RU2355328C2 - "nonstrain" hernioplasty version in middle and great postoperative hernias - Google Patents

Abstract

FIELD: medicine; surgery.

SUBSTANCE: hernial sac is opened transversely. Prosthesis is placed between separated leaf of pariantal peritoneum and transformed thinned musculofascial layer of hernial sac. Lower leaf is lined to upper edge of aponeurosis. On lower leaf, there is pre-shaped and sized prosthesis thereafter fixed to aponeurosis edge and covered with upper leaf. The edge of the latter is fixed to aponeurosis.

EFFECT: method allows avoiding recurrent hernias.

6 dwg, 1 ex

Description

The invention relates to medicine, namely to surgery, and can be used in surgical treatment of large postoperative ventral hernias of the abdomen.

Analogs

According to the literature, there are a number of different approaches to the implementation of the option of non-tensioned hernioplasty using explants. The incidence of postoperative ventral hernias (PVG) is second only to inguinal hernias and makes up 20-22% of the total number of hernias. Over a century-long period of improvement of surgical treatment of postoperative ventral hernias shows that the results of plastic surgery with local tissues for this pathology are unsatisfactory. The relapse rate in the long term is up to 45%. Moreover, often a postoperative hernia causes more suffering than the disease itself, for which the patient was operated on (Chugunov A.N., Slavin L.E., Rechkovsky L.R. Alloplasty with a polypropylene prosthesis of postoperative ventral hernias. // Gerniology, 2004, No. 1, p. 18-19).

The principle of stitching tissues without tension gradually became the basis for the implementation of any hernioplasty. Its observance fundamentally changes the conditions for wound healing after plastic surgery. Firstly, normal microcirculation in adaptable tissues and the absence of vascular spasm due to tissue tension and the associated pain syndrome are maintained. This provides optimal conditions for wound healing and prevents the progression of dystrophic processes in the tissues. Secondly, the load on the sutures is significantly reduced, which determines the duration of their fixing role (Timoshin A.D., Yurasov A.V., Shestakov A.L. The concept of surgical treatment of postoperative hernias of the anterior abdominal wall. // Herniology, 2004, No. 1, pp. 20-26).

Compliance with the principle of plastic without tension almost always necessitates the use of prostheses that are well implanted in the body tissue, and also makes the operation shorter, reduces trauma, which is very important for patients and allows them to return to work.

In 1970, Liechtenstein proposed a hernia repair technique without tissue tension by suturing a polypropylene mesh prosthesis. The method consists in implanting a prosthesis in order to strengthen the posterior wall of the inguinal canal with inguinal hernias. Further, various authors have repeatedly improved hernioplasty techniques using prostheses. So, the prosthesis was placed under the sutured aponeurosis, fixing it to the aponeurosis with polypropylene or nylon seams. In this case, the hernial sac was not removed, the prosthesis was fixed to the aponeurosis outside the hernial portal directly above the hernial sac (Chugunov AN et al. Alloplasty with a polypropylene prosthesis of postoperative ventral hernias. // Herniology, 2004, No. 1, pp. 18-19) . After wide exposure of the external oblique muscle of the abdomen laterally from the hernial ring, it was dissected in the form of an oval, the maximum width of which should correspond to the width of the hernial gate. After that, between the lateral flap of the external oblique muscle and the medial portion of the hernial ring, a polypropylene prosthesis was sewn in the form of a patch (Belokonev V.I. et al. Options for the surgical treatment of lateral postoperative abdominal hernias in a combined way. // Surgery, No. 6, 2002, p. 38 -40). Zhuravlev P.A. suggests that when plasticizing hernia defects in soft tissues of the anterior abdominal wall, a Lintex mesh polypropylene prosthesis was used, which they placed on top of the aponeurosis of the external oblique muscle of the abdomen, while it was sutured to the aponeurosis with mattress sutures, one for each square centimeter (P. Zhuravlev Operational treatment of recurrent ventral hernias with mesh polypropylene grafts in a district hospital. // Annals of Plastic, Reconstructive and Aesthetic Surgery, No. 2, 2005, p. 43-45).

The most commonly used methods of hernioplasty for large postoperative ventral hernias are prosthetic techniques from traditional access, which are divided into three groups: combined plastic with on-neurotic placement of the prosthesis (“onlay”), combined plastic with preperitoneal or axillary location of the prosthesis (“sublay”) and closing defect of the abdominal wall with synthetic material ("inlay).

Criticism of analogues

The above analogues have the following disadvantages. With hernias of the abdominal wall, an operative measure is performed, which involves the isolation of the hernial sac, exposure of the aponeurosis of the abdominal wall around the hernial portal, preparation of the peritoneum of the hernial sac beyond the edges of the aponeurosis with its excision. The need to open the walls of the vagina of the rectus abdominis muscles along the length of the abdominal wound on both sides leads to additional surgical trauma, and facilitates the migration of the prosthesis in the early postoperative period.

With the above methods, there is additional surgical trauma, weakening of the fixing properties of the aponeurosis of the anterior abdominal wall, forced dissociation of the vascular flows, the implementation of complex technical steps, an increase in the period of the operation in time, an increased risk of intraoperative and postoperative complications, such as bleeding, thromboembolism, fat embolism.

Prototype.

Closest to our method is the method proposed by Guzeev A.I. (2001), for hernioplasty with hernias of the abdominal wall (Guzeev A.I. Plastic surgery for hernias of the abdominal wall using synthetic materials. // Surgery, 2001, No. 12, p. 38-40). This method is taken as a prototype.

Prototype description

The essence of the prototype method is as follows. For the purpose of plastic repair of hernia gates, the domestic carbon-woven prosthesis “Carbonicus-I” was used. The surgical intervention itself implied: the isolation of the hernia sac, exposure of the aponeurosis of the abdominal wall around the hernia gate, then partly the aponeurosis was dissected along the midline up and down through all the small defects, after the peritoneum of the hernia sac was dissected far beyond the edges of the aponeurosis, the latter was also dissected and sutured. In this case, there is always a need to open the posterior wall of the vagina of the rectus abdominis muscles for the entire length of the abdominal wound on both sides. The edges of the aponeurosis, which are coarse, scar-changed tourniquets unsuitable for plastics, are mobilized from scars and excised. Under conditions when the vagina of the rectus abdominis was previously opened, the edges of the aponeurosis were able to be stitched without much tension over the implanted prosthesis. The implantation stage itself means sewing the mesh from the inside with U-shaped interrupted sutures to the front wall of the vagina through the rectus muscles at a distance of 5-6 cm from the edge of the aponeurosis along the entire perimeter of the hernial portal after preliminary cutting of the prosthesis over the corresponding area. The edges of the aponeurosis left free were sutured over the prosthesis with interrupted sutures (monofilament). In some cases, with the arising tension of the stitched edges, laxative pararectal sections of the aponeurosis were made. Before suturing the abdominal wound, subcutaneous tissue was necessarily drained with 1-2 drains with their addition to the Redon vacuum system. The duration of hospital stay for patients with ventral hernias on average did not exceed 10-12 days.

Prototype criticism

With the purpose of hernioplasty for abdominal hernias, an operative procedure is used, which implies - after isolation of the hernial sac and exposure of the abdominal wall aponeurosis around the hernial portal, preparation of the peritoneal hernia sac far beyond the edges of the aponeurosis and excision of the latter, which was also sutured. At the same time, there is always a need to open the posterior wall of the vagina of the rectus abdominis muscles along the entire length of the abdominal wound on both sides, which leads to additional surgical trauma, may favor the migration of the prosthesis in the early postoperative period, and enhances the adhesion process in the abdominal cavity, trauma to the fibers of the rectus muscles the abdomen and the accumulation of serous-hemorrhagic effusion between the leaves of the anterior and posterior walls of the vagina of the rectus muscles. Under conditions when the vagina of the rectus abdominis was previously opened, the edges of the aponeurosis were able to be stitched without much tension over the implanted prosthesis. In some cases, with the arising tension of the stitched edges, laxative pararectal sections of the aponeurosis were made. Based on the foregoing, it is possible, without detracting from the merits of this technique, to draw a conclusion about some of the disadvantages that occur:

- this technique according to Guzeev A.I. It does not allow to complete the surgery without increasing intra-abdominal pressure in the postoperative period;

- with this method of surgery, the edges of the aponeurosis are stitched together over the implanted prosthesis, in order to achieve this task, it becomes necessary to open the posterior wall of the rectus sheath muscles of the abdomen for the entire length of the abdominal wound on both sides or, when the stitched edges are tensioned, produce laxative pararectal sections of the aponeurosis, which leads in turn:

a) additional operating injury;

b) weakening the fixing properties of an uninterested part of the aponeurosis of the anterior abdominal wall;

c) dissociation of vascular flows and the intersection of nerve pathways in the layers of the anterior abdominal wall;

g) helps to strengthen the adhesive process in the abdominal cavity;

e) may favor the migration of the prosthesis in the early postoperative period;

e) the accumulation of serous-hemorrhagic effusion between the leaves of the anterior and posterior walls of the vagina of the rectus muscles;

- when performing this variant of the operation, due to the technical stages that are quite complicated to perform (preparation of tissues, mobilization of the layers of the abdominal wall, etc.), the intervention significantly increases in time, which is fraught with greater anesthesiological aggression, an increased risk of intraoperative and postoperative complications such as fat embolism, thromboembolism, bleeding, suppuration;

- requires qualified personnel of the operating team with certain skills.

The purpose of the invention is to improve the results of treatment of patients with large ventral hernias by developing an optimal method for placing the prosthesis between the tissues of the abdominal wall with "non-tensioned" hernioplasty.

SUMMARY OF THE INVENTION

A method of treating postoperative hernias of the abdomen of medium and large sizes by means of plastic surgery with the placement of the prosthesis between the sheets of hernial protrusion is schematically illustrated in FIGS. 1, 2, 3, 4, 5, 6, namely, hernial protrusion with a defect in which the transverse dimension is larger than the longitudinal one, FIG. .one; hernial protrusion with a defect in which the longitudinal size is larger than the transverse, figure 2; the hernial sac is opened in the transverse direction, Fig.3; the lower leaf of the hernial sac is sutured with interrupted U-shaped sutures to the muscular aponeurotic edge of the defect of the abdominal wall, Fig. 4; a defect in the muscle-aponeurotic layer of the abdominal wall is closed by a prosthesis, Fig. 5; the prosthesis is covered by the upper leaf of the hernial sac, Fig.6.

The essence of the invention lies in the fact that a method for the treatment of postoperative hernias of the abdomen of medium and large sizes by plastic surgery with the placement of the prosthesis between the sheets of hernial protrusion.

When localizing hernias in the right hypochondrium, epigastrium, right ileal, lumbar regions, when there is no hanging skin-fat apron, the old postoperative scar is excised so that after the hernia sac is isolated, excess skin remains for better modeling of the incision shape before suturing the wound.

In cases where there is a hanging skin-fat apron, mainly patients with meso- and hypogastric localization of hernias, the apron is excised by two converging semi-oval incisions in the transverse direction. The lower incision is made along the fold formed by the skin apron, and the upper one is modeled after the plastic surgery of the anterior abdominal wall with respect to the lower one to achieve a good cosmetic result.

When allocating a hernial sac, the walls of the sac should be preserved as much as possible and not injure it.

The hernial sac is secreted, if possible, without opening it to the hernial gate. Then the line along which the opening of the bag is carried out is determined. In cases where the transverse size of the hernia gate is larger than the longitudinal one, it is better to open the hernia sac in the transverse direction and vice versa (Figs. 1, 2). The contents of the bag are released from adhesions and set into the abdominal cavity (figure 3). In the presence of an infiltrated and highly developed omentum, its resection is performed. When the hernia gate is elongated in the transverse direction, the lower leaf of the hernia sac is sutured to the upper edge of the aponeurosis with a continuous suture (figure 4). Then, on the surface of the lower leaf of the hernial protrusion, a prosthesis pre-modeled in shape and size of the hernial portal is placed and fixed to the edge of the aponeurosis along the perimeter with U-shaped sutures (Fig. 5). Next, the prosthesis is covered with the upper leaf of the hernial sac and the edge of the latter is fixed to the aponeurosis (Fig.6). In all cases, the operation ends with drainage of subcutaneous fat with one or two silicone tubes.

Thus, the prosthesis is placed between the sheets of the hernial protrusion, namely, between the selected sheet of the parietal peritoneum and the changed, thinned muscle-aponeurotic layer of the hernial sac.

An example of a specific implementation of the method

The method proposed as an invention was applied with the aim of “non-tension” hernioplasty of postoperative ventral hernias to 42 patients at the Department of General Surgery of the Dagestan State Medical Academy, on the basis of the Republican Hepatoscopy Center. The course of treatment averaged 9.7 bed days.

Example. Patient Ch., 55 years old, was admitted to the hospital on 27/08/03 with a direct diagnosis: postoperative ventral hernia of large sizes. Upon admission, the patient complains of protrusion in the epigastric and umbilical regions, discomfort, dull moderate pain during physical exertion. Anamnesis: 5/10/02 surgery performed mid-access cholecystectomy. Was discharged under dynamic observation 12/10/02. A hernial protrusion was first noticed six months after surgery.

Status lokalis: the abdomen is deformed upon examination, along the midline of the abdomen with coverage of the epigastric and umbilical regions there is a hernial protrusion, with a formation size of 18.5 × 16.0 cm, with palpation of a soft-elastic consistency, without signs of inflammation and infringement of internal organs, with multiple pockets. The defect of the hernia gate is 6.5 × 7.0 cm.

The patient was investigated:

Intra-abdominal pressure (IOP): A double-lumen probe was used to measure IOP. The distal end of one lumen opens freely, and the second - in the form of a rubber balloon. The probe was inserted through the patient’s nose and positioned so that its end was in the stomach. After aspirating the gastric contents in one of the lumens, 200 ml is injected through the other lumen. air, the probe extends to a sensation of resistance. This ensures a snug fit of the swollen ball to the cardiac part of the stomach, which prevents the contents of the stomach from being thrown into the esophagus. Then, using a manometer adapted at the proximal end of the probe, the pressure level was measured inside the rubber balloon, which was taken as the initial intra-abdominal pressure.

FVD - state of stable compensation (ZHEL-75% to the proper level, NPV - 20 per min, Stange test - 38 s, Soobrae - 22 s).

ECG is a normal variant.

All general clinical laboratory tests are within acceptable limits. Surgical intervention was performed on 08/28/03: “non-tensioned” hernioplasty according to the proposed technique. The wound healed by first intention, on drains in 1 day up to 50 ml of serous-hemorrhagic fluid, 2 days up to 30 ml of serous-hemorrhagic fluid, on the 3rd day there is practically no discharge. Drainage removed by the end of 3 days. Sutures were removed on the 9th day. In the postoperative period, dynamic monitoring of the wound process was carried out under ultrasound control: the formation of cavities and accumulation of fluids in the area of operational activity was not observed.

A control study was also conducted.

WBD: Intra-abdominal pressure at baseline.

FVD - there were no significant deviations from the previous study (VC - 78% to the proper level, NPV - 18 per min, Stange test - 40 s, Soobrae - 22 s).

ECG is a normal variant.

The patient was discharged under the supervision of a local doctor 5/09/03. During the follow-up for 3.5 years, no recurrence of hernial protrusion was noted.

Features distinctive from the prototype

The prosthesis is placed between the sheets of the hernial protrusion itself, namely, between the selected sheet of the parietal peritoneum and the changed, thinned muscle-aponeurotic layer of the hernial sac.

The positive effect of the application of the invention.

Over the past decade, a significant improvement in the results of surgical treatment of patients with postoperative hernias of the anterior abdominal wall has been achieved. The number of relapses within 5% is no longer unusual. Such results became possible due to the introduction of modern technologies in clinical practice. First of all, this is the use of high-quality synthetic prosthetic materials.

The usefulness of the invention lies in the fact that a method for the treatment of postoperative abdominal hernias of medium and large sizes by placing a prosthesis between the sheets of hernial protrusion, which allows to make plastic hernia gate in the most accessible and technically simple way, and also optimally strengthens the aponeurosis of the anterior abdominal wall, is proposed.

With this method, it is possible to complete the surgery without increasing intra-abdominal pressure in the postoperative period. With the technique, when the edges of the aponeurosis are not mobilized and stitched over the prosthesis, there is no need to open the posterior wall of the rectus sheath of the rectus muscles for the entire length of the abdominal wound on both sides and not make laxative pararectal incisions of the aponeurosis, which, in turn, avoids such undesirable the consequences of the intervention, as an additional surgical injury; weakening the fixing properties of the aponeurosis of the anterior abdominal wall; uncoupling of vascular flows and the intersection of nerve pathways in the layers of the anterior abdominal wall; prosthesis migration in the early postoperative period; the accumulation of serous-hemorrhagic effusion between the leaves of the anterior and posterior walls of the vagina of the rectus muscles. Fewer technical steps (tissue preparation, mobilization of the layers of the abdominal wall, etc.) of the intervention significantly reduce the time of surgery, which significantly reduces anesthetic aggression, predictably reduces the risk of intraoperative and postoperative complications, such as fat embolism, thromboembolism, bleeding, suppuration .

The invention uses significant features that can solve the problem, namely, to develop a method of surgical intervention for large postoperative ventral hernias by using a prosthesis, with its placement between the tissues of the anterior abdominal wall, which has optimally fixing properties and the least number of intra- and postoperative complications.

Information sources

1. Guzeev A.I. Plastic surgery for hernias of the abdominal wall using synthetic materials. // Surgery, 2001, No. 12, p. 38-40 - prototype.

2. Belokonev V.I., Kovaleva Z.V., Pushkin S.Yu., Supilnikov A.A. Surgical treatment options for lateral postoperative abdominal hernias in a combined way. // Surgery, No. 6, 2002, p. 38-40.

3. Zhuravlev P.A. Surgical treatment of recurrent ventral hernias with mesh polypropylene grafts in a district hospital. // Annals of plastic, reconstructive and aesthetic surgery, No. 2, 2005, p. 43-45.

4. Timoshin A.D., Yurasov A.V., Shestakov A.L. The concept of surgical treatment of postoperative hernias of the anterior abdominal wall. // Herniology, 2004, No. 1, pp. 20-26.

5. Chugunov A.N., Slavin L.E., Rechkovsky L.R. Alloplasty with a polypropylene prosthesis of postoperative ventral hernias. // Herniology, 2004, No. 1, p. 18-19.

Claims (1)

A method of non-tensioned hernioplasty for the surgical treatment of medium and large postoperative ventral hernias, including plastic hernia gate, characterized in that the hernial sac is opened in the transverse direction, the lower leaf of the hernial sac is sutured to the upper edge of the aponeurosis, a pre-modeled shape and size are placed on the lower leaf the collar of the prosthesis, fix it to the edge of the aponeurosis, the prosthesis is covered with the top sheet, the edge of the latter is fixed to the aponeurosis.

Images