Surgical treatment of sepsis

Given the severity and multi-organ damage in patients with sepsis and especially septic shock, including decompensation of the cardiovascular and respiratory systems, treatment of such patients should be carried out in specialized departments that have all the methods of diagnosis, monitoring and treatment, including methods of extracorporeal detoxification. If it is impossible to transfer patients to such departments, treatment should be carried out in a ward or intensive care unit. A mandatory condition is the availability of an operating unit.

Treatment of sepsis should be conservative and surgical, necessarily including both components. Even to this day, doctors continue to be mistaken about the appropriateness and scope of surgical intervention in sepsis and especially septic shock. This consists mainly in refusing surgery or limiting the scope of surgical intervention due to the serious condition of patients and the fear that patients "will not survive the operation." In the best case, with this approach, palliative interventions are carried out, in the rest, treatment is reduced to vigorous conservative therapy, primarily antibacterial.

However, the issue of radical removal or sanitation of the primary purulent focus in patients with sepsis (as well as pyemic foci, if any) is no longer discussed worldwide. Thus, the outcome of the disease, i.e. the life of the patient, often depends on the thoroughness and radicality of the surgical component of the treatment of gynecological sepsis (extirpation of the uterus in the hysterogenic form of sepsis, removal of tubo-ovarian abscesses, emptying of extragenital abscesses, removal of purulent-necrotic tissue of the pelvic tissue in parametritis, adequate excision of the edges of the purulent wound with the opening of all pockets and leaks in wound infection), as well as on adequate drainage.

Surgical tactics

It is now generally accepted that surgical tactics in sepsis and even septic shock should be active, and an adequate sanitizing surgical component of treatment is the key to the survival of such patients. It is necessary to remember that palliative interventions in patients with generalized infection not only do not save the situation, but often aggravate it.

Attempts to curettage the uterine cavity in patients with hysterogenic sepsis are strictly contraindicated, since they practically take away the already insignificant chances of life from the patients. Removal of placental tissue, ovum and purulent-necrotic endometrium in patients with generalized infection (sepsis) makes no sense and can catastrophically worsen the patient's condition due to the development of septic shock, especially if entry into the uterus is carried out at low arterial pressure or at the time of curettage, "prevention" of septic shock is carried out by intravenous administration of antibacterial agents that promote massive lysis of microorganisms.

Timely hysterectomy - removal of the active primary lesion, toxins and infected emboli from which enter the blood in large quantities - is vitally indicated, and even the patient's severe condition (except atonal) is not an obstacle, since this is the only, although not guaranteed, chance to avoid a fatal outcome.

In fulminant and acute forms of hysterogenic sepsis (directly related to childbirth, abortions), all patients are indicated for hysterectomy after preoperative preparation and recovery from shock.

The operation should not be delayed, the best results (survival) are obtained in patients operated on in the first 12 hours after admission. An adequate volume of surgical intervention is extirpation of the uterus with tubes, sanitation and drainage of the abdominal cavity. Removal of the primary source of infection "en bloc" is prognostically favorable, when the uterus is removed together with the infected fetus, placenta or remnants of placental tissue (in the event that a miscarriage or birth has already occurred).

The course of the postoperative period, and often survival, depends on the technical execution of the operation, in particular the nature of blood loss, reliability of hemostasis and adequacy of drainage. Gaining time can only be ensured by the presence of a well-coordinated, highly qualified operating team, and not by haste, which is accompanied by careless hemostasis and other surgical defects.

Features of surgical intervention in such patients:

• It is advisable to use only lower midline laparotomy.
• During the operation, a thorough revision of not only the pelvic organs and abdominal cavity, but also the retroperitoneal space is necessary, especially if the intraoperative findings are incomparable in volume and severity with the clinical picture and do not agree with the preliminary preoperative conclusion. In such cases, it is logical to pay attention to the search for the true source, which may be, for example, destructive pancreatitis.
• Mistakes that undoubtedly worsen the patient's condition are: incision of the uterus and removal of the fetus and placenta during surgery, as well as fixation of the uterus with sharp instruments that penetrate the cavity (corkscrew, Muso-type clamps). These manipulations facilitate the technical performance of the surgery by reducing the size of the uterus, but in this case, especially in the first case, a large number of thromboplastins and purulent emboli additionally enter the blood, which can cause a sharp deterioration in the condition up to septic shock and death of the patient.
• It is advisable to use the technique of removing the uterus “block”, for which, if the uterus is large, it is necessary to extend the incision of the anterior abdominal wall.
• The uterus is fixed before all manipulations with two long Kocher clamps placed on the uterine ribs. The clamps prevent toxins from entering the blood, perform a hemostatic function, and can be additionally tied together and used as a "holder".
• It is advisable to apply clamps to the ligaments in such a way that their ends are in avascular zones, this is especially important in the presence of large venous, sometimes varicose plexuses; blood loss in this case is minimal.
• Much attention should be paid to the thoroughness of hemostasis. Operations performed in the hypocoagulation phase of DIC syndrome are accompanied by increased bleeding and hematoma formation, they are often prolonged due to the need for additional hemostasis. If bleeding occurs in the parametrium, if the bleeding vessel is not visible, temporary hemostasis should be achieved by pressing or applying soft clamps. After palpation, and in some cases visual revision of the ureter, the vessel is ligated. Ligation of the uterine vessels and individual vessels in the parametrium is usually sufficient.
• In some cases, with ongoing bleeding, it is more appropriate and safer to ligate the internal iliac artery on the corresponding side. To do this, it is necessary to widely open the parametrium in order to orientate oneself in the features of the topography of the retroperitoneal space. It should be remembered that ligation of the internal iliac artery is a responsible measure and should be resorted to only in case of extreme necessity, since this area contains vital structures, such as the main vessels of the pelvis - the common, external and internal iliac arteries and the corresponding veins, of which the internal iliac vein poses the greatest danger for manipulation, with its lateral wall adjacent to the posterior and lateral walls of the internal iliac artery, and the posterior one is intimately connected with the pelvic periosteum along its entire length (therefore, when the vein is injured, attempts to ligate it are always unsuccessful). In order to preserve tissue trophism (primarily the bladder and gluteal region), it is more advantageous to ligate the internal iliac artery as low as possible from the point where it branches off from the main trunk, i.e. below the point where the superior vesical artery branches off from it. If this is impossible for any reason, ligation is performed immediately after the internal iliac artery branches off from the common artery. It is necessary to palpate and visually verify once again that it is the internal iliac artery that is being ligated, and not the external or common artery (such cases have been described in practice). In questionable situations, as well as in the absence of experience in performing such a manipulation, a specialist in vascular surgery should be invited to the operation. It is advisable to use dissecting scissors to dissect the fascial sheet (case) covering the vessel, tangentially bring the appropriate Deschamps needle under the vessel and ligate it twice with a strong non-absorbable ligature, without crossing it. It is important to remember that the ureter is also in the area of the operation, usually fixed to the posterior leaflet of the broad ligament, but sometimes (hematomas, manipulations in the parametrium) lying freely in the parametrium. To prevent injury to the ureter, an indispensable rule when ligating the internal iliac artery should be not only palpation, but also visual control, since large veins when squeezed can give a "click" symptom similar to what the ureter gives when palpated.
• It is extremely rare that only bilateral ligation of the internal iliac arteries is effective, which undoubtedly worsens the conditions of reparation, but is the only means of saving the patient.
• The absence of capillary bleeding during surgery is an unfavorable sign (spasm and thrombosis of peripheral vessels). After a virtually bloodless operation, bleeding may occur in this case, often requiring relaparotomy, additional hemostasis and drainage. The surgeon should remember that even with the most technically sound operation in septic patients, intra-abdominal bleeding and bleeding from the wound associated with the progression of DIC syndrome and the development of hypocoagulation may subsequently occur. To control possible intra-abdominal bleeding in such patients, it is always necessary, even with minimal blood loss, to leave the vaginal dome open and avoid applying frequent blind sutures to the skin and aponeurosis, which will allow timely recognition of extensive subaponeurotic hematomas. The operation is completed with sanitation and drainage of the abdominal cavity. In the postoperative period, APD is performed for 1-3 days, which allows to reduce intoxication and remove exudate from the abdominal cavity. In late admissions of patients (subacute course of hysterogenic sepsis, chronic sepsis), when the role of the primary focus decreases, surgical treatment is indicated in the following cases:
  • the presence of a purulent process in the appendages or tissue of the small pelvis;
  • detection of pus or blood in a puncture from the abdominal cavity;
  • suspicion of old uterine perforation;
  • the presence of progressive acute renal failure that is not relieved by treatment;
  • active purulent process in the primary focus;
  • the appearance of signs of peritoneal irritation.

Manifestations of sepsis or septic shock in patients with purulent inflammatory formations of the pelvic organs of any severity or any localization serve as vital indications for surgical treatment.

As a rule, the development of sepsis in patients with purulent inflammatory diseases of the pelvic organs is caused by extremely prolonged (over many months, and sometimes several years) conservative treatment, often with repeated palliative interventions.

Surgical treatment after sepsis diagnosis should not be delayed, since with a purulent focus remaining in the body, the course of the disease can at any time be complicated by septic shock, a sharp progression of multiple organ failure in sepsis is possible, as well as the appearance of thromboembolic complications. Any of these complications of sepsis is fraught with a fatal outcome.

Patients with sepsis are shown a rapid examination, aimed primarily at clarifying the degree and form of multiple organ failure, identifying extragenital and pyemic purulent foci, as well as complex treatment, which is also preoperative preparation. As a rule, with the beginning of intensive treatment, the patient's condition improves. This time is appropriate to use for surgical treatment.

When septic shock develops, surgical treatment begins after a short but intensive preoperative preparation, including all pathogenetic aspects of influencing shock and bringing the patient out of shock.

Conservative treatment of patients with sepsis consists of intensive therapy, pathogenetically affecting the main damaging factors.

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