RU2348363C2 - Ventral hernia alloplasty procedure - Google Patents

Abstract

FIELD: medicine; surgery.

SUBSTANCE: adhesion barrier is used as abdominal cavity protector from allogenic implant. It is fixed within two levels: the first level includes implant on the periphery of hernia defect, then adhesion barrier and aponeurosis edge. The second level involves implant and aponeurosis edge.

EFFECT: procedure eliminates immediate contact of allograft and free abdominal cavity, reduces reactive tissue processes, simplifies fixation of barrier and implant.

2 ex, 4 dwg

Description

The invention relates to medicine, namely to abdominal surgery, can be used for the prevention of adhesive disease with allo- and xenoplasty in patients with ventral hernias.

To date, there are known methods of protecting the abdominal cavity with alloplasty with sections of the transverse fascia or parietal peritoneum, mobilization and fixation of a large omentum along the edges of an existing defect.

With alloplasty of ventral hernias using various mesh prostheses, methods of fixing an allograft on the surface of previously connected sections of the parietal peritoneum or transverse fascia are used. Due to the use of this type of non-tensile plastic surgery of ventral hernias, which allows creating favorable conditions for biomechanics of the abdominal cavity, preventing the formation of fluid accumulations in the allograft area, gross morphological changes from the muscles of the anterior abdominal wall (Pat. RU 2199271. Hernia of the abdominal wall. K. Toscin. February 27, 2003; Patent WO 0185058, November 15, 2001. KINGLE U. Functional and morphological evaluation of a low-weight, monofilament polypropylene mesh for hernia repair. J. Biomed. Mater. Res. 2002; 64 (2); 129 -36; application 2004122966/14 (RU) Sedov V.M. Method of plastic surgery of postoperative ventral hernias).

The disadvantage of this method is the often developing deficiency of the parietal peritoneum and transverse fascia during surgical treatment of giant hernias, the risk of possible infection of the abdominal cavity through defects of the associated parietal peritoneum

Plastic surgery of ventral hernias with allogeneic materials with additional protection of the abdominal cavity by a strand of a pre-mobilized omentum allows you to fence off the free abdominal cavity with a deficiency of the parietal peritoneum from a foreign transplant, which in turn reduces the level of development of a possible undesirable reaction, even when using inert materials. This method also allows the use of options for non-tensioned hernioplasty with the prevention of abnormalities in the biomechanics of the abdominal cavity, accumulation of serous fluid, reduces the likelihood of adhesions and the possibility of infection of allogeneic material (Non-tensioned hernioplasty under the general editorship of EGIEVA V.N.M .: Medpraktika, 2002, p. 112-113; application 2003113309/14 (RU) Nosov V.G. Method for surgical treatment of postoperative ventral hernias).

The disadvantage of this method is a possible omentum deficiency with extensive hernial defects, high tropism for adhesions between the omentum of the parietal peritoneum and intestinal loops.

The purpose of our invention is the prevention of commissural disease of the abdominal cavity through the use of a specific absorbable anti-adhesion barrier as a protective agent for non-tensile intraperitoneal alloplasty of giant and extensive hernias of the anterior abdominal wall in conditions of deficiency of the parietal peritoneum and transverse fascia, of a pathologically altered omentum.

Our method is effective, reliably protects the abdominal cavity during intraperitoneal non-tensioned hernioplasty with allogeneic implants in case of extensive and giant ventral hernias in conditions of deficiency of autogenous tissues, such as parietal peritoneum, transverse fascia, omentum. The method of applying this barrier allows to reduce the likelihood of adhesions between the contents of the abdominal cavity and the implant in the postoperative period and maintain acceptable biomechanics of the abdominal wall, in this regard, improve the quality of life of patients undergoing hernioplasty for ventral hernia.

The technical result is achieved by the fact that during the main stage of plasticity of the hernial defect with an allogeneic implant, simultaneous intraperitoneal fixation of the absorbed anti-adhesion barrier is performed, for example, GYNECARE INTERCEED, manufactured by Ethikon, along the edges of the hernial defect and to the implant. As a result, direct contact between the allograft and the free abdominal cavity is excluded, which leads to inhibition of fibroblast migration to the area of damage to the peritoneum, normalization of re-epithelialization processes, the formation of mesothelial complexes and inhibition of the formation of fibrin structures between the intestinal loops and the implant.

The method is as follows. An incision is made in the skin and subcutaneous fat over the hernial protrusion, a hernial sac is isolated, the walls of which are scar-modified parietal peritoneum and transverse fascia (Figs. 3-5, 6). The hernial sac is opened, the adhesions are divided between its walls and the contents of the abdominal cavity. The edges of the hernial defect are mobilized, visual and instrumental revision of the abdominal cavity is performed. The size of the hernia defect is established, the size of the allogeneic implant is selected so that its edges extend beyond the edge of the hernia defect by 3-5 cm. The plate of the absorbable anti-adhesion barrier is cut out in accordance with the contour of the allogeneic implant, exceeding the latter by 3-4 cm above the edges (Fig. 3-11, 12). The anti-adhesion barrier (Figure 1-2) is fixed intraperitoneally with U-shaped sutures on a long thread (Figure 1-1) simultaneously to the aponeurosis and allograft at 4-6 points from the edge of the hernial defect (Figure 2-3). Thus, the two stages of surgical intervention are reduced to one, which reduces the time spent by the patient on the operating table. Next, an additional fixation of the allogeneic implant is made along the perimeter of the hernial defect with a continuous suture of a non-absorbable thread on an atraumatic needle (Figure 3-10). The remaining tissues of the hernial sac and subcutaneous fat along with the superficial fascia (Figure 3-8) are sutured over the implant and sutured to the skin. Pre-installed vacuum drainage, which is brought to the implant and subcutaneous fat.

On the 2nd day, drainage is removed, and on the 3-4th day of the postoperative period, an ultrasound examination of the anterior abdominal wall and abdominal cavity is performed in order to clarify the presence or absence of any fluid structures in the subcutaneous fat (Figure 3-8 Figs. 4-13, 14), the muscle structures of the anterior abdominal wall (Figs. 3-7; Figs. 4-7), visualizing the location of the allogeneic implant and the anti-adhesion barrier (Figs. 4-3, 2), assessing the level of peristaltic contractions intestines.

In this case, additional research methods in the postoperative period are used in the required volume.

Our method allows us to effectively protect the abdominal cavity from the pronounced development of the adhesion formation process, reduce the time of surgical intervention at the plastic stage, and reduce the intensity of the postoperative pain syndrome.

Case Study No. 1

A 52-year-old patient B. was admitted to the surgical department No. 1 of the Road Clinical Hospital at Voronezh Station 1 of Russian Railways on 03.04.06, with complaints of recurrent abdominal pain, protrusion in the area of the postoperative scar of the anterior abdominal wall, manually adjusting to the abdominal cavity. In 2004, he was operated on for a penetrating knife wound of the abdominal cavity, a protrusion appeared a few months later. Signs of infringement is not noted. Marks several cases of adhesive partial obstruction. History of intermittent increase in blood pressure. Drug intolerance is not revealed. Upon receipt of the skin of normal color, the peripheral nodes are not enlarged. P / o scar along the white line 20 × 1.0 cm, in s / 3 defects 4 × 6 cm and 4 × 3 cm, the edges are clearly pronounced. There are no changes in the general blood test, glucose - 5.5 mmol / l, ASAT - 25 units / l, ALAT - 26.3 units / l, total bilirubin - 11.7 mmol / l, blood amylase - 112 units. / l ECG - sinus rhythm, EOS is not rejected, violation of intraventricular conduction. Signs of left ventricular hypertrophy with changes in the myocardium of the lateral wall, supraventricular extrasystole. 04/05/06 consulted by a cardiologist - hypertension 2 tbsp., Supraventricular extrasystole.

Operated on 04/06/06, after correction of concomitant cardiovascular pathology. Laparotomy, hernia repair, plastic surgery of the anterior abdominal wall by a prolene mesh were made under the cover of an absorbable anti-adhesion barrier according to the method described above.

Control ultrasound of the anterior abdominal wall and abdominal cavity from 04/08/06 - with ultrasound in the projection of the area of the middle of the scar of the delimited fluid formations were not detected. At a depth of 5.8 cm from the skin, a hyperechoic structure (grid) is determined, to which actively re-circulating loops of the small intestine are attached. Free fluid in the abdominal cavity and subcutaneous tissue was not detected. From 10.04.06 there are no changes in the general blood test, glucose - 5.0 mmol / l, ASAT - 23 units / l, ALAT - 25 units / l, total bilirubin - 11.4 mmol / l, blood amylase - 30 units / l

The seams are removed. Discharged in satisfactory condition 04/17/06

Diagnosis: Postoperative ventral hernia of the anterior abdominal wall. Adhesive disease of the abdominal cavity. Hypertension 2 tbsp., The risk of MTR 3. Supraventricular extrasystole.

Stay in the hospital after surgery - 10 days.

The application of the described method eliminated the early signs of adhesive disease of the abdominal cavity, reduce the risk of unwanted hyperergic reactions from the abdominal organs. Rapid restoration of the biomechanics of the abdominal wall by reducing the intensity of the pain syndrome, which is associated with a reduction in the patient's time on the operating table. In a particular case, this led to a quick recovery of disability.

Example No. 2 of the use of the proposed method

Patient N., 77 years old, was admitted to the surgical department No. 1 of the Road Clinical Hospital at Voronezh Station 1 of Russian Railways on 22.06.06 with complaints of abdominal pain, protrusion in the area of the postoperative scar in the right lumbar region without signs of infringement. In 2001, she was operated on for calculus of the right kidney, a few months later a protrusion appeared. A history of periodically increased, hypertension, urolithiasis, removal of uterine fibroids. Signs of adhesive disease of the abdominal organs, for which I have repeatedly received conservative therapy. Drug intolerance is not revealed. Upon receipt of the skin of normal color, the peripheral nodes are not enlarged. In the right lumbar region, a formation of up to 25 cm in diameter of a soft-elastic consistency is determined, partially corrected in the abdominal cavity, painless. The symptom of a cough push is positive. Hernia gate up to 10 cm in diameter. There are no changes in the general blood test, glucose -5.4 mmol / l, ASAT-53 units / l, ALAT-69 units / l, total bilirubin - 11.2 mmol / l, blood amylase - 71 units / l . ECG - sinus rhythm, EOS horizontal position. 06/27/06 Consulted by a cardiologist - atherosclerotic cardiosclerosis.

Operated on 06/29/06, hernia repair, appendectomy, plastic surgery of the anterior abdominal wall by a prolene mesh under the cover of an absorbable anti-adhesion barrier were performed according to the method described above.

Control ultrasound of the anterior abdominal wall and abdominal cavity from 07/03/06 - with ultrasound in the lower corner of the wound at the site of the drainage, there is a limited fluid formation 38 × 6 × 27 mm in size. At a depth of 4.2 cm from the skin, the fragments determine the hyperechoic structure (mesh) to which the peristaltic loops of the small intestine are attached. Free fluid in the abdominal cavity was not detected. From 07.07.06 there are no changes in the general and biochemical analysis of blood.

Vacuum drainage removed on the 5th day. The seams are removed. Discharged in satisfactory condition on 07/11/06

Diagnosis: Postoperative ventral hernia. Adhesive disease of the abdominal cavity. Atherosclerotic cardiosclerosis.

Stay in hospital after surgery - 12 days.

The application of the described method significantly reduced the signs of adhesive disease of the abdominal cavity, reduced the frequency of undesirable hyperergic reactions from the abdominal organs, prevented infection of the abdominal cavity, and ensured earlier restoration of biomechanics of the anterior abdominal wall by reducing the time of surgery.

The application of our method allowed to significantly reduce the signs of adhesive disease of the abdominal cavity, to reduce the frequency of undesirable hyperergic reactions from the organs of the abdominal cavity. By reducing the time of surgical intervention, there was a decrease in the intensity of postoperative pain syndrome, which allowed to ensure earlier restoration of biomechanics of the anterior abdominal wall, as well as reducing the likelihood of developing undesirable postoperative complications.

Bibliography

1. Hernias of the abdominal wall. / Toskin K.D.// M .: Medicine, 1990, p.180-183, 209-214.

2. Tension-free hernioplasty under the general editorship of Egiev V.N. / Egiev V.N. // M .: Medpraktika, 2002, p.112-113.

3. Pat No. 2270614 (RU) Method of plastic surgery of postoperative ventral hernias. / Sedov V.M., Tarbaev S.D., Gostevskaya A.A. 2006.02.27.

4. Pat. No. 2241383. RU. A method for the surgical treatment of postoperative ventral hernias. / Nosov V.G., Usov S.A. 2004.12.10.

5. WO. 0185058. Functional and morphological evaluation of a low-weight, monofilament polypropylene mesh for hernia repair. / KINGLE U.// J. Biomed. Mater. Res. 2002; 64 (2): 129-36.

A brief description of the drawings.

Figure 1. Simultaneous implantation of an allogeneic transplant and an anti-adhesion barrier.

Figure 1-1: U-shaped seams on a long thread;

Figure 1-2: anti-adhesion barrier;

Figure 1-3: intraperitoneal simultaneous fixation to the aponeurosis and allograft at 4-6 points from the edge of the hernial defect.

Figure 2. View of the surgical wound before suturing of the subcutaneous tissue.

Figure 2-2: anti-adhesion barrier;

Figure 2-4: allogeneic implant;

Figure 2-3: intraperitoneal simultaneous fixation to the aponeurosis and allograft at 4-6 points from the edge of the hernial defect.

Figure 3. The final view of the surgical wound (frontal projection).

Figure 3-5: scar-modified parietal peritoneum;

Figure 3-6: transverse fascia;

Figure 3-7: muscle structure of the anterior abdominal wall;

Figure 3-8: subcutaneous fat;

Figure 3-9: stitched over the implant remaining tissue of the hernial sac and superficial fascia; U-shaped sutures, fixing simultaneously allogeneic implant with an anti-adhesion barrier located under it;

Figure 3-10: fixation of the allogeneic implant around the perimeter of the hernial defect with a continuous suture;

Figure 3-11: plate absorbable anti-adhesive barrier;

Figure 3-12: the excess of the allogeneic implant by the contour of the plate of the absorbable anti-adhesion barrier at the edges by 3-4 cm.

Figure 4. Ultrasound of the anterior abdominal wall on the 3rd day of the postoperative period

Figure 4-13: the presence of fluid structures in the subcutaneous fat;

Figure 4-14: the absence of fluid structures in the subcutaneous fat;

Figure 4-3: allogeneic implant;

Figure 4-7: muscle structure of the anterior abdominal wall;

Figure 4-2: anti-adhesion barrier.

Claims (1)

A method of protecting the abdominal cavity during surgical treatment of giant ventral hernias by the alloplastic method, characterized in that they use an anti-adhesion barrier as a protective agent to protect the abdominal cavity from an allogeneic implant, the fixation is carried out in two levels: the first is an absorbable anti-adhesion barrier plate is cut in accordance with the allogeneic contour the implant, exceeding the latter at the edges by 3-4 cm, fix them to each other with U-shaped seams; the second is immersed intraperitoneally on a long thread, fixed to aponeurosis, an allogeneic implant is additionally fixed along the perimeter of the hernial defect with a continuous suture of a non-absorbable thread on an atraumatic needle.

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