RU2228714C1 - Method for surgical treating giant ventral hernias - Google Patents

Abstract

FIELD: medicine, surgery. SUBSTANCE: the present innovation deals with plasty of anterior abdominal wall at treating giant ventral hernias. One should carry out partial intestinal resection, aponeurosis defect should be removed with the help of monofilamentous ladder-type carcass made due to successive suturing aponeurosis along wound's edge followed by taking the edges nearer to each other with cross- sectional sutures by taking carcass longitudinal filaments up that removes intraperitoneal hypertension and prevents hernial relapse. EFFECT: higher efficiency of operation. 2 dwg, 2 ex

Description

The present invention relates to medicine, namely to surgery, and can be used for simultaneous plastic surgery of the anterior abdominal wall with large and giant ventral hernias (SHG).

The most difficult section in surgery is the treatment of extensive and HHG.

The injuries of the proposed methods of hernioplasty, the difficulty in eliminating extensive defects of the abdominal wall with their own tissues, led to the development and implementation in surgical practice of various methods for replacing a hernial defect with transplants. The expansion of the possibilities of immunocorrection and the production of biologically inert synthetic materials gives the right to citizenship to this idea to date. However, the lack of a full framework of the abdominal wall when replacing a defect with a graft allows us to consider the proposed methods as palliative. In addition, a significant increase in abdominal pressure with irreducible hernias with a large volume (over 1500 cm ³ ) of hernial contents is the cause of frequent postoperative disorders (respiratory failure, hernioplasty failure).

Increased requirements for assessing the postoperative rehabilitation of patients from a position of quality of life require a revision of the requirements for the proposed methods.

So, the success of surgical treatment of SHG is determined by the following points:

1. the creation of optimal conditions for wound healing (prevention of wound infection, adequate microcirculation) [Tsoi, 1978, Toskin, 1982],

2. the use of inert high-strength grafts and suture material [Ballusek, 1976, Yatsenko, 1977, Shkrob, 1980, Shevchuk, 1981],

3. restoration of the anatomy of biomechanics and the function of the abdominal wall in the area of damage,

4. decrease in abdominal pressure.

The unsolved tactical and technical problems in SHG surgery determines the relevance of the planned invention.

The following methods of surgical treatment of ventral hernias were taken as an analogue.

A method for the surgical treatment of diastases of rectus abdominis muscles (Deryugina M.S. Patent No. 2069537 dated 10.31.91).

After excision of the excess stretched skin along with subcutaneous fat throughout the diastasis, the approach of the rectus abdominis is carried out by semi-submersible corrugating sutures, for which the medial edges of the vaginas of the rectus abdominis and its white line are sutured, folding into normal sizes. Alloplasty of weaknesses is carried out with finely porous lavsan threads, and first, with a single tape, they strengthen the white line of the abdomen, fixing it at the top to the lower edge of the sternum and xiphoid process, the lower one to the pubic joint, the lateral edges are sutured with a continuous suture all the way to the inner edges of the connected rectus muscles. The following tapes are fixed with a continuous suture along the entire length in the zones of tendon jumpers of the rectus muscles, lateral non-muscular spaces, aponeuroses of the lateral abdominal muscles. The ends of the ribbons are hemmed with separate sutures from lavsan in the epigastrium to the costal arches, the mesogastrium is attached to the edge of the aponeurosis of the latissimus dorsi through additional incisions, and in the hypogastrium, to the anteroposterior iliac spine.

Disadvantages:

1) The method does not provide for the reduction of intra-abdominal pressure.

2) The invasiveness of the method, involving the allocation of aponeurosis from the xiphoid process to the bosom and widely in the lateral direction.

3) Use for plastic a significant amount of absorbent porous polyfilament material.

As a prototype taken the method of treatment of ventral hernias proposed by V.D. Zatolokin and V.V. Lopukhin (VD Zatolokin, VV Polukhin. The invention of a “Method for the treatment of ventral hernias.” Copyright St. No. 1651866 A1 of 07.27.87).

Plastic surgery of the aponeurosis is performed without creating duplicate 8-shaped sutures, while each subsequent suture is displaced relative to the previous one in height and overlap each other, with these seams additionally stitching the aponeurosis at the same level in the immediate vicinity of the edges of the defect and tightening the sutures, combining the diverged leaves of the aponeurosis.

Disadvantages:

1) The method does not provide for the reduction of intra-abdominal pressure.

2) The use of an 8-shaped suture with a wide capture of the aponeurosis involves an increase in the distance between the centers of the sutures.

Objectives of the invention:

1. Improving the reliability of hernioplasty.

2. Prevention of a significant increase in abdominal pressure.

3. Elimination of extensive defects of the muscular-aponeurotic skeleton of the abdominal wall with their own tissues.

4. Definition of indications for intestinal resection in case of irreversible non-stiff hernias.

The essence of the proposed method consists in herniotomy, excision of the walls of the hernial sac, resection of the intestinal section with the mesenteric sector, taking into account the volume of the hernial contents, elimination of the hernial defect by creating a ligature skeleton performed by sequential longitudinal stitching of the edge of the hernial collar and bringing it together with Z-shaped transverse cross-seams between the transverse sutures between the sutures by myself.

For clarity, the method is illustrated in FIG. 1 and 2:

figure 1 presents the plasticity of the anterior abdominal wall with ventral hernias. Along the edge of the wound, frame threads are sewn, to bring the edges of the wound together, Z-shaped seams are applied with the capture of frame threads;

figure 2 - the final view of the staircase, Z-shaped seams are ligated.

The method is as follows. At the beginning, a hernial sac is dissected along the line of the previous postoperative scar. Loops of the intestine and omentum are separated from the hernial sac. The walls of the hernial sac are excised before aponeurosis.

Assessment of the volume of the contents of the hernial sac is carried out with muscle relaxation. The results of the study are taken into account when determining the required volume of bowel resection. The hernial gates, if necessary, are expanded taking into account the anatomical landmarks of the neurovascular bundles and the orientation of the muscle and aponeurotic fibers. Analyzing our own material, the protocols of intraoperative research, we can conclude that the isolated resection of the omentum, as a rule, is incommensurable with the volume of hernial contents with large sizes of hernias. When deciding on the resection of the small intestine, deserted or deformed sections of it are determined. Under the control of transillumination, the angioarchitectonics of the mesentery of the removed jejunum is examined. The intestinal artery and vein, with good visualization, cross at the base. After ligation of the arcade vessels, a section of the intestine is resected with the mesenteric sector. The criterion for the sufficiency of intestinal resection is its free immersion in the abdominal cavity. The continuity of the small intestine is restored by a single-row end-terminal anastomosis. Then, departing from the edge of the defect by 1-3 cm, along the fascial vagina of the abdominal muscles, the aponeurotic case of the muscles is sutured without grasping the lavsan polyfilament or double monofilament threads 1. The thread is carried out extraperitoneally through the aponeurosis 3 taking into account its blood supply 4 from both sides of the defect. The distance between the stitches is 1.0-1.5 cm, while the surface loop of the thread should be well visualized. The distance between the puncture site of the free ends of the opposite threads is not more than 1 cm. The free ends of the frame threads are tightened with the help of the manual approach of the edges of the hernia and tied. The adaptation of the edges of the aponeurosis is carried out by Z-shaped sutures 2 with the capture of longitudinal frame threads. Start a Z-shaped seam at a distance of 0.5-1.0 cm outwards from the frame thread. Convenient is the first overlay of the middle seam. Then flush the edges of the defect (Fig. 1). After 1.0-1.5 cm towards the middle, the next seam is applied. The number of such joints is determined by the extent of the defect (on average 5 joints per 10 cm). To reduce tension, ligation of Z-shaped joints is performed after distal sutures are applied and the edges of the defect come closer (Fig. 2).

The method was tested on 248 patients. Data for hernia recurrence was not observed. In 12 patients with large recurrent ventral hernias, restoration of the skeleton of the abdominal wall did not require bowel resection. In 9 patients operated for the prevention of intra-abdominal hypertension, resection was performed from 50 to 80 cm of the small intestine with the mesentery and part of the omentum. In 3 patients, hernioplasty was supplemented with left-sided hemicolectomy, in 2 patients with colon resection. The expansion of the intervention was justified by a number of indications: a predisposing moment of excessive colon mobility and, as a result, additional loop formation of the sigmoid colon (type 2 structure), the location of the sigmoid colon in the hernial cavity led to its structural changes, colostasis syndrome was clinically observed in patients. Therefore, for the prevention of intra-abdominal hypertension, the method of resection of a structurally and functionally changed left half of the colon was chosen. There were no fatal outcomes. In 2 patients in the early postoperative period, suppuration of subcutaneous tissue was revealed.

In the observation period from 1 to 15 years, relapses (defects less than 2 cm) in the plastic zone were twice detected. Relapse was associated with a violation of the integrity of the frame due to the untying of 1 Z-shaped seam.

Example 1: Patient O., 58 years old, was admitted to the hospital with a diagnosis of giant irreducible postoperative (appendectomy, complicated by suppuration of the postoperative wound), ventral hernia. Sick for 12 years, surgical treatment has been repeatedly proposed. In the past 2 years, he has noted a clinic of partial intestinal obstruction, which served as the reason for the last hospitalization. Objectively: a hernial protrusion 30 × 25 × 15 cm in size is located in the right lateral iliac, meso- and hypogastric regions. The skin is thinned with contouring of the peristalsis. Operated on 03/26/99 after opening the hernial sac and its subsequent preparation, the sizes of the hernial defect were determined: 22 × 11 cm. The data of the intraoperative study were consistent with the results of ultrasound. The plane commissures fixing the loops of the small intestine in the hernial sac and between each other are disconnected. In the area of the jejunum up to 25 cm, the mesenteric margin is deserted. The mesentery of the small intestine located in the hernial sac is swollen with traces of previous strangulation (lymphostasis, fibrosis). The large volume of hernial contents when immersed in the abdominal cavity under conditions of muscle relaxation did not allow forcibly to reduce the edges of the aponeurosis. It was decided to reduce the volume of the contents of the abdominal cavity due to the resection of the deserted portion of the small intestine and the injured omentum. Under the control of transillumination, the angioarchitectonics of the deserted portion of the small intestine was studied. At the base 2 intestinal arteries are bandaged. Then, arcade vessels were crossed along the blood line, a section of the jejunum (30 cm) with the mesenteric sector was resected. In total, the volume of the resected intestine corresponded approximately with the volume of the hernial sac. Formed single-row end-terminal small intestinal anastomosis with the restoration of the mesentery. Through a hernial defect, an examination of the abdominal organs was performed, pathological adhesions disrupting intestinal mobility were disconnected. The edges of the aponeurosis with suture material were cut extremely economically (in two places with paraligature abscesses). Aponeurosis up to 4 cm was separated along the perimeter of the hernial defect. On both sides of the muscle-aponeurotic defect of the abdominal wall, along the fibers of the external oblique muscle of the abdomen, departing from the edge 3-4 cm, sewn extraperitoneally with stitches double monofilament polypropylene suture (cross-section) 0.40 mm On the tops of the aponeurotic defect, the opposite ends of the stitched threads are taken to the holders and pulled up to lift the abdominal wall. Further adaptation of the edges of the muscle defect was performed using transverse Z-shaped sutures with the capture of longitudinal sewn threads into the loop. The distance between the transverse lines of the seams is up to 15 mm. A slight simultaneous pull-up of the formed sutures provides unhindered adaptation of the aponeurotic edges. First of all, frame longitudinal seams were tied, then alternately Z-shaped. The control of hemostasis of the subcutaneous vessels. Skin scars and its overgrown areas were excised. Transit perforated tubular drainage with a clearance of 6 mm was installed at the bottom of the wound. Layer wound closure. Flush control of the flushing system. Aseptic sticker. The postoperative period was uneventful. On day 9, transit drainage was removed from subcutaneous fat. On the 11th day the patient was discharged from the hospital. Examined after 6 and 12 months, recurrence of a hernia was not detected.

Example 2. Patient S., 55 years. Received on September 18th. 99 with a diagnosis of giant postoperative ventral hernia. Functioning colostomy. 20 years ago, a rectal extirpation, colostomy was performed for a rectal tumor (accompanying documents are absent). The postoperative period was complicated by suppuration of the surgical wound. According to the patient, the wound was sanitized for 1.5 months, after which the patient noticed a change in the shape of the abdomen. The size of the hernia increased gradually. In the last 2 years notes difficulty in bowel movements, periodic pain throughout the abdomen. Objectively: an irreducible hernial protrusion is determined in the left lateral and iliac regions with a transition to the mesogastric region measuring 35 × 20 × 15 cm. A sigmostoma is located at the top of the hernial protrusion (10 cm to the left of the navel). On the midline in the meso- and hypogastrium is the postoperative scar. In the course of the scar, two aponeurosis defects are determined up to 3 cm in size.

Operated on 09/22/1999. Under the TBA bordering incision, retreating 1 cm from the edge of the sigmostomy, the skin is dissected. An intestinal fistula is hermetically sealed with a continuous suture using a skin flap. A hernial sac is transversely dissected. The contents of the bag are a conglomerate of loops of the small intestine, omentum and sigmoid colon. The aponeurosis defect is located in the lateral region and the mesogastrium 15 × 10 cm in size, a large volume of hernial contents, limited access for examination of the abdominal organs. The presence of defects of the aponeurosis in the midline served as indications for the implementation of median laparotomy. After separation of numerous adhesive adhesions in the left ileal region, an infiltrate was formed, formed by the vermiform appendix, terminal ileal loop, omentum. When the infiltrate is separated, the ileum is deserted. No evidence of recurrence of tumor growth has been identified. Performed appendectomy, resection of the ileum, single-row end-to-end anastomosis. The distal part of the sigmoid colon is resected. A section of the descending intestine was prepared for the formation of a colostomy. The stoma location was determined: the level of the left lateral canal is in the middle of the distance between the iliac crest and the costal arch.

The edges of the aponeurotic defect are exempted from ligatures, separated from the fiber along the perimeter up to 4 cm. On both sides of the muscle-aponeurotic defect of the abdominal wall, along the fibers of the external oblique muscle of the abdomen, departing from the edge 3-4 cm, double monofilament thread is sewn extraperitoneally with stitches. On the tops of the aponeurotic defect, the opposite ends of the stitched threads are taken on the holders. Adaptation of the edges of the muscle defect is performed using transverse Z-shaped sutures with the capture of longitudinal sewn threads into the loop. The distance between the transverse lines of the seams is about 10 mm. First of all, frame longitudinal seams were tied, then alternately Z-shaped. Control of hemostasis. Skin scars and its overgrown areas were excised. Transit perforated tubular drainage with a clearance of 6 mm was installed at the bottom of the wound. Layer wound closure. The tightness control of the washing system was performed. Similarly, the median wound is sutured.

Aseptic sticker. The postoperative period was uneventful. On day 9, transit drainage was removed from subcutaneous fat. On the 11th day the patient was discharged from the hospital. Examined after 6 and 12 months, hernia recurrence was not detected.

Using the method allows to achieve the cure of patients with large ventral hernias and significantly reduce the frequency of relapse of the disease. The high functionality of the operation consists in the prevention of intra-abdominal hypertension with the help of intestinal resection and the use of own tissues of the abdominal wall reinforced with a monofilament frame. Thus, the application of the method leads to a quick and reliable recovery of this complex group of patients, their social and mental rehabilitation, provides them with a high quality of life.

Claims (1)

A method for the surgical treatment of giant ventral hernias, including excision of the walls of the hernial sac and plastic surgery of the aponeurosis, characterized in that partial intestinal resection is performed, and the aponeurosis defect is eliminated with the help of the created monofilament staircase scaffold, performed by sequentially flashing the aponeurosis along the margin of the wound, followed by the edge Z, with -shaped seams with the capture of frame longitudinal threads.

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