RU2391052C1 - Method of combined plastics of large postoperative median ventral hernias - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention refers to medicine, namely to surgery, and can be used for plastics of large postoperative median ventral hernias. After longitudinal dissection of the posterior walls of the rectus sheath and separation of the rear sheet of aponeurosis of the abdominal muscles to the site of attachment of tendinous part of the internal oblique and transverse abdominal muscles performing amputation of tendinous part of the internal oblique and transverse abdominal muscles. Medial aponeurotic scraps of sheaths are sutured together along the midline. Reticular endoimplant is placed under the rectus muscle and sutured to the tendinous part of the external oblique abdominal muscles without tension on both sides. ^ EFFECT: this method prevents development of compartment syndrome. ^ 1 ex, 1 dwg

Description

The invention relates to medicine, namely to surgery, and can be used for plastic surgery of large postoperative median ventral hernias.

Surgical treatment of hernias of the anterior abdominal wall is still significant. This is due, firstly, to the large specific gravity of this disease. About 10-15% of all operations performed in general surgical departments are herniotomy [1, 10]. Secondly, the results of surgical treatment leave much to be desired, since the frequency of postoperative relapses ranges from 5-20% [7, 8]. It is well known that one of the main causes of relapses is the tension of stitched, inferior, thinned anatomical structures. This was the reason for the search for methods of closing hernial gates without tensioning their own tissues using allo-or autoplastic materials [2, 4, 6].

The known method Ramirez, proposed in 1990, the Idea of the method is at the intersection of the tendon of the external oblique muscle of the abdomen from two sides, which reduces the width of the hernial defect. Initially, the hernial sac and the front sheets of the vaginas of the rectus abdominis muscles are mobilized to the spigel lines on both sides. After that, along the edge of the muscle part of m.obliquus abdominis externus, its tendon part intersects along the entire length from the costal arch to the ilium. It is advisable to limit the area of the plate either with the help of hernia sac flaps, or with the help of a large omentum. Hernial gates reduce sutures, avoiding much tension. Followed by explantation [9].

The disadvantage of this method is the contact of the endoprosthesis with subcutaneous tissue, which contributes to the formation of seromas. Separation of subcutaneous tissue additionally injures the tissue, creating a residual cavity in which wound is accumulated. Cavities require additional drainage. There is a risk of infection of the accumulated wound discharge, the formation of abscesses and ligature fistulas, which can lead to rejection of the endoprosthesis and, in the future, to hernia recurrence.

A known method developed by V.I.Orokhovsky. It lies in the fact that if it is impossible to adapt the muscle-aponeurotic tissue in the area of the hernial portal using combined plastic. In this case, the defect of the abdominal wall is closed with an artificial implant in the form of a mesh located at two levels: under and above the rectus muscles [3].

The essence of this method is as follows. After removal of the hernial sac and excision of the scars, the posterior wall of the vagina is separated to the full width from the rectus abdominis muscles. The first implant is cut out in the form of a mesh, according to the size and shape of the prepared space, it is placed in a stretched state in the bed under the rectus muscles and fixed with V-shaped ligatures tied under or on the skin. The second implant in the form of a mesh is placed subcutaneously and the hernial defect is closed by sewing the prolene mesh to the front walls of the rectus sheaths.

The advantage of this method of plasty is the formation of straight muscles from the implant in the form of a mesh of the aponeurotic vagina, the walls of which uniformly perceive the lateral pull of the wide muscles, and ensure optimal conditions for the functioning of the rectus abdominis muscles.

However, the method has the following disadvantages: a) the risk of complications characteristic of the subcutaneous location of the implant (seroma, hematoma, infiltrates), b) two-level placement of the implants (at the level of the posterior and anterior walls of the vagina) increases the risk of rejection of the implant, requires a higher consumption of expensive plastic material , and also increases the area of the "passive" in the functional relation of the abdominal wall, which reduces its elasticity.

Closest to the proposed one is a method of combined plastic surgery of large and giant median ventral hernias [5], it consists in the following: two surplus skin and subcutaneous tissue are excised over the hernial protrusion, herniated, refresh the edges of the aponeurosis defect, restore the integrity of the peritoneum by suturing between with the remains of a hernial sac, the posterior walls of the vagina are longitudinally dissected, the medial aponeurotic flaps of the vagina are separated from the rectus muscles, the implant is cut out in the form of a mesh, which is placed on the sutured peritoneum behind the rectus muscles and sutured to the lateral flaps of the vagina, the medial flaps of the vagina are sutured along the midline above the straight muscles, a drainage from the PVC tube is installed into the subcutaneous tissue along the entire length of the wound, and the skin wound is sutured.

The advantage of this method of plastics is the lack of contact of the endoprosthesis with subcutaneous fat.

Disadvantages:

1) the inability to restore the case of the rectus abdominis muscles;

2) the location of the endoprosthesis is preperitoneally fraught with rupture of the peritoneum with tension of the anterior abdominal wall and contact of the mesh with internal organs, which subsequently can lead to the development of adhesive intestinal obstruction;

3) the inability to eliminate diastasis of the rectus abdominis muscles;

4) with large and giant postoperative ventral hernias, tissue deficiency occurs in the posterior wall of the rectus abdominis muscle due to a scarred hernial sac fused with the posterior sheath of the rectus abdominis muscle, after excision of which there is a large aponeurosis defect, due to which the defect is replaced without endoprosthesis without tension is not possible without dissection of the tendon of the attachment of the lateral muscles to the rectus abdominis.

The objective of the invention is to improve the results of treatment of large postoperative median hernias and reduce relapse, strengthen the anterior abdominal wall and reduce the degree of tension on the white line of the abdomen.

The task is carried out due to the fact that after longitudinal dissection of the posterior walls of the vagina of the rectus abdominis muscles and separation of the posterior leaf of the aponeurosis from the rectus abdominis to the place of attachment of the tendon of the internal oblique and transverse abdominal muscles, the tendon of the internal oblique and transverse abdominal muscles is cut off, the medial aponeurotic the flaps of the vagina are sutured together along the midline, the mesh endoprosthesis is placed under the rectus muscle and sutured to the tendon of the external oblique muscle that without tension on both sides.

The proposed method is schematically depicted in the drawing, where:

A - longitudinal section of the posterior walls of the vagina, separation of the posterior sheets of the aponeurosis from the rectus abdominis muscles;

B - cutting off the tendon of the internal oblique and transverse muscles of the abdomen, suturing of the medial aponeurotic flaps of the vagina to each other along the midline;

B - suturing of an implant placed under the rectus muscles in the form of a mesh endoprosthesis to the tendon of the external oblique muscle of the abdomen and suturing of the medial flaps of the anterior leaf of the aponeurosis of the rectus abdominis muscles.

The essence of the invention is as follows: two semi-oval cuts excise excess skin and subcutaneous tissue over a hernial protrusion. A hernia repair is performed. Refresh the edges of the aponeurosis defect. Restore the integrity of the peritoneum by suturing among themselves the remains of a hernial sac. The posterior walls of the vagina are longitudinally dissected (drawing, pos. A), the posterior leaf of the aponeurosis is separated from the rectus abdominis to the place of attachment of the tendon of the internal oblique and transverse abdominal muscles. Cutting off the tendon of the internal oblique and transverse muscles of the abdomen. Medial aponeurotic flaps of the vagina are sutured together along the midline (drawing, pos. B). Cut out the implant in the form of a mesh endoprosthesis and sew to the tendon of the external oblique muscle of the abdomen. The medial flaps of the vagina are sutured together along the midline above the rectus muscles (drawing, pos. B). Before suturing the front leaf of the aponeurosis, a vacuum drainage according to Redon is established in the subaponeurotic space. The skin wound is sutured tightly.

An example of the method.

Patient K., 45 years old, (source. Bol. No. 2223) was admitted to the surgical department No. 1 of the City Clinical Hospital No. 7 on April 29, 2005 with complaints of a hernial mass in the region of the anterior abdominal wall, which increases with physical exertion and walking that causes the appearance of pain.

In 1993, she underwent surgery for gallstone disease, acute cholecystitis. Two years after the operation, she noticed the appearance of a hernia, which gradually increased in size.

Locally. In the midline of the abdomen, from the xiphoid process to the navel, the old postoperative scar is determined. In the middle third of the postoperative scar, a hernial protrusion, 26 × 15 cm in size, of a soft-elastic consistency is determined. The rectus abdominal muscles are flabby, the hernial protrusion is not completely immersed in the abdominal cavity. Aponeurosis defect up to 15 cm across.

After preliminary preparation, an operation was performed under endotracheal anesthesia. Two semi-oval sections excised an old postoperative scar with excess skin and subcutaneous tissue over hernial protrusion. Performed hernia repair. Refreshed edges of the aponeurosis defect. The integrity of the peritoneum was restored by suturing the remains of a hernial sac between each other. The posterior walls of the vagina are longitudinally dissected, the posterior leaf of the aponeurosis is separated from the rectus abdominis to the place of attachment of the tendon of the internal oblique and transverse abdominal muscles. Cutting off the tendon part of the internal oblique and transverse muscles of the abdomen. Medial aponeurotic flaps of the vagina are sutured together along the midline. An implant in the form of a mesh endoprosthesis, 30 × 30 cm in size, was cut and sewn to the tendon of the external oblique muscle of the abdomen. Established Redon vacuum drainage in the subaponeurotic space. The medial flaps of the vagina are sutured together along the midline above the rectus muscles. The skin wound is sutured. Iodine. Ass. bandage.

The postoperative period was uneventful. Examined after 3 years, no complaints.

The proposed method allows you to:

- to ensure the optimization of abdominal functions, the absence of high intra-abdominal pressure and the prevention of the development of the compartment syndrome due to dissection of the tendon of the internal oblique and transverse abdominal muscles, mobilization of the posterior leaf of the aponeurosis of the rectus abdominis muscles and stitching of medial flaps without tension;

- eliminate diastasis by suturing the medial flaps of the posterior leaf of the aponeurosis of the rectus abdominis muscle and restore the aponeurotic vagina of the rectus abdominis muscles;

- to exclude the eruption of sutures and migration of the mesh endoprosthesis into the intra-abdominal position due to its location on the posterior sheets of the aponeurosis of the rectus abdominis muscle.

Information sources

1. Belokonev V.I. et al. Plastics of the abdominal wall with ventral hernias in a combined way. Surgery, 2000. 8. P.24-26.

2. Zhebrovsky V.V. Monograph: Surgery of abdominal hernias. 2005, p. 341.

3. Orokhovsky V.I. Fundamentals of hernia repair. Donetsk 2000.241 s.

4. Orfanidi A.Kh. Surgery, 1992; 2: 83-85.

5. RF patent No. 2323427, IPC A61B 17/00, publ. BIPM No. 14, 05.20.2008

6. Toskin K.D., Zhebrovsky V.V. Hernia of the abdomen. M. 1983; 179-189.

7. Fedorov V.D., Adamyan A.A., Gogia B.Sh. Treatment of large and giant postoperative ventral hernias. Surgery 2000; 1: 11-14.

8. Deysine M., Soroff H.S. Am J Surg, 1999; 160: 239-241.

9. Ramirez O.M., Ruas E., Dellon L. 'Components separation' method for closure of abdominal-wall defects: an anatomic and clinical study // Plastic and Reconstructive Surgery. - 1990. - Vol. 86. - Number 3. - H.519-526.

10. Rutkov I.M. Arch Surg 1992; 127: 1271.

Claims (1)

The method of combined plastic surgery of large postoperative median ventral hernias, including removal of the hernial sac and repair of the peritoneal defect, longitudinal dissection of the posterior walls of the vagina, characterized in that after longitudinal dissection of the posterior walls of the vagina of the rectus abdominis muscles and separation of the posterior leaf of the aponeurosis from the rectus abdominis to the place of attachment of the tendon parts of the internal oblique and transverse muscles of the abdomen cut off the tendon of the internal oblique and transverse muscles of the abdomen, medial apon vroticheskie sheaths flaps are sutured together along the median line, the mesh prosthesis is placed under the rectus muscle and sutured to the tendon part of the external oblique abdominal muscles without tension on both sides.

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