RU2365342C1 - Method of endoprosthesis bracing at performance of non-tension plasty of anterior abdominal wall - Google Patents

Abstract

FIELD: medicine; surgery.

SUBSTANCE: absence of extensive amotio of a hypodermic fat excludes formation of cavities in a wound and formation of hematomas, seromas, abscesses. Bracing of a mesh endoprosthesis by a seamless technique excludes formation of ligature abscesses, reduces quantity of a foreign material in a zone of an anterior abdominal wall plasty. Mobilisation of hernial hiluses is carried out after opening of a hernial sack only from an abdominal cavity within 7 cm from edges of hernial defect. Treatment of hernial hiluses from a wound is carried out without aponeurosis separation from hypodermic fat. Not less than 6 strips in the length corresponding to abdominal wall thickness and 1 cm width are exsected on the endoprosthesis perimetre. The endoprosthesis is placed in an abdominal cavity. Further the bent trocar is applied from a skin under manual and visual control through all layers of an abdominal wall on distance of not less than 5 cm from edges of the hernial defect. The mandrin is removed, a loop is entered into a trocar sleeve and guided to an abdominal cavity. The endoprosthesis strip exsected previously is grasped using a loop and traction of the strip and carried out outside through a sleeve. The sleeve is retrieved, a strip grid is left in a depth of an anterior abdominal wall, endoprosthesis bracing on all perimetre is carried out by the same applying of the strips.

EFFECT: reliable bracing of an endoprosthesis at the expense of mutual friction force of the last and structures of an anterior abdominal wall.

1 ex, 7 dwg

Description

The invention relates to medicine, namely to surgery, and can be widely used in surgical treatment of patients with hernias, eventings, tumors, germinating anterior abdominal wall, that is, in all situations requiring closure of a defect in the anterior abdominal wall.

The most reliable and modern option for closing a defect in the anterior abdominal wall is atension grafting with implantation of a mesh endoprosthesis. Plastic surgery with synthetic prostheses is introduced everywhere, however, the number of local and systemic postoperative complications reaches 7-10%. Such results cannot be considered satisfactory, which prompted us to develop a new method of endoprosthesis fixation, which would simplify the surgical technique and reduce the number of complications.

A known method of fixation of the endoprosthesis with transaponeurotic sutures (see Fedorovtsev VA, Sidorov MA The first experience of laparoscopic hernioplasty of ventral hernias. Collection of abstracts of the VIII Congress of the ROEH. M., 2005).

The known method is as follows.

The operation is carried out laparoscopically. Mobilize the hernial portal from the side of the abdominal cavity at least 5 cm from the edges of the hernial defect. An endoprosthesis is placed in the abdominal cavity. Sutures are applied through separate incisions, starting from the aponeurosis, while the needle with the thread is injected externally inward through the aponeurosis, muscles, peritoneum, and then it is passed through the endoprosthesis, after which the needle direction is reversed from the inside outwards through the endoprosthesis, peritoneum, muscles, aponeurosis, after why the thread is knotted over the aponeurosis, the skin is sutured over the knot. In this way, the endoprosthesis is fixed around the perimeter.

However, the known method has the following disadvantages:

1. With the method of fixation of the endoprosthesis with transaponeurotic sutures, the hernial sac is not removed, while its cavity serves as the site for the formation of seromas, hematomas with their subsequent suppuration.

2. Laparoscopic adhesions are not always divided appropriately, in some cases they are converted to open hernioplasty methods.

3. Fixation of the mesh with transaponeurotic sutures creates tension zones that are difficult to dose, which in some cases leads to separation of ligatures, displacement of the endoprosthesis and hernia recurrence.

For the prototype of the present invention, a well-known method of fixation of the endoprosthesis when performing athension repair of the anterior abdominal wall is selected, including opening the hernia sac, placing the endoprosthesis in the abdominal cavity, fixing it and suturing the aponeurosis (see Kux M., Myrvold HE, Simmermacher RKJ Langenbeck's Arch Surg (2001 ) 386, 65-73).

The known method is as follows.

The operation is performed by an open method. After opening the hernia sac, and in some cases excising it, mobilize the hernia gate from the side of the abdominal cavity at least 5 cm from the edges of the hernia defect and process the hernia gate from the side of the wound with separation of the subcutaneous tissue from aponeurosis. Then the endoprosthesis is placed in the abdominal cavity. Sutures are applied starting from the aponeurosis, while the needle with the thread is injected from the outside inwards through the aponeurosis, muscles, peritoneum and then it is passed through the endoprosthesis, after which the needle direction is reversed, from the inside out through the endoprosthesis, peritoneum, muscles, aponeurosis, after which the thread knotted. In this way, the endoprosthesis is fixed around the perimeter and then the aponeurosis is sutured over it.

The disadvantage of this method is that with this method of fixation of the endoprosthesis, an extensive detachment of the skin and subcutaneous tissue from aponeurosis inevitably forms, which causes tissue alteration, a pronounced local inflammatory reaction. In this case, the cavity formed serves as a place for the formation of seromas, hematomas with their subsequent suppuration.

The task of the invention is to reduce postoperative complications.

The problem is solved in that in the known method of fixation of the endoprosthesis when performing atension grafting of the anterior abdominal wall, including opening the hernial sac, placing the endoprosthesis in the form of a polypropylene mesh in the abdominal cavity, fixing it and suturing the aponeurosis, after opening the hernial sac, only the hernia is mobilized with side of the abdominal cavity within 7 cm from the edges of the hernial defect, the treatment of hernial gates from the side of the wound and the separation of the subcutaneous tissue from aponeurosis are not performed, according to Strips are cut to the endoprosthesis’s length, corresponding to the thickness of the abdominal wall and 1 cm wide, the endoprosthesis is placed in the abdominal cavity, then the curved trocar is inserted from the skin side under manual and visual control through all layers of the abdominal wall at least 5 cm from the edges of the hernial defect , the stylet is removed, a loop is inserted into the sleeve of the trocar and carried out into the abdominal cavity, the pre-cut strip of the endoprosthesis is grasped with a loop and the strip is traced through the sleeve to the outside, after which the sleeve is removed, leaving nn grid strip in the thickness of the anterior abdominal wall, by means of the same endoprosthesis strips produce fixation of the endoprosthesis around the perimeter,

The invention is illustrated by graphic materials.

Figure 1 shows the initial view of the zone of the upcoming operation.

Figure 2 presents the appearance of the mesh endoprosthesis.

Figure 3 shows the appearance of the mesh endoprosthesis after cutting out on its periphery of the fixing strips.

Figure 4 is a diagram of the conduct of trocars through the layers of the anterior abdominal wall.

Figure 5 shows the loop through the sleeve of the trocar and the capture of the fixing strip of the mesh endoprosthesis on its periphery.

In Fig.6 - the location of the fixing strips in the thickness of the tissues of the anterior abdominal wall after traction from the inside out and removing the sleeve of the trocar.

Figure 7 shows the final stage when the wound of the anterior abdominal wall is sutured over the endoprosthesis.

In figure 1 is indicated:

1 - leather

2 - subcutaneous fat

3 - aponeurosis

4 - muscles

5 - peritoneum

6 - hernial sac

7 - hernia gate

In figure 2 is indicated:

8 - endoprosthesis

In figure 3 is indicated:

9 - strips cut from the endoprosthesis

In figure 4 is indicated:

10 - trocar

Figure 5 is indicated:

11 - loop drawn through the sleeve of a trocar;

12 - sleeve of a trocar.

In Fig.6 indicated:

13 - the position of the strips cut from the endoprosthesis in the thickness of the tissues of the abdominal wall.

The proposed method is as follows.

Figure 1 shows the zone of the upcoming operation. A skin incision is made 1, subcutaneous adipose tissue 2, aponeurosis 3, muscle 4 and peritoneum 5. The hernia sac 6 is opened. The hernia gate 7 is mobilized only from the side of the abdominal cavity within 7 cm from the edges of the hernia defect. The treatment of hernial gates from the side of the wound and the separation of subcutaneous tissue 2 from aponeurosis 3 are not performed. As the endoprosthesis 8 use a polypropylene mesh (Figure 2). Strips 9 are cut along the perimeter of the endoprosthesis 8 (FIG. 3), the length of which corresponds to the thickness of the abdominal wall, the width of the strip is 1 cm. The endoprosthesis 8 is placed in the abdominal cavity. On the skin side 1 (Figure 4) under manual and visual control, trocars 10 are introduced through all layers of the abdominal wall at a distance of at least 5 cm from the edges of the hernia gate 7. The stylet is removed. Outside, a loop 11 is inserted into the sleeve of the trocar 12 and is carried inside the abdominal cavity. Loop 11 (FIG. 5) captures the pre-cut strip 9 of the endoprosthesis 8 and traces the strip 9 through the sleeve to the outside, after which the sleeve is removed, and the strip of mesh 9 remains in the thickness of the anterior abdominal wall (FIG. 6). Similarly, all cut strips 9 are carried out in the thickness of the abdominal wall, thereby reliably fixing the endoprosthesis along the entire perimeter by the friction force arising between the strips of the endoprosthesis and the tissues of the abdominal wall. A wound is sutured over the prosthesis (Fig. 7).

The present invention allows using the following positive effect.

To assess the effectiveness of the proposed method, we took the following indicators.

1. The general condition of patients.

2. The severity of pain.

3. Clinical (leukocyte formula, leukocyte intoxication index) and biochemical (glucose, urea, transaminases) blood tests.

4. The amount and nature of the exudate on the drainage of the wound.

5. Data from ultrasound of the abdominal cavity and wounds.

6. Intra-abdominal pressure.

On the basis of the Municipal Unitary Hospital "City Hospital No. 35" of Nizhny Novgorod, the proposed method is used in surgical treatment of patients with large hernias of the anterior abdominal wall. The authors of the invention carried out a comparative analysis of the results of treatment of two groups of patients. The main group included patients operated on using the proposed method of fixation of the endoprosthesis when performing atension repair of the anterior abdominal wall. The control group consisted of patients who underwent hernia repair according to the prototype method. All patients received complex therapy according to the standards of medical care. The dynamics of the main indicators of the postoperative period was studied by us using the methods of nonparametric statistics and the Mann-Whitney criterion. In the groups of patients there were no significant differences in gender, age, indicators of clinical and biochemical analyzes, sizes of hernial defect. At the same time, it was found that in patients of the main and control groups, the course of the postoperative period had a number of significant differences.

In patients of the control group, the general condition remained severe longer (p <0.01), while the duration of stay of patients of the main group in the intensive care unit was shorter. In the main group, the condition of the patients was assessed as satisfactory significantly earlier than in the control group (p <0.01).

In patients of the main group, the function of the gastrointestinal tract was restored faster. At earlier dates, the appearance of peristalsis and the absence of congestive discharge by the nasogastric tube were observed (p <0.01). Complete restoration of peristalsis and gas discharge was observed significantly earlier than in the control (p <0.01). This allowed the enteral nutrition of patients of the main group to begin earlier. In patients operated on using the proposed method, seromas of the postoperative wound were not observed, which was verified by ultrasound control (p <0.01). This is a confirmation that the method allows you to adapt to each other all layers of the abdominal wall and without suturing. Thus, the absence of an extensive detachment of subcutaneous tissue excludes the formation of cavities in the wound and the formation of hematomas, seromas, abscesses in them. There were no suppurations and hematomas in the main group (p <0.01). Fixation of the mesh endoprosthesis using a seamless technique eliminates the formation of ligature abscesses. In the main group, pain was less pronounced, which allowed patients to be activated earlier. Normalization of clinical and biochemical analyzes was faster and more complete. Lower and closer to normal indicators of intra-abdominal pressure were also noted.

In the main group (11 patients), complications and mortality were not noted. Moreover, all patients operated on by the proposed method had several concomitant diseases and belonged to the high-risk group and in most were older than 60 years.

Thus, the proposed method:

1. provides reliable fixation of the endoprosthesis due to the forces of mutual friction of the latter and the structures of the anterior abdominal wall;

2. eliminates the formation of a cavity in the wound by rejecting an extensive wide separation of the skin and subcutaneous tissue from aponeurosis;

3. reduces the morbidity of the preparation of hernial gates for plastic surgery, eliminating the wide separation of the skin and subcutaneous tissue from aponeurosis;

4. reduces the amount of foreign material in the plastic zone of the anterior abdominal wall, using a seamless technique for fixing the endoprosthesis;

5. the absence of an extensive detachment of subcutaneous tissue excludes the formation of cavities in the wound and the formation of hematomas, seromas, abscesses in them; fixation of the mesh endoprosthesis using a seamless technique eliminates the formation of ligature abscesses.

An example of a specific performance is given in the form of an extract from a medical history. Patient Apykhtina EA, 64 years old, was admitted to the municipal hospital "City Hospital No. 35" on 10/28/2007 with an irreparable recurrent ventral hernia. In 2004, for umbilical hernia, she underwent hernioplasty with local Mayo tissue, and a relapse occurred. October 29, 2007, hernia repair was performed with plastic mesh using the proposed method. Incision of the skin, subcutaneous adipose tissue, discharge of the hernial sac. Mobilization of the hernial portal only from the side of the abdominal cavity within 7 cm from the edges of the hernial defect. The treatment of hernial gates from the side of the wound and the separation of subcutaneous tissue from aponeurosis were not performed. Stripes were cut along the perimeter of the endoprosthesis from a polypropylene mesh, the length of which corresponded to the thickness of the abdominal wall, the strip width was 1 cm. The endoprosthesis was placed in the abdominal cavity. From the skin side, under manual and visual control, a trocar was introduced through all layers of the abdominal wall at a distance of 5 cm from the edges of the hernial defect. The stylet is deleted. Outside, a loop was introduced into the sleeve of the trocar and held inside the abdominal cavity. The loop of the endoprosthesis was captured by the loop and the strip was traced through the sleeve to the outside, after which the sleeve was removed, and the strip of mesh remained in the thickness of the anterior abdominal wall. In a similar way, all cut strips were made into the thickness of the abdominal wall, thereby reliably fixing the endoprosthesis along the entire perimeter. The wound over the prosthesis is sutured. The postoperative period is smooth. Discharged for outpatient treatment on day 12.

Claims (1)

The method of fixation of the endoprosthesis when performing abdominal atension plastic surgery for large ventral hernias, including opening the hernial sac, placing the endoprosthesis in the form of a polypropylene mesh in the abdominal cavity, fixing it and suturing the aponeurosis, characterized in that after opening the hernial sac, only hernial gates are mobilized side of the abdominal cavity within 7 cm from the edges of the hernial defect, the treatment of hernial gates from the side of the wound is performed without separation of the subcutaneous tissue from aponeurosis, along the perimeter at least 6 strips with a length corresponding to the thickness of the abdominal wall and a width of 1 cm are cut out, the endoprosthesis is placed in the abdominal cavity, then a curved trocar is inserted from the skin side under manual and visual control through all layers of the abdominal wall at least 5 cm from the edges of the hernia defect, the stylet is removed, a loop is inserted into the sleeve of the trocar and carried out into the abdominal cavity, the pre-cut strip of the endoprosthesis is grasped with a loop and the strip is traced through the sleeve to the outside, after which the sleeve is removed, the floor the mesh is left in the thickness of the anterior abdominal wall, by the same holding of the strips, the endoprosthesis is fixed along the entire perimeter.

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