RU2469660C1 - Method for choosing optimal repair version of surgical management of median ventral hernias - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: substance consists in choosing an optimal repair version of surgical management of median ventral hernias and involves intraoperative measurement of intraabdominal pressure. The repair, as well as endoprosthesis size and shape are chosen by the relation of pressure to a threshold value at the stages of coupling and closing hernial orifice, and eliminating diastasis recti abdominis. The endoprosthesis is fixed from metasternum to pubic articulation. Skin and subcutaneous fat are incised along a border of pubis hairs and parallel to inguinal fold, and a cellulocutaneous flap is mobilised to metasternum. The operation is completed by incision of excess subcutaneous fatty layer and layer wound closure.

EFFECT: higher reliability of surgical management of median ventral hernias for prevention of recurrences and postoperative complications.

3 cl, 8 dwg, 4 ex

Description

The invention relates to medicine and can be used in abdominal surgery.

In various publications, it is increasingly indicated that in order to ensure optimal results of surgical treatment of patients with hernias of the anterior abdominal wall and the prevention of postoperative complications, it is necessary to take into account the anatomical and functional features of the patient and the state of blood supply to the anterior abdominal wall in the area of the proposed intervention (see Choosing a method for plastic surgery hernia of the abdomen with polypropylene endoprostheses. / A.S. Ermolov et al. // Surgery.ZH. named after Pirogov: Scientific and practical zh.L. 2005. No. 8, p.16). However, this is quite difficult to accomplish due to the lack of clear diagnostic criteria. An analysis of the literature on this problem shows that the choice of the method of operation is often based on the subjective opinion of the surgeon, the preferences of a particular clinic.

There is a method of choosing the plastic surgery of postoperative ventral hernias, the purpose of which is to objectify this choice to achieve improved treatment results (see RF patent 2408273 from 06.15.2009). The essence of the method consists in the fact that in the preoperative period an ultrasound scan of the anterior abdominal wall is carried out with an assessment of the width of the hernia gate and blood flow parameters at six points, followed by interpretation into points in the range up to 12 points, up to 17 points, above 18 points and the choice of hernioplasty method in depending on the total points sub-lay, sub- and in-lay and in-lay, respectively.

The method allows to optimize the choice of surgical tactics and treatment of postoperative and recurrent ventral hernias and to minimize the subjective factor. However, the method is quite complex, requiring precision equipment and highly qualified personnel, which limits its application.

There is also a method for choosing the optimal plastic surgery option for surgical treatment of ventral hernias with clinical and instrumental examination of the patient, including sonography and anthropometry of the patient’s abdominal wall, the stress coefficient K is determined by the formula, at which up to 2.09 plastic surgery is performed with local tissues, and at K 2.1 produce plastic using a mesh endoprosthesis (see RF patent 2199271 from 08/09/2001).

The method allowed to improve the results of surgical treatment, it is cheaper than the previous analogue, however, local tissue repair at K up to 2.9 has a very large percentage of relapses, and at K≥2.9 the anatomy of the anterior abdominal wall is not taken into account.

A known method for the surgical treatment of diastasis of the rectus abdominis muscles and median postoperative ventral hernias and their combination, in which the authors take into account that postoperative and umbilical hernias are combined with diastasis of the rectus abdominis muscles, which is one of the factors of hernia recurrence. Therefore, during operations for postoperative ventral hernias, diastasis of the rectus abdominis muscles is eliminated (see RF patent 2410041 dated January 24, 2008). However, solving this problem, the authors differentiate hernias by the size of hernias up to 10 cm and after, which does not contribute to the exclusion of subjectivity when choosing the method of plasty.

The closest to the claimed combination of essential features and the achieved result is a method for the prevention of multiple organ failure in the postoperative period with hernioplasty, which consists in determining the optimal option for plastic surgery of ventral hernias by continuously monitoring intra-abdominal pressure during surgery, at the stage of manual reduction of the edges of the wound (matching hernial gates ) conduct a choice of surgical treatment. When the value of intra-abdominal pressure is less than 300 mm water column plastic hernia gate is performed by creating a biological bandage, and at a pressure of more than 300 mm water column plastic is made using alloplastic materials, or it is stopped and the final closure of the hernia gate is carried out after 6-8 months (see patent EA 8281 of 02.28.2005).

The known method due to intraoperative measurement of intra-abdominal pressure according to objective indications provides an earlier identification and elimination of the pathogenetic factor for the development of multiple organ failure. However, the method does not take into account the anatomical and physiological characteristics of the anterior abdominal wall and the need to eliminate diastasis of the rectus abdominis muscles, which often leads to a hernia recurrence. The manufacture of a biological bandage is a laborious procedure, and the option of surgery with its use has a large percentage of relapses.

The task is to increase the reliability of surgical treatment of median ventral hernias for the prevention of relapse and postoperative complications, including death.

The technical result is associated with the development of an algorithm for choosing the optimal, excluding relapse, option for surgery for patients with various median ventral hernias.

The problem is achieved by the method of choosing the optimal plastic surgery for surgical treatment of median ventral hernias, including intraoperative measurement of intra-abdominal pressure, the ratio of which to the threshold value makes the choice of surgical treatment, in which, according to the invention, if at the stage of manual comparison of hernial gates, they are sutured by any known by way of intra-abdominal pressure is less than the threshold value, and at the stage of elimination of diastasis of the rectus abdominis muscles, diastasis is equal to or less than the endoid prosthesis to the pubic joint is applied and fixed with an endoprosthesis extending from the midline 5 cm to both sides of the removed diastasis, if, after matching and suturing the hernial collar and then at the stage of rectal diastasis elimination, a threshold value of intra-abdominal pressure is reached, elimination of the diastasis is stopped by knot tying continuous suture or by applying the last node of the nodal suture, then an endoprosthesis is applied and fixed from the xiphoid process to the pubic joint with the extension beyond the edges of the sutured diastasis of 5 cm, and from the midline of unrepaired diastasis of 10 cm in both directions, if suturing of the hernial collar led to a threshold value of intra-abdominal pressure, an endoprosthesis is fixed from the xiphoid process to the pubic articulation with an extension from the midline of 10 cm in both directions if when comparing hernial gates, the intra-abdominal pressure exceeded the threshold value, the abdominal cavity was closed with the saved hernial gates, then the dissection of the rectus sheaths from the two sides of the rectus sheaths was performed directly venous proximity to the place of their connection with the anterior leaflets, the posterior leaflets are opened all the way from the xiphoid process to the lunate line, below which the transverse fascia is opened, the rectus abdominis are bluntly separated from the posterior leaflets of the rectus sheaths, onto the formed bed, which consists laterally of the posterior leaflets the vagina of the rectus abdominis muscles up to the lunar line, the peritoneum and preperitoneal tissue from the lunar line to the pubic joint, midline from the peritoneum and hernial sac, impose and fix continuous and whether an endoprosthesis is done with interrupted sutures, then immediately under the xiphoid process and above the pubic articulation, the first stitch of a continuous suture or the first nodal suture is applied and the anterior abdominal sheaths of the rectus muscle are sutured in opposite directions under intra-abdominal pressure until a threshold is reached with the last knot tied, then the front sheets of the dissected vaginas, together with the rectus muscle, are sutured to the underlying endoprosthesis with a continuous suture.

The task is also achieved by the fact that an incision of the skin and subcutaneous tissue is made along the border of the pubic part of the pubis and parallel to the inguinal folds on both sides, with the mobilization of the skin-fat flap to the xiphoid process of the sternum and costal arches.

The task is also achieved by the fact that the operation is completed by excision of excess skin-fat layer and layer-by-layer suturing of the wound.

Figure 1 shows a diagram of the anterior abdominal wall with a hernial defect, where 1 is the xiphoid process, 2 is the costal arch, 3 is the midline of the abdomen, 4 is the rectus abdominis muscle, 5, 6 is its inner and outer edge, respectively, 7 are hernial gate, 8 - hernial sac (defect), 9 - pubic joint, 10 - mobilized skin-fat flap;

figure 2 shows a view of the anterior abdominal wall with sutured hernia gate 11 according to the first, second and third versions of the operation;

figure 3 shows a completed view of the first variant of the operation, where 12 is the eliminated diastasis of the rectus abdominis muscles, 13 is the endoprosthesis;

figure 4 is the same - the second version of the operation;

figure 5 is the same - of the third variant of the operation;

Fig.6 shows the location of the endoprosthesis on the formed bed under the rectus abdominis muscles, where 14 is the lunar line, 15 is the endoprosthesis fixed to the hernial portal 7, located under the rectus abdominis muscles, 16 is the dissected vagina of the rectus abdominis muscle;

Fig.7 shows a finished view of the fourth variant of the operation, where 17 are the front sheets of the dissected vagina 16 of the rectus abdominis sutured in opposite directions, 18 is the edge of the dissected anterior leaf with the rectus abdominis muscle, hemmed to the endoprosthesis 15 located under the rectus abdominis muscles;

on Fig shows a diagram of the measurement of intra-abdominal pressure using a urinary catheter, where 19 is a Foley catheter, 20 is a tee, 21 is a transparent tube, 22 is a ruler.

The inventive method according to Fig.1-8 is as follows. Cut the skin of adipose tissue horizontally above the hairline and parallel to the inguinal folds to the muscle-aponeurotic layer (figure 1). A skin-fat flap 10 is mobilized to the xiphoid process 1 of the sternum and costal arches 2 with the release of a hernial sac 8. According to indications, they enter the abdominal cavity and perform the cavity stage of the operation. Then, the course of the operation depends on the intraoperative indications of intra-abdominal pressure. At this point, the surgeon should be prepared for any of the four options for surgery described below. As a method for assessing the pressure in the abdominal cavity, a simple, known method that does not require special complex equipment is selected according to the level of pressure in the bladder. To measure pressure in the bladder, a Foley catheter 19 (Fig. 8), a tee (needle) 20, a transparent tube 21, for example, from a blood transfusion system, a ruler or a special hydrometer 22 are required. When measuring, the patient is on his back. Before surgery, under aseptic conditions, a catheter 19 is inserted into the bladder, its balloon is inflated. After complete emptying of the bladder, 80-100 ml of physiological saline or furatsillin solution is introduced. The catheter 19 is squeezed distal to the measurement site, and a transparent tube 21 is connected to it using a tee 20. The level of pressure in the abdominal cavity is estimated with respect to the zero mark - the upper edge of the pubic joint 9. For the threshold pressure value in the bladder Pbr. taken 300 mm water column Further, with constant monitoring of Rvn.br. perform manual matching hernia gate 7. When Rvn.br. less RPG. sutured hernia gate 7 polypropylene thread (figure 2, position 11). The second continuous or any other polypropylene suture eliminates diastasis of the rectus abdominis 4 (Fig. 3, item 12) from the xiphoid process 1 to the pubic articulation 9 under the control of Rv.br., which should be less than or equal to Rpr. The operation is completed by the application and fixation from the xiphoid process 1 to the pubic joint 9 of the polypropylene endoprosthesis (mesh) 13 with the margin of the removed diastasis of 5 cm on both sides (the first version of the operation, figure 3). If at the stage of elimination of diastasis Rvn.br. reached Rprg., the further elimination of diastasis is stopped by tying the last knot or by the end of a continuous seam. A polypropylene mesh 13 is applied and fixed from the xiphoid process 1 to the pubic articulation 9 with a spacing of 5 cm throughout the eliminated diastasis and 10 cm from the midline 3 in the rest of the gap (second version of the operation, Fig. 4). If suturing of the hernia gate 7 has led to an Rv.br equal to Prg., Diastasis is not eliminated, and from the xiphoid process 1 to the pubic articulation 9, a polypropylene mesh 13 is applied and fixed with a 10 cm extension from the median line 3 on both sides (third option, figure 5). If matching hernia gate 7 led to Rvn.br. exceeding Rpr., the abdominal cavity is closed with the saved hernial gates, then the dissection of the rectus sheaths of the rectus muscle muscles on both sides in the immediate vicinity of the junction with the anterior sheets is made on both sides. The back leaf is opened all the way from the xiphoid process 1 to the lunate line 14, below which the transverse fascia is opened. The rectus abdominis muscle is bluntly separated from the posterior leaf of the rectus sheaths. On the formed bed, consisting laterally: of the back leaves of the vaginas of the rectus abdominis muscles up to the lunate line 14 and the peritoneum and preperitoneal fiber from the lunate line 14 to the pubic joint 9, midline: with the peritoneum, hernial sac 8, a polypropylene mesh 13 is applied and fixed with continuous or nodular sutures. Then, directly under the xiphoid process 1 and above the pubic joint 9, the first stitch of the continuous suture or the first node of the nodular suture is applied and the anterior sheets of the vagina of the rectus abdominis are sutured in the counter x areas under the control of Rvn.br. before reaching Rvn.br. equal Rprg. with tying the last knot. After that, the front leaves of the dissected vaginas, together with the rectus muscle, are sutured to the underlying mesh 13 by continuous sutures. In operations according to options 1, 2, and 3, the wound is drained with two tubular drains installed under a skin-fat flap. In the case of the fourth option, the space is drained by tubular drains under the rectus abdominis muscles and under the subcutaneous fat flap.

Clinical examples.

1. Patient A., 43 years old. The diagnosis is postoperative median ventral hernia.

Under endotracheal anesthesia, an incision was made according to the previously performed marking, namely above the level of pubic hair growth and parallel to the inguinal ligaments on both sides. The incision is deepened with an electric knife to the aponeurosis. The skin-fat flap was raised to the xiphoid process and both hypochondria with the release of 6 hernial sacs. Hernia sacs in the umbilical region are from 1.0 to 3.0 cm in diameter. Contents - locks of an omentum. The bags are opened and after resections of the soldered strands are connected into a single hernia gate measuring 11 × 4 cm, which is sutured edge to edge with a polypropylene thread. Intra-abdominal pressure is below a threshold value. Then, rectal diastasis of the rectus abdominis muscles was removed by continuous suture with polypropylene thread with immersion of the first row of sutures. Diastasis of the rectus muscles up to 4 cm in a wide place. Monitoring abdominal pressure - increasing pressure below a threshold value. On the muscle-aponeurotic layer of the anterior abdominal wall, a polypropylene mesh is fixed from the xiphoid process to the pubic joint with 5 cm extending beyond the edges of the eliminated diastasis of the rectus abdominis muscles in both directions. The mesh is hemmed in two rows of continuous and interrupted seams with polypropylene thread. The hold is sturdy. The resulting excess skin-fat flap is excised, weight 5 kg. Two silicone tubular drainage. Hemostasis is dry. Layer wound closure. Aseptic dressing. Bandage. Awakening on the table. Transfer to the ward, cold on the stomach. The postoperative period was uneventful. It was noted moderate (up to 50 ml) separated by vacuum drainage for 3 days. Drainage removed on the 5th day. The patient is activated on the 1st day after surgery. Sutures were removed on the 11th day. Primary healing. Examined a month, six months, a year and three years after surgery. Relapse of the disease is not marked.

2. Patient N., 51 years old. The diagnosis is multiple postoperative median recurrent ventral hernias. Under endotracheal anesthesia in the patient’s position on the back, an incision was made according to previously made markings, namely above the level of pubic hair growth and parallel to the inguinal ligaments on both sides. The incision is deepened with an electric knife to the aponeurosis. The skin-fat flap was raised to the xiphoid process and both hypochondria with the release of three hernial sacs. The first hernial sac in hypogastrium has dimensions 17x15 cm multi-chamber. Content: - loops of the small intestine with many adhesions with hernia gates. After dissection of the adhesions, the loops of the intestines are immersed in the abdominal cavity. Hernial gate 11 × 6 cm. The second hernial sac with dimensions 8 × 5 cm, hernia gate 6 × 3 cm without contents - did not open. Third hernia gate 5 × 4 cm, hernial sac also without contents. All hernial gates are sutured edge to edge, an increase in intra-abdominal pressure is below a threshold value. Then, the diastasis of the rectus rectus muscles under the control of intra-abdominal pressure was started from the xiphoid process with a continuous polypropylene suture. In the middle of the distance from the xiphoid process and pubic joint, a critical increase in intra-abdominal pressure was noted; elimination of diastasis was stopped by tying a continuous suture site. The increase in intra-abdominal pressure is critical, namely 300 mm water column. On the muscle-aponeurotic layer of the anterior abdominal wall, a polypropylene mesh is fixed from the xiphoid process to the pubic joint, extending beyond the edges from the eliminated divergence of the rectus abdominis muscles by 5 cm from the white line of the abdomen 10 cm in both directions. Initially taken polypropylene mesh 30 × 30 cm. The mesh is hemmed with two rows of continuous and nodal seams with polypropylene thread. The hold is sturdy. The resulting excess skin-fat flap is excised, weight 3 kg. Two silicone tubular drainage. Hemostasis is dry. Layer wound closure. Aseptic dressing. Examined a month, six months, a year and three years after surgery. Relapse of the disease is not marked.

3. Patient D., 46 years old. The diagnosis is postoperative median recurrent large ventral hernia and epigastric small hernia. Under endotracheal anesthesia in the patient’s position on the back, an incision was made according to previously made markings, namely above the level of pubic hair growth and parallel to the inguinal ligaments on both sides. The incision is deepened with an electric knife to the aponeurosis. The skin-fat flap was raised to the xiphoid process and both hypochondria with the release of both hernial sacs. The hernial sac in hypogastrium has dimensions 17 × 15 cm, multi-chamber. The contents of the loop of the small intestine with many adhesions with hernia gates. After dissection of the adhesions, the loops of the intestines are immersed in the abdominal cavity. The edges of the hernia gate 12 × 6 cm are sutured edge to edge, the increase in intra-abdominal pressure is below the threshold value. The hernial sac in the epigastrium is 12 × 6 cm in size, the contents are a soldered lock of the omentum. A resection of the omentum was performed. Gates of the second hernia 5/4 cm, sutured edge to edge. The increase in intra-abdominal pressure is critical, namely 300 mm water column. Between the edges of the hernia gate there is a 5 cm section of intact aponeurosis. A polypropylene mesh from the xiphoid process to the pubic articulation with a 10 cm extension from the white line of the abdomen on both sides is fixed on the muscle-aponeurotic layer of the anterior abdominal wall. The mesh is hemmed in two rows of continuous and interrupted seams with polypropylene thread. The resulting excess skin-fat flap is excised, weight 3 kg. Two silicone tubular drainage. Hemostasis is dry. Layer wound closure. Aseptic dressing. Examined a month, six months, a year and three years after surgery. Relapse of the disease is not marked.

4. Patient Ch., 61 years old. The diagnosis is postoperative median recurrent giant ventral hernia. Under endotracheal anesthesia in the patient's position on the back, with rollers under the knees, an incision was made according to the previously performed marking, namely above the level of pubic hair growth and parallel to the inguinal ligaments on both sides. The incision is deepened with an electric knife to the aponeurosis. The skin-fat flap is raised to the xiphoid process and both hypochondria. A hernial sac 24 × 16 cm was isolated. Contents - loops of the small intestine and large omentum. The hernia is multi-chamber. The adhesions were partially dissected, the multichamber of the hernia was eliminated, the contents easily set into the abdominal cavity. A further audit revealed multiple defects along the midline from a hernia above the navel to the xiphoid process. When comparing the edges of the hernia gate, the intra-abdominal pressure significantly exceeds the critical value. The rectus sheaths are opened along the medial edge from the xiphoid process to the pubic joint. The saved sheets of the hernial sac are sutured together without reducing the volume of the abdominal cavity, respectively, without increasing the intra-abdominal pressure. The upper lower size of the formed bed is 30 cm. A polypropylene mesh is laid under the rectus muscles: 30 cm in length and 22 in width. In this case, the mesh completely lies to the lateral edge of the rectus abdominis muscles. A mesh of polypropylene thread is fixed to the posterior sheet of the vagina of the rectus muscle, the peritoneum, and below the lunate line to the transverse fascia. Intra-abdominal pressure below threshold. Tubular silicone drainages are laid on the mesh under the rectus muscles. Then, the dissected front sheets of the rectus abdominis muscles under the xiphoid process and above the pubic joint are sutured with polypropylene thread in the opposite direction until the threshold value of intra-abdominal pressure is reached. Then a continuous suture was applied with the capture of the anterior sheet of the vagina of the rectus abdominis muscle of the rectus abdominis muscle to the underlying mesh. Excess skin-fat layer dissected, weight about 10 kg. Two silicone drains are placed under the skin-fat flap. Hemostasis is dry. Layer wound closure. Aseptic dressings, awakening on the table, transfer to the ward. Cold on the stomach. Examined a month, six months, a year and three years after surgery. Relapse of the disease is not marked.

The proposed method compared to the prototype is simpler, allows you to more flexibly choose the method of plastics and bring the operation to the end, and not to postpone the final closure of the remaining part of the hernial defect for 6-8 months, as in the prototype. Due to the fact that the proposed method necessarily involves the elimination of diastasis of the rectus abdominis muscles with the application of a mesh endoprosthesis of one or another shape and size from the xiphoid process to the pubic joint, the probability of relapse is sharply reduced. The author of the 57 operations performed for the period 2007-2011. there was not a single relapse.

Claims (3)

1. A method for choosing the optimal plastic surgery option for surgical treatment of median ventral hernias, including intraoperative measurement of intra-abdominal pressure, according to the ratio of which to the threshold value, a surgical treatment is selected, characterized in that if at the stage of manual comparison of hernia gates, intra-abdominal pressure is sutured by any known method less than the threshold value, and at the stage of elimination of diastasis of the rectus abdominis muscles is equal to or less, from the xiphoid process to the pubic joint impose and fix the endoprosthesis with a gap of 5 cm from the midline on both sides of the eliminated diastasis, if, after matching and suturing the hernial collar and then at the stage of rectal diastasis elimination, a threshold value of intra-abdominal pressure is reached, elimination of diastasis is stopped by tying a continuous suture site or applying the last site of the nodal suture, then an endoprosthesis is applied and fixed from the xiphoid process to the pubic articulation with 5 cm beyond the edges of the sutured diastasis, and from the midline of the unrepaired diastasis stasis of 10 cm on both sides, if suturing of the hernia gate led to a threshold value of intra-abdominal pressure, an endoprosthesis is fixed from the xiphoid process to the pubic joint with a gap of 10 cm from the midline, if the intra-abdominal pressure exceeds the threshold value when comparing the hernia gate the abdominal cavity is closed with preserved hernial gates, then dissection is made on both sides of the posterior leaves of the vagina of the rectus abdominis muscles in the immediate vicinity of the place of their connection with the anterior leaflet and, the posterior leaflets are opened all the way from the xiphoid process to the lunate line, below which the transverse fascia is opened, the rectus abdominis are bluntly separated from the posterior leaflets of the rectus sheaths, onto the formed bed, consisting laterally of the posterior leaflets of the rectus sheaths of the rectus muscles to the lunate line, peritoneal and preperitoneal fiber from the lunate line to the pubic joint, midline from the peritoneum and hernial sac, impose and fix the implant with continuous or interrupted sutures, then directly under m the first stitch of the continuous suture or the first node of the nodal suture is applied to the cheviform process and above the pubic joint, and the anterior abdominal sheaths of the rectus abdominis are sutured in opposite directions under the control of intra-abdominal pressure until a threshold is reached with the last knot tied, then the anterior sheaths of the dissected vagina together with the rectus muscle hem to the underlying endoprosthesis with a continuous suture. 2. The method according to claim 1, characterized in that the incision of the skin and subcutaneous tissue is made along the border of the pubic part of the pubis and parallel to the inguinal folds on both sides, with the mobilization of the skin-fat flap to the xiphoid process of the sternum and costal arches. 3. The method according to one of claims 1 and 2, characterized in that the operation is completed by excision of excess skin-fat layer and layer by layer suturing of the wound.

Images