RU2375972C1 - Method of two-stage hernioplasty with application of reticuilar polypropylene endoprosthesis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method relates to medicine, namely to surgery of median ventral hernias. Method includes two stages. At the first stage in patient from two minimal cuts above rectus abdominis muscles, from two sides, implantation of reticular endoprosthesis into sheaths of rectus abdominis muscles is performed. Second stage is carried out after organism adaptation to endoprosthesis and complete union of endoprosthesis with surrounding tissues. Herniotomy with elimination of all hernia sacs is performed. Aponeurosis edges are sewn with interrupted suture with capturing of medial edges of rectus abdominis muscles sheaths, edges of earlier installed endoprosthesis.

EFFECT: method allows to strengthen posterior wall, is more easily endured by patients, blood supply of rectus abdominis muscles is disturbed less.

2 cl, 5 dwg

Description

The invention relates to medicine, to surgery for hernias of the anterior abdominal wall.

The most common type of surgical intervention in surgery are operations with ventral hernias. One of the most difficult during surgical treatment is a ventral median hernia, which is often postoperative, recurrent - after several surgical interventions. The unsatisfactory results of operations for recurrence of hernias dictated the need for additional reinforcing materials for hernioplasty. The achievement of recent years in this area has been the use of mesh polypropylene endoprostheses using various methods of implantation of the endoprosthesis into the anterior abdominal wall.

There is a method for the simultaneous implantation of a mesh endoprosthesis with median hernias by attaching on the formed single posterior aponeurosis along the length from the xiphoid process to the transverse fascia and width to the spigel line. A single posterior aponeurosis is formed due to the mobilization of the posterior leaves of the vaginas of the rectus abdominis muscles along the entire length and to the spigelic lines throughout. The leaves of the aponeurosis in the midline are fully adapted with a continuous loop polypropylene suture (A.S. Ermolov, A.K. Alekseev, A.V. Upyrev, V.A. Il'ichev, V.K.Gorchakov, N.A. Chernyaeva. - Journal named after N.I. Pirogov “Surgery”, 2005, No. 8, Moscow).

This method gives good long-term results, but differs in a large volume of surgical intervention, a difficult postoperative period, possible purulent complications due to extensive incisions, a long period of adaptation of the patient's body to an endoprosthesis, poor tolerance in patients with severe concomitant pathology due to the above disadvantages. An endoprosthesis is implanted behind the rectus muscles and in front of the sheets of the vagina of the rectus muscles, i.e. in a place where large epigastric and branches of the hypogastric arteries approach the rectus muscles. After exfoliation of the muscles, these arteries in most cases are ligated - ischemia of the rectus abdominis occurs.

The purpose of the invention is to reduce the severity of surgery, reducing the time of surgery, reducing the risk of postoperative complications in patients who undergo a hernia surgery with implantation of a mesh polypropylene endoprosthesis for ventral median hernias. With this method of implantation of the endoprosthesis, damage to arteries that feed the rectus muscles also does not occur. the anterior sheet of the vagina of the rectus muscles exfoliates. The blood supply to the muscles is produced mainly by arteries suitable for them through the posterior sheet of the vagina of the rectus muscles and the transverse fascia from the preperitoneal space. A method is proposed for performing surgery in median ventral hernias using a mesh polypropylene endoprosthesis that minimizes complications in hernia repair and is more easily tolerated by patients with severe concomitant pathology. Surgery is performed in two stages.

The first stage of the operation is preparatory, easily tolerated by the patient, performed without opening the abdominal cavity. The goal of the first stage is implantation of the mesh polypropylene endoprosthesis in the deep layers of the anterior abdominal wall, specifically in the vagina of the rectus abdominis muscles and the subsequent complete adaptation of the patient's body to the endoprosthesis and the most dense fusion of the abdominal wall tissues with the endoprosthesis.

The proposed method of two-stage hernioplasty using a mesh polypropylene endoprosthesis is implemented as follows.

Before the operation, the patient undergoes an ultrasound examination of the anatomical structures of the anterior abdominal wall, determines the inner and outer edges of the rectus abdominis muscles and the inner and outer corners of the vagina of the rectus abdominis muscle on both sides, i.e. left and right, and landmarks are marked on the skin of the abdomen with a marker. (1) Under general anesthesia, to the right and slightly above the navel, a small, minimal incision 9 of the skin 5 and subcutaneous tissue 6 5-6 cm long is made above the middle part of the rectus abdominis muscle (see Fig. 1), the front sheet 2 of the aponeurosis of the rectus muscle 4 is exposed the abdomen, the aponeurosis opens longitudinally by 5-6 cm, the edges of the aponeurosis are captured by the clamp and stupidly exfoliate under visual control from the rectus muscle to the maximum distance from the edges of the wound. Small vessels are coagulated, vessels of larger diameter are clipped and intersect or bandaged and intersected. Muscle detachment and hemostasis in the most distant epigastric and hypogastric regions are performed using a sterile surgical laryngoscope 10 with a direct blade 11 with a light guide. The blade of the laryngoscope is inserted into the created cavity above the rectus muscle and the anterior leaf 2 of the aponeurosis is lifted with the blade upward, opening the space for visual inspection (Fig. 4).

Muscle detachment in the most distant areas is also performed by tupfer, hemostasis by coagulation, clipping or stitching. The operating ruler measures the internal size of the created cavity along the length and width for implantation of the endoprosthesis. Next, the endoprosthesis is prepared for implantation in size. A standard mesh endoprosthesis of 20 × 20 cm is cut in half, the right angles of the prosthesis are cut off, the prosthesis is sized to fit into the cavity in the rectus abdominis muscle. In Fig.2,3, the prosthesis 1 with forceps and a tupfer is installed in the space under the front sheet 2 of the aponeurosis of the rectus abdominis muscle and rectus abdominis muscle 4. The medial and lateral edges 12 of the prosthesis 1 are sutured to the edges of the inner leaf of the aponeurosis or the corners of the vagina of the rectus abdominis muscle by interrupted sutures or attached by a hernial stapler in 4-5 places from each edge.

Figure 2 presents a General schematic view in a direct projection of the installed mesh endoprostheses 1 in the anterior abdominal wall after the first stage of the operation. The places of incisions above the rectus abdominis 9, the sites of attachment of the edges of the endoprosthesis to the medial and lateral edges of the vaginas of the rectus abdominis 12, the spigel line 13 are shown.

1-2 thin drainage tubes, nodal sutures for incision of the aponeurosis of the outer sheet are installed in the cavity, the wound is sutured in layers to the drainage. Then immediately implantation of the endoprosthesis on the left is performed in the same way.

Figure 3 presents a General view of the layers of the anterior abdominal wall in cross section with installed endoprostheses 1 after the first stage of the operation. Shown are the front sheet 2 of the vagina of the rectus abdominis muscle 4, the posterior sheet of the vagina 3 of the rectus abdominis muscle, skin 5, subcutaneous fat 6, hernial sac 7, peritoneum 8, cut lines 9.

Drainages are removed after 1-2 days. Sutures are removed on the 8-9th day.

After 5-6 months, a tight fusion of the endoprosthesis with the surrounding tissues occurs, the body fully adapts to the endoprosthesis, the patient is prepared for the second main stage - hernia repair with the closure of the aponeurosis by local tissues. The patient undergoes hernia repair with the isolation and elimination of the hernial sac and all dissected and scarred edges of the aponeurosis are excised to the edge of the vagina of the rectus abdominis muscles (Fig. 4). The aponeurosis is sutured with nodular non-absorbable sutures 16. When suturing the aponeurosis, the medial edge of the aponeurosis of the anterior leaflet 2 of the rectus sheath 4 of the abdomen is grasped, the medial edge of the previously implanted mesh endoprosthesis 1, the medial edge of the posterior sheet of the vagina of the rectus abdominis muscle with nodular non-absorbable sutures 16 (Fig. 4) .

Figure 4 presents a cross section of the layers of the anterior abdominal wall after the second stage of hernioplasty using mesh endoprosthesis 1, suture line 16 of the aponeurosis with the capture of the edges of the endoprosthesis. With a low location of the hernia below the semicircular line, the medial edges of the transverse fascia are captured into the suture as an extension of the posterior leaf. Stitches for subcutaneous tissue and skin. Drainage of the subcutaneous tissue at the discretion of the operator. For even more reliable plastic surgery, it is proposed to duplicate the lap aponeurosis according to the type of double-breasted jacket with mattresses, U-shaped sutures 14 (Fig. 5).

Figure 5 presents a cross section of the layers of the anterior abdominal wall after hernioplasty using a mesh endoprosthesis 1 of the type of double-breasted jacket with U-shaped sutures 14.

Literature

Magazine them. N.I. Pirogova "Surgery", 2005, No. 8, p.16, "The choice of the method of plastic surgery of postoperative abdominal hernias with polypropylene endoprostheses", 2005, Moscow. A.S. Ermolov, A.K. Alekseev, A.V. Upyrev, V.A. Ilyichev, V.K. Gorchakov, N.A. Chernyaeva.

Claims (2)

1. The method of hernioplasty for ventral median hernias using a mesh polypropylene endoprosthesis, characterized in that the surgery is performed in two stages, where at the first stage the implant is implanted into the vagina of the rectus abdominis muscles from both sides from small incisions above the middle of the rectus muscles, positioning and fixing the implant under the anterior sheet of the vagina of the rectus muscle and above the rectus muscle, and after complete fusion and adaptation of the patient's body to the endoprosthesis, the second main stage is performed surgery - hernia repair with the elimination of the hernial sac, stitching of the edges of the aponeurosis with nodular non-absorbable sutures with the capture of the medial edge of the aponeurosis of the anterior sheet of the vagina of the rectus abdominis muscle, the medial edge of the previously implanted mesh endoprosthesis, the medial edge of the posterior sheet of the vagina of the rectus abdominis muscle, and below the g line the medial edge of the fascia. 2. The method according to claim 1, characterized in that at the second stage of the operation, the aponeurosis is not sutured with interrupted sutures, but the plastic of the aponeurosis is made with U-shaped mattress sutures with the creation of duplicate aponeurosis according to the type of double-breasted jacket with the capture of the edges of the endoprosthesis.

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