Treatment of purulent gynecological diseases

The tactics of managing patients with purulent inflammatory diseases of the pelvic organs is largely determined by the timeliness and accuracy of the diagnosis of the nature of the process, the extent of its spread and an assessment of the real risk of purulent complications, while the clinical approach and the ultimate goal - the timely and complete elimination of this process also prevention of complications and relapses.

That is why the importance of the correct, and most importantly, timely diagnosis in these patients is difficult to overestimate. The concept of purulent lesion diagnosis (clinically clear and instrumentally proven definition of the stages of localization of the process and stage of suppuration) should be the foundation for successful treatment.

In this concept, the main thing is:

1. Determining the exact location of the lesion, it is important to identify not only the main "genital", but also extragenital foci. It is necessary to clarify whether there are foci of purulent destruction of cellular spaces, adjacent and remote organs and what is their depth and degree of prevalence.
2. Determining the degree of damage to the organ or organs (for example, there is purulent salpingitis or pyosalpinx, purulent endometritis, purulent endomyometritis or panmetritis), i.e. Solution of the most important issue of the reversibility of the process and, accordingly, the determination of an adequate individual volume and the optimal method of surgical intervention (drainage, laparoscopy or laparotomy), and forecasting immediate and remote perspectives (life, health, reproduction) for each patient.
3. Clarification of the form of purulent inflammation (acute, subacute, chronic) and phases of chronic suppurative process (exacerbation, remission) for choosing the optimal moment of surgical intervention and determining the extent and nature of conservative therapy during preoperative preparation (inclusion of antibiotic therapy in the preparation complex or refusal of its application , for example, in patients with chronic purulent inflammation in the remission phase of the process).
4. Determination of the severity of intoxication and general disorders, since in patients with purulent diseases of the genitals, as in the purulent process of any other localization, the degree of intoxication directly correlates with the nature and severity of the lesions. Therefore, only after assessing the degree of metabolic disturbances and intoxication, it is possible to carry out the necessary correction (up to extracorporeal detoxification methods) and prepare the patient for subsequent manipulations and interventions.

Thus, the attending physician should answer the main questions: where the lesion is located, what organs and tissues are involved and in what extent are involved in it, what is the stage of the inflammatory process and what is the degree of intoxication.

The choice of instrumental, laboratory and other diagnostic methods of research depends, of course, on the physician himself - his experience, qualifications and knowledge. But he must do everything to ensure that the answers to the above questions in these patients were exhaustive, because the outcome of the disease ultimately depends on this.

The basis for a successful outcome of the treatment lies in the surgical and medicament components, and they should always be considered as a single whole. The medicamentous component is the prologue to surgical treatment (even with emergency interventions in patients with purulent inflammation, a short but vigorous correction of vollemic and metabolic disorders is necessary), and in addition, it always follows the surgical component, providing immediate and delayed rehabilitation.

Essential in the surgical component of treatment is the following:

1. Complete removal of the focus of purulent destruction. It can be a "block" of organs, an organ, a part of it, fiber, etc. The main condition for performing surgical reconstructive organosaving operations is complete removal of pus, destructive necrotic tissue, pyogenic membrane, etc. The thesis "to preserve the reproductive function at any cost" in some patients with a purulent lesion of the genitals is unacceptable, moreover, it is dangerous for their life. However, there exist and will always exist situations and operations, which we call "situations and operations of conscious risk." These are mainly surgical interventions in young patients with complicated and sometimes septic forms of purulent infection, when all surgical canons need to perform a radical operation, which will undoubtedly have the most destructive effect on the future fate of this girl. However, consciously limiting the amount of surgery and giving a chance to such a patient to realize a menstrual and possibly reproductive function in the future, on the other hand, the doctor risks getting a progression or even a generalization of a purulent process, i.e. Severe and sometimes fatal complications. Taking on all the responsibility for the patient's fate, the surgeon in each specific case must decide how justified the risk is. To carry out operations of "conscious risk" can only be a highly skilled specialist who uses the optimal surgical technique, drainage that conducts dynamic postoperative observation (with a worsening of the condition - timely relaparotomy and radical surgery) and intensive treatment (including antibiotics of the last reserve). It should be emphasized that in any situation, even when performing radical interventions, it is necessary, with the slightest opportunity, to fight for the preservation of the patient's hormonal function, i.e. Leave at least part of the ovarian tissue (at any age, except menopausal), since surgical castration, even with modern means of substitution therapy, is a crippling intervention.
2. Adequate drainage of all operational zones of destruction. It should be remembered that the term "adequate" means aspiration drainage, which ensures a permanent evacuation of not only a wound secret, but also a surgical substrate - liquid blood and clots, pus leftovers, necrotic masses. This is why evacuation must be permanent and compulsory.
3. Refusal of local (intraoperative) use in patients with purulent lesions of pelvic organs of various local sorbents, hemostatic sponges, and especially tampons, etc., for in these cases the basic condition for a safe outcome is violated - free evacuation of the wound detachable - and preconditions are created for the cumulation of microbes and toxins, i.e. A real basis for postoperative complications, and in particular abscessing.
4. The categorical refusal of intraoperative use in such patients electrocoagulators, coagulation scalpels and other devices for surgical coagulation. Any, even minimal, coagulation necrosis in conditions of purulent inflammation leads to its aggravation (an ideal environment for anaerobic microorganisms, the possibility of severe coagulation tissue damage, even with the correct use of apparatus due to tissue trophism and conductivity changes - increased hydrophilicity, tissue infiltration, correlations) and complicates the already serious course of the postoperative period.

These conceptual principles by no means mean the exception of a purely individual surgical approach in each specific case: in the technique of approach and isolation of the focus of destruction, in the technique of its removal and hemostasis, in the features and duration of drainage, etc.

The medicamentous component, in fact, is an intensive therapy of a patient with purulent lesions of the genitals. Its scope and features, of course, should always be individual, but it is necessary to adhere to the following principles:

1. Adequate analgesia in the postoperative period (from non-narcotic analgesics to prolonged epidural anesthesia). This component is extremely important, since only in the conditions of anesthesia the course of the reparative processes is not disrupted.
2. Antimicrobial therapy, the importance, need and importance of which do not need an explanation.
3. Detoxification therapy. The approach to this type of treatment is certainly unique, but it is important to remember that there is no purulent process without intoxication, the latter remains for a long time after the removal of pus and the purulent focus, often its degree depends on the severity of the accompanying extragenital diseases.

Of course, that the medicamental treatment of these patients is much broader, in each case is individual and often involves the use of immunomodulators, adaptogens, steroid hormones, heparin, symptomatic agents, etc.

Thus, in the case of patients with purulent diseases of the genital organs, an active approach in general and the observance of the basic conceptual concepts in particular are important, without which the outcome of the process can be questioned.

Currently existing different views on treatment methods are associated with the lack of a unified classification of purulent diseases of the pelvic organs and a single terminology in the treatment of forms of purulent inflammation.

Concerning the existing classifications, it is necessary to say that abroad use mainly the G.Monif classification, which divides the acute inflammatory processes of the internal genital organs into:

1. acute endometritis and salpingitis without signs of inflammation of the pelvic peritoneum;
2. acute endometritis and salpingitis with signs of inflammation of the peritoneum;
3. acute salpingo-oophoritis with occlusion of the fallopian tubes and development of tubo-ovarian formations;
4. the breakdown of tubo-ovarian formation.

According to the clinical course of the disease and on the basis of pathomorphological studies, our clinic considers it expedient to distinguish two clinical forms of purulent inflammatory diseases of the genitals: uncomplicated and complicated, which ultimately determines the choice of tactics of reference. Uncomplicated forms include only acute purulent salpingitis, to complicated forms - all encysted inflammatory adnexal tumors - purulent tubo-thoracic formations.

Acute purulent salpingitis develops, as a rule, as a result of a specific infection - gonorrhea. With timely diagnosis and targeted therapy, the process can be limited to the endosalpinx lesion followed by a regression of inflammatory changes and recovery.

In case of delayed or inadequate therapy, acute purulent salpingitis is complicated by pelvic peritonitis with partial delimitation of purulent exudate in the utero-rectal cavity (abscess of the Douglas pocket) or passes into a chronic form - pyosalpinx or purulent tubo-ovarian formation. In these cases, changes in all layers of the uterine tube and ovarian stroma are irreversible, which is confirmed by morphological studies.

If early complete and adequate treatment of purulent salpingitis is possible full recovery of patients and the implementation of reproductive function, then with purulent tubo-ovarian formations the prospect for subsequent childbearing is sharply reduced or problematic, and the patient can recover only after surgical treatment. With delayed surgical intervention and further progression of the process, severe purulent complications that threaten the life of the patient develop.

Further development of the purulent process proceeds along the path of development of complications: simple and complex genital fistulas, microperforation of the abscess into the abdominal cavity with the formation of intestinal and subdiaphragmatic abscesses, purulent-infiltrative omentite. The lethality in such cases, according to the literature, reaches 15%. The final outcome of severe complications of the purulent process is peritonitis and sepsis.

Clinical manifestations of the purulent inflammatory process of the uterine appendages are diverse. They are caused by a number of factors: the nature of microbial pathogens, the duration of the disease, the stage of inflammation, the depth of the destructive process and the nature of the damage to organs and systems, as well as the features of the previous conservative treatment, the dosage and the nature of the antibacterial drugs used.

Even in the presence of the possibility of using the most modern methods of research, the main way of diagnosis, indicating professional qualifications and the level of clinical thinking, is clinical. According to our data, the coincidence of clinical (history and data of general and gynecological research) and intraoperative diagnosis was 87.2%. All purulent diseases have specific symptoms, reflected in subjective complaints or objective research data. The development of complications also goes through successive stages and is clearly observed in all patients when collecting information about the history of the disease (unless, of course, the physician is aware of the peculiarities of the course of the disease and directs questions). For example, an episode in an anamnesis of a frequent stool with the separation of mucus or pus through the rectum and subsequent improvement in the patient with a prolonged course of the purulent process can indirectly indicate the perforation of the abscess in the rectum. Periodic recurrence of such symptoms will be most likely to indicate the possibility of an active purulent appendage-intestinal fistula, which can be clarified by ultrasound and additional contrasting of the rectum, as well as invasive methods of investigation, in particular, a colonoscopy or CT with fistulography.

Even if the diseases have a similar clinical picture (for example, purulent salpingitis, purulent tubo-ovarian formations in the acute stage), there are always clinical signs (the initiation of the disease, its duration, the degree of intoxication, etc., as well as microsymptomatics) that allow clarifying the primary clinical diagnosis.

All subsequent diagnostic measures should be aimed at determining the depth of purulent-destructive lesions of the uterus and appendages, the pelvic cellular tissue and the adjacent pelvic organs (intestines, ureters, bladder).

The duration of preoperative preparation and the volume of the proposed surgical intervention should be clarified even before the operation.

Sufficient information allows the use of non-invasive and invasive diagnostic methods.

In uncomplicated forms:

• Stage 1 - clinical examination, including bimanual, as well as bacteriological and laboratory studies;
• 2 nd stage - transvaginal echography of the pelvic organs;
• Stage 3 - laparoscopy.

With complicated forms:

• The first stage is a clinical examination, including bimanual and rectovaginal studies, bacteriological and laboratory diagnostics;
• 2 nd stage - transabdominal and transvaginal echography of the pelvic organs, abdominal cavity, kidneys, liver and spleen; echography with additional contrasting of the rectum, according to indications - computed tomography (we recently used extremely rarely in a limited number of patients due to the high information content of modern echography);
• Stage 3 - additional invasive methods of examination: cysto- and colonoscopy, fistulography, X-ray examination of the intestine and urinary system.

Principles of treatment

The severity of general and local changes in patients with purulent formations of the uterine appendages, the morphologically proven irreversibility of destructive changes and, finally, the extreme danger of complications of different in nature and severity give seemingly all grounds to believe that only surgical treatment is the best for these patients, and most importantly, the only way to recovery. Despite the obviousness of this truth, up to now some gynecologists have been advocating the tactic of conservative management of such patients, which consists of two manipulations:

1. puncture and evacuation of pus;
2. introduction of antibiotics and other medicinal substances into the focus.

Recently in the domestic and foreign press there have been reports of successful results of therapeutic drainage of purulent inflammatory formations of the uterine appendages and pelvic abscesses under the control of transvaginal ultrasound or computed tomography.

However, there is no single opinion on the indications, contraindications, the frequency of complications in comparison with the operative intervention, either openly or by laparoscopic access, either in domestic or in foreign literature, and there are no uniform views on terminology.

According to AN Strizhakov (1996), "supporters of this method note its safety, believing that the evacuation of pus and the introduction of antibiotics directly into the inflammatory focus can improve the results of treatment and in many cases avoid traumatic surgical intervention."

Although the authors believe that there are no absolute contraindications to the use of the proposed method, they nevertheless consider it inexpedient to use it "in the presence of purulent formations with numerous internal cavities (tubo-ovarian abscess of the cystic-solid structure), as well as a high risk of injury to the intestinal loops and main vessels ".

In the works of foreign authors contain conflicting information. So, V.Caspi et al. (1996) drained tubo-ovarian abscesses under ultrasound control in combination with the introduction of an antibiotic into the abscess cavity in 10 patients. The average duration of the disease before drainage was 9.5 weeks. Severe complications in the immediate postoperative period were not observed. However, later in three patients out of ten (30%), a recurrence of the purulent process was noted.

It is believed that under the control of ultrasonography, even multiple abscesses can be emptied. The authors consider the method of ultrasound-controlled drainage as a method of selecting the treatment of tubo-ovarian abscesses, which at the same time in a number of patients should be only a palliative preceding laparotomy.

There are reports of complications of this method and relapses of the disease: for example, T. Perez-Medina et al. (1996) noted a relapse of purulent process in 5% of patients 4 weeks after discharge. According to G.Casola et al. (1992), after drainage of tubo-ovarian abscesses, complications were noted in 6 of 16 patients (38%) (three of them developed sepsis, and one patient required a radical operation due to inadequate drainage and the development of an extensive phlegmon). Two patients had relapses 3 and 4 months after drainage. Sonnenberg et al. (1991) performed transvaginal drainage of tubo-ovarian abscesses in 14 patients (half with a needle, others with a catheter). The catheter was removed on average after 6-7 days. Two patients (14%) were subsequently operated on because of the development of an extensive phlegmon.

The efficiency of percutaneous drainage of intraperitoneal abscesses was 95%, while 5% died of septic shock.

FWShuler and CNNewman (1996) evaluated the efficacy of percutaneous drainage of abscesses in 67% of cases. One third of patients (33%) required surgical treatment due to inadequate drainage (22% due to clinical worsening after drainage and 11% due to complications - perforation of the abscess and the formation of a purulent intestinal fistula). There were technical problems, including the movement or loss of drainage in 16.6% of cases and its obstruction in 11.1% of patients. As a result, the authors concluded that the method of drainage was inadequate in one third of the cases and suggested immediately identifying a group of patients whose drainage is unlikely to be successful.

O.Goletti and PVLippolis (1993) used percutaneous drainage in 200 patients with single and multiple intra-abdominal abscesses. The share of successful attempts was 88.5% (94.7% for "simple" abscesses and 69% for "complex" abscesses). At the same time, lethal outcome was noted in 5% of cases (1.3% for simple and 16% for complex abscesses). Hence, according to the authors, drainage can be the initial procedure in patients with "simple" abdominal abscesses, while in multiple abscesses, drainage is a risky manipulation.

TRMcLean and K.Simmons (1993) as an alternative to the surgical method used percutaneous drainage of postoperative intra-abdominal abscesses. Only 33% of the attempts were successful. The authors concluded that the method is useful only in certain rare situations, while the majority shows abdominal incision.

Thus, on average, every third patient develops relapses or severe complications after drainage of abscesses, and in 5% of cases, patients die from generalization of purulent process.

The puncture method is possible in some patients with certain indications as preoperative preparation. Contraindicated this method of treatment in patients with complicated forms of inflammation, since purulent formations of the uterine appendages are characterized by the presence, as a rule, of numerous purulent cavities - from microscopic to very large ones. In this connection, it is impossible to talk about the complete evacuation of pus in these cases. In addition, as purulent contents are removed from the main cavity, it decreases and several other chambers are formed, from which it is impossible to completely remove the pus. Finally, irreversible destructive processes not only in the cavity of the abscess, but also in surrounding tissues create the prerequisites for the development of another relapse. Repeated application of the puncture method can contribute to the formation of an adnexa-vaginal fistula. Similar data led R.Feld (1994), who described the complications of drainage in 22% of patients, the most frequent of which was the formation of prikatkovago-vaginal fistula.

Special mention should be made of the recommendations of a number of domestic and foreign authors to introduce various antibiotics into the purulent cavity.

It is necessary to exclude from the arsenal the local use of antibiotics in the purulent process (administration of antibacterial drugs for puncture of purulent formation, drainage to the abdominal cavity, etc.), given the fact that with local use of drugs resistance to them develops faster than with any other the route of administration. This stability remains in the genetic apparatus of the cell. As a result of the transfer of the resistance factor, antibiotic resistant cells rapidly multiply in the microbial population and make up the majority, which leads to ineffectiveness of subsequent treatment.

Local application of antibiotics causes a sharp increase in multiresistance of strains. By the 5th day of such treatment, pathogens that are sensitive to this drug practically disappear, and only the resistant forms remain, which is the result of immediate continuous exposure to antibiotics on the microbial flora.

In view of the severity of general and local changes in patients with purulent pelvic diseases and the extreme risk of generalization of the process, in our opinion, the following principal points are important: in any form of purulent inflammation, treatment can only be complex, conservative-surgical, consisting of:

• pathogenetically directed preoperative preparation;
• timely and adequate volume of surgical intervention aimed at removing the focus of destruction;
• rational management, including intensive treatment, postoperative period (the earlier the surgical sanitation of the focus was performed, the better the outcome of the disease).

I. Tactics of management of patients with uncomplicated forms of purulent inflammation.

To treat patients must be approached differentially, taking into account the form of purulent inflammation. As it was stated above, we refer purulent salpingitis to uncomplicated forms of purulent inflammation.

Preoperative preparation in patients with purulent salpingitis should be aimed at arresting acute manifestations of inflammation and suppressing the aggression of the microbial pathogen, therefore, drug therapy with purulent salpingitis is the basic medical intervention, the "gold standard" of it is the correct choice of antibiotic.

Against conservative treatment in the first 2-3 days, it is necessary to evacuate purulent exudate (surgical component of treatment).

The method of "small" surgical intervention can be different, and its choice depends on a number of factors: the severity of the patient's condition, the presence of complications of the purulent process and the technical equipment of this hospital. The easiest and simplest method of purulent secretion is the puncture of the utero-rectal cavity through the posterior vaginal arch, the purpose of which is to reduce the degree of intoxication of the body as a result of the products of purulent decay and prevent the generalization of the process (peritonitis and other complications of the pelvic abscess). Puncture has a greater effect if performed in the first three days.

The use of aspiration drainage increases the effectiveness of treatment. NJWorthen et al. Reported percutaneous drainage of 35 pelvic abscesses with purulent salpingitis. The share of successful attempts in normal drainage was 77%, while in aspiration drainage it increased to 94%.

However, the most effective method of surgical treatment of purulent salpingitis at this stage should be considered laparoscopy, which is shown to all patients with purulent salpingitis and certain forms of complicated inflammation (pyosalpinx, pyovar and purulent tubo-vascular formation) with a disease duration of not more than 2-3 weeks, when there is no coarse adhesive -infiltrative process in the small pelvis.

With timely diagnosis of purulent salpingitis and timely hospitalization, the patient laparoscopy is advisable to perform within the next 3-7 days with relief of acute signs of inflammation. During laparoscopy, the small pelvis is sanitized, the affected tissues are economically removed (if tubo-ovarian formation is formed), the small pelvis is drained transvaginally through the colpotomic wound. The introduction of drains through the contour of the abdominal wall is less effective. The best results are achieved with the use of active aspiration of purulent exudate. The use of laparoscopy is mandatory in young, especially nulliparous patients.

With purulent salpingitis, an adequate amount of intervention is the adhesion, sanitation and transvaginal (through the colpotomy orifice) drainage of the small pelvis. In cases of purulent salpingo-oophoritis and pelvic-peritonitis with formation of a blocked abscess in the rectum-uterine cavity, mobilization of the uterine appendages is considered to be an adequate benefit, as indicated by removal of the uterine tube, emptying the abscess, sanation and active aspiration drainage through the colpotomy. With the formed pyosalpinex, it is necessary to remove the fallopian tube or pipes. With pyovar small sizes (up to 6-8 cm in diameter) and preservation of intact ovarian tissue, it is advisable to produce a purulent formation. If there is an abscess of the ovary, it is removed. Indication for the removal of the appendages of the uterus is the presence in them of irreversible purulent-necrotic changes. In the postoperative period within 2-3 days after the operation, it is advisable to perform aspiration-flushing drainage with the help of the OP-1 apparatus.

In the postoperative period (up to 7 days) continues antibacterial, infusion therapy, resorption therapy with subsequent rehabilitation for 6 months.

Rehabilitation of the reproductive function is facilitated by control laparoscopy to perform adhesion after 3-6 months.

II. The management of patients with complicated forms of purulent diseases also consists of three main components, however, in the presence of a purulent purulent formation of the uterine appendages, the basic component determining the outcome of the disease is surgical treatment.

Most often, all the abscessed small pelvis abscesses are complications of an acute purulent process and, in fact, represent a form of chronic purulent-productive inflammation.

In contrast to patients with acute purulent inflammation (purulent salpingitis, pelvioperitonitis), the use of antibiotics in patients with opacified ulcers in the preoperative period in the absence of an acute inflammatory reaction is impractical for the following reasons:

• due to severe violation or lack of blood circulation in purulent-necrotic tissues, insufficient concentration of drugs is created;
• in patients with complicated forms of inflammation, for many months the duration of the process, resistance to many drugs is acquired, since at different stages during the treatment they receive at least 2-3 courses of antibiotic therapy;
• most infectious agents are immune to antibacterial drugs without exacerbation, while carrying out the same "provocation" in such patients is absolutely contraindicated;
• the use of reserve antibiotics acting on beta-lactamase strains in the "cold" period excludes the possibility of their use in the intra- and postoperative periods, when this is really vital.

So, in most cases, patients with complicated forms of purulent inflammation (chronic purulent-productive process) antibiotic therapy is not indicated. However, there are clinical situations that are an exception to this rule, namely:

• presence of obvious clinical and laboratory signs of activation of infection, including the presence of clinical, laboratory and instrumental symptoms of preperforation of abscesses or generalization of infection;
• all generalized forms of infection (peritonitis, sepsis).

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

Thus, detoxification and detoxification therapy (detailed in Chapter 4 of this monograph) is of paramount importance in conducting preoperative preparation.

The effect of detoxification and preparation of patients for surgery is significantly increased when purulent exudate is evacuated.

Drainage, including laparoscopic, as an independent method of treatment can be safe and successful only in cases of purulent salpingitis and pelvic peritonitis with the formation of abscess of the rectum-uterine cavity, since in these cases there is no capsule of formation and removal of purulent exudate is made from the abdominal cavity, in the strength of the anatomical prerequisites is well draining at any position of the patient.

In other cases, drainage should be considered as an element of complex preoperative preparation, which allows performing the operation in conditions of remission of the inflammatory process.

Indications for conducting draining palliative operations (puncture or colpotomy) in patients with complicated forms of purulent inflammation are:

• threat of perforation of the abscess into the abdominal cavity or hollow organ (to prevent peritonitis or fistula formation);
• the presence of acute pelvioperitonitis, against which surgical treatment is least favorable;
• severe degree of intoxication. The conditions for performing the puncture are:
• accessibility of the lower pole of the abscess through the posterior vaginal fornix (the lower pole is softened, swollen or easily detected during examination);
• At survey and additional research the abscess, instead of plural abscessing (in appendages and ekstragenitalnyh the centers) is revealed.

It is advisable to perform a colpotomy only in those cases when the subsequent aspiration-flushing drainage is assumed. With passive drainage, the outflow of purulent contents is quickly disrupted, the introduction of any aseptic liquid for washing the abscess does not guarantee its complete elimination and promotes the dissemination of the microbial flora. It is not permissible to perform puncture and drainage through the lateral and anterior vaults of the vagina, as well as the anterior abdominal wall. Carrying out repeated punctures of the posterior fornix and colpotomies in one patient is also inadvisable, as it contributes to the formation of severe pathology - pridatkovo-vaginal fistulas.

The duration of preoperative preparation is determined individually. Optimal for the operation is the stage of remission of the purulent process.

If there is abscessing in the small pelvis, intensive conservative treatment should last no more than 10 days, and when the picture of the threat of perforation develops - no more than 12-24 hours (if palliative intervention can not be carried out to eliminate it).

In case of occurrence of emergency indications for operation within 1,5-2 hours preoperative preparation is carried out. It involves catheterization of the subclavian vein with transfusion therapy under the control of CVP in a volume of at least 1200 ml of liquid (colloids, proteins and crystalloids in the ratio 1: 1: 1).

Indications for emergency intervention are:

• perforation of the abscess into the abdominal cavity with the development of diffuse purulent peritonitis;
• perforation of the abscess in the bladder or its threat;
• septic shock.

With the development of septic shock, antibiotic therapy should be started only after stabilization of hemodynamic parameters, in other cases - immediately upon diagnosis.

In uncomplicated forms, the character of the surgical component also differs. In these cases, only laparotomy is indicated.

The volume of surgical intervention in patients with purulent pelvic organs is individual and depends on the following main points: the nature of the process, the concomitant pathology of the genitals and the age of the patients.

Representations about the scope of the operation must be developed before it, after receiving the survey data and determining the degree of uterine involvement, appendages, detection of complications and extragenital foci.

Indications for performing a reconstructive operation with preservation of the uterus are primarily: absence of purulent endometriometritis or panmetritis, multiple extragenital purulent foci in the small pelvis and abdominal cavity, as well as other accompanying severe genital pathology (adenomyosis, myoma). In the presence of bilateral purulent tubo-ovarian abscesses complicated by genital fistula, a pronounced purulent-destructive process in the small pelvis with multiple abscesses and infiltrates of pelvic and parametric fiber, confirmation of purulent endometriometritis or panmetritis, it is necessary to perform extirpation of the uterus with at least a part of the unchanged ovary preserved.

With extensive purulent processes in the small pelvis, both complicated and not complicated by the formation of fistulas, it is not advisable to perform a supravaginal amputation of the uterus, since the progression of inflammation in the neck cervix creates a real threat of recurrence of the purulent process after the operation and the formation of an abscess in it with the development of its insolvency and fistula formation , especially in cases of using a reactive suture material, such as silk and kapron. In addition, when performing supravaginal amputation of the uterus, it is difficult to create conditions for transvaginal drainage.

To prevent bacterial-toxic shock to all patients during the operation, one-step administration of antibiotics with continuation of antibacterial therapy in the postoperative period is shown.

The main principle of drainage is the establishment of drains in the main places of fluid migration in the abdominal cavity and small pelvis, i.e. The main part of the drainage should be in the lateral canals and the anterior space, which ensures the complete removal of the pathological substrate. We use the following ways of introducing drainage tubes:

• transvaginal through an open dome of the vagina after extirpation of the uterus (drains 11 mm in diameter);
• through posterior colpotomy with the preserved uterus (it is advisable to use a single drainage 11 mm in diameter or two drains with a diameter of 8 mm);
• In addition to transvaginal transabdominal administration of drains through the counter-lines in the meso- or epigastric regions with sub-hepatic or intercuspinal abscesses (drains 8 mm in diameter). The optimal mode of discharge in the apparatus for draining the abdominal cavity is 30-40 cm of water. The average duration of drainage in patients with peritonitis is 3 days. The criteria for cessation of drainage are the improvement of the patient's condition, the restoration of bowel function, the relief of the inflammatory process in the abdominal cavity, the tendency to normalize the clinical analysis of blood and body temperature. Drainage can be stopped when the washing water becomes completely clear, light and has no sediment.

The principles of intensive therapy aimed at correcting polyorganism disorders (antibiotic therapy, the use of adequate anesthesia, infusion therapy, intestinal stimulation, the use of protease inhibitors, heparin therapy, glucocorticoid therapy, the appointment of non-steroidal anti-inflammatory drugs, drugs that accelerate reparative processes, the use of extracorporeal methods of detoxification) in Chapter 4 of this monograph.

Concluding this chapter, we want to emphasize that purulent gynecology is a special discipline that differs significantly from purulent surgery in view of the existing features both in etiology, pathogenesis and course of processes, and in their outcomes. In addition to common outcomes for surgery and gynecology, such as peritonitis, sepsis, multiple organ failure, lethal outcome, the latter is characterized by specific abnormalities of the functions of the female body, in particular reproductive. The longer the course of the purulent process, the less chance of maintaining the possibility of reproduction. That is why we are opposed to prolonged conservative treatment of patients with both uncomplicated and complicated forms of purulent inflammation and believe that the treatment can only be conservative surgical, allowing to obtain more encouraging results.

The choice of method, access and scope of surgical intervention is always individual, but in any case its main principle is radical removal of the site of destruction, whenever possible atraumatic intervention, adequate sanitation and drainage of the abdominal cavity and pelvic cavity, properly selected intensive therapy and subsequent rehabilitation.