RU2226992C1 - Method for carrying out hernioplastic repair - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves additionally introducing instrumental trocar via pierce at 10-20 cm distant from hernial gate on the same side with laparoscope relative to hernial defect. Ligature end is brought into the abdominal cavity via hollow direct needle and hold with endoclamp brought via the instrumental trocar. The distal end of the needle is brought out into the subcutaneous fat. The needle is moved along the subcutaneous fat passing the hernial sack and piercing it into the opposite hernial gate edge. Wire loop is introduced into the needle. Ligature end hold with the endoclamp is brought into the loop and the loop is withdrawn with the ligature. The needle is removed. EFFECT: improved cosmetic effect. 3 dwg

Description

The invention relates to medicine, more specifically to the surgical treatment of hernias of the anterior abdominal wall.

External abdominal hernia is one of the most common surgical diseases and occurs in 3-7% of the population, i.e. more than 50 out of 10,000 people. Umbilical hernias make up 3-5% of the total number of hernias, hernias of the white line of the cattle - 2-4%, postoperative hernias up to 21% (Toskin KD, Debrovsky V.V. Hernias of the cattle. - M., 1983, Toskin K.D., Khebrovsky B.V. Hernia of the brow wall. - M, 1990, Cherenko MP and other Abdominal hernias. - Kiev, 1995).

To date, there are no alternatives to surgical treatment of hernias.

There is a method of plastic surgery of correctable umbilical hernias, hernias of the white line of the abdomen, postoperative hernias, diastasis of the rectus muscles, in which after cutting the skin, subcutaneous tissue, highlighting the edges of the hernial defect, the hernial sac is either repaired or excised, and the hernial defect is sutured with separate interrupted sutures (Rusakov V . I. Fundamentals of Private Surgery. - Publishing House of Rostov University, 1975, v. 1, p. 192, 194).

The disadvantages of the method is the need for percutaneous access, which significantly increases the invasiveness of the intervention, and therefore the risk of purulent complications in the postoperative period. Through a relatively small laparotomic wound, it is impossible to conduct a complete revision of the abdominal organs. The cosmetic effect of the operation also leaves much to be desired.

Golovatsky B.V. He suggested using laparoscopic hernioplasty with subcutaneous sutures in the treatment of uncomplicated ventral hernias. In this case, a laparoscope is inserted into the abdominal cavity at a distance of 6-8 cm from the edge of the hernial portal. After examining the abdominal cavity, a large length cutting needle with a ligature under the control of a laparoscope is inserted along the edge of the hernial portal into the abdominal cavity and is brought out from the opposite side. Without removing the threads, the needle is again inserted into the outlet, carried out in the subcutaneous tissue over the aponeurosis and withdrawn into the first hole. Thus, with an interval of 1.5-2 cm, the required number of sutures is applied along the entire hernia gate. The threads are tightened, the nodes are immersed through the outlet holes under the skin. A control examination of the hernia gate is carried out, a laparoscope is removed. The wound on the skin is sutured. If the width of the hernia gate is greater than the length of the needle, make an intermediate puncture and injection in the middle of the hernial sac. (Golovatsky B.V. Laparoscopic hernioplasty. // Clinical surgery. - 1988. - No. 2. P.76.)

The disadvantage of this method is the need to make several additional punctures and injections on the skin, which worsens the cosmetic effect, prolongs the time of surgery and increases the risk of purulent complications. The need to conduct a long, poorly controlled needle through the abdominal cavity is fraught with the danger of damage to the abdominal organs.

The objective of the invention is to simplify the ligature, and therefore shortening the time of the operation, the development of a safer method of ligature, improving the cosmetic effect of surgery.

The task is achieved by the fact that they additionally inject the instrumental trocar through a puncture at a distance of 10-20 cm from the edge of the hernial gate from the same side with respect to the hernial defect as the laparoscope, the end of the ligature is fed into the abdominal cavity through a hollow straight needle and is held with endo-clamp, fed through the instrumental trocar, the distal end of the needle is removed into the subcutaneous tissue, a needle is passed through the subcutaneous tissue, bypassing the hernial sac, and a needle loop is injected into the opposite edge of the hernial gate, a wire loop is inserted into the needle, the end of the ligature, held by the end clamp, is fed into the loop and the loop with the ligature is removed, the needle is removed.

The novelty of the method lies in the use of a straight hollow needle, once injected into the skin for each ligation, to draw a wire loop through the lumen of the needle, with which the end of the ligature is removed from the abdominal cavity, which facilitates the ligature, simplifies and makes safer management of sharp the end of the needle in the abdominal cavity, allows you to reduce the number of wounds on the skin several times.

The invention is illustrated by drawings, where:

Figure 1 presents a section of a hernial defect with a needle inserted into the aponeurosis edge and a ligature passed through it;

Figure 2 is a section of a hernial defect with a needle drawn along the subcutaneous tissue and inserted into the opposite edge of the hernial defect and a loop held therein;

Figure 3 is a section of a hernial defect after tightening the suture and immersing it under the skin.

The essence of the method is as follows.

The patient lies on his back. Under anesthesia, according to one of the generally accepted methods, a laparoscope is inserted into the abdominal cavity at the most convenient point for visualizing hernial gates. At the most convenient point for further manipulation, from the same side with respect to the hernial defect as the laparoscope, an instrumental trocar is introduced at a distance of 10-20 cm from the edge of the hernial portal. An audit of the abdominal organs is performed. In the event that any organ is fixed to the hernial sac, the adhesions are dissected. When a preperitoneal lipoma is detected, the latter is excised with the hernial sac and removed from the abdominal cavity through an instrumental trocar. A thick long straight hollow needle with a ligature inside pierces the skin, subcutaneous tissue, the edge of the hernial defect. The end of the ligature, inserted into the abdominal cavity, is captured by the end clamp. In this case, the second end remains in the hand of the assistant. The distal end of the needle is discharged into the subcutaneous tissue and at the right angle is passed through the subcutaneous tissue, bypassing the hernial sac, to the opposite edge of the hernial defect and is inserted into the abdominal cavity through it. A wire loop is inserted through the needle, which opens due to the elasticity of the wire. The end of the ligature, held by end-clamping, is held in the loop formed. The loop with the ligature through the lumen of the needle is displayed on the anterior abdominal wall. The needle is removed. Similarly, with an interval of 1-1.5 cm, the required number of sutures is applied along the entire hernia defect. After reducing the tension of the pneumoperitoneum under visual control, the threads are tied and tightened to the edges of the hernial defect with the immersion of the nodes under the skin through the injection site. After desufflation, the trocars are removed. Trocar wounds are twisted with interrupted sutures.

Example.

Patient Danilov G.M. Born 1950, medical history No. 179/54. He entered the department on January 14, 2002 with complaints of the presence of hernial protrusion in the umbilical region, periodic pulling pains in it. The presence of hernial protrusion is noted throughout the year; over the past month, education has significantly increased in size. Objectively: in the umbilical region, a correctable, soft-elastic, almost painless hernial protrusion of up to 3 cm in diameter. The skin above it is not changed.

Diagnosis: Reinforced umbilical hernia.

After examination on January 15, 2002 at 8 hours 45 minutes laparoscopic hernioplasty was performed. Under endotracheal anesthesia at a distance of 15 cm from the lower edge of the hernial portal, a laparoscope was inserted into the abdominal cavity along the midline. When revising effusion, changes in the peritoneum, gross organ pathology was not detected. On the anterior abdominal wall in the projection of the umbilical ring, a rounded hernia defect with a diameter of 2 cm. The hernial sac is empty. At the level of introduction of the optical trocar, an instrumental trocar was introduced along the left pararectal line. The scarred hernia sac along with the preperitoneal lipoma freely sets into the abdominal cavity. The hernial sac and preperitoneal lipoma were excised using mono- and bipolar coagulation and removed from the abdominal cavity through an instrumental trocar. A thick long straight hollow needle with a ligature inside punctured skin, subcutaneous tissue, the left edge of the hernial defect. The end of the ligature is captured by the end clamp. The second end is in the assistant’s hand. The distal end of the needle is brought out into the subcutaneous tissue, along it passed to the opposite edge of the hernial defect and inserted into the abdominal cavity. A wire loop is inserted through the needle. An end-clamped end of the ligature was held into the loop. The loop with the ligature through the lumen of the needle brought to the front abdominal wall. The needle is removed. Similarly, two more stitches were laid. One is 0.5 cm higher and one is 0.5 cm lower than the hernial defect. Control of hemostasis. After reducing the tension of pneumoperitoneum to 4 mm Hg under visual control, the threads are tied and tightened to the edges of the hernial defect with the immersion of nodes under the skin through the injection site of the needle. After desufflation, the trocars are removed. Trocar wounds are twisted by interrupted sutures. Aseptic dressing. The duration of the operation is 25 minutes.

At 16 hours, the patient walks around the department on his own. He refused to administer painkillers. The postoperative period was uneventful. January 17, 2002, the patient was transferred to treatment in the regime of a day hospital. Postoperative wounds healed by first intention. Skin sutures were removed on January 22, 2002. There are no complaints.

Thus, in the MPLU "City Clinical Hospital No. 22", Novokuznetsk, 7 patients were operated on. Complications and relapses during observation up to 1.5 years were not observed.

Claims (1)

The method of hernioplasty, including suturing the hernia gate through the skin by submersible interrupted sutures, ligating with a needle injected along the edge of the hernia defect into the abdominal cavity and re-injecting it into the opposite edge of the hernia defect, and introducing the ligature outward under the control of a laparoscope, characterized in that the trocar through a puncture at a distance of 10-20 cm from the edge of the hernial gate from the same side with respect to the hernial defect as the laparoscope, the end of the ligature is fed into the abdominal cavity through a hollow straight needle and held with an endo-clamp fed through an instrumental trocar, the distal end of the needle is removed into the subcutaneous tissue, a needle is inserted through the subcutaneous tissue, bypassing the hernial sac, and a wire loop is inserted into the opposite edge of the hernia gate, the end of the ligature is held by the endo-clamp , served in the loop and remove the loop with the ligature, the needle is removed.

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