RU2291670C2 - Method for applying tensionless preperitoneal hernioplasty of umbilical, paraumbilical and midline hernia - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves introducing reticular polypropylene implant into preperitoneal position and attaching it to muscular aponeurotic part of the abdominal wall with minimum number of sutures. Reticular implant angles and sides are fixed with polypropylene sutures at the level of hernial defect middle part, that is, with 6-8 sutures. The reticular implant covers the hernial defect taking role of umbilical fascia loosing its function. The hernial defect is partially sutured in edge-to-edge way or not sutured in edge rigidity cases. The edges are additionally fixed to the reticular implant with several sutures in the latter case.

EFFECT: reduced risk of early stage postoperative complications and remote relapses.

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Description

The invention relates to medicine, namely to abdominal surgery and can be used in patients with umbilical, paraumbilical and hernias of the white line of the abdomen to be surgically treated, including in outpatient surgery by implanting synthetic mesh prostheses in the peritoneal space.

A known method of eliminating umbilical hernias by applying a mesh alloprosthesis over a hernial defect with fixation by a continuous suture over the edges of the defect. (Atlas of surgical hernia surgery. V.N.Egiev, K.V. Lyadov, P.K. Voskresensky. Medical practice - M., Moscow, 2003).

There is also a method of hernioplasty for umbilical hernias, even very large ones, by creating a duplicate of the aponeurosis, with the graft sewn in the form of a patch over the duplicate.

However, these methods have two significant drawbacks: firstly, the transplant takes a load of intra-abdominal pressure only in case of failure of the main autoplasty; secondly, located in the subcutaneous fat, it promotes the formation of seromas with their possible suppuration, long-term nonhealing fistulas, which is the reason for rejection. (V.V. Zhebrovsky, Mohammed Tom Elbashir. Surgery of abdominal hernias and eventions. "Business Inform", Simferopol, 2002).

Another method is known, consisting in the fact that the first stages of the operation are performed, as with autoplastic methods, and after dissection of the gate in the longitudinal direction and excision of their edges, as well as thinned tissues in the area of rectal diastasis, which, as a rule, is accompanied by complex forms of umbilical hernias, the peritoneum is separated from the vaginas of both rectus muscles by 3-4 cm and thorough hemostasis is performed. After this, the peritoneum is sutured edge to edge, for which sometimes it is necessary to use part of the hernial sac, not excising it completely. One edge of the graft is sutured with nodular U-shaped lavsan sutures from the inside to the back wall of the vagina of the rectus abdominis muscles along the entire circumference of the hernial defect, calculated on the subsequent creation of muscle-aponeurotic duplicate. Through sutures are placed on the other edge of the graft with access to the anterior vaginal wall of the rectus muscles. These U-shaped seams are tied last, after creating a duplicate. It is necessary to calculate in such a way that the transplant is completely spread, without folds (V.V. Zhebrovsky, Mohammed Tom Elbashir. Surgery of hernias of the abdomen and eventings. "Business Inform", Simferopol, 2002).

However, with all known methods, the implant is either located in the subcutaneous tissue, with all the negative consequences, or the hernial defect is dissected, the hernial sac is removed and only then the implant is laid and fixed around the entire circumference of the hernial defect.

The problem solved by the invention is the creation of a low-traumatic, reliable, easy to learn non-tensioning hernioplasty of the umbilical, paraumbilical and hernias of the white line of the abdomen with a hernia diameter greater than 2 cm, suitable for widespread use, including in outpatient herniology.

The technical essence of the invention lies in the fact that without dissecting the hernial gate and without opening the hernial sac, they mesh the polypropylene mesh implant preperitoneally, after separating the peritoneum from the aponeurosis, fix it with through seams at the corners and lateral parts at the level of the middle part of the hernia defect to the muscular aponeurotic part abdominal wall; after which the hernial defect is sutured to the joint, partially or not sutured with stiff edges, in the latter case, the edges of the hernial portal are additionally fixed with sutures to the implant.

As a suture material, a synthetic monofilament thread is used - polypropylene 2/0.

The method is as follows. Operation Technique. A skin incision was made transverse under the navel. At the base of the hernial sac, the aponeurosis was separated from the subcutaneous tissue at a distance of 2.5-3 cm from the edge of the hernial foramen. A thorough hemostasis was performed. The hernial sac was not opened if there was no need to revise its contents. The following techniques were used to place the mesh implant in the preperitoneal space. With relatively large hernias (3-4 cm), in which the hernial sac, entering the hernial defect, displaced the parietal peritoneum, and its peeling was not difficult. Pulling the hernial sac to the wound in one direction, in the opposite direction - the edge of the defect, lifting it, dissected the peritoneum from the white line and aponeurosis of the rectus abdominis muscles at the same distance as the subcutaneous tissue. In cases where the hernial sac in the area of the hernial gate was intimately fused with the umbilical ring (usually with small hernias), and the allocation of the preperitoneal space was difficult, the following technique was used. Retreating from the edge of the hernia gate by 0.3-0.5 cm, the aponeurosis was dissected to the peritoneum and without any difficulties stupidly peeled off the cut off umbilical ring with the peritoneum soldered to it. Then the hernial sac was immersed in the abdominal cavity. Between the peritoneum and the abdominal wall, a suitable size polypropylene mesh implant was placed in the prepared space. The principles of cutting and fixing were the same for all operations using polypropylene implants, taking into account the reduction in its subsequent area. The size of the mesh implant was selected so that its outer edges from the edge of the hernial defect were at a distance of at least 2.5-3 cm. The angles of the mesh implant and its lateral edges were fixed through the interrupted sutures at the level of the middle part of the hernial defect, i.e. maximally 6-8 seams are used. Seams are made as follows. Having departed from the edge of the net at least 0.8-1 cm, the needle is injected and punctured from the side opposite from the peritoneum. Then both threads are inserted into the eye of a large-sized needle, which pierces the muscular-aponeurotic part of the abdominal wall from the abdomen to the outside in a place corresponding to the size of the mesh. The outer sheet of the rectus sheath is stitched with one of the threads (in order to fix the suture to the abdominal wall) and the suture is tied. Then, in a similar manner, the next corner of the grid is fixed. The lateral edges of the mesh are fixed last at the level of the middle of the hernial defect. To do this, they are preliminarily taken onto the holders, so that when tightening the last seam at the corners, do not lose the edge of the grid. You can stitch and alternately from top to bottom, but the place of fixation of the side edges in this case, it is not always possible to accurately calculate. (Fig. No. 1-4).

The mesh implant reliably closes the hernial defect, playing the role of an umbilical fascia that has lost its function. The hernial defect after this is sutured edge to edge, partially or, with the stiffness of the edges, is not sutured. In the latter case, its edges are additionally fixed with several sutures to the mesh implant. The operation was completed traditionally. Drains in the subcutaneous tissue were not installed.

The same technique of hernioplasty was used when a umbilical cord and a hernia of the white line were combined with a close arrangement of hernia defects; in these cases, the implant was placed one under both hernia defects and was fixed according to the method already described.

In the Surgut Outpatient Surgery Center, in 81 (control group) patients with uncomplicated umbilical, paraumbilical and hernias of the white line of the abdomen, we performed traditional Mayo and Sapezhko hernioplasty and 124 (the main group) of patients - non-tensioned preperitoneal hernioplasty, which we proposed. The average age is 43.3 years. The indications for the use of non-tension hernioplasty with the indicated hernias were their most complex forms: the size of the hernial defect was more than 2-2.5 cm (79), recurrent hernias (13), and abdominal type of obesity (32). Operations in most cases were performed under local infiltration anesthesia. In 10.7% of patients with recurrent and complex forms of hernias, general anesthesia was used.

In the long-term period, in a control group of 81 patients with hernias who underwent traditional hernioplasty, 5 (6.2%) patients had recurrence of hernias. Restriction of physical activity was recommended for them from 2 to 4 months.

When examining patients who underwent non-tensile preperitoneal hernioplasty, all patients performed without restriction physical activity after 4 weeks, and no complaints were made. Despite the fact that non-tension hernioplasty was used in all cases in a more difficult situation, out of 124 patients of the main group, not a single recurrence of hernias was detected in the long-term period.

We give the following observation as an example. Patient L., born in 1965, was operated on for a 10-year-old period of umbilical hernia. A hernial defect of 3 cm in diameter, concomitant abdominal type obesity of 2 degrees, a patient of physical labor. Operated according to our proposed technique. Postoperative course without complications. Exercise without restriction is allowed to perform 4 weeks after surgery. Examined after 6 and 12 months. No complaints, notes good physical condition. Freely tolerates heavy loads. There is no recurrence of a hernia.

Thus, the developed method made it possible to achieve the goal - the creation of a less traumatic, reliable, easy to learn non-tensioning hernioplasty of the umbilical, paraumbilical and hernias of the white line of the abdomen with a hernia diameter greater than 2 cm, suitable for widespread use, including in outpatient herniology.

A brief description of the drawings, demonstrating the steps of the method of non-tensile preperitoneal hernioplasty of umbilical, paraumbilical and hernias of the white line of the abdomen.

Figure 1 shows the general principle of operation. The hernial sac is invaginated, the mesh implant is placed in the preperitoneal space, the principle of fixing the mesh implant through the suture.

Figure 2 demonstrates the principle of applying a through, fixing mesh seam. The hernial defect is not dissected, the hernial sac is immersed in the abdominal cavity with a tupfer. Having departed from the edges of 1 cm, over the upper corner the mesh is stitched from the side opposite from the peritoneum. Using a large needle, both threads are drawn through the muscular aponeurotic part of the abdominal wall from the side of the abdomen to the outside. Similarly, the remaining corners of the mesh implant and its lateral edges are fixed.

Figure 3 shows the step of completing fixation of the mesh implant. The implant is fixed at 3 angles and sides at the level of the middle part of the hernial defect. The fixation of the last lower corner is completed, the threads are not yet interconnected.

Figure 4 photograph of an operating wound. The implant is fixed. A propylene implant located preperitoneally is visible in the hernial defect.

Information sources

1. Atlas of operative hernia surgery. V.N. Egiev, K.V. Lyadov, P.K. Voskresensky; Medical practice - M, Moscow, 2003, - P.156.

2. V.V. Zhebrovsky, Mohammed Tom Elbashir. Surgery of abdominal hernias and eventings. "Business Inform", Simferopol, 2002, - S.176-177.

Claims (1)

The method of non-tensile preperitoneal hernioplasty of the umbilical, paraumbilical and hernias of the white line of the abdomen with a hernia diameter greater than 2 cm, characterized in that, without dissecting the hernia gate and without opening the hernial sac, the polypropylene mesh implant is placed preperitoneally, after separation of the peritoneum from the aponeurosis at the corners and lateral parts at the level of the middle part of the hernial defect to the muscle-aponeurotic part of the abdominal wall, after which the hernial defect is sutured to the joint, partially or not sutured with Riga the edges of the edges, in the latter case, the edges of the hernia gate are additionally fixed with sutures to the implant.

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