RU2357677C1 - Method of reconstruction of front abdominal wall - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention pertains to surgery and may be used for reconstruction of front abdominal wall. Incision of skin and subcutaneous fat from ensisternum to pubic bone is made, separating subcutaneous fat from the front leaf of the sheath of rectus abdominis muscle, whereat lateral boundary is presented by the lateral edge of the abdominal rectus muscle on the right and on the left. Front leaf of the abdominal rectus muscle is incised perpendicular to the white line and below the costal arch by 1 cm along the midclavicular line, from the right lateral edge of the sheath of rectus abdominis muscle to cognominal contra-lateral edge on the left. Incisions are extended on the right and on the left along the lateral edges of the sheaths of rectus abdominis muscles, thus forming on the right and on the left two flaps of front sheaths of rectus abdominis muscles with medial edge along the white line, and lateral - along the edge of abdominal rectus muscle. Formed flaps of sheaths of rectus abdominis muscles are turned towards pubic bone. Lower edge of the turned flap is fixed to the periosteal coverage of the pubic bone with separate interrupted stitches along its entire length. Medial edges of flaps fixed between each other with separate interrupted stitches are sutured. Lateral edges of the moved flaps are sutured to internal edges of abdominal external oblique muscle on the right and on the left.

EFFECT: method makes it possible to replace wide defect with self-tissues, create a frame and minimise risk of development of necrosis of the flaps.

2 ex

Description

The invention relates to medicine, namely to surgery.

To date, the surgical problem of reconstructive surgery on the anterior abdominal wall remains extremely relevant. The occurrence of such a complex problem is caused by the occurrence of extensive defects of the anterior abdominal wall after traumatic injuries of the abdomen, tissue removal with metastatic lesion of the tissues of the anterior abdominal wall, and the formation of postoperative ventral hernias.

The prototype of the method, the authors propose a method of restoring the anterior abdominal wall after removal of the rectus abdominis muscles according to the method of Krakowski. After removal of the tissues of the anterior abdominal wall, the aponeurosis is sutured over the spermatic cord from the pubis to the deep opening of the inguinal cord. Turning the patient on a healthy side, make a linear incision along the axis of the thigh from the greater trochanter almost to the patella and, exposing the wide fascia of the thigh, cut out a rectangular flap on a leg 30 cm long with the base up. In the upper corner of the wound on the thigh, a forceps is performed under the skin towards the upper corner of the wound of the inguinal region. A flap is pulled through this tunnel into the inguinal wound. The skin wound on the thigh is sutured tightly, the fascia is not sutured. The tape of the well-stretched fascia is fixed from below to the inguinal ligament and to the periosteum of the pubic bone, and from above to the aponeurosis of the oblique muscle of the abdomen under the spermatic cord. The fascia over the cord and then the skin are sutured with interrupted sutures (N.I. Kukudzhanov. Inguinal hernias of the abdomen. - Moscow. - 1969. - P.192).

The disadvantages of the method.

1. Technical complexity.

2. Injury.

3. Promotes the formation of a number of functional and degenerative complications.

4. High risk of injury to large vessels of the lower limb.

5. A high degree of risk of necrosis carried out on the anterior abdominal wall of a muscle flap.

The technical result of the proposed method is the replacement of an extensive defect of the anterior abdominal wall with its own tissues and the creation of its frame.

The authors offer their own way to restore the anterior abdominal wall. An incision of the skin and subcutaneous fat is carried out from the xiphoid process to the pubic bone, after which, on both sides, subcutaneous fat is separated from the outer sheet of the vagina of the rectus abdominis muscle, with the lateral border of the rectus abdominis muscle on the right and left side being the lateral border. Then, one flap below the costal arch along the midclavicular line, two flaps are cut out on both sides so that their medial edge is the white line of the abdomen, and lateral is the edge of the rectus abdominis muscle, respectively, on the right and left. An incision is made of the selected connective tissue sheet as follows: below the costal arch, 1 cm perpendicular to the white line of the abdomen from the right lateral edge of the vagina of the rectus abdominis muscle to the contralateral border of the same name on the left. Further on the right, and then on the left, the incisions are extended along the lateral edges of the vaginas of the rectus abdominis muscles to the lower bridge, which will be the place of graft attachment from above. This achieves the formation of two connective tissue flap on the right and left. After that, the formed flaps of the anterior sheets of the rectus sheaths are turned over in the direction of the pubic bone. Then, the lower edge of the inverted leaf is fixed along its entire length to the periosteum of the pubic bone by applying individual nodal sutures. The medial edges of the fixed flaps are sewn together with separate interrupted sutures with an intersutomary distance of 0.5 cm between them along their entire length. The lateral edges of the displaced flaps are sutured to the inner edges of the external oblique muscles of the abdomen, respectively, to the right and left, by nodal sutures with an intersutomous distance of 1.0 cm.Then they begin to suture the subcutaneous fat, followed by suturing the skin.

The method proposed by the authors has the following advantages.

1. It is less traumatic for the patient.

2. Easy to execute.

3. Does not require the use of additional equipment.

4. Does not require repeated reconstructive surgery.

5. Does not require the use of synthetic implants.

6. Helps prevent the development of postoperative ventral hernia at the site of removal of the rectus abdominis muscle.

The authors according to the method described above, operated on 5 patients.

Clinical example No. 1: medical history No. 4312 - 2007. Patient. I., 61 years old, was admitted to the hospital with a diagnosis of metastasis of ovarian cancer in the suprapubic region after extirpation of the uterus with appendages. The tumor sprouted the contralateral rectus abdominis muscles. After removal of the conglomerate of metastatic nodes with rectus abdominis muscles, an extensive defect of the anterior abdominal wall was formed. According to the above method, the patient was operated on. The course of the postoperative period without features. In satisfactory condition on the 17th day after the operation she was discharged home. With further observation of the ventral hernia was not found.

Clinical example No. 2: medical history No. 107 - 2007. Patient I., 21 years old, was admitted with a mine-explosive wound to the abdomen, with an extensive defect in the tissues of the anterior abdominal wall. No abdominal injuries were detected during surgery. According to the above method, plastic tissue of the anterior abdominal wall was produced. The postoperative course was complicated by moderate suppuration of the wound, which was eliminated on the 6th day of the postoperative period. On the 20th day after the operation, the patient was discharged. Able to work. Dynamic observation of ventral hernia was not detected.

Claims (1)

A method for restoring the anterior abdominal wall, including the formation and fixation of skin flaps with subcutaneous fat, characterized in that an incision of the skin and subcutaneous fat is carried out from the xiphoid process to the pubic bone, separating subcutaneous fat from the front sheet of the rectus sheath from both sides the abdomen, with the lateral border being the lateral edge of the rectus abdominis muscle on the right and left, an incision is made of the anterior sheet of the vagina of the rectus abdominis muscle perpendicular to the white line of the abdomen and below costal arch 1 cm along the midclavicular line, from the right lateral edge of the vagina of the rectus abdominis muscle to the contralateral border of the same name on the left, then the right and left sections extend along the lateral edges of the vaginas of the rectus abdominis muscles, thus forming two flaps of the anterior vagina of the rectus muscles on the right and left the abdomen with a medial edge along the white line of the abdomen, and lateral - along the edge of the rectus abdominis muscle, the resulting flaps of the anterior sheets of the rectus sheaths are inverted towards the pubic bone, fixing with separate nodal sutures, the lower edge of the inverted leaf along its entire length to the periosteum of the pubic bone, the medial edges of the fixed flaps are sutured together with separate nodal sutures along their entire length with an intersutomary distance of 0.5 cm, the lateral edges of the displaced flaps are sutured to the inner edges of the external oblique muscles the abdomen on the right and left with an intersutomous distance of 1.0 cm, subcutaneous fat is sutured with subsequent suturing of the skin.