Purulent tubo-ovarian formations

Microbial factor: unlike purulent salpingitis, which is usually caused by a specific infection, patients with purulent tubo-ovarian formations have an aggressive associative flora.

There are two main options for the development of purulent tubo-ovarian formations:

1. can be the outcome of acute salpingitis with delayed or inadequate therapy (the third stage of development of the inflammatory process according to the classification of G. Monif (1982) - acute salpingo-oophoritis with occlusion of the fallopian tubes and the development of tubo-ovarian formations);
2. are formed primarily, without going through the obvious clinical stages of acute purulent salpingitis.

A sudden onset of diseases with a pronounced clinical picture, general and local changes characteristic of acute inflammation of the internal genital organs, occurs only in one out of three women who fell ill for the first time. For the first time, 30% of women seek medical help, in whom inflammation of the appendages has already turned into a chronic form.

In the last decade, according to numerous authors, a predominance of erased forms of inflammation with the absence of clinical and laboratory signs typical of acute inflammation has been noted.

Causes of the purulent tubo-ovarian formations

Microbial factor: unlike purulent salpingitis, which is usually caused by a specific infection, patients with purulent tubo-ovarian formations have an aggressive associative flora.

Risk factors

The provoking factors are:

1. VMK.
2. Preceding operations.
3. Spontaneous childbirth.

Pathogenesis

There are two main options for the development of purulent tubo-ovarian formations:

1. can be the outcome of acute salpingitis with delayed or inadequate therapy (the third stage of development of the inflammatory process according to the classification of G. Monif (1982) - acute salpingo-oophoritis with occlusion of the fallopian tubes and the development of tubo-ovarian formations);
2. are formed primarily, without going through the obvious clinical stages of acute purulent salpingitis.

A sudden onset of diseases with a pronounced clinical picture, general and local changes characteristic of acute inflammation of the internal genital organs, occurs only in one out of three women who fell ill for the first time. For the first time, 30% of women seek medical help, in whom inflammation of the appendages has already turned into a chronic form.

In the last decade, according to numerous authors, a predominance of erased forms of inflammation with the absence of clinical and laboratory signs typical of acute inflammation has been noted.

Inflammatory diseases initially proceed as primary chronic and are characterized by a long, recurrent course with extreme ineffectiveness of drug therapy.

Symptoms of the purulent tubo-ovarian formations

The main clinical symptom in this contingent of patients, in addition to pain and fever, is the presence of signs of initially severe purulent endogenous intoxication. Purulent leucorrhoea is characteristic of patients in whom the cause of the formation of abscesses was childbirth, abortion and IUD. They are usually associated not with the emptying of the epididymis, but with the presence of ongoing purulent endometritis.

It should be noted the presence of severe neurotic disorders, while along with the symptoms of excitement (increased irritability) against the background of intoxication, symptoms of CNS depression appear - weakness, fatigue, sleep and appetite disturbances.

It should also be noted that the course of the purulent process against the background of the IUD is particularly severe, and conservative (even intensive) treatment is ineffective. Removing the spiral, including at the earliest stages of the development of purulent inflammation of the uterine appendages, not only did not contribute to the relief of inflammation, but often, on the contrary, aggravated the severity of the disease.

For patients with purulent complications after previous operations, the following clinical symptoms are typical: the presence of transient intestinal paresis, preservation or increase of the main signs of intoxication against the background of intensive therapy, as well as their resumption after a short "light" interval.

For obstetric patients, along with changes in the uterine appendages, there are characteristic signs indicating the presence of purulent endomyometritis, panmetritis or hematomas (infiltrates) in the parametria or posterior cystic tissue. First of all, this is the presence of a large uterus, which obviously does not correspond to the period of normal postpartum involution. Also noteworthy is the absence of a tendency to form the cervix, the purulent or putrefactive nature of lochia.

One of the distinctive features of the clinical course of purulent tubo-ovarian formations is the undulation of the process associated with the treatment, changes in the nature, shape of the microbial pathogen, concomitant flora, immune status and many other factors.

The periods of exacerbation or activation of the process in such patients alternate with periods of remission.

In the stage of remission of the inflammatory process, clinical manifestations are not pronounced, of all the symptoms, only mild or moderate intoxication remains practically.

In the exacerbation stage, the main signs of acute purulent inflammation appear, while new complications often appear.

Most often, an exacerbation is accompanied by acute pelvioperitonitis, characterized by a deterioration in the patient's well-being and general condition, hyperthermia, an increase in intoxication, the appearance of pain in the lower abdomen, weakly positive symptoms of peritoneal irritation and other specific signs of pelvioperitonitis.

Acute pelvioperitonitis in patients with purulent tubo-ovarian formations can at any time lead to further serious complications, such as perforation of the abscess into adjacent organs or bacterial shock.

Spilled purulent peritonitis in such patients develops extremely rarely, since the chronic purulent process, as a rule, is limited to the pelvic cavity due to numerous dense adhesions, peritoneum and ligaments of the small pelvis, omentum and adjacent organs.

With purulent appendages, there are always characteristic changes in the adjacent parts of the intestine (edema and hyperemia of the mucous membrane, punctate hemorrhages, sometimes in combination with erosions), and already in the early stages of the disease, the normal function of various parts of the intestine is disrupted. The nature and depth of intestinal changes (up to narrowing of the lumen) are in direct proportion to the age and severity of the main inflammatory process in the uterine appendages.

Therefore, one of the most important features of the course of acute pelvioperitonitis in the presence of a purulent process in the appendages is the possibility of developing severe complications in the form of perforation of the abscess into the hollow organs with the formation of fistulas. Currently, almost one third of patients with complicated forms of HVRPM have single or multiple perforation of pelvic abscesses. A single perforation of the abscess into the intestine, as a rule, does not lead to the formation of a functioning fistula and is defined at the operation as “purulent-necrotic fibrous destructive changes in the intestinal wall”.

Multiple perforation into the adjacent intestine leads to the formation of genital fistulas. It is important to emphasize that perforation of an abscess into the pelvic organs is observed in patients with a prolonged and recurrent course of a purulent process in the uterine appendages. According to our observations, fistulas are most often formed in various parts of the colon, more often in the upper ampullar region or rectosigmoidal angle, less often in the cecum and sigmoid colon. The intimate adherence of these parts of the intestine directly to the capsule of the tubo-ovarian abscess and the absence of a layer of fiber between them lead to more rapid destruction of the intestinal wall and the formation of fistulas.

Adnexa-vesicular fistulas are much less common, since the peritoneum of the vesicouterine fold and pre-vesicular tissue melt much more slowly. Such fistulas are more often diagnosed at the stage of their formation (the so-called threat of perforation into the bladder).

Adnexa-vaginal fistulas in all patients arise only as a result of instrumental manipulations carried out to treat HVPM (multiple punctures of pelvic abscesses, colpotomies).

Pryatkovo-abdominal fistulas, as a rule, form in patients with pelvic abscesses in the presence of a scar on the anterior abdominal wall (as a result of a previous non-radical surgery in patients with HVMR or the development of purulent complications of other operations).

Breakthrough of the abscess into the hollow organ is preceded by the so-called state of "pre-perforation". It is characterized by the appearance of the following clinical manifestations:

• deterioration of the general condition against the background of remission of the existing purulent inflammatory process;
• temperature rise to 38-39 ° С;
• the appearance of chills;
• the appearance of pains in the lower abdomen of a "pulsating", "jerking" character, the intensity of which increases significantly over time, and they pass from pulsating to permanent;
• the appearance of tenesmus, loose stools (the threat of perforation in the distal intestine, less often in the small intestine adjacent to the abscess);
• the appearance of frequent urination, microhematuria or pyuria (threat of perforation into the bladder);
• the appearance of infiltration and pain in the area of the postoperative suture.

With the threat of perforation at any localization of the abscess, laboratory tests reflect the intensification of infection and a sharp exacerbation of the inflammatory process, with perforation - chronic purulent intoxication.

The presence of parametritis in patients with purulent tubo-ovarian formations may be indicated by the following clinical signs:

• pain during urination, pyuria (anterior parametritis);
• constipation, difficulty in defecation (posterior parametritis);
• impaired renal function - the appearance of urinary syndrome, edema, decreased urine output (lateral parametritis);
• the appearance of infiltration and hyperemia of the skin over the pupar ligament (anterior parametritis);
• periphlebitis of the external iliac vein, manifested by edema and cyanosis of the skin of the thigh, bursting pain in the leg (upper lateral parametritis);
• paranephritis, clinically in the early stages characterized by the phenomena of psoitis - the forced position of the patient with the adducted leg (upper lateral parametritis);
• phlegmon of perinephric tissue - high hyperthermia, chills, severe intoxication, the appearance of swelling in the kidney area, smoothing of the contours of the waist (upper lateral parametritis).

The appearance of pain in the mesogastric parts of the abdominal cavity, accompanied by the phenomena of transient intestinal paresis or partial intestinal obstruction (nausea, vomiting, stool retention), may indirectly indicate the presence of interintestinal abscesses.

The appearance on the side of the lesion of chest pain, pain in the costal arch and neck in the place of the phrenic nerve projection may serve as indirect evidence of the formation of a subphrenic abscess.

Peripheral blood indices reflect the stage of the inflammatory process and the depth of intoxication. So, if at the stage of acute inflammation, the characteristic changes are leukocytosis (mainly due to stab and young forms of neutrophils), an increase in ESR and the presence of a sharply positive C-reactive protein, then in remission of the inflammatory process, attention is drawn primarily to a decrease in the number of erythrocytes and hemoglobin, lymphopenia with normal parameters of the neutrophilic formula and increased ESR.

Clinical features of purulent appendages at different age periods

• In adolescents:

It is believed that tubo-ovarian abscesses develop as a complication of purulent salpingitis in sexually active adolescents. Pain syndrome is not always expressed, palpation and laboratory data are scarce (there is no leukocytosis). An elevated ESR and echoscopic data can help with the diagnosis. In adolescent patients with formed tubo-ovarian abscesses, signs of acute inflammation are less common than in the absence of inflammatory formations of the uterine appendages (purulent salpingitis). The disease often takes an atypical course, which leads to the development of severe complications.

• During pregnancy:

N.Sukcharoen et al. (1992) report a case of a right-sided purulent tubo-ovarian mass of large sizes during a pregnancy of 40 weeks in a woman who had previously used an IUD for 2 years. Microbiological examination revealed actinomycosis.

P. Laohaburanakit and P. Trevijitsilp (1999) described a case of peritonitis due to rupture of a tubo-ovarian abscess at a 32-week pregnancy. Extirpation of the uterus with appendages was performed. The newborn and mother had no postoperative complications.

• Postmenopausal:

GHLipscomb and FWLing (1992) described 20 cases of tubo-ovarian abscesses in postmenopausal women. 45% of patients had previous intrauterine interventions, 40% of patients had a combination of malignant and purulent processes. In 60% of patients, abscesses were unilateral, in 55% there was a pronounced adhesive process. Every third patient (35%) had an abscess rupture. Based on observations, the authors concluded that the diagnosis of tubo-ovarian abscesses in postmenopausal women requires a great deal of clinical experience, since even the rupture of an abscess and the development of peritonitis are not accompanied by typical clinical signs, and only a study of the number of leukocytes in dynamics makes it possible to make a diagnosis. In addition, clinical thinking is traditionally not aimed at identifying purulent diseases in postmenopausal patients, since they are considered their prerogative of the reproductive period.

The prolonged course of the purulent process is always accompanied by a dysfunction of almost all organs, i.e. Multiple organ failure. This primarily concerns the parenchymal organs.

Most often, the protein-forming function of the liver suffers. With the prolonged existence of purulent tubo-ovarian formations, severe dysproteinemia develops with a deficiency of albumin, an increase in the globulin fraction of the protein, an increase in the amount of haptoglobin (a protein that is a product of depolymerization of the basic substance of connective tissue) and a sharp decrease in the albumin / globulin ratio (the figures were 0.8 before surgery, 0, 72 after surgery and 0.87 at discharge with a rate of at least 1.6).

The prolonged course of the purulent process significantly affects the function of the kidneys and urinary system. The main factors causing impaired renal function are impaired passage of urine when the lower third of the ureter is involved in the inflammatory process, intoxication of the body with products of purulent tissue decay, and massive antibioscopy therapy to stop the inflammatory process without taking into account the nephrotoxic effect of drugs. The structure of the ureters of inflammatory genesis, according to research (1992), occurs in 34% of patients with complicated forms of purulent inflammatory diseases of the internal genitals.

To assess the initial impairment of renal function, we consider it appropriate to apply such a concept as "isolated urinary syndrome" or "urinary syndrome". This term is widely used by therapists, denoting the initial manifestations of renal pathology. Isolated urinary syndrome, according to some doctors, is manifested most often by proteinuria, sometimes in combination with microhematuria, cylindruria or leukocyturia, and may be "... The debut of severe kidney damage with subsequent addition of arterial hypertension and renal failure." However, as a rule, this kind of kidney damage proceeds favorably, without a tendency to rapid progression, and when the underlying disease is eliminated, they completely disappear. At the same time, even renal amyloidosis, which developed during a septic infection, can manifest itself for a long time only as a urinary syndrome, and it almost always proceeds without an increase in blood pressure. The latter circumstance is explained by the action of such hypotensive factors as infection, intoxication and fever.

Urinary syndrome in patients with purulent inflammatory diseases of the uterine appendages is expressed in proteinuria up to 1% (1 g / l), leukocyturia - over 20 in the field of view, erythrocyturia (more than 5 erythrocytes in the field of view) and cylindruria (1-2 granular and hyaline cylinders in sight). The frequency of urinary syndrome in women with purulent lesions of the uterine appendages fluctuates, according to our data, at present from 55.4 to 64%. To this it should be added that a more detailed study of kidney function (ultrasound of the kidneys, Zimnitsky's, Robert-Tareev's tests, radioisotope renography) allows us to reveal its initial and latent forms. We revealed a violation of the functional ability of the kidneys in 77.6% of patients with complicated forms of purulent inflammation.

Based on the foregoing, it can be concluded that purulent diseases of the uterine appendages are a polyetiologic disease that causes severe disorders of the homeostasis system and parenchymal organs.

[1], [2]

Diagnostics of the purulent tubo-ovarian formations

In patients with formed encapsulated abscesses of the uterine appendages, during vaginal examination, special attention should be paid to such symptoms of the disease as the contours of the inflammatory formation, its consistency, mobility, pain and location in the pelvic cavity. Purulent formation of appendages in an acute inflammatory process during vaginal examination is characterized by fuzzy contours, uneven consistency, complete immobility and severe soreness. Moreover, it is always in a single conglomerate with the uterus, which is determined and palpated with great difficulty. The sizes of the purulent formations of the appendages are very variable, but in the acute stage of inflammation they are always somewhat larger than the true ones.

In the stage of remission, the conglomerate has more distinct outlines, although uneven consistency and its complete immobility remain.

With the concomitant parametritis in patients, infiltrates of different consistency are determined depending on the stage of the process - from woody density in the stage of infiltration to uneven with areas of softening during suppuration; infiltrates can be of different sizes (in severe cases, they not only reach the lateral walls of the small pelvis, sacrum and womb, but also spread to the anterior abdominal wall and perirenal tissue).

The defeat of the parametrium, primarily of its posterior parts, is especially well detected during rectovaginal examination, while the degree of involvement of the rectum in the process is indirectly assessed (the mucous membrane is mobile, limitedly mobile, motionless).

The main additional diagnostic method is echography. Currently, abscesses are identified echographically earlier than clinically. For patients with purulent tubo-ovarian formations, the following echographic signs are characteristic:

1. Concomitant endomyometritis, manifested by the presence of multiple heterogeneous echo-positive structures in the uterine cavity, the presence of echo-positive structures more than 0.5 cm thick on the walls of the uterine cavity, diffuse changes in the structure of the myometrium in the form of multiple inclusions of reduced echogenicity with indistinct contours (which reflects the presence of purulent endomyometritis with areas of microabsorption)... If endomyometritis has developed as a result of wearing an IUD, a contraceptive is clearly defined in the uterine cavity.
2. In the cavity of the small pelvis, a pronounced adhesive process is determined. In all cases, pathological appendages are fixed to the rib and posterior wall of the uterus. In 77.4% of patients, a single conglomerate without clear contours is determined in the pelvic cavity, consisting of the uterus, pathological formation (formations), intestinal loops and omentum welded to them.
3. The form of inflammatory formations with a complicated course is often incorrect, although it approaches the ovoid one.
4. The dimensions of the formations vary from 5 to 18 cm, the area, respectively, from 20 to 270 cm ².
5. The internal structure of purulent inflammatory formations is characterized by polymorphism - it is heterogeneous and is represented by a medium-dispersed echo-positive suspension against the background of an increased level of sound conductivity. In no case did we succeed in echoscopically clearly distinguishing between the fallopian tube and the ovary in the structure of tubo-ovarian formation, only in 3 patients (8.1%) fragments of tissue resembling ovarian tissue were determined.
6. The contours of the GVZPM can be represented by the following options:
   • echo-positive thick (up to 1 cm) capsule with clear contours;
   • echo-positive capsule with areas of uneven thickness;
   • echo-positive capsule with areas of sharp thinning;
   • education without clear contours (the capsule cannot be clearly traced throughout the entire length).
7. The study of the blood supply of purulent tubo-ovarian formations revealed the absence of a vascular network within the formation. The indicators of blood flow in the ovarian artery had the following numerical values of vascular resistance: C / D - 5.9 +/- 0.7 and IR - 0.79 +/- 0.08. Moreover, there were no significant differences in these indicators in the groups of patients with tubo-ovarian formations with and without abscess perforation into adjacent organs.

The method of additional contrasting of the rectum greatly facilitates the task of diagnosing pelvic abscesses and lesions of the distal intestines. Additional contrasting of the rectum during ultrasound examination is carried out using a thin-walled balloon (condom) attached to a polyethylene rectal probe. Immediately before the examination, the probe is inserted into the rectum and advanced under ultrasound control to the "zone of interest" - most often the upper ampullar rectum or rectosigmoidal section. Then, using a syringe, the balloon is filled with liquid (350-400 ml). The appearance (along with the bladder) of the second acoustic window (contrasting rectum) allows one to more clearly orientate in the altered anatomical relationships and determine the position of the pelvic abscess wall and distal intestine.

The diagnostic capabilities of computed tomography in patients with purulent diseases of the genitals are the highest among all non-invasive research methods, the information content of the CT method in the diagnosis of abscesses of the uterine appendages is close to 100%. However, due to the low availability and high cost, the study is indicated for a limited number of the most severe patients - after previous operations or palliative interventions, as well as in the presence of clinical signs of preperforation or perforation.

On a tomogram, tubo-ovarian formations are defined as one- or two-sided volumetric pathological structures, the shape of which approaches oval or round. Formations adjoin the uterus and displace it, have fuzzy contours, heterogeneous structure and density (from 16 to 40 Hounsfield units). They contain cavities with reduced density, visually and according to densitometric analysis corresponding to purulent contents. In our studies, 16.7% of patients had gas bubbles in the structure of the formation. The number of purulent cavities varied from 1 to 5; in some cases, the cavities were of a communicating nature. The thickness of the capsule varied from sharply thickened (up to 1 cm) to thinned. In 92.7% of patients, perifocal inflammation was observed - infiltration of cellulose (cellulitis) and involvement of adjacent organs in the process. In a quarter (24.4%) of patients, a small amount of fluid was detected in the utero-rectal space. Lymph node enlargement, well detected by CT, was found in almost half of the patients (41.5%).

In contrast to acute purulent salpingitis with purulent tubo-ovarian formations, invasive diagnostic methods do not provide sufficient information and have a number of contraindications. A single puncture followed by colpotomy and aspiration-lavage drainage is indicated only in the complex of preoperative preparation to clarify the nature of the exudate, reduce intoxication and prevent the formation of purulent genital fistulas.

The same applies to laparoscopy, which in some cases has contraindications and has a low diagnostic value due to a pronounced adhesions-infiltrative process.

Difficulties caused by the involvement of various pelvic organs in inflammatory diseases of the uterine appendages, or complications associated with the production of the laparoscopy itself in these patients, force gynecologists in some cases to switch to urgent laparotomy, which, of course, limits the use of laparoscopy. So, A.A. Yovseev et al. (1998) cite the following data: in 7 out of 18 patients (38.9%), laparoscopy "switched" to laparotomy due to the severity of the adhesive process and the inability to examine the pelvic organs.

Differential diagnosis

With right-sided localization of purulent tubo-ovarian formation, it is necessary to carry out differential diagnosis with appendicular infiltrate. So, according to research, an appendicular abscess was found in 15% of patients operated on for gynecological diseases. Careful collection of anamnesis allows one to suspect the possibility of a surgical disease before surgery, however, even with celiac disease in advanced cases, it is difficult to find out the root cause (right-sided tubo-ovarian mass with secondary appendicitis or vice versa). Tactically, this is not of fundamental importance, since an adequate volume of surgery in both cases is appendectomy and the corresponding gynecological volume of surgical intervention followed by drainage of the abdominal cavity.

With a predominantly left-sided localization of the process, the possibility of diverticulitis should be borne in mind. Inflammation of Meckel's diverticulum is a rare disease in young women that is hardly recognized until it is complicated by perforation or fistula formation. Due to the proximity of the left ovary to the sigmoid colon, perforation of the diverticulum into the ovary is possible with the formation of a tubo-ovarian abscess, which is difficult to distinguish from the "usual" one. The presence of a symptom of "irritable" colon and diverticulosis may help in the diagnosis.

When making a differential diagnosis, it is necessary to always keep in mind the primary carcinoma of the tube, especially in the presence of genital tuberculosis.

The involvement of the intestine in the inflammatory process is often accompanied by the formation of adhesions and inflammatory strictures with partial or (less often) complete intestinal obstruction, while tubo-ovarian abscesses are difficult to distinguish from ovarian cancer or endometriosis.

[3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13]

Treatment of the purulent tubo-ovarian formations

Treatment of patients with complicated forms of purulent diseases also consists of three main components, however, in the presence of an enclosed purulent formation of the uterine appendages, the basic component that determines the outcome of the disease is surgical treatment.

In most cases, antibiotic therapy is not indicated for patients with complicated forms (chronic purulent-productive process). An exception to this rule is the presence in patients of obvious clinical and laboratory signs of intensification of infection, including the presence of clinical, laboratory and instrumental symptoms of pre-perforation of abscesses or generalization of infection.

In these cases, antibiotic therapy is prescribed immediately, continues intraoperatively (prevention of bacterial shock and postoperative complications) and in the postoperative period.

The following drugs are used:

• combinations of beta-lactam antibiotics with beta-lactamase inhibitors - ticarcillin / clavulonic acid (tymentin) in a single dose of 3.1 g, a daily dose of 12.4 g and a course dose of 62 g;
• combinations of lincosamines and aminoglycosides, for example lincomycin + gentamycin (netromycin) or clindamycin + gentamicin (netromycin) (lincomycin in a single dose of 0.6 g, daily dose of 2.4 g, course dose of 12 g, clindamycin in a single dose of 0.15 g, a daily dose of 0.6 g, a course dose of 3 g, gentamicin in a single dose of 0.08 g, a daily dose of 0.24 g, a course dose of 1.2 g), netromycin in a daily dose of 0.3-0.4 g i.v. V; the combination of lincosamines and netromycin is more effective, has fewer side effects and is well tolerated by patients;
• III generation cephalosporins or their combinations with nitro-imidazoles, for example, cefotaxime (claforan) + metronidazole or ceftazidime (fortum) + metronidazole (cefotaxime in a single dose of 1 g, a daily dose of 3 g, a course dose of 15 g, ceftazidime in a single dose of 1 g, a daily dose of 3 g, a course dose of 15 g, metronidazole (metrogil) in a single dose of 0.5 g, a daily dose of 1.5 g, a course dose of 4.5 g);
• monotherapy with meropenems, for example, meronem in a single dose of 1 g, a daily dose of 3 g, a course dose of 15 g.

It should be remembered that lincosamines (bacteriostatics) and zminoglycosides (create a competitive block with muscle relaxants) cannot be administered intraoperatively.

Detoxification therapy with infusion media is of paramount importance in carrying out preoperative preparation.

1. In case of severe intoxication, transfusion therapy should be carried out for 7-10 days (the first three days every day, and then every other day) in a volume of 1500-2000 ml per day. With an average degree of intoxication, the volume of daily transfusions is halved (up to 500-1000 ml per day).

Infusion therapy should include:

• crystalloids - 5 and 10% solutions of glucose and substitutes, contributing to the restoration of energy resources, as well as correctors of electrolyte metabolism - isotonic sodium chloride solution, Ringer-Locke solution, lactasol, ionosteril;
• plasma-replacing colloids - rheopolyglucin, hemodez, gelatinol. As part of infusion therapy, it is recommended to use leaded 6% starch solution HAES-STERIL - 6 in a volume of 500 ml / every other day;
• protein preparations - fresh frozen plasma; 5, 10 and 20% albumin solutions.

2. An improvement in the rheological properties of blood is facilitated by the use of antiaggregants (trental, courantil). The latter are added, respectively, at 10 or 4 ml IV in infusion media.
3. The appointment of antihistamines in combination with sedatives has been substantiated.
4. It is advisable to use immunomodulators: thymalin or T-activin, 10 mg daily for 10 days (for a course of 100 mg).
5. According to appropriate indications, cardiac, hepatotropic agents are prescribed, as well as drugs that improve the function of the brain (cardiac glycosides in an individual dose, Essentiale 5-10 ml IV and Nootropil 5-10 ml IV).

The effect of detoxification and preparation of patients for surgery is significantly increased with the evacuation of purulent exudate. Drainage should be considered only as an element of a comprehensive preoperative preparation, allowing the operation to be performed in conditions of remission of the inflammatory process. Indications for draining palliative operations (puncture or colpotomy) in patients with complicated forms of purulent inflammation are the threat of abscess perforation into the abdominal cavity or hollow organ, severe intoxication and the presence of acute pelvioperitonitis, against which surgical treatment is least favorable.

It is advisable to perform colpotomy only in cases where subsequent aspiration-lavage drainage is expected.

The duration of preoperative preparation should be purely individual. The stage of remission of the purulent process is considered optimal for the operation. In the presence of abscess formation in the small pelvis, intensive conservative treatment should last no more than 10 days, and if the clinic of the threat of perforation develops, no more than 12-24 hours, if palliative intervention cannot be performed to eliminate the threat of perforation.

In case of emergency indications for surgery, preoperative preparation is carried out within 1.5-2 hours. It includes catheterization of the subclavian vein and transfusion therapy under the control of CVP in a volume of at least 3,200 ml of colloids, proteins and crystalloids in a 1: 1: 1 ratio.

Indications for emergency intervention are:

• perforation of an abscess into the abdominal cavity with the development of diffuse purulent peritonitis (photo 3 on color incl.);
• perforation of an abscess into the bladder or its threat;
• septic shock.

In all other cases, a planned operation is performed after the appropriate preoperative preparation in full. Laparotomy is shown. The optimal method of anesthesia that provides complete analgesia with reliable neurovegetative protection, as well as sufficient relaxation, is combined anesthesia - a combination of intubation anesthesia with prolonged epidural anesthesia.

The volume of surgical intervention depends on the characteristics of the initiation of the purulent process (an unfavorable factor is the development of inflammation against the background of the IUD, after abortion and childbirth due to purulent endomyometritis or panmetritis that persists even against the background of intensive preoperative treatment), its severity (adverse factors are the presence of bilateral purulent tubo-ovarian abscesses, and also complications in the form of a pronounced extensive purulent-destructive process in the small pelvis with multiple abscesses and infiltrates of pelvic and parametric tissue, fistulas, extragenital purulent foci) and the age of patients.

In the absence of aggravating factors, organ-saving operations are performed.

If it is impossible to preserve the menstrual and reproductive functions, it is necessary to "fight" for the preservation of the patient's hormonal function - the extirpation of the uterus should be carried out, leaving, if possible, at least a part of the unchanged ovary.

Technical features of performing operations in the conditions of a coniferous-infiltrative process.

1. The method of choosing the incision of the abdominal wall is the lower-median laparotomy, as it provides not only adequate access for revision and surgical intervention, but also the possibility (for example, if it is necessary to empty interintestinal and subphrenic abscesses, intubation of the small intestine, identify surgical pathology) to continue the incision freely.
2. The first and mandatory stage of any operation for inflammatory formations of the uterine appendages is the restoration of normal anatomical relationships between the abdominal and pelvic organs. It is advisable to start the separation of adhesions with the complete release of the free edge of the greater omentum, which is almost always affected by the inflammatory process. To do this, it is necessary first with sawing movements with the hand and then, using a sharp path, under the control of vision, to separate the omentum from the parietal and visceral peritoneum, and then from the affected appendages. The separated omentum is often infiltrated to a greater or lesser extent; therefore, its resection within healthy tissues should be considered justified. In the presence of purulent-infiltrative omentitis with abscess formation, resection of the omentum within the "healthy" tissue is mandatory. Attention should be paid to the need for careful hemostasis during omentum resection. It is advisable to ligate the stumps with their preliminary suturing, since when the edema is eliminated, the threads may slip or weaken, which will lead to a severe postoperative complication in the form of intra-abdominal bleeding.
3. The next step is the release of inflammatory formations from the loops of the large and small intestine welded to them. We want to draw special attention of gynecological surgeons to the need to separate any adhesions only in an acute way. The use of gauze tampons and tupffers in such cases to release adhesions from adhesions is the main cause of trauma to the intestinal wall: its deserosis, and sometimes opening the lumen. The use of thin, long dissecting scissors avoids trauma to the intestines in these patients. It must be emphasized that one cannot be limited only to the separation of the intestinal loops from the inflammatory formation. To make sure that there are no large and small interloop intestinal abscesses, it is necessary to revise the entire small intestine. During the operation, a revision of the appendix is required.
4. Isolation of purulent formation of the uterine appendages from adhesions should begin, if possible, from the posterior wall of the uterus. It should be remembered that in most cases, purulent formations of the uterine appendages are "wrapped" in the posterior leaf of the wide uterine ligament, thus separating from the rest of the small pelvis and abdominal cavity. Such delimitation occurs on the right side counterclockwise, and on the left - clockwise. As a result, the inflammatory formation is pseudo-intraligamentary. In this regard, the allocation of purulent inflammatory formations should begin from the posterior surface of the uterus, as if spinning the formation in a blunt way in the opposite direction. Inflammatory formation of the right appendages should be separated clockwise (from right to left), and left - counterclockwise (from left to right).
5. The next stage of the operation is to determine the topography of the ureters. When performing extirpation of the uterus in conditions of altered anatomical relationships (endometriosis, tubo-ovarian formations, atypical fibroids), the ureters are injured in 1.5% of cases (from parietal injury to complete transection or ligation). The left ureter is more often injured, the ratio between unilateral and bilateral injuries is 1: 6. Intraoperatively, no more than one third of all injuries are recognized.

Ureteral-genital fistulas always have a traumatic origin, i.e. In all cases, we can talk about a violation of the operation technique, as the only reason for this pathology.

As you know, the abdominal ureters are located retroperitoneally.

The ureters cross the common iliac vessels near their ramifications, then travel posteriorly and sideways along the pelvic wall down to the bladder. Here, the ureters are located at the base of the wide ligaments of the uterus behind the ovaries and tubes, then they pass under the vessels of the uterus and are 1.5-2 cm away from the cervix.Then they go parallel to the uterine artery, cross it and go anteriorly and upward, and at the intersection with the vessels and before entering the bladder, the ureters are only 0.8-2.5 cm away from the neck. Further, the ureters are adjacent to the anterior wall of the vagina for a short distance, then they penetrate into the bladder in an oblique direction and open at the corners of the Lietot triangle. Naturally, in conditions of a purulent-infiltrative process, the risk of injury or ligation of the ureter increases many times.

The danger of injury to the ureter is represented by the following manipulations:

• dressing a. Hypogastrica,
• ligation of the funnel-pelvic ligament,
• ligation of uterine vessels,
• manipulations in parametria,
• separation of the walls of the vagina and bladder.

You should never force the implementation of the main stages of the operation without mandatory preliminary revision, and sometimes the release of the ureter on the side of the lesion. In such cases, the operation should begin with dissection of the round uterine ligament on the side of the affected appendages (preferably further from the uterus) and a wide dissection of the parametrium up to the funnel-pelvic ligament. If necessary, the ligament should be crossed and tied. Behind the funnel-pelvic ligament is the ureter, which is determined by palpation or visually. The ureter is gradually separated from the posterior leaflet of the wide uterine ligament towards the bladder. The ureter should be separated only within the palpable inflammatory formation, which completely excludes its trauma during the subsequent separation of the adhesions.

If there is any suspicion of ureteral injury, the operation should not be continued without making sure that the target's ureter is free. To do this, you should inject a solution of methylene blue into a vein. If the ureter is injured, the dye will appear in the wound. The complication is corrected intraoperatively.

• When the ureter is punctured with a needle, the parametrium is drained.
• With a parietal wound, sutures are applied in the transverse direction with a thin catgut, a catheter or stent is inserted into the ureter to drain urine, and the parametrium is drained.
• With short-term ligation or compression with a clamp (up to 10 minutes) after removing the ligature, a catheter or stent is inserted into the ureter to drain urine. The parametrium is drained. With more prolonged compression, the injured area is resected and ureterocystoanastomosis is applied according to the antireflux technique of V.I. Krasnopolsky.
• When the ureter is crossed, the ureterocystoanastomosis is applied using the antireflux technique of V.I. Krasnopolsky.

6. Further, the operation of removing the appendages is performed typically. One of the main ones is the principle of mandatory complete removal of the destruction focus, i.e. The most inflammatory formation. No matter how gentle the operation in these patients, it is always necessary to completely remove all tissues of the inflammatory formation. Preservation of even a small portion of the capsule often leads to severe complications in the postoperative period, recurrence of the inflammatory process, and the formation of complex fistulas. In conditions of purulent inflammation, isolated ligation of the ligaments with a "turnover" and their preliminary stitching with absorbable suture material is advisable.
7. It is better to carry out peritonization with separate catgut or vicryl sutures with full immersion of the ligament stumps.

Extirpation of the uterus in patients with purulent lesions of its appendages is associated with great technical difficulties. They are caused by severe edema and infiltration, or, conversely, severe destructive tissue changes, which leads to an atypical location of vascular bundles, venous plexuses, deformations and displacements of the bladder and ureters.

Features of performing extirpation of the uterus in a purulent-infiltrative process.

1. Separation of adhesions and mobilization of the uterus and appendages are carried out according to the principles described above.
2. It is advisable to perform extirpation of the uterus without preliminary dissection and ligation of the sacro-uterine ligaments and uterine vessels. To do this, after dissection of the round ligaments corresponding to the funnel-pelvic ligament, the own ligament of the ovary and the tube (and, if necessary, two funnel-pelvic ligaments) and the separation and displacement of the bladder along the cervix as close as possible to it, direct long Kocher clamps are applied, the cardinal ligaments, and then suture and ligate the tissue. The manipulation is carried out with strict control of the topography of the bladder. Additional prevention of trauma to the bladder and ureters and provides dissection of the prevesical fascia (usually infiltrated) at the level of the ligated cardinal ligaments and its displacement along with the bladder. The manipulation continues until both or one of the lateral walls of the vagina are exposed, after opening which it is not difficult to cut off and remove the uterus.
3. The question of the advisability of excreting the ureter is controversial.

Discharge of the ureter is considered justified in the clinical situations described below.

• In the presence of severe infiltrative processes in the parametrium with impaired passage of urine and the development of hydronephrosis and hydroureter (according to the data of preoperative examination or intraoperative revision). Early restoration of the passage of urine in the postoperative period serves as the prevention of inflammatory processes in the calyx-pelvis system, and also contributes to a more complete evacuation of toxic products from the patient's body.
• With a high risk of injury to the ureter in cases when the inflammatory infiltrate is "pulled up" and located in the intervention zone (primarily at the level of the intersection with the uterine vessels). When performing radical operations for cancer of the genitals, when there is also an infiltrative process in the parametrium, intraoperative trauma to the ureters reaches 3%. Isolation of the ureter from the infiltrate is advisable to begin after dissection and ligation of the funnel-pelvic ligament almost at the site of its discharge. It is here that it is easiest to find an unchanged part of the ureter, since usually parametric infiltrates that compress the ureter are located in the lower and extremely rarely in its middle third. Further, the ureter should be separated from the posterior leaflet of the wide uterine ligament, after which the boundaries of the infiltrate and the ureter become clearly visible, and the release of the latter is no longer difficult.

4. Sheathing of the vaginal dome is performed with separate or Z-shaped catgut or vicryl sutures with the capture of plica vesicouterina in the anterior sutures, and plica rectouterine and sacro-uterine ligaments in the posterior sutures, if the latter are not completely destroyed. The narrowing of the vaginal tube with tightening sutures should not be allowed, since the open dome of the vagina is an excellent natural collector and evacuator of pathological exudate from the abdominal cavity and parameters in any position of the patient.
5. In conditions of edematous, infiltrated and inflammatory-altered tissues, we do not recommend applying a continuous peritonizing suture. Such a suture often erupts, injures the peritoneum, does not ensure its tight fit and complete isolation of the surgical wound. In this regard, separate sutures should be applied for peritonization, and absorbable ligatures should be used as suture material. Only parametria are peritoneal, the vaginal tube should remain open under any conditions.
6. Particular attention should be paid to suturing the anterior abdominal wall. With purulent diseases, to a greater or lesser extent, the processes of regeneration and healing are always disrupted, therefore there is a danger of partial and sometimes complete divergence of the sutures, and in the subsequent formation of postoperative hernias of the anterior abdominal wall. For reliable prevention of postoperative eventrations in early and postoperative hernias in the late postoperative period, it is advisable to suture the anterior abdominal wall with separate nylon or caproag sutures through all layers in two levels (peritoneum-aponeurosis and subcutaneous tissue-skin). In those cases when it is possible to carry out layer-by-layer suturing, only separate nylon sutures should be applied to the aponeurosis, and separate silk sutures should be applied to the skin.

For the prevention of bacterial toxic shock during the operation, all patients are shown the simultaneous administration of antibiotics acting on the main pathogens.

• Combinations of penicillins with beta-lactamase inhibitors - for example, tymentin, which is a combination of ticarcillin with clavulanic acid at a dose of 3.1 g.

Or

• Generation III cephalosporins - for example, cefotaxime (claforan) at a dose of 2 g or ceftazidime (fortum) in the same amount in combination with metronidazole (metrogil) - 0.5 g.

Or

• Meropenems (meronem) at a dose of 1 g (for generalized infection).

Adequate drainage should ensure complete removal of the pathological substrate from the abdominal cavity. The following methods of introducing drainage tubes are used:

• transvaginal through the open dome of the vagina after extirpation of the uterus (drainage 11 mm in diameter);
• transvaginal by means of posterior colpotomy with preserved uterus (it is advisable to use drains with a diameter of 11 mm).

The optimal discharge mode in the device during abdominal drainage is 30-40 cm aq. Art. The average duration of drainage in patients with peritonitis is 3 days. The criteria for stopping drainage are the improvement of the patient's condition, restoration of intestinal function, relief of the inflammatory process in the abdominal cavity, a tendency towards normalization of clinical blood tests and body temperature. Drainage can be stopped when the wash water is completely clear, light and free of sediment.

Principles of intensive care in the postoperative period.

1. Antibiotic therapy. Since the causative agents of purulent-septic infections are associations of microorganisms with a predominance of colibacillary flora, non-spore-forming anaerobes and gram-positive microbes, antibiotics of choice are broad-spectrum drugs or combinations of drugs that affect the main pathogens. Depending on the severity of the disease, treatment is carried out with average or maximum permissible single and daily doses with strict adherence to the frequency of administration for 5-7 days.

The use of the following antibacterial drugs or their combinations is recommended:

• combinations of beta-lactam antibiotics with beta-lactamase inhibitors - ticarcillin / clavulonic acid (tymentin) in a single dose of 3.1 g, a daily dose of 12.4 g and a course dose of 62 g;
• combinations of lincosamines and aminoglycosides, for example: lincomycin + gentamicin (netromycin) or clindamycin + gentamicin (netromycin);
  • lincomycin in a single dose of 0.6 g, a daily dose of 2.4 g, a course dose of 12 g;
  • chlindamycin in a single dose of 0.15 g, a daily dose of 0.6 g, a course dose of 3 g;
  • gentamicin in a single dose of 0.08 g, a daily dose of 0.24 g, a course dose of 1.2 g;
  • netromycin in a single daily dose of 0.3-0.4 g, a course dose of 1.5-2.0 g intravenously;
  • the combination of antibacterial drugs with netilmicin is highly effective, less toxic and more comfortably tolerated by patients;
• III generation cephalosporins or their combinations with nitroimidazoles, for example:
  • cefotaxime (claforan) + clion (metronidazole) or ceftazidime (fortum) + clion (metronidazole);
  • cefotaxime (claforan) in a single dose of 1 g, a daily dose of 3 g, a course dose of 15 g;
  • ceftazidime (fortum) in a single dose of 1 g, a daily dose of 3 g, a course dose of 15 g;
  • clion (metronidazole) in a single dose of 0.5 g, a daily dose of 1.5 g, a course dose of 4.5 g;
• monotherapy with meropenems, for example:
  • meronem in a single dose of 1 g, a daily dose of 3 g, a course dose of 15 g.

At the end of antibacterial therapy, all patients should be corrected with therapeutic doses of probiotics: lactobacterin or acylact, 10 doses 3 times in combination with growth stimulators of normal intestinal microflora, for example, Khilak forte 40-60 drops 3 times a day and enzymes (festal, mezym forte) 1-2 tablets with each meal.

2. Adequate pain relief. The optimal method is the use of long-term epidural anesthesia. If, for some reason, not related to the presence of contraindications, during the operation, combined anesthesia was not performed, then this method of anesthesia and treatment should be used in the postoperative period.

If there are contraindications to the use of the DEA method, during the first three days, anesthesia should be carried out with narcotic analgesics with their introduction at adequate intervals (4-6-8-12 hours). To potentiate the action and reduce the need for drugs, they should be combined with antihistamines and sedatives.

It is inappropriate to jointly prescribe narcotic and non-narcotic analgesics, since the analgesic effect of drugs against the background of the use of non-steroidal anti-inflammatory drugs is sharply reduced.

3. Infusion therapy. For the correction of multiple organ disorders in the postoperative period, both the quality of the infusion media and the volume of infusions are important.

The introduction of colloids (400-1000 ml / day), protein preparations is shown at the rate of 1-1.5 g of native protein / 1 kg of body weight (in case of a severe course of the process, the dose of protein can be increased to 150-200 g / day); the rest of the volume is replaced by crystalloids.

The amount of injected fluid, provided the renal function is preserved, should be 35-40 ml / kg of body weight per day.

With an increase in body temperature by 1 degree, the amount of liquid injected per day should be increased by 5 ml / kg of body weight. Thus, the total amount of injected fluid per day with normal urination of at least 50 ml / h averages 2.5-3 liters.

In severe forms of complications (peritonitis, sepsis), the amount of injected fluid can be increased to 4-6 liters (hypervolemic mode) with regulation of urination (forced diuresis). In case of septic shock, the amount of injected fluid should not exceed the amount of excreted urine by more than 800-1000 ml.

The nature of infusion media is similar to those used in the preoperative period, with the exception of the predominant use in the group of colloids of ethylated starches, which have normovolemic and anti-shock effects.

As part of infusion therapy, it is recommended to use leaded 6 and 10% starch solution: HAES-CTERIL-6 or HAES-STERIL-10 (plasma-substituting colloid) in a volume of 500 ml / day.

To normalize microcirculation in infusion media, it is advisable to add antiplatelet agents (trental, courantil).

4. Bowel stimulation. Adequate is "soft", physiological stimulation of the intestine due to the use of, first of all, an epidural blockade, in the second - adequate infusion therapy in the amount of normo - or minor hypervolemia, in the third - due to the predominant use of metoclopramide preparations (cerucal, raglan), which have a regulatory effect on the motility of the gastrointestinal tract.

Correction of hypokalemia also plays an important role in the treatment of intestinal paresis. It is necessary to inject potassium preparations under the control of its content in the blood serum slowly, in a diluted form, preferably in a separate vein. On average, 6-8 g of potassium are injected per day, taking into account its content in other solutions (fresh frozen plasma, hemodez, etc.).

5. Protease inhibitors. It is advisable to use 100,000 U of gordox, 75,000 U of trasilol or 30,000 U of contrikal, which improves the proteolytic activity of the blood and potentiates the effect of antibiotics.
6. Heparin therapy. In all patients, in the absence of contraindications, heparin should be used in an average daily dose of 10 thousand units. (2.5 thousand units under the skin of the abdomen in the umbilical region) with a gradual decrease in the dose and withdrawal of the drug with an improvement in the condition and indicators of the coagulogram.
7. Treatment with glucocorticoids is a controversial issue. It is known that prednisolone and its analogs have a number of positive properties:
   • suppress the excessive formation of immunocomplexes with endotoxin;
   • have a detoxifying effect on endotoxin;
   • exhibit an antihistamine effect;
   • stabilize cell membranes;
   • have a positive myocardial effect;
   • reduce the severity of the syndrome of disseminated intravascular coagulation.

In addition, prednisolone has a non-pyrogenic effect and, less than other steroid hormones, inhibits the functional activity of neutrophils. Clinical experience shows that the appointment of prednisolone in a daily dose of 60-90 mg with a gradual decrease and discontinuation of the drug after 5-7 days significantly improves the course of the postoperative period.

8. ... The use of non-steroidal anti-inflammatory drugs with anti-inflammatory, analgesic and antiaggregatory effects is pathogenetically substantiated. The drugs are prescribed after the abolition of antibiotics and heparin. It is recommended to use diclofenac (voltaren), 3 ml / m daily or every other day (for a course of 5 injections).

At the same time, it is advisable to prescribe drugs that accelerate reparative processes: Actovegin 5-10 ml IV or Solcoseryl 4-6 ml IV drip, then 4 ml IM daily.

9. Therapy of organ disorders with hepatotropic (essential, antispasmodics) and cardiological agents is carried out according to indications.

Prevention

As already mentioned, the overwhelming majority of complicated forms of purulent diseases of the internal genital organs arise against the background of wearing an IUD, therefore, we consider the work in this direction as the main reserve for reducing the incidence, and in particular:

• expanding the use of hormonal and barrier contraception methods;
• a reasonable assessment of the risk of using IUD;
• limiting the use of IUDs in young and nulliparous women;
• limiting the use of the IUD after childbirth and abortion;
• refusal to use IUD for chronic inflammatory diseases of the genitals, STIs;
• compliance with the terms of wearing the IUD;
• extraction of the IUD without scraping the uterine cavity;
• with the development of the inflammatory process, removal of the IUD against the background of antibacterial therapy without scraping the uterine cavity (in the hospital).