RU2750520C2 - Method of surgical treatment of median ventral hernia - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery, herniology. An incision of the skin and subcutaneous tissue, isolation and processing of the hernial sac, isolation of the hernial orifice are performed. Further, through separate punctures of the anterior walls of the sheaths of the rectus abdominis muscles, two rollers rolled from a synthetic mesh material are implanted into the sheaths of the rectus abdominis muscles and located at the medial edges of the sheaths of the rectus abdominis muscles. The hernial defect is closed with an insert made of synthetic mesh material attached by stitching to the edges of the hernial defect and to the rollers implanted into the sheaths of the rectus abdominis muscles. The insert made of synthetic mesh material along the edges of the hernial defect is folded inward or outward and attached by stitching the two layers of the folded part of the insert, wherein the size of the insert with the folded edges corresponds with the size of the hernial orifice.

EFFECT: method ensures increased efficiency and reliability of plastic surgery in large ventral hernias, also reducing pain syndrome and ensuring early activation of patients.

1 cl, 6 dwg, 2 ex

Description

The proposed invention relates to the field of medicine, namely to surgery, and can be used in the treatment of large median incisional ventral hernias.

It is known that at present in the surgical treatment of ventral hernias for performing alloplasty, synthetic mesh prostheses are used.

So there is a known method of surgical treatment of large incisional ventral hernias by using a mesh prosthesis when closing the defect with the tissues of the hernial sac without suturing or narrowing the hernial orifice. The mesh prosthesis is fixed with a continuous suture along the perimeter, retreating 5 cm outward from the edge of the hernial orifice. The edges of the prosthesis are positioned both above the aponeurosis and below it - preperitoneally. In the latter case, the edge of the prosthesis is freely placed in the preperitoneal space, and fixation is carried out along the perimeter of the hernial orifice. Drainages are installed on top of the prosthesis and a skin-subcutaneous flap is fixed (Timoshin A.D., Yurasov A.V., Shestakov A.L. Concept of surgical treatment incisional hernias of the anterior abdominal wall. / Herniology, 2004, No. 1, S. 8).

The advantage of this method is that it can be used in cases of large hernia orifices, when it is impossible to bring their edges together.

The disadvantages of this method include the fact that as a result of the wrinkling effect of the mesh prosthesis, its dislocation is possible, followed by the formation of a recurrent hernia.

The closest in technical essence to the proposed is the method of surgery for median ventral hernias (Pat. 2614938 Russian Federation, IPC A61B 17/00. Method of surgery for median ventral hernias / Shalashov S.V., Semenischeva E.A. and others; applicant and the patent holder of the NUZ "DKB at the station Irkutsk-Passazhirskiy" JSC "Russian Railways". - No. 2016104712; filed. 02/11/2016; publ. 03/30/2017 Bul. No. 10).

The known method is carried out as follows. An incision of the skin and subcutaneous tissue is performed, the hernial sac is isolated and treated, the hernial orifice is isolated, the implantation of a synthetic mesh material is carried out into the muscular-aponeurotic layer of the anterior abdominal wall, departing from the edge of the hernial defect. The synthetic mesh material is presented in the form of two identical rolled-up parts, the length of each of which is greater than the length of the hernial defect when its edges are brought together. The mesh material is implanted into the sheaths of the rectus abdominis muscles through separate punctures of the anterior walls of the sheaths of the rectus abdominis muscles and their medial edge is placed opposite the hernial defect. The hernial defect is sutured with the seams of the rollers made of synthetic mesh material. The diameter of the cross-section of rollers made of rolled synthetic mesh material is 0.5-1 cm. Punctures in the front walls of the sheaths of the rectus abdominis muscles are sutured while suturing the hernial defect with the capture of synthetic mesh material in the seams, after which layer-by-layer tissue suturing is performed.

The disadvantage of this method is that it cannot be used in the surgical treatment of median postoperative ventral hernias of large sizes due to the inability to bring the edges of the hernial defect without tension.

The objective of the claimed invention is to develop a method for the surgical treatment of large postoperative median ventral hernias.

The technical result of the proposed method is to increase the efficiency and reliability of plastic closure of a large hernial defect, as well as to reduce the trauma of the operation and early activation of the patient.

The technical result of the proposed method is achieved by the fact that the method of surgical treatment of a median ventral hernia includes an incision of the skin and subcutaneous tissue, isolation and treatment of the hernial sac, isolation of the hernial orifice, implantation of two rollers rolled from a synthetic mesh material through separate punctures of the front walls of the sheaths of the rectus abdominis muscles into the sheaths of the rectus abdominis muscles with their location at the medial edges of the sheaths of the rectus abdominis muscles, elimination of the hernial defect with the capture of rollers made of synthetic mesh material into the seams, layer-by-layer suturing of tissues.

Distinctive techniques of the proposed method is that the hernial defect is closed with an insert made of synthetic mesh material, which is fixed by stitching to the edges of the hernial defect and rollers implanted into the sheaths of the rectus abdominis muscles.

The difference between the proposed method and the known one also lies in the fact that the insert of synthetic mesh material along the edges of the hernial defect is tucked inward or outward and fixed by stitching these two layers of the tucked part of the insert, while the size of the insert with tucked edges corresponds to the size of the hernial orifice.

Comparative analysis with the prototype showed that the proposed method differs from the known by the above techniques and, therefore, meets the criterion of patentability "novelty".

From the analysis of the patent and special literature, the authors found that the proposed method has features that distinguish it not only from the prototype, but also from other technical solutions in this and related fields of medicine.

The differences of the proposed method are that in case of a large hernial defect, when it is impossible to bring its edges without tension, an insert made of synthetic mesh material is used, which is used to close the hernial defect and fix it to the edges of the hernial defect with stitching of synthetic rollers implanted into the vagina of the rectus abdominis muscles. mesh material.

A distinctive feature of the method is also the fact that there are four punctures for implantation of rollers rolled from a synthetic mesh material into the sheaths of the rectus abdominis muscles: two above the hernial defect on both sides of the midline of the abdomen, two below it on both sides of the midline of the abdomen.

The difference between the proposed method lies in the fact that the insert made of synthetic mesh material along the edges of the hernial defect is tucked inward or outward and fixed by stitching these two layers of the tucked part of the insert, while the dimensions of the insert with tucked edges correspond to the size of the hernial orifice.

From the analysis of the patent and special literature, the authors found that the proposed technical solution has features that distinguish it not only from the prototype, but also from other technical solutions in this field of medicine. We have not found an operation method containing the distinctive techniques of the proposed method for the surgical treatment of median ventral hernias.

The interaction of the essential features of the proposed method provides a new technical result, namely, an increase in the efficiency and reliability of closure of a large hernial defect, as well as a decrease in the invasiveness of the operation and early activation of the patient. From the above, it follows that the proposed method meets the criterion of "inventive step".

The claimed invention is intended for use in practical health care, its implementation of its capabilities is confirmed by the methods and means described in the application. From the foregoing it follows that the claimed invention meets the condition of patentability "industrial applicability".

The essence of the proposed method is illustrated by six figures, reflecting the stages of its implementation, where: 1 - skin; 2 - subcutaneous fatty tissue; 3 - the front walls of the sheaths of the rectus abdominis muscles; 4 - the edge of the hernial defect; 5 - hernial sac, set into the abdominal cavity; 6 - punctures in the anterior walls of the sheaths of the rectus abdominis muscles; 7 - clamps for placing rollers made of synthetic mesh material in the sheaths of the rectus abdominis muscle; 8 - the end of the roller made of synthetic mesh material before the introduction into the vagina of the rectus abdominis muscle; 9 - the ends of the rollers located in the sheaths of the rectus abdominis muscles; 10 - thread of continuous polypropylene seam; 11 - suture along the left edge of the hernial defect with the capture of rollers made of synthetic mesh material and the edge of the insert made of synthetic mesh material; 12 - a circular seam with a polypropylene thread with the capture of the rollers and the edges of the insert made of synthetic mesh material; 13 - sutured punctures in the anterior walls of the sheaths of the rectus abdominis muscles; 14 - rollers rolled from a synthetic mesh material; 15 - insert made of synthetic mesh material; 16 - the contour of the ridges through the aponeurosis.

FIG. 1 shows the anatomical structures of the hernioplasty zone, punctures 6 of the front walls of the sheaths of the rectus abdominis muscles 3 are shown, rollers 14 are shown, rolled from synthetic mesh material and clips 7 for their passage through the tissues.

FIG. 2 shows the stage of implantation of a roller 14 made of synthetic mesh material into the sheath of the rectus abdominis muscle 3.

FIG. 3 shows the ends 9 of the rollers 14 implanted in the sheaths of the rectus abdominis muscles 3.

FIG. 4 shows the contours of the rollers 16 made of synthetic mesh material, implanted into the sheaths of the rectus abdominis muscles, as well as the initial ties of the continuous suture 10 for closing the hernial defect.

FIG. 5 - the left edge of the insert is fixed with suture 11 along the left edge of the hernial defect.

FIG. 6 - the plastic is completed: punctures 13 in the front walls of the sheaths of the rectus abdominis muscles are sutured, a circular suture 12 with polypropylene thread with the capture of rollers and rolled edges of the insert made of synthetic mesh material 15.

The inventive method of surgery for median ventral hernias of the abdomen is as follows. After the treatment of the operating field, an incision of the skin 1 and subcutaneous tissue 2 is made, the isolation and treatment of the hernial sac 5, the isolation of the hernial orifice 4. The punctures 6 of the front walls of the sheaths of 3 rectus abdominis muscles are made with a scalpel. Punctures 6 in the anterior walls of 3 sheaths of the rectus abdominis muscles are made at a distance of 0.6-1 cm from their medial edges. Punctures 6 are made two on each side above and below the hernial defect. The synthetic mesh material is rolled up in the form of two rollers 14, the cross-sectional diameter of which is 0.5-1 cm. The length of the rollers 14 should exceed half the length of the perimeter of the edge of the hernial defect by 3.0-4.0 cm. Through the punctures 6 with curved long clamps 7 form a bed for the rollers 14 in the sheaths of the rectus abdominis muscles along their medial edge. Then, with the same clips 7, through the punctures 6, the rollers 14 are placed in the sheaths of the rectus abdominis muscles in their maximum medial position, placing the ends of the rollers 9 protruding outward. Then they begin to close the hernial defect. The ends 9 of the rollers 14 are immersed under the front walls of the sheaths of the rectus abdominis muscles 3. The edges of the insert 15 are tucked inward or outward in accordance with the size and shape of the hernial orifice.

Next, the hernial defect is eliminated with a continuous polypropylene suture 10. In this case, the punctures 13 in the front walls of the sheaths of the rectus abdominis muscles are closed with the suture, both rollers 14 with aponeurotic and scar tissue are captured from one end (Fig. 4), and then aponeurotic tissue along the perimeter of the hernial defect 4 hernial orifice, a roller made of synthetic mesh material 14 and duplicates of the edges of the insert 15 made of synthetic mesh material. The second ends of the rollers (Fig. 5, 6) are sewn in the same way as when applying the first stitches of a continuous seam (Fig. 4), after immersing the ends of the rollers under the aponeurosis.

The essence of the proposed method is illustrated by examples of specific implementations.

Example 1.

Patient K., 38 years old, was in the department of surgery with a diagnosis of reducible postoperative ventral median hernia (large, the edges of the hernial orifice are irreducible, the distance between the edges is 8 cm). Surgery was performed: hernia repair with plastic according to the claimed method. After processing the hernial sac, which was inserted into the abdominal cavity, plastic was performed using rollers rolled from a polypropylene mesh. The rollers were 30 cm long and 6 mm thick. Two punctures were made on each front wall of the sheaths of the rectus abdominis muscles 2 cm above and below the hernial defect. An insert of synthetic mesh material was formed according to the size and shape of the hernial defect and placed in the area of the hernial defect. The hernial defect was eliminated with a continuous polypropylene suture. In this case, the punctures in the anterior walls of the sheaths of the rectus abdominis muscles were closed with a suture, with the capture from one end of two ridges with aponeurotic and cicatricial tissues, and then along the perimeter of the hernial defect aponeurotic tissue, a roller made of synthetic mesh material and the edge of an insert made of synthetic mesh material. The second ends of the rollers were sewn in the same way as when applying the first stitches of a continuous seam (after immersing the ends of the rollers under the aponeurosis.

The postoperative period was uneventful. The pain syndrome is moderate. The patient began to walk on the first day. The time spent in the hospital is 6 days. She was discharged under the supervision of a polyclinic surgeon. Control examination every 6 months. No complaints, local status is unremarkable. On examination after 2.5 years, no relapse was noted.

Example 2.

Patient Μ., 83 years old, was in the department of surgery with a diagnosis of reducible postoperative ventral median hernia (large, the edges of the hernial orifice are irreducible with a distance between the edges of 10 cm). Surgery was performed: hernia repair with plastic according to the claimed method using polypropylene mesh rollers and polypropylene mesh inserts. The rollers were 30 cm long and 7 mm thick.

The postoperative period was uneventful. The pain syndrome is moderate. On the first day, the patient began to walk. The time spent in the hospital is 8 days. Control examination every 6 months. No complaints, local status is unremarkable. On examination after 2 years, no relapse was noted.

A total of 17 patients were operated using the proposed method. In all cases, these were postoperative median ventral hernias with a hernia orifice width of 10 cm and more. In three patients, hernias were irreducible. Standard polypropylene meshes from Lintex were used as a synthetic mesh prosthesis. The pain syndrome is moderate, patients begin to walk on the first day. There were no complications; no relapses were observed with follow-up periods from 6 months to 2.5 years.

Thus, the proposed method can be used in the treatment of median postoperative ventral hernias of large sizes, when it is impossible to reduce the edges of the hernial defect. The method provides an increase in the efficiency and reliability of plastic surgery for large ventral hernias, as well as reduces pain and provides early activation of patients.

Claims (1)

A method of surgical treatment of a median ventral hernia, including an incision of the skin and subcutaneous tissue, isolation and treatment of the hernial sac, isolation of the hernial orifice, implantation of two rollers rolled from synthetic mesh material through separate punctures of the anterior walls of the sheaths of the rectus abdominis muscles into the sheaths of the rectus abdominis muscles with the location them at the medial edges of the sheaths of the rectus abdominis muscles, elimination of the hernial defect with the capture of rollers made of synthetic mesh material into the seams, layer-by-layer suturing of tissues, characterized in that the hernial defect is closed with an insert made of synthetic mesh material, which is fixed by stitching to the edges of the hernial defect and the rollers implanted into the sheaths of the rectus abdominis muscles, while the insert made of synthetic mesh material along the edges of the hernial defect is tucked inward or outward and fixed by stitching these two layers of the tucked part of the insert, while the size of the insert with tucked edges corresponds to the size of the hernia out gate.

Images