Postoperative scar ligature fistula
The result of the operation, not related to the treatment of a purulent wound, is the closure of the operating field by suturing. If the tissues are infected, the surgeon creates an opportunity to drain the pus and reduce the amount of infiltration. Suture material used in surgery can be natural or synthetic. Ligature sutures may dissolve spontaneously some time after surgery, or a doctor's help is required to remove them.
If a dark cherry-colored serous fluid or purulent discharge is released at the suture site, this is a sign of a developed inflammatory process and the formation of a ligature fistula. The appearance of these symptoms is a sign of ligature rejection and a reason to resume treatment. Fistula that appears after surgery cannot be considered a normal occurrence; urgent treatment is required under the guidance of a surgeon.
Reasons for the appearance of a ligature fistula:
- Getting an infection into the wound due to ignoring the requirements of antiseptics;
- Allergic reaction to suture material.
There are factors that increase the likelihood of a postoperative fistula:
- The age of the patient;
- Immune reactivity (in young people it is usually higher);
- Accession of a chronic infection;
- Hospital infection, typical for surgical and medical hospitals;
- Getting into the wound of staphylococcus and streptococcus, which is normally always on the skin of a person;
- Localization and type of surgical intervention (caesarean section operation, surgery for paraproctitis, etc.);
- Protein depletion in cancer;
- Deficiency of vitamins and minerals;
- Metabolic disorders (diabetes mellitus, obesity, metabolic disorders).
Features of ligature fistulas:
- Occur anywhere on the body;
- Occur in all types of tissues of the human body (epidermis, muscle tissue, fascia);
- Occur any time (week, month, year) after the operation;
- They have a different development of the clinical picture (the sutures can be rejected by the body with further wound healing, or they can become intensely inflamed with suppuration of the wound and not heal);
- They arise regardless of the material of the ligature threads.
Content:
- Symptoms of a ligature fistula
- Complications arising from the appearance of a postoperative fistula
- Diagnostics
- Treatment of a ligature fistula
- Forecast and prevention
Symptoms of a ligature fistula
The development of a postoperative fistula occurs according to the following scenario:
- Within a few days after the operation, the wound area becomes denser, swells slightly, and becomes painful. The skin around it reddens and becomes hotter to the touch than other areas.
- After 6-7 days, with pressure, serous fluid and pus emerge from under the seam.
- The general body temperature rises to subfebrile values (37.5-38 °).
- The fistulous passage can spontaneously close, later reopen.
- Recovery is possible only after a second operation.
Complications arising from the appearance of a postoperative fistula
- An abscess is a cavity filled with pus;
- Phlegmon - the inclusion of subcutaneous fat in the inflammatory process;
- Eventration - loss of internal organs due to purulent tissue fusion;
- Sepsis - the spread of purulent contents in the chest cavity, skull, in the abdominal cavity;
- Toxic-resorptive fever - severe hyperthermia, as a reaction of the body.
Diagnostics
The primary diagnosis of a ligature fistula is carried out in the dressing room during a visual examination of the wound by a surgeon. To clarify the localization of the fistula, the presence or absence of complications (abscess, purulent leaks), ultrasound of the operating wound is performed.
If the fistula is located in the thickness of the tissues, and its diagnosis is difficult, fistulography is used. During the examination, a contrast agent is injected into the fistulous passage and an X-ray is performed. As a result of such manipulation, the fistulous course will be clearly visible on the X-ray.
Treatment of a ligature fistula
The vast majority of cases of ligature fistula can be resolved only through surgery. The longer a postoperative fistula exists, the more difficult it is to heal. For treatment, complex therapy is used with the use of medicines.
Groups of drugs used to treat fistula:
- Local antiseptics - water-soluble ointments (Levosin, Levomekol, Trimistan), fine powders (Gentaksan, Tyrozur, Baneocin);
- Antibacterial agents - Ampicillin, Norfloxacin, Ceftriaxone, Levofloxacin;
- Enzymes for the destruction of dead tissue - Trypsin, Chymotrypsin.
Since the drugs retain their effect for several hours, they are injected into the fistulous passage, spread over the tissues surrounding the wound several times a day.
Fat-based ointments (Syntomycin ointment, Vishnevsky's ointment) prevent the outflow of pus, therefore they are not used in the presence of extensive purulent discharge.
In addition to the surgical and medical treatment, physiotherapy is used:
- quartzing of the wound surface;
- UHF therapy.
As a result of the use of UHF therapy, microcirculation of blood and lymph improves, which leads to a decrease in edema and an end to the spread of infection. Quartzization has a detrimental effect on pathogenic bacteria, contributing to a stable remission of the process, although it does not guarantee a complete recovery.
The "gold standard" treatment for a ligature fistula is an operation that eliminates the problem completely.
The course of the operation to eliminate the ligature fistula:
- Three times treatment of the operating field with an antiseptic in the form of an alcohol solution of iodine.
- Injection of an anesthetic solution into the tissues around the surgical wound and under it (Lidocaine - 2% solution, Novocaine - 5% solution).
- Introduction of a dye into the fistulous tract in order to fully examine it ("brilliant green" and hydrogen peroxide).
- Dissection of the fistula, removal of the ligature completely.
- Removal of the cause of the appearance of the fistula along with the revision of the surrounding tissues.
- Stopping possible bleeding with an electrocoagulator or hydrogen peroxide 3%, since suturing a blood vessel can provoke a new fistula.
- Wound washing with antiseptics (Dekasan, 70% alcohol, Chlorhexidine).
- Closing the wound with sutures again with the installation of active drainage.
After the operation, the patient needs dressings and drainage flushing. If the purulent discharge is not fixed, the drainage is removed.
Medicines used in the presence of complications (phlegmonous inflammation of the cellulose, purulent streaks):
- Antibacterial agents;
- Non-steroidal anti-inflammatory drugs (NSAIDs) - nimesil, diclofenac, dicloberl;
- Ointments for tissue regeneration - troxevasin and methyluracil ointment;
- Herbal preparations with vitamin E (aloe, sea buckthorn oil).
Local revision of inflamed tissues with a wide dissection of the fistula is a classic form of surgical treatment of a postoperative fistula. Most minimally invasive techniques are ineffective in treating this complication.
Self-treatment of the ligature scar will not bring recovery, because only the operation and subsequent debridement of the wound can save the patient from complications. When trying to self-treatment, precious time will be lost.
Forecast and prevention
In cases of rejection by the body of surgical threads from any material, the prognosis of the operation is unfavorable. The same is the case with self-medication - in this case it is very difficult to make a forecast.
Preventive measures for the appearance of a fistula cannot be applied, since even with strict adherence to antiseptics, infection can enter the operating wound and suture material can be rejected.
The author of the article: Volkov Dmitry Sergeevich | c. m. n. surgeon, phlebologist
Education: Moscow State University of Medicine and Dentistry (1996). In 2003 he received a diploma from the Educational and Scientific Medical Center of the Presidential Administration of the Russian Federation.
