depends on preparation of the wound surface, as well as on the square of tissue (cutaneous, subcutaneous and muscular) flaps [7, 14, 15]. The technique of dosed tissue expansion (DTE) is offered for increasing square of transferrable tissues. Its different forms are actively used: balloon (expander), ligature, pins [12, 14, 16]. The principle of the technique consists in application of constant load to the region of healthy tissue (skin, subcutaneous fat and muscles) near the wound defect [9, 11]. The duration of extension and load degree depend on the square of a replaced tissue defect and regionary features of blood flow in skin surface.
During the experimental and clinical testing, the researchers offered some modifications for DTE and the expansion devices [6, 14, 17]. Most of them do not consider the flat pattern of the wound surface. As result, during tension, some complications appear as result of injuries to subjacent soft tissues from sutures (pins). The reports on DTE for mine-blast injuries and extensive tissue defects of the anterior abdominal wall are rare [1, 19, 19].
The study objective – to show the possibility and efficiency of using the technique of dosed tissue expansion in treatment of an extensive defect of the anterior abdominal wall in the patient with a severe mine-blast wound.
The patient gave the written consent for participation in the clinical study. The ethical committee confirmed the correspondence to the ethical principles and the standards (the session protocol of the local ethical committee of Sochi City Hospital No.4, #9/2017, October 6, 20170. 

Clinical observation

The patient V., age of 33, suffered from an injury to the head, the abdomen and the extremities as result of explosion of a self-made explosive device. The primary specialized medical aid was realized in Sochi City Hospital No.4, where the emergent procedures were carried out: laparotomy with revision of abdominal organs, resection of the part of the jejunum with the end-to-end anastomosis, suturing for multiple wounds of the ileum, sanitation and draining for abdominal cavity, primary plastic surgery of the anterior abdominal wall with own tissues; amputation of the right hand with formation of the stump at the level of the heads of the forearm; surgical preparation of the wounds of the left hand with amputation and formation of the stumps of the fingers 1, 2, 3 and 4. After relative stabilization of the patient’s condition, 5 days after the injury, the patient was transferred to the purulent surgery unit, Krasnodar Clinical Hospital No.1 named after professor S.V. Ochapovskiy.
At the moment of admission to Krasnodar City Hospital No.1 (April 8), the patient’s condition was severe, the consciousness was clear. The patient was agitated, with pulse rate of 102-110/min. (rhythmic), AP – 130/90 mm Hg, independent and superficial breathing, HR – 22-24/min. The face had the multiple wounds and grazes with burned eyelashes, eyebrows, scalp and burns of the face and eyelids of degree 1-2 (Fig. 1). The anterior abdominal wall included a sutured wound of incorrect shape consisting of 3 parts: two parts in the right half (12 and 16 cm) and one part in the left half of the abdomen. Boundary necrosis was along the whole length of the wound. The suprapubic region included two horizontal incised wounds (5 and 7 cm), with paravulnar infiltration and blood in tissues (Fig. 1b). The right hand was absent. There was a sutured amputation stump at the level of the radiocarpal joint, with PVC drain tubes (Fig. 1c). The left hand did not have the fingers 1, 2, 3 and 4 from the level of the proximal phalanges. Their stumps were sutured and drained with PVC drains (Fig. 1d).

Figure 1: a, b – the patient’s appearance; c – the right hand stump; d – the amputation stump at the level of the radiocarpal joint to the left

    


CT examination at the moment of admission: no CT-signs of cerebral changes. The signs of right-sided lower lobe pneumonia. Right-sided small hydrothorax. The postpneumatic changes C10 in the left lung. Multiple foreign bodies in the abdominal wall body and the in the abdominal cavity. The suspected damage of the ascendant part of the colon (gas in the retroperitoneal space). The drains in the abdominal cavity.  

The diagnosis was made:

The main diagnosis: “A severe concomitant mine-blast injury to the head, the abdomen and the extremities. Multiple shrapnel wounds of the facial soft tissues. The burns of the face, eyelids and corneas of both eyes of degree 1-2. Multiple blind fragmentary penetrating abdominal wounds with damages of small intestine and the colon, an extensive wound of the anterior abdominal wall, multiple foreign bodies in the abdominal cavity. A partial detachment of the right hand. An extensive wound of the left hand with destruction of the fingers 1, 2, 3 and 4. Acute massive blood loss. Traumatic shock of degree 2”.
Complications: “General fibropurulent peritonitis. Sepsis. Posttraumatic pancreatitis. Subdepression”.
The patients was operated in the admission day in Krasnodar City Hospital (April 8): relaparotomy, abdominal cavity revision, Hartmann surgery for the ascendant colon, greater omentum resection, nasogastral intubation with Miller-Abbott tube, abdominal sanitation and draining, secondary surgical preparation of the wound of the anterior abdominal wall.
The results of inoculation of the abdominal exudate (April 8): staphylococcus aureus sensitive to penicillin, gentamicin, levofloxacin, vancomycin and tetracycline.

Several operations were carried out:

April 11 – programmed sanitation relaparotomy, recurrent surgical preparation of the wound in the anterior abdominal wall, abdominal revision and sanitation, small intestine recurrent intubation, colostomy correction, draining correction. Secondary surgical preparation of the injuries to the upper extremities, K-wire fixation for the joints of 5th finger;
April 14 – recurrent surgical preparation of the right hand stump, and recurrent surgical preparation of the stump of the fingers of the left hand with application of secondary early sutures;
April 18 – recurrent surgical preparation of the anterior abdominal wall wound with plastics for defects of the retroperitoneum, the muscles and aponeurosis with use of the mesh implant: application of the pins for DTE and the wound closing with local tissues (Fig. 2).

Figure 2. The wound appearance after recurrent surgical preparation

In our clinic we developed the original dermotension device for plastic surgery of extensive wound defects with use of local tissues (the patent: 7 MPK A 61 B 17/00, 17/56 The treatment technique for extensive wound defects of the anterior abdominal wall). The specific features of the device are:
- prevention of ischemia and necrosis of expanding tissues by means of removing the pressure from some parts of the device to the wound borders, as well as prevention of damages of tissues (impact of sutures) forming the walls and the bottom of the wound;
- provision of staged and adequate extension of cutaneous and subcutaneous fascial flap without removal or dressing at any time of day;
- provision of regulation of the flank angle of the cutaneous-subcutaneous-muscular flap to the wound surface for creation of favorable conditions for contact of wound walls and for healing without secondary sutures.
The use of the offered DTE device for extensive wound defects of the anterior abdominal wall means the use of the pins and the pelvic rod external fixing device (Fig. 3). Preliminary, K-wires (6) are conducted through the whole depth, 1-1.5 cm from the wound boundaries. The ends of the pins are drawn out and are folded for preventing injuries to the skin surface. With use of the suturing needle, the tension (lavsan, capron) sutures (5) are stretched from the internal surface of the flap with grabbing the K-wires (6). It creates the possibility for DTE without damages and ischemia in expanded tissues. Then the bilateral pelvic device for external fixation is mounted with two rods through the iliac crests (1). Two parallel rods with the holes (2) are strengthened in the device at the height at least 10 cm over the abdomen surface. The rods are connected with the wire tighteners (3) with the mobile bolts (4). The wire tighteners are fixed with the ends of sutures (5). The amount and the length of the pins (6), sutures (5) and the wire tighteners (3) depend on the size, shape and location of a wound defect.

Figure 3. The scheme of treatment of the anterior abdominal wall wound defects


DTE was performed in stage by stage manner, 3-4 times per day without removal of a dressing, by means of tightening the screws (7) of the wire tighteners (3). Changing the position of the transient bolts (4) and the rods with holes (2), one can change the plane and the directional angle of tension within 180°. The dressings are changed one time per day with use of water-soluble ointments and/or iodine-containing solutions. After achieving the adaptation of the wound boundaries, the rod device is dismounted, and the secondary sutures are applied to the wound.
The microflora (with estimation of sensitivity to antibiotics) is regularly examined during closing the wound defect with DTE. If necessary, the skin microcirculation is estimated by means of measuring the transcutaneous partial pressure of oxygen (ТсРО2) in the capillary blood using the oxymonitor and laser doppler flowmetry.
April 23 – the patient received the plastic stage of closing the extensive damage of the anterior abdominal wall with use of DTE and the above-mentioned original device (Fig. 4).

Figure 4. The wound appearance at the beginning of dosed tissue expansion technique


The cultures of the anterior abdominal wall (April 28) showed the growing Ps. Aeruginosa, the microbial number – 105, the sensitivity to cefoperazonum, gentamicin, amikacin, ciprofloxacin and meronem.
April 29 – the rod device was dismounted. The secondary sutures were applied for the wound, and PVC tubes were placed (Fig. 5).

Figure 5. The wound appearance after demounting the external fixing device and the anterior abdominal wall wound suturing

The figure 6 shows the appearance of the wound on the day 6.

Figure 6. The appearance of the anterior abdominal wall wound without signs of purulence


CONCLUSION

The traditional techniques for closing the extensive wound defects of the anterior abdominal wall has some disadvantages, which decrease the effect of use [1, 4, 12, 20]: skin plastic surgery with local tissues is sometimes impossible due to big sizes of the wound and possible displacement of tissues; if free autodermoplasty with split-thickness skin graft is used, the patients suffer from significant personal discomfort relating to appearing functional and cosmetic defects [6, 21]; the use of microsurgical technique of tissue grafts with a vascular pedicle is a technically difficult intervention that requires much time and availability of expensive equipment [16].
Currently, there is a generally accepted fact that DTE activates the dermogenesis that allows rational using the local tissues for closure of extensive wound defects [5, 11, 12, 15, 21]. The technique has some positive properties: a possibility for early closure of extensive defects using the proper skin surface; the technique does not require transfer of complex flaps for replacing the soft tissue defects; opened management of the wound allows the dynamic control of the wound process course; extension of tissues is realized immediately after surgical preparation and can be controlled with the clinical criteria [12].
The clinical case of the patient with severe mine-blast trauma showed the efficiency of DTE technique for closing the extensive tissue defect of the anterior abdominal wall. The offered original treatment technique optimizes this method and gives the good functional and cosmetic results, with significant reduction of hospital stay.

Information about conflict of interests

The study was conducted without sponsorship. The authors declare the absence of any clear and potential conflicts of interests relating to publication of this article.

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