RU2843844C1 - Method of treating parastomal hernias - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to abdominal surgery, herniology, coloproctology, and can be used for surgical management of parastomal hernias. Access to the retromuscular space is provided by inserting three trocars. Incision is made along lateral edge of sheath of rectus muscle of abdomen between external oblique and transverse muscle of abdomen. Hernial orifice and stoma-carrying intestine are separated; the hernial orifice is closed with the condition of a residual distance around stoma of 0.5-0.7 cm. Polypropylene mesh is dissected linearly from its edge to the stoma along the shortest distance towards the stoma-bearing intestine. Hole corresponding to a cross-section of the stoma-bearing intestine is made in the mesh. Mesh is placed in the retromuscular space surrounding the stoma-bearing intestine; the linear incision of the mesh is closed; the trocar wounds are desufflated and closed.

EFFECT: method does not require fixation of the mesh prosthesis, reduces the risk of displacement of the prosthesis and the development of adhesive process in the postoperative period, reduces the duration of the surgical intervention, eliminates the risk of bedsores and intestinal necrosis, which in turn reduces the risk of purulent-septic complications, reduces the length of hospitalization and postoperative rehabilitation, reduces the risk of recurrence by placing the prosthesis in the retromuscular space and dissecting the prosthesis linearly from its edge to the stoma at the shortest distance.

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Description

The proposed invention relates to medicine, namely to surgery, and can be used for surgical treatment of parastomal hernias.

According to WHO, the number of patients with stomas is growing every year, and thanks to the development of medicine, the life expectancy of these patients is increasing. However, literary sources of recent years claim that 47% - 80% [1] of surgical interventions to form intestinal stomas are complicated by the development of parastomal hernia. The solution to this complex and ambiguous problem has occupied the minds of more than one generation of surgeons. At the first stage, the problem was solved by plastic surgery with local tissues, the risk of relapse was close to 100%.

With the discovery of mesh endoprostheses in herniology, Sugarbaker [3] began to develop this direction in relation to parastomal hernias.

The Sugarbaker parastomal hernia repair procedure consists of the following: surgeons gain access to the abdominal cavity. Insufflation. An optical video system is inserted. Additional trocars for manipulators are installed at typical points. Step-by-step adhesioviscerolysis is performed. The mesentery of the stoma-bearing intestine is mobilized. The hernial orifice is sutured with separate extra-intracorporeal interrupted sutures using monofilament thread. A non-adhesive coated mesh endoprosthesis is placed in the area of the hernial defect with sufficient overlab. The prosthesis is fixed to the anterior abdominal wall (peritoneum) using "biodegradable staples". Hemostasis during the operation. Dry. Desufflation. The manipulators are removed. The wounds are sutured layer by layer. Aseptic wound dressings. Disadvantages:

1. Intraperitoneal placement of the mesh endoprosthesis leads to the risk of relapse and the formation of an adhesion process in the postoperative period.

2. Transabdominal access involves the stage of adhesioviscerolysis, which significantly increases the duration of surgical treatment and leads to the risk of deserosis/perforation of intestinal loops.

3. The large area of contact between the mesh endoprosthesis and the intestine leads to the risk of pressure ulcers/necrosis of the stoma-bearing intestine and the development of septic complications [2].

4. The risk of relapse is 10.2%.

5. Risk of intestinal necrosis due to close contact with the mesh [5].

The closest analogue is the ePauli operation (TAR), which consists of the following stages: access to the abdominal cavity. Insufflation. Insert the optical system. Install trocars on the contralateral side relative to the hernial defect. Next stage of adhesioviscerolysis. Open the sheath of the rectus abdominis muscle on the side of the stoma. Perform a transverse incision of the lateral edge of the sheath of the rectus abdominis muscles with subsequent dissection in the space between the external oblique and transverse abdominal muscles [4] with isolation of the stoma-bearing intestine in the retromuscular space. Suture the hernial defect with interrupted sutures. Lateralize the intestine bearing the stoma by suturing the defect of the posterior leaf of the aponeurosis. Install a mesh endoprosthesis and fix it to the muscles with biodegradable staples. Suture the posterior leaves of the aponeurosis with a continuous suture. Desufflation. Postoperative wounds are sutured.

Flaws:

1. High probability of developing adhesions in the long term,

2. A prolonged stage of adhesioviscerolysis and the associated risk of deserosis and perforation of intestinal loops,

3. A long stage of mastering the method by the surgeon,

4. Extensive contact surface of the endoprosthesis with the intestine, which leads to a high risk of developing pressure ulcers/intestinal necrosis and the development of purulent complications.

Tasks

1. Minimize the risk of recurrence of parastomal hernias,

2. Reduce the risk of developing postoperative complications by reducing contact between the mesh and the ostomy-bearing intestine,

3. Reduce the trauma of surgical intervention,

4. Reduce the time of surgical intervention,

5. Improve the patient’s quality of life by reducing trauma and shortening the time of surgical intervention.

The essence of the invention is: providing access to the retromuscular space by installing a trocar in the epigastrium on the side of the hernial protrusion, lateral to the white line of the abdomen in the projection of the rectus abdominis muscle, the second trocar - paraumbilical, also on the side of the hernial protrusion and the third trocar - in the hypogastrium, lateral to the white line of the abdomen also in the retromuscular space, then making an incision along the lateral edge of the sheath of the rectus abdominis muscle between the external oblique and transverse abdominal muscles, isolating the hernial orifice and the stoma-bearing intestine, suturing the hernial orifice, subject to the residual distance around the stoma of 0.5-0.7 cm, then a polypropylene mesh - implant, dissection linearly from its edge to the stoma along the smallest distance, towards the stoma-bearing intestine, free placement of the mesh in the retromuscular space around the stoma-bearing intestine intestines, suturing the linear mesh incision, performing desufflation and suturing trocar wounds.

The method was tested on 13 patients of working age, from 18 to 55 years old, 7 men and 6 women, for 1.5 years.

Technical result: The use of this plastic surgery of parastomal hernias, due to providing access to the retromuscular space, allows the use of a polypropylene mesh prosthesis with an adhesive coating, which does not require fixation, the risk of mesh displacement is minimal, the stage of adhesioviscerolysis is excluded, which significantly reduces the duration of the surgical intervention, and the risk of developing an adhesive process in the postoperative period is unlikely.

Due to the linear dissection of the mesh from its edge to the stoma along the shortest distance, towards the stoma-bearing intestine, free placement of the mesh in the retromuscular space around the stoma-bearing intestine, the contact of the mesh and the stoma-bearing intestine is minimized, which eliminates the risk of bedsores and intestinal necrosis due to minimal contact with the mesh endoprosthesis. All of the above leads to a decrease in the risk of developing purulent-septic complications, a reduction in the period of hospitalization and postoperative rehabilitation, as well as a decrease in the risk of relapse.

The method is carried out as follows:

The operation is performed under combined endotracheal anesthesia. After three times treating the surgical field with an antiseptic solution, access to the retromuscular space is provided by installing a trocar in the epigastrium on the side of the hernial protrusion, lateral to the white line of the abdomen in the projection of the rectus abdominis muscle. In the course of dissection, additional trocars are installed in the retromuscular space: the second trocar - paraumbilical, also on the side of the hernial protrusion, and the third trocar - in the hypogastrium, lateral to the white line of the abdomen, also in the retromuscular space, then an incision is made along the lateral edge of the sheath of the rectus abdominis muscle between the external oblique and transverse abdominal muscles, the hernial orifice and the stoma-bearing intestine are isolated, the hernial orifice is sutured, subject to the residual distance around the stoma of 0.5-0.7 cm, in order to prevent intestinal stenosis. Then the mesh is preliminarily dissected linearly from its edge to the stoma along the shortest distance, towards the stoma-bearing intestine, an opening is made in the mesh corresponding to the cross-section of the stoma-bearing intestine, the mesh is freely placed in the retromuscular space around the stoma-bearing intestine, the linear incision of the mesh is sutured, and desufflation is performed. The manipulators and trocars are removed. The trocar wounds are sutured. Aseptic dressings are applied.

Example No. 1. Patient Zh., 47 years old, consulted a surgeon at his place of residence with complaints of a hernial protrusion in the stoma area and was referred to a surgical hospital for surgical treatment.

Upon admission to the hospital of the Research Institute of Clinical Hospital No. 1, the diagnosis was confirmed: Parastomal hernia type 3.

The operation was performed under combined endotracheal anesthesia. After three times treating the surgical field with an antiseptic solution, access to the retromuscular space was provided by installing a trocar in the epigastrium on the side of the hernial protrusion, lateral to the white line of the abdomen in the projection of the rectus abdominis muscle. In the course of dissection, additional trocars were installed in the retromuscular space: the second trocar - paraumbilical, also on the side of the hernial protrusion, and the third trocar - in the hypogastrium, lateral to the white line of the abdomen, also in the retromuscular space, then an incision was made along the lateral edge of the sheath of the rectus abdominis muscle between the external oblique and transverse abdominal muscles, the hernial orifice and the stoma-bearing intestine were isolated, the hernial orifice was sutured, subject to the condition of a residual distance of 0.5-0.7 cm around the stoma, in order to prevent intestinal stenosis. Then, the mesh was preliminarily dissected linearly from its edge to the stoma along the shortest distance, towards the stoma-bearing intestine, an opening was made in the mesh corresponding to the cross-section of the stoma-bearing intestine, the mesh was freely placed in the retromuscular space around the stoma-bearing intestine, the linear incision of the mesh was sutured, and desufflation was performed. The manipulators and trocars were removed. Trocar wounds were sutured. Aseptic dressings were applied. The postoperative period was uneventful. Due to the reduction in trauma and reduction in the duration of the surgical intervention, the patient was activated on the first day. The result of the above was a decrease in the risk of secondary thromboembolic complications.

Due to the extraperitoneal type of surgical intervention, early and late postoperative intestinal obstruction was not detected. The patient spent 5 bed-days in hospital. Two weeks after the operation, the patient returned to his normal lifestyle. In the subsequent year of observation - no relapse.

Example No. 2. Patient M., 38 years old, with a history of surgical treatment in the volume of left-sided hemicolectomy, during a preventive examination by a surgeon the diagnosis was: Parastomal hernia type 1. She was referred to a surgical hospital for surgical treatment. Upon admission to the hospital, the diagnosis was confirmed.

The operation was performed using the above-described method. Due to the extraperitoneal type of surgical intervention, early and late postoperative intestinal obstruction was not detected. The postoperative course was uneventful, 6 bed-days were spent in the hospital. Two weeks after the operation, the patient returned to his normal lifestyle. There was no relapse in the subsequent year of observation.

List of identified analogues

1. Köhler G. Principles and parallels of prevention and repair of parastomal hernias with mesh. Surg. 2020 Mar; 91(3):245-251. German, doi: 10.1007/s00104-019-01047-z. PMID: 31570963.

2. DeAsis F.J., Lapin B., Gitelis M.E., Ujiki M.B. Current state of laparoscopic parastomal hernia repair: A meta-analysis. World J Gastroenterol. 2015 Jul 28; 21 (28): 8670-7. doi: 10.3748/wjg.v21.i28.8670. PMID: 26229409; PMCID: PMC4515848.

3. Stelzner S., Hellmich G., Ludwig K. Die Versorgung der Parakolostomiehernie nach Sugarbaker. Eine Analyse eigener Erfahrungen [Sugerbaker technique in para-colostomy hernia. An analysis of personal experiences]. Zentralbl Chir. 1999; 124 Suppl 2:13-7. German. PMID: 10544466.

4. Burenkov Ya.A., Glagolev N.S., Ivakhov G.B., Andryashkin A.V., Loban K.M., Kalinina A.A., Sazhin A.V. EVOLUTION OF SEPARATION PLASTIC SURGERY METHODS (REVIEW ARTICLE). Surgical practice. 2022; (3): 32-41. https://doi.org/1038181/2223-2427-2022-3-32-41.

5. Tastaldi L, Haskins I.N., Perez A.J., Prabhu A.S., Rosenblatt S., Rosen M.J. Single center experience with a modified Sugarbaker retromuscular technique for parastomal hernia repair. Hernia. 2017 Dec;21(6):941-949. doi: 10.1007/s10029-017-1644-5. Epub 2017 Aug 24. PMID: 28840354.

Claims (1)

A method for treating parastomal hernias, including the introduction of a laparoscopic optical system, trocars, insufflation, suturing of the hernial orifice, the use of an endoprosthesis, characterized in that access to the retromuscular space is provided by installing a trocar in the epigastrium on the side of the hernial protrusion, lateral to the white line of the abdomen in the projection of the rectus abdominis muscle, a second trocar - paraumbilical, also on the side of the hernial protrusion and a third trocar - in the hypogastrium, lateral to the white line of the abdomen also in the retromuscular space, then an incision is made along the lateral edge of the sheath of the rectus abdominis muscle between the external oblique and transverse abdominal muscles, the hernial orifice and the stoma-bearing intestine are isolated, the hernial orifice is sutured with the condition of a residual distance of 0.5-0.7 cm around the stoma, then a polypropylene mesh - an implant, they cut linearly from its edge to the stoma along the shortest distance, towards the stoma-bearing intestine, an opening is made in the mesh corresponding to the cross-section of the stoma-bearing intestine, the mesh is placed in the retromuscular space around the stoma-bearing intestine, the linear incision of the mesh is sutured, desufflation and suturing of the trocar wounds are performed.