St. Petersburg Medical Academy of Postgraduate Education

Historical information

Early reports of PDA speak of it only as a pathological finding. PDA found during autopsies were described at one time by Thylesius (1670), Grossius (1696), Weit (1797), Gruveillier (1832).

In 1845, Barlax first described the clinical picture of PDA in a woman. She complained of pain in her side that came on suddenly. During the examination, tympanitis and amphoric breathing with a metallic tint were found at the angle of the left shoulder blade; a splashing noise was also heard there, indicating the accumulation of fluid, which was a zone of dullness below the area of ​​tympanitis. Analysis of these data allowed the author to make an accurate diagnosis of PDA intravitally for the first time.

The section confirmed the presence of the source of the abscess - two perforated stomach ulcers.

Subsequently, a number of works appeared on PDA, in which diagnostic issues occupied a prominent place for the first time.

Leyden (1870) and Senator (1884) described clear signs of PDA. Jaffe (1881) proposed the term “subdiaphragmatic abscess”. Gerlach (1891) established the anatomical boundaries of the abscess. Novack (1891) described its pathological picture. Schehrlen (1889) was the first to propose surgical treatment of PDA.

During the same period, domestic works on this topic appeared (E. Moritz, 1882; S.A. Trivus, 1893; V.P. Obraztsov, 1888; L.P. Bogolepov, 1890). In 1895, A.A. Gromov proposed transpleural access to the PDA, and N.V. Pariysky performed an extrapleural opening of the abscess.

By the end of the 19th century, there are works that discuss the use of X-rays for diagnosing PDA. For this purpose, they were first used by Beclere in 1899, and in Russia by Ya.M. Rosenblat in 1908.

Subsequently, a number of important theoretical topographic-anatomical works were published that substantiated surgical measures for the treatment of PDA (V.N. Novikov, 1909; A.Yu. Sozon-Yaroshevich, 1919; A.V. Melnikov, 1920).

In the 50-60s, interest in this problem increased significantly in the USSR. In 1958, the issue of PDA was included in the program of the All-Russian Congress of Surgeons.

With the development of antibiotic therapy, not only surgical, but also conservative and complex treatment of PDA began to be developed. It was at this time that the principles of complex treatment of PDA were developed, which have not changed to this day (but have only been supplemented and adjusted). 2 monographs on this problem were published (Apovat B.L. and Zhielina M.M. “Subdiaphragmatic abscess”, M., 1956 and Belogorodsky V.M. “Subphrenic abscess”, L., “Medicine”, 1964) .

In the period 70-90 in the USSR and Russia, interest in this problem remained stable. In many articles of these years, the emphasis is not on the treatment of PDA, but on their diagnosis using modern methods (echography, CT). These methods have greatly facilitated the diagnosis of PDA, even small and deeply located ones. At the same time, many issues of prevention and the earliest possible detection (and, consequently, treatment) of PDA remain unresolved.

For many years, the frequency of PDA was relatively small - 0.01% (Belogorodsky V.M., 1964). However, in recent years, with the deterioration of social and hygienic conditions in Russia, with a decrease in living standards, and a worsening crime situation, an increase in the incidence of PDA (abdominal injuries, operations for peptic ulcers, stomach and colon cancer, a decrease in immunoreactivity in the majority of the population) should be predicted associated with a decrease in the proportion of proteins in the diet). This demonstrates the need for every practicing surgeon to know the topic.

The concept of PDA

PDA - there is an accumulation of pus in the space between the diaphragm and the underlying organs. More often, its development is observed between the diaphragmatic layer of the peritoneum and adjacent organs (it begins as peritonitis). This is the so-called intraperitoneal PDA. Less commonly, the abscess is located extraperitoneally, starting in the retroperitoneal space like a phlegmon.

Abscesses can be located in various parts of the subphrenic space (subdiaphragmatic space). Located directly under the diaphragm, this abscess, to one degree or another, disrupts the shape and function of the diaphragm and neighboring organs. The localization of the abscess in the PDP causes great difficulties for its diagnosis and emptying and distinguishes it from other abscesses of the upper floor of the abdominal cavity (hepatic, subhepatic, splenic, bursa of the lesser omentum, abdominal wall abscesses, etc.).

Statistical data

The question about the frequency of PDA disease has not yet been given an exact scientifically based, statistically reliable answer, despite the large number of works devoted to this pathology. The main reason for this is the relative rarity of the disease. According to Belogorodsky (1964) from the Kuibyshev Hospital in Leningrad (1945-1960), among more than 300 thousand patients, patients with PDA accounted for 0.01%. Follow-up studies studied a much smaller number of patients and therefore cannot be considered more statistically reliable.

Among PDAs, currently about 90% are postoperative (Gulevsky B.A., Slepukha A.G.; 1988).

Etiology and pathogenesis of PDA

In the occurrence of PDA, the leading role belongs to the microbial flora. According to most authors, streptococcus, staphylococcus, and Escherichia coli are most often found in PDA pus. Often, cultures from PDA pus show an increase in non-clostridial anaerobic flora.

Most often, the source of infection in PDA is local purulent-inflammatory processes located in the abdominal cavity. Most often (about 90% of cases (Gulevsky B.A., Slepukha A.G., 1988) this is postoperative local or diffuse peritonitis. Any surgery on the abdominal organs can lead to the occurrence of PDA. But statistics show that most often PDA develops after gastrectomies, subtotal resections of the stomach, operations for cancer of the pancreas and the left half of the colon (Gulevsky B.A., Slepukha A.G., 1988). S.N. Malkova (1988) even identifies a “risk group” for the development of PDA - these are patients who have undergone gastrectomy or subtotal resection of the stomach for cancer, especially in combination with paragastric operations (splenectomy, pancreatic resection).The reason for this is massive surgical tissue trauma, bleeding, failure of anastomoses (especially esophageal-intestinal), decreased immunity against the background cancer intoxication, disorders of leukopoiesis, splenectomy and postoperative anemia.Technical errors during surgery (rough handling of tissues, poor hemostasis, trauma to the peritoneum, use of dry wipes and tampons) lead to a decrease in the peritoneum's resistance to infection. Although PDA can also occur after relatively minor operations that took place without any special technical difficulties (appendectomy, suturing of a perforated ulcer, etc.).

The second most common group of causes of PDA is injuries to the abdominal organs (both closed and open). With all the variety of trauma, its consequences have common features - the formation of hematomas, accumulations of bile, which then suppurate and turn into abscesses of the PDP. In open injuries, the occurrence of PDA is observed mainly when the peridiaphragmatic region is damaged (gunshot wounds, puncture and incised wounds).

Only 10% of patients with PDA (Belogorodsky V.M., 1964; Gulevsky B.A., Slepukha A.G., 1988) had no history of previous operations or injuries. Among the diseases that cause PDA, the first place is occupied by diseases of the organs of the upper floor of the abdominal cavity (primarily peptic ulcer, liver abscesses). Much less often, PDA is a complication of diseases of the organs of the middle and lower floors of the abdominal cavity (unoperated appendicitis, diseases of the female genital organs, purulent paranephritis, prostatitis). Sometimes PDA complicates the course of purulent-inflammatory diseases of the lungs and pleura (on the contrary, reactive pleurisy is much more often associated with PDA of abdominal origin).

Pathological anatomy

Most often, PDAs are located intraperitoneally, less often - in the retroperitoneal space (89-93 and 7-11%, respectively - Belogorodsky V.M., 1964; Gulevsky B.A., Slepukha A.G., 1988). With an intraperitoneal abscess in the initial stage, transudation and emigration of blood cells are observed. Retroperitoneal PDA begins with cellular infiltration of tissue and the development of lymphadenitis. PDA of traumatic origin is based on suppuration of infected accumulations of blood and bile. This is stage I of PDA development. The inflammation may stop there. According to De Bakey, this happens in approximately 70% of cases. Otherwise, exudate appears in the crevices of the peritoneum, and periadenitis appears retroperitoneally. The PDA is delimited from the abdominal cavity by adhesions and fascia. The abscess gradually increases and can reach significant sizes. PDAs have different shapes, most often round. The shape depends on the location of the abscess. Organs adjacent to the diaphragm exert pressure on the lower surface of the abscess, which can give it a flat shape.

There are intra- and extraperitoneal PDAs, which are divided into left-, right- and medial. These abscesses, in turn, vary in location in relation to the vault of the diaphragm. Right-sided: anterosuperior, superoposterior, central, posterior-inferior. Left-sided: superior, inferoanterior, posteroinferior, perisplenic. In addition, a distinction is made between lower extraperitoneal right- and left-sided abscesses.

Data from different authors on the frequency of PDA in different localizations sometimes differ quite significantly. For example, V.M. Belogorodsky (1964) observed 163 right-, 72 left-sided and 5 bilateral abscesses. S.M. Malkova (1986) writes that in her work there were 52% left-, 19% right-sided and 29% median PDA.

Taking into account the data of recent works (Aliev S.A., 1991; Gulevsky B.A., Slepukha A.G., 1988; Nepokoinitsky E.O., Rodina L.I., 1988), we should apparently talk about approximately equal occurrence left- and right-sided PDA; in any case, the difference in their frequency does not exceed 10-12%

According to the nature of the contents, PDAs are gasless (containing only pus) and gaseous.

Diagnosis of PDA

Symptoms of PDA

The first and main symptom of PDA is pain. Pain with PDA is usually localized. Most patients report acute, “sharp”, “burning” pain. At the beginning of the disease, pain is moderate, less often severe. There are frequent complaints of nagging pain in the right half of the chest, radiating to the neck. Pain accompanies PDA almost throughout the entire course of the disease. The pain may ease and/or intensify with movement, coughing, breathing, or straining. Characteristic irradiation is to the shoulder girdle, scapula, collarbone on the same side of the PDA. This is a consequence of irritation of the endings of the n.phreniсi, the fibers of which spread in the tendon center, therefore irradiation is more often observed when the PDA is localized under the center of the diaphragm.

Body temperature in patients with PDA is usually elevated. Hectic fever is sometimes the only symptom of developing PDA. According to E.I. Bakuradze, fever is the leading symptom of PDA (Belogorodsky V.M, 1964). It is accompanied by chills, sweating, pale face, dry tongue, and a feeling of heaviness in the lower parts of the chest. The pulse in these patients is usually rapid.

Inspection and palpation make it possible to identify changes that may indicate PDA. In the first place is the forced position of the patient. In bed, patients occupy a high, elevated position on their back, often with their legs bent. Sometimes patients lie on the affected side. When moving, patients avoid unnecessary movements of the body, holding straight or, for example, with right-sided PDA, bending forward and to the right.

Many symptoms, the most characteristic ones, are determined by examining the chest.

Already upon examination, one can detect an expansion of the chest. Langenbuch (1897) compared its shape to a bell (however, now no one describes such drastic changes). Less significant changes are quite common. Smoothness of the intercostal spaces and their expansion are noted; their protrusion according to the PDA; protrusion of false ribs on the sore side (it is more pronounced with the accumulation of pus in the peripheral parts of the RAP).

At the onset of the disease, examination of the abdomen fails to detect any symptoms of PDA. Later, characteristic symptoms appear - swelling of the subcostal region with right-sided PDA and paradoxical breathing, in which the epigastric region retracts when inhaling and protrudes when exhaling. In some cases, changes in the skin and subcutaneous fat are detected. In later stages, the skin becomes slightly yellowish and dry to the touch. Sometimes there is a stripe of swelling and swelling on the lateral surface of the lower half of the chest; this symptom is due to poor circulation in this area.

Palpation of the chest and abdomen near the diaphragm reveals muscle tension corresponding to the localization of the PDA (more clear from the abdominal wall). Sometimes you can feel the edge of the PDA as it descends from under the diaphragm along the posterior surface of the anterior abdominal wall. Palpation from the back with posterior PDA reveals smoothness and tension in the upper part of the lumbar fossa. Unlike paranephritis, palpation of the lumbar region from the front will be painless (more precisely, the kidney area).

The most important symptom of PDA obtained by palpation is sensitivity and especially pain in the area of ​​its location. In this case, a diffuse area of ​​​​pain is sometimes noted, corresponding to the location of the abscess. To identify pain, it is recommended to perform chest compressions (Fakson).

For topical diagnosis, it is necessary to identify the area of ​​pain corresponding to the PDA. Characteristic is pain in the area of ​​the costal arch (opposite the IX - XI ribs), first noted by M.M. Kryukov (1901). This symptom is now called Kryukov's symptom.

Sometimes there are areas of severe pain in the neck at the site of attachment of the legs of the sternocleidomastoid muscle, in the shoulder girdle.

Physical research methods

They can detect changes in the position and condition of neighboring organs. With PDA, detect accumulation of liquid and gas in places where they should not be, effusion in the pleural cavity, compression of lung tissue, hepatoptosis. These symptoms appear at an early stage and clearly manifest themselves in stages II and III.

Non-gas PDA

Percussion of the chest may reveal a dullness located above the normal border of the liver; this dullness is less intense than hepatic dullness. The mobility of the lower edge of the lung is often reduced or absent.

The reaction of the pleura with PDA is noted already in the first days (dry pleurisy). A.A. Troyanov noted a dry, painful cough in patients with PDA (without sputum), explaining this as irritation of the sensitive nerve endings of the diaphragmatic pleura.

Pleural effusion is also common in early PDA. Effluent pleurisy of other origins can complicate diagnosis. It is important to note that such pleurisy, even of large sizes, does not displace the edge of the liver downward, but can displace (unlike the PDA) the shadow of the heart.

The lower edge of the lung is compressed by the PDA, its airiness decreases until atelectasis. Depending on the degree of compression of the lung, the results of percussion will range from a pulmonary sound to absolute dullness (especially clearly in the front). During auscultation, you can hear various changes - from weakened vesicular to bronchial breathing. At the border of the abscess, breathing sounds suddenly disappear.

The dullness of percussion sound over the PDA does not change with respiratory movements, but when the body position changes, the dullness band shifts. When a patient with a right-sided abscess is positioned on the left side, the area of ​​dullness shifts to the left. The abscess will move away from the right side wall of the chest, which is manifested by the appearance of a clear pulmonary tone here.

Displacement of the liver together with an abscess above it gives rise to liver balloting. If you tap the chest from behind at the angle of the patient's right shoulder blade, the hand placed in the right hypochondrium in front will feel the shocks of the liver. This is a symptom of G.G. Yaure (1921).

With right-sided PDA, as a rule, the lower edge of the liver descends and is well palpated.

When examining the left half of the chest, the same relationships are determined as on the right, but the left dome of the diaphragm does not rise as high as the right (no higher than the third rib, while the right - up to the second rib).

The appearance of dullness in the back of the lower part of the chest is also observed with retroperitoneal PDA. The dull zone does not reach a great height. The accumulation of pus in the retroperitoneal space smoothes the upper part of the lumbar fossa, and sometimes even protrudes it. In these cases, pain, pasty soft tissue on palpation and the absence of pain in the front (unlike paranephritis) are determined.

Sometimes percussion of the chest from the front reveals below the pulmonary tone not dullness, but tympanitis. This is a sign of gas in the abscess cavity (gas PDA). Percussion reveals 3 areas of different tones - a clear tone of the lung, tympanic gas and dullness of pus. The PDA gas shifts when the position of the body changes. It is always located at the top of the PDA (Dave's symptom). The gas-liquid ratio is clearly visible on fluoroscopy. When auscultating in the abscess area, you can hear the sound of a falling drop, and when the patient quickly changes position, a “splashing noise” of Hippocrates occurs.

When reactive pleurisy occurs, a four-stage sound is noted during percussion - pulmonary tone, dullness of exudate, tympanic sound of gas, dull tone of pus and liver (L.D. Bogalkov).

X-ray methods for diagnosing PDA

The basis of radiological diagnosis for PDA is the analysis of the condition of the diaphragm; clearing of gas, darkening of pus. Changes in the lungs, heart, and liver caused by PDA are its indirect signs.

During the first study (fluoroscopy or radiography), changes characteristic of PDA are detected: either darkening above the line of the diaphragm (as if protruding the shadow of the liver) with gas-free PDA, or a focus of clearing with a lower horizontal line separated from the lung by the arc of the diaphragm. Sometimes it is possible to note a higher position of the diaphragm dome and a decrease in its mobility.

Complete immobility of the dome of the diaphragm when the patient is in a vertical position and immobility or minimal passive mobility when the patient is horizontal are characteristic of PDA.

With PDA, a decrease in the airiness of the lower parts of the lung, raised by a high-standing diaphragm, is determined. In this case, accumulations of fluid - reactive effusion - in the pleural sinus are often observed. X-ray examination helps to identify changes in neighboring organs: displacement of the longitudinal axis of the heart, deformation of the stomach, downward displacement of the splenic angle of the colon.

However, the X-ray method does not always detect PDA. This happens either because the PDA has not “ripened” and has not taken shape, or because the picture obtained during the study is incorrectly assessed.

Due to swelling and infiltration of the diaphragm during PDA, it thickens to 8-17 cm. The contours of the dome of the diaphragm become unclear and blurred.

The most characteristic radiological sign of PDA is changes in the area of ​​the crura of the diaphragm. V.I. Sobolev (1952) found that with PDA the legs of the diaphragm become more clearly visible. This sign appears very early in PDA, so it is valuable for early diagnosis.

Due to the presence of gas in the hollow organs of PD, differential diagnosis of PDA with gas from the normal picture may be required. Diagnosis of PDA on the left is difficult due to the presence of gas in the stomach and colon. In unclear cases, fluoroscopy with a barium suspension taken orally helps.

Air in a free PD is identified on the radiograph as a saddle-shaped stripe above the liver, and there is no fluid level underneath it, as in the lower part of the PD. The gas in a pulmonary abscess and tuberculous cavity is similar to PDA gas, the only difference is that they are located above the diaphragm.

Repeated x-ray examinations are of great importance in the diagnosis of PDA. Patients who show signs of an incipient complication in the postoperative period, even if they are mild, should undergo x-ray examination. Serial photographs are especially valuable, in which not only PDA is detected, its shape and location are determined, but also the dynamics of the process and changes in the size of the abscess are visible. Repeated studies are important after evacuation of pleural effusion, which often masks PDA. The X-ray method can be used to monitor the abscess cavity. The PDA is often poorly emptied even through drains due to anatomical features. Fluoroscopy allows you to determine the reasons for the delay in the patient’s recovery, if any.

In recent years, computed tomography (CT) has been introduced into clinical practice. This method is very good for diagnosing PDA. Its resolution is 95-100% (Bazhanov E.A., 1986). With CT, there is a need to differentiate fluid in the abdominal and pleural cavities, since the diaphragm is often not visualized on axial tomograms - its optical density is equal to the density of the liver and spleen. To do this, pictures are repeated on the stomach or healthy side - organs are displaced and fluid moves. The fluid in the pleural cavity is located posterolaterally, in the abdominal cavity - anteriorly and medially, which corresponds to the anatomy of the PD and pleural sinuses. Using CT, it is also possible to exclude PDA in cases where the picture is not entirely clear. In the material by E.A. Bazhanova (“Computer tomography in the diagnosis of subdiaphragmatic abscesses // Surgery, -1991-No. 3, p. 47-49) of the 49 patients observed, in 22 the diagnosis of PDA was removed after CT, in the remaining 27 it was confirmed and detected at surgery.

Other instrumental methods for diagnosing PDA

Let us briefly touch upon methods other than radiological for diagnosing PDA.

The most important, recently widespread method is ultrasonography (echography, ultrasound). Its resolution in relation to PDA is very high and approaches 90-95% (Dubrov E.Ya., 1992; Malinovsky N.N., 1986). Small left-sided PDAs are visualized somewhat worse, especially those surrounded by abdominal adhesions. The value of the method is its harmlessness, non-invasiveness, the possibility of dynamic observation and control of the postoperative state of the purulent cavity. Under ultrasound control, puncture drainage of abscesses can be performed (Krivitsky D.I., 1990; Ryskulova, 1988).

The effectiveness of liquid crystal thermography is noted (Smirnov V.E., 1990), but the number of observations here is small.

Laparotomy is used as the last stage of the diagnostic search for PDA (with the goal, in addition, if possible, of draining the abscess through manipulators). However, the “closed” method of treating PDA is not recognized by everyone (Belogorodsky V.M., 1986; Tyukarkin, 1989). The possibilities of laparotomy are also limited in cases of severe adhesions in the abdominal cavity.

B.D. Savchuk (Malinovsky N.N., Savchuk B.D.; 1986) notes the effectiveness of isotope scanning with Ga 67 and Zn 111. These isotopes are tropic to leukocytes; this technique is based on this. Leukocytes obtained from the patient are incubated with the isotope and then returned. Leukocytes rush to the purulent focus, and there will be an increased "glow". The method is applicable in the diagnosis of not only PDA, but also other abdominal abscesses.

Laboratory diagnostics of PDA

These studies occupy a huge place in the diagnosis and control of the course of PDA. There are no specific changes in the analyzes for PDA. Blood tests show changes characteristic of general purulent processes (anemia, leukocytosis with a shift to the left, accelerated erythrocyte sedimentation, dysproteinemia, the appearance of C-reactive protein, etc.). Moreover, it is important that these changes persist with antibiotic therapy. Some information about the genesis of PDA can be obtained by examining punctures (detection of tyrosine, hematoidin, bile pigments).

The main positions of differential diagnosis

In the process of diagnosing PDA, it becomes necessary to differentiate it from other diseases.

The main difference between PDA is the deep location of the source of the disease, the dome-shaped shape of the diaphragm, its high standing, limitation of movements, as well as the appearance of tympanitis or dullness under the diaphragm.

In a patient with PDA, upon percussion, attention is drawn to the appearance of dullness in unusual places. It is detected above the normal boundaries of the liver, sometimes reaching the II-III ribs in front and the middle of the scapula in the back. Such a picture can be observed with exudative pleurisy.

Much more difficult differential diagnosis in basal pleurisy. Its distinctive signs are the location of the process in the chest cavity, a sharp increase in pain with any movement of the diaphragm, shallow and frequent breathing. However, differential diagnosis of these diseases is difficult (see Table 1).

Table 1

Signs of differential diagnosis of PDA and effusion pleurisy

With gangrene of the lung, extensive infiltration of the lung tissue occurs, causing dullness of percussion sound, which may resemble the picture of gas-free PDA. Severe general condition, high body temperature; pronounced pulmonary symptoms and foul-smelling sputum allow the correct diagnosis of lung gangrene.

With pulmonary abscesses, unlike PDA, patients experience prolonged remitting fever, dullness of percussion sound, weakened breathing in the absence of wheezing, and symptoms of a cavity in the lung with gases and pus. After opening the abscess, purulent sputum is secreted into the bronchus for a long time. Differential diagnosis in these cases is facilitated by echography and radiography.

Acute pyopneumothorax often occurs after physical exertion, giving a picture of shock or collapse with sharp pain in the chest, shortness of breath, pallor, which resembles the picture of a breakthrough of the PDA into the pleural cavity. Acute pyopneumothorax is preceded by a long-term lung disease (tuberculosis, lung abscess).

Distinctive signs of a liver abscess are a subacute course of the disease, remitting fever, pain in the right hypochondrium, aggravated by coughing and inhalation, weakening of respiratory excursions of the diaphragm, hepatomegaly with a normal location of the anterior edge of the liver, changes in the boundaries of the liver when changing body position, pain in the suprahepatic region, absence reactive pleurisy. The most accurate differential diagnosis is possible by echography and CT.

Diseases of the retroperitoneal space can produce symptoms similar to those of extraperitoneal PDA. These are paranephritis, retroperitoneal abscesses and phlegmon. Common signs for these diseases and PDA are localized pain in the posterior and posterolateral parts of the body, fever, and swelling of the skin. Pain during paranephritis is localized between the XII rib and the iliac crest, radiates to the thigh and intensifies with changes in body position. There are no personal symptoms associated with paranephritis. The focus in this case lies closer to the surface of the body, so phenomena from the soft tissues of the back appear earlier and occur more often than with PDA. The contours of the back are smoothed out, the diseased half of it bulges, which is especially clear when examining a sitting patient. With paranephritis, pain is more pronounced in the angle between the XII rib and the long back muscles. And again, the results of ultrasound and CT are decisive in diagnosis.

table 2

Differential diagnosis of PDA and gallbladder diseases

Table 3

Differential diagnosis of PDA and diaphragmatic hernia

PDA treatment

The basis of treatment for PDA is surgical treatment (opening and drainage). Usually it is complemented by conservative therapy (detoxification, antibacterial, symptomatic). But conservative methods cannot replace surgical intervention. Therefore, this section will discuss surgical methods, or more precisely, various approaches for opening the PDA.

The operation of opening the PDA is far from a safe intervention, which is associated with the anatomical features of the location of the abscesses and has been associated with high mortality for a long time. The question of the best operation for PDA actually comes down to the question of safe access to it.

The largest number of methods for surgical treatment of PDA were proposed at the end of the 19th and beginning of the 20th centuries. At this time, a number of the simplest, shortest and safest accesses to the PDA are resumed.

In each individual case, the approach to PDA is determined by the localization of PDA and topographic-anatomical relationships in the abscess area.

But there are a number of general provisions during surgery, regardless of the method of intervention. This includes the position of the patient on the operating table. The patient should lie either on his healthy side or on his back, slightly inclined on the healthy side and with a cushion placed under his body. In the lateral position, the leg lying on the table is bent and attached to it.

Anesthesia during operations is usually general.

The incision is often made in the area of ​​the abscess, but not necessarily in the center. More often, the abscess is opened sharply through a small incision and then the hole is enlarged with a forceps to the desired size. The emptying of the PDA must be done slowly, otherwise the patient may collapse. After emptying the abscess, it is necessary to revise the abscess cavity, tear the existing strands with your finger, open the pockets and bays widely, eliminating the jumpers between them. Next, it is necessary to ensure good drainage of the abscess cavity. Previously, tampons with Vishnevsky's ointment were most often used, introduced into the cavity, sometimes tampons and drainage were introduced. In recent years, the most popular (as more effective) method is the intake-aspiration drainage of the PDA cavity, in particular, with double-lumen silicone drainages (according to Kashinin N.N., Bystritsky A.L.; 1980). With this method of treatment, the abscess cavity is cleared faster, the length of the patient's stay in the hospital is reduced.

The most common accesses to the DAP of the most common localization

Transpleural access for superior anterior and posterior abscesses

A skin incision 10-12 cm long is made above the location of the PDA, preferably at its lower edge. The tissue is cut layer by layer down to the rib. 1-2 ribs are resected subperiosteally. After that, sutures are applied along the edges of the wound, bringing together and suturing the periosteum and costal pleura with the diaphragmatic one. Sew with a needle, or interrupted sutures, or interrupted. After suturing, an incision is made in the area limited by the sutures, while the stitched pleura sheets are cut, the diaphragm is cut deeper and the abscess is emptied. Tampons (drains) are inserted into the abscess cavity.

The difficulty and danger of this method is that the operation is performed on a moving diaphragm and requires fine technique. It is not always possible to avoid the release of pus through punctures in the diaphragm, sometimes the pleura breaks, the holes in it are difficult to sew up, and therefore there is a great danger of purulent pleurisy.

Right-sided pleural access for anterior-superior abscesses is universal. Lateral approach.

A skin incision 10-12 cm long is made along the X rib, parallel to the expected edge of the pleural sinus. The skin, subcutaneous tissue is dissected, m.serratus post is incised; The IX and X ribs are resected for 8-10 cm. The thin fibrous fibers that fix the edge of the sinus to the edges of the ribs are cut. After this, the edge of the sinus easily peels off from the chest wall, diaphragm and moves upward. Pleural tears are immediately sutured. An incision along the fibers exposes the intraperitoneal fascia and diaphragmatic peritoneum above the abscess. The diaphragm is cut along the wound, its upper edge is sutured with catgut to the chest muscles. They puncture the abscess, and, having received pus, open it. If pus is not obtained, the peritoneum is peeled off to the sides and punctures are made in different directions until an abscess is found and then it is emptied with an incision. Revision halfway, smoothing the walls, tamponade (drainage).

Rear approach

Skin incision along the 11th rib, starting from the long muscles of the back. The XI rib is exposed and resected (if necessary, the end of the XII) and the intercostal muscles are bluntly divided. Having mobilized the sinus (see mobilization technique above), the pleura is separated from the ribs (with a sponge), then from the diaphragm and pushed upward. The diaphragm muscle is cut along the fibers, the RAP is opened. Opening, drainage. If there is no abscess in the incision area, the peritoneum is peeled off from the lower surface of the diaphragm until the abscess is found.

Extraperitoneal subcostal access. Front and side approach

A 10 cm long skin incision parallel to the costal arch, starting from the lateral edge of the rectus abdominis muscle and to the l.axillaris ant. (anterior approach) or according to l.medioclav. to l.axillaris media. Dissect the tissue to the aponeurosis and fibers of the transverse muscle. An incision is made in its presenting part, the costal arch is pulled upward and anteriorly. The surgeon slides his finger upward along the transverse fascia, peeling it away from the inner surface of the transversus muscle and the lower surface of the diaphragm. Having determined the fluctuation, the surgeon opens the abscess by moving his finger up. If the abscess is not palpable, a puncture is made. Lack of access - retention of pus if the edge of the costal arch is pressed against the liver. This may require the imposition of counter-opening. A second incision is made in the skin, tissue and superficial fascia 5-6 cm outward from the wound, after which the abdominal wall tissue is separated through the first incision using a forceps. From the second cut similarly penetrate into the first. From the new wound, the surgeon peels off the peritoneum and dissects it under the abscess at its bottom (K.S. Shakhov’s method, 1960).

Rear approach

Skin incision 12-15 cm parallel to and below the XII rib, tissue dissection to m.serratus post.inf. The tissue is dissected after the wound has expanded to the transverse fascia. Detachment of fascia, tissue and peritoneum from the lower surface of the diaphragm. The diaphragm is incised and the PDA is drained.

Upper medial approach for anterior PDA

Upper median incision to the transverse fascia 8 cm. Infiltration of preperitoneal tissues with novocaine. Detachment of the peritoneum with a finger up and to the sides. Opening of an abscess.

Transperitoneal subcostal approach

Used for anterior PDA. A layer-by-layer incision of the abdominal wall on a finger below the costal edge from the rectus muscle to the l.axillaris media. After opening the abdominal cavity, the PDA is found. The lower edge of the liver is sutured to the lower lip of the wound to delimit the abdominal cavity. Tampons should be inserted into the outer corner of the wound in the abdominal cavity. Opening, drainage.

Extrapleural posterior access for posterior extraperitoneal abscesses

A 10-15 cm incision is made posteriorly along the 11th rib. Its resection (subtotal). The transitional fold of the pleura is found and mobilized. The diaphragm is exposed and cut along the fibers to the peritoneum. If an abscess is found, the peritoneum is dissected, otherwise the peritoneum is peeled off from the lower surface of the diaphragm and the abscess is found.

Extraperitoneal posterior access

Good for posterior extraperitoneal PDA. The incision is below and parallel to the XII rib, starting 3 transverse fingers from the paravertebral line to the axillary. The tissue is dissected to the transverse fascia (if necessary, by resecting the XII rib). Further actions are the same as with the anterior approach. With retroperitoneal access, the most favorable conditions for drainage of the PDA are created.

Postoperative management of patients

After opening the PDA, its cavity is eliminated at different times. According to V.M. Belogorodsky (1964) this is 30-50 days. When using active supply and exhaust drainage, the cavity closes on average in 20-27 days (Kapshin N.N., Bystritsky A.L.; 1980).

After surgery, patients must be placed in a position favorable for the drainage of pus. For posterior incisions - Fowler's; for front and side - on the side. The first dressing is best done after 5-7 days; tampons should be removed gradually.

In the postoperative period, physical therapy, breathing exercises, and early activation of the patient are very useful. Antibiotics are prescribed according to strict indications (Zaitsev V.T., Slyshkov V.P., Osmanov R.I.; 1984), one of which is opening the pleural cavity during surgery. Adequate pain relief after surgery is necessary, which facilitates the manifestation of motor activity.

With the correct choice of access and a well-performed operation, the prognosis is favorable. Mortality after surgery is usually due to concomitant diseases of the cardiopulmonary system. According to A.L. Bystritsky, mortality is 7.3% (Bystritsky A.L., Fainberg K.A., Golubev L.P.; 1986).

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