Page 37 of 43
Development of keloid cicatrixes of a postoperative wound in 4 patients occurred among other complications from a front abdominal wall to us. Development of a keloid is connected with infection of an operational wound, and also an injury of fabrics during intervention (N. F. Boyarchuk, A.S. Mulyarchuk, 1965; R. I. Kravchenko, 1968; Ya. A. Raushenbakh, 1969).
The following supervision can be an example.
Sick M., 31 years, came to clinic 12/03 1969 with complaints to existence of a tumor in the field of a postoperative hem and
fistulas in the same area. In September, 1968 operation for phlegmonous appendicitis is made. The postoperative wound healed second intention.
In October, 1968 repeated operation in connection with availability of dense, sharply painful infiltrate in the right ileal area, subfebrile temperature is made. Infiltrate is opened and trained. However after operation alloyed fistula and dense sharply painful keloid cicatrix which disturbed the patient when walking was formed. In a month fistula was independently opened in the field of the first postoperative hem. The fistular course was repeatedly sanified, 5 silk ligatures were removed, however fistula did not heal.
Objectively: in the right ileal area of 2 postoperative painful keloid cicatrixes, fistulas of hypodermic cellulose. Fabrics around fistulas moderately infiltrirovana, infiltrate extends to an aponeurosis, the fistular courses are reported among themselves.
14/03 1969 are made excision of a keloid hem together with fistulas. At audit it is established that the fistular course is reported with the purulent cavity located under an aponeurosis.
Macroscopically: a keloid cicatrix 9 cm long, a dense consistence, places with a hilly surface (fig. 19). Recovery.
At survey in 22 months of pain in the field of a postoperative hem and signs of a keloid were absent.
In this supervision an excessive injury of fabrics at the time of performance of appendectomy which took place with considerable technical difficulties and repeated operations on an occasion nagnoivshegosya infiltrate and alloyed fistulas finally led to development of a keloid hem.
Establishing a certain connection of development of a keloid of a postoperative hem with traumatizing fabrics and infection of a wound, we could not deny roles of a certain individual readiness of an organism of the patient for hyperplastic reactions. It is established at careful poll and survey of the patient when keloid cicatrixes are found in other body parts subject to an injury earlier. It does not exclude careful attitude to fabrics in the course of operation that is the prevention of a number of local complications including developments of keloid cicatrixes.
Sometimes keloid cicatrixes turn out so painful that even the friction of linen causes unpleasant feelings in the patient. Patients are forced to carry the bandages covering a painful hem.
Treatment of keloids by conservative methods reasonablly at prescription of hems of 9 — 12 months. Satisfactory results are received after use of corticosteroids and AKTG (R. I. Kravchenko, 1968; Ya. A. Raushenbakh, 1969). A number of authors recommend to apply to surgical intervention ionization by iodide potassium, massage, radiation by a mercury-quartz lamp, a paraffinotherapy, at treatment of fresh keloids — to a lidaz and a ronidaz. Depending on the size of a hem enter 64 — 128 — 192 units of a lidaza and carry out an electrophoresis with ronidazy within 10 — 15 days (R. I. Kravchenko, 1968).
Fig. 19. Keloid cicatrix. Macrodrug.
Treatment has to be long as after its termination the noticeable growth of a keloid is quite often observed. Are sometimes forced to resort to operational excision of an operational hem. At development of a keloid cicatrix we excised it only at simultaneous emergence of pain in it.
Emergence of pain in a hem after appendectomy can be connected with development of neurinoma (A. D. Mishchuk, 1968; P. N. Danilyuk, 1971) or growing of nerve fibrils. Neurinoma can develop on large nervous trunks and on small branches, including their skin terminations. They are single, is more rare — multiple, are sometimes combined with radicular tumors. Neurinoma slowly grow. Complaints of patients to paresthesias, hyperesthesias, neuralgic pain on the nerve course, are less often observed paresis and an atrophy of muscles in the separate sites innervated by nerves in which the tumor (I. Ya. Razdolsky, is found 1960; E. A. Dikstein, 1970). Superficially located larger neurinoma can be visible under skin. At palpation they represent the dense, spindle-shaped tumor located on the course of a nervous trunk. With a pressure upon it often there are paresthesias. The tumor is mobile, is easily displaced together with a nerve in the lateral directions, but not displaced in longitudinal. At reduction of nearby muscles the neurinoma remains motionless.
Their conservative treatment is ineffective, and gives only a temporary relief (I. Ya. Razdolsky, 1961). Neurinoma are removed in the surgical way. Operation consists in enucleating of a tumor of a nervous trunk, whenever possible without damage of nerve fibrils.
We operated 3 patients with neurinoma of a postoperative hem. The immediate and long-term results of operation good.
Developing of pains in a hem after appendectomy is possible also in connection with a prelum of nervous trunks cicatricial fabric. The following supervision can be an example.
The patient To., 37 years, came to surgical department of 20/XII 1972 g with complaints to the constant thermalgia in the field of a postoperative hem giving to the right lumbar area, a stomach bottom, the right inguinal area and a hip. In March, 1970 it is operated concerning an acute appendicitis. A month later the constant thermalgia in the right ileal area appeared. It was treated conservatively in a neurology unit (UVCh on a boundary sympathetic trunk of lumbar department of a backbone on the right, injections of ATP, vitamins of group B). Conservative treatment was unsuccessful, pain in a postoperative hem accrued.
Objectively: in the right ileal area a postoperative hem of a linear form 8 cm long. In its zone painful tumorous formation of an oval form decides on accurate smooth edges and a smooth surface the sizes of 2X1,5 cm.
29/XII 1971 g under an endotracheal anesthesia made excision of a neurinoma of a postoperative hem and granuloma of a stump of a worm-shaped shoot. During operation it is found rubtsovo the changed site of muscular tissue of the right ileal area with the thin branch of a nervous trunk soldered to it.
Histologic research: cicatricial fabric around nerve fibril is poor in cellular elements (fig. 20).
The wound is sewn up tightly, healed first intention. At survey in 4 months does not show any complaints. Pain in the right ileal area disappeared.
In this supervision in rubtsovo the changed site of muscular tissue of the right ileal area the branch of an ilioinguinal nerve was involved in inflammatory process, as caused a constant thermalgia.
Very rare complication from a front abdominal wall is defeat of postoperative hems endometriosis. According to V. P. Baskakov (1966), in domestic literature on it there are no more than 20 messages (Z. V. Galkina and L. X. Kukhterina, 1960; L. S. Ogorodnikova, 1968; I. M. Oganov, 1968; V. P. Baskakov, 1969, etc.).
Endometriosis occurs at 8 — 15% of all menstruating women, it possesses ability to the penetrating growth in surrounding fabrics and to innidiation.
Endometriosis of postoperative hems happens primary (that is it is not combined with endometriosis of other localization) and secondary (developing from earlier existing endometriosis center).
Development it in a postoperative hem after appendectomy results from mechanical entering of pieces of an endometria to regions of an operational wound. It becomes possible if surgical intervention matches the term of periods or occurs soon after it and is connected with entering of menstrual blood from a duglasov of a pocket to regions of an operational wound (V. P. Baskakov, 1969). The union of the abdominal end of a uterine tube with a parietal peritoneum in the field of a wound or a hem can promote hit retrogradno of the thrown menstrual blood on an abdominal wall and adjacent bodies.
Fig. 21. A melanoblastoma of a postoperative hem (on Rode).
Viable elements of an endometria can be brought to regions of an operational wound by the surgeon's hands during audit of bodies of a basin and an abdominal cavity, at contact with menstrual blood in zamatochny space.
Clinically endometriosis is characterized by pain in the field of a postoperative hem which develops the day before, in time or at the end of periods; bloody dark brown allocations from a hem during periods; the increased perspiration of skin. At objective survey in the field of a postoperative hem cystous formations and small knots of various size and a form which are especially well noticeable the day before, in time and in the first days after periods, a xanthopathy in the field of a hem are observed.
Treatment is operational. Operation consists in excision of the centers of endometriosis within not changed fabric together with a hem.
From a front abdominal wall it is necessary to refer developing of malignant tumors to extremely rare complications on site of postoperative hems. Rode (1962) describes supervision of emergence of a melanoblastoma with metastasises and a spontaneous melanuria in the field of a postoperative hem a year later after appendectomy when at the patient during appendectomy the pigmental nevus (fig. 21) was dissect.