RU2825770C1 - Method for surgical management of large and giant incisional ventral hernias - Google Patents

Abstract

FIELD: medicine; surgery.

SUBSTANCE: two endoprostheses are installed in different layers of an anterior abdominal wall: a composite endoprosthesis with an anti-adhesive coating and a mesh endoprosthesis made of polypropylene. Composite endoprosthesis It is placed intraperitoneally and fixed with four transfascial sutures to the anterior abdominal wall: the first suture is placed in the upper part of the composite endoprosthesis, the second suture is in the lower part of the composite endoprosthesis, the third and fourth sutures are in the right and left parts of the composite endoprosthesis. Edges of the composite endoprosthesis are sutured to the anterior abdominal wall with a continuous suture along the perimeter of the endoprosthesis, consisting of four sections between the transfascial sutures, with placement of sutures between intraperitoneally located composite endoprosthesis and peritoneum. Continuous suture is formed starting from the needle sticking into the peritoneum from the side of the abdominal cavity next to the already applied transfascial suture. Needle is delivered from top to bottom, capturing only the peritoneum. After puncturing from the peritoneum, the composite endoprosthesis is pricked in at a distance of not less than 0.5 cm from its edge, needle is delivered through the composite endoprosthesis into the abdominal cavity towards its center. Needle is pricked out at distance of 1 cm from the prick on the outer part of the composite endoprosthesis not coated with an anti-adhesive coating. Knot is tied between external part of endoprosthesis and parietal peritoneum, at the same time the suture is left for continuation of continuous suturing in the same way at the next section between transfascial sutures. Further, a continuous suture is performed towards the next transfascial suture along the perimeter of the endoprosthesis. After the composite endoprosthesis is installed, the hernia orifice is closed above the first endoprosthesis using a hernial sac without tension, forming a bridge connection. Mesh endoprosthesis from polypropylene is inserted supraponeurotically with hemming of the latter with a continuous suture to surrounding tissues locally above the bridge connection point without wide mobilization of the subcutaneous fat flap at a distance of not more than 5 cm from the edges of the hernia orifice. Fixation of mesh endoprosthesis from polypropylene is performed by continuous sutures in two rows along perimeter of this mesh endoprosthesis.

EFFECT: method enables closing the hernia orifice in large and giant postoperative hernias of the anterior abdominal wall without a significant increase in intra-abdominal pressure, reducing the frequency of recurrences, reduce the rate of local postoperative complications and chronic pain syndrome, prevent migration of intestinal loops into the space between the endoprosthesis and the anterior abdominal wall, as well as prevent the development of compartment syndrome.

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Description

Field of technology to which the invention relates

The invention relates to medicine, namely to surgery, and can be used to treat large and giant (or complex) postoperative hernias of the anterior abdominal wall with a hernial orifice width of more than 10 cm.

State of the art

The term "complex abdominal wall hernia" is often used by general surgeons and other abdominal surgery specialists to describe abdominal wall hernias that are technically challenging to repair [Hadeed JG, Walsh MD, Pappas TN, Pestana IA, Tyler DS, Levinson H, Mantyh C, Jacobs DO, Lagoo-Deenadalayan SA, Erdmann D. Complex abdominal wall hernias: a new classification system and approach to management based on review of 133 consecutive patients. Ann Plast Surg. 2011 May;66(5):497-503. https://doi.org/10.1097/SAP.0b013e3182145387; Slater NJ, Montgomery A, Berrevoet F, Carbonell AM, Chang A, Franklin M, Kercher KW, Lammers BJ, Parra-Davilla E, Roll S, Towfigh S, van Geffen E, Conze J, van Goor H. Criteria for definition of a complex abdominal wall hernia. Hernia. 2014 Feb;18(1):7-17. https://doi.org/10.1007/s10029-013-1168-6]. These difficulties are caused, first of all, by the width of the hernial orifice more than 10 cm, “loss of domain” (i.e. the ratio of the hernia volume to the volume of the abdominal cavity more than 20% [3. Sabbagh, C., Dumont, F., Robert, B. et al. Peritoneal volume is predictive of tension-free fascia closure of large incisional hernias with loss of domain: a prospective study. Hernia 15, 559–565 (2011). https://doi.org/10.1007/s10029-011-0832-y]) and the presence of local complications, such as a long-term non-healing wound or ligature fistulas of the abdominal wall. The use of an endoprosthesis in the “bridge” position with a hernial orifice width of more than 10 cm allows to increase the volume of the abdominal cavity and prevent an increase in intra-abdominal pressure during hernioplasty, but predisposes to more frequent recurrence [Giordano S, Garvey PB, Baumann DP, Liu J, Butler CE. Primary fascial closure with biologic mesh reinforcement results in lesser complication and recurrence rates than bridged biologic mesh repair for abdominal wall reconstruction: A propensity score analysis. Surgery. 2017; 161(2):499-508. https://doi.org/10.1016/j.surg.2016.08.009]. The component separation technique allows increasing the volume of the abdominal cavity, but is accompanied by high tissue trauma, and it is not always possible to close the hernial orifice; the recurrence rate varies from 32 to 53% [de Vries Reilingh TS, van Goor H, Rosman C, Bemelmans MH, de Jong D, van Nieuwenhoven EJ, van Engeland MI, Bleichrodt RP (2003) ‘‘Components separation technique’’ for the repair of large abdominal wall hernias. J Am Coll Surg 196(1):32–37 https://doi.org/10.1016/S1072-7515(02)01478-3; de Vries Reilingh TS, van Goor H, Charbon JA, Rosman C, Hesselink EJ, van der Wilt GJ, Bleichrodt RP (2007) Repair of giant midline abdominal wall hernias: ‘‘components separation technique’’ versus prosthetic repair: interim analysis of a randomized controlled trial. World J Surg 31(4):756–763 https://doi.org/10.1007/s00268-006-0502-x]. The “Sandwich” technique is known to be used for the treatment of complex postoperative ventral hernias. At the same time, the recurrence rate after the use of biological endoprostheses in combination with polypropylene endoprostheses according to the “Sandwich” technique reaches 13.3% [Hicks CW, Poruk KE, Baltodano PA, Soares KC, Azoury SC, Cooney CM, Cornell P, Eckhauser FE. Long-term outcomes of sandwich ventral hernia repair paired with hybrid vacuum-assisted closure. J Surg Res. 2016 Aug;204(2):282-287. doi: 10.1016/j.jss.2016.04.072.]. This is primarily due to the resorption of the biological endoprosthesis, which indicates insufficient reliability of hernioplasty. In this regard, the development of new effective methods for treating complex postoperative hernias is an urgent task.

A method of hernioplasty for postoperative ventral hernias is known [RU 2546927], according to which, after isolating the hernial sac and hernial orifice with two semi-oval converging incisions at a distance of up to 1.5 cm from the hernial orifice and the white line of the abdomen, the anterior sheets of the sheaths of the rectus abdominis muscles are opened. The medial sheets of the aponeurosis are turned 180 degrees. The first polypropylene endoprosthesis is sutured into the defect of the turned medial sheets. The second polypropylene endoprosthesis is sutured into the defect formed by the lateral sheets of the sheaths of the rectus abdominis muscles. The first and second endoprostheses are sutured together at the point of fixation of the lower endoprosthesis to the medial sheets of the sheath of the rectus abdominis muscles with a continuous suture.

The disadvantage of this method is the installation of endoprostheses in the edges of the defect, namely in the edges of the dissected medial and lateral anterior leaves of the sheaths of the rectus abdominis muscles using the Inlay technique. This technique of endoprosthesis implantation is currently not used due to the frequent development of relapse [Holihan JL, Nguyen DH, Nguyen MT, Mo J, Kao LS, Liang MK. Mesh Location in Open Ventral Hernia Repair: A Systematic Review and Network Meta-analysis. World J Surg. 2016 Jan;40(1):89-99. https://doi.org/10.1007/s00268-015-3252-9]. According to the national clinical guidelines of the All-Russian Society of Herniologists, the endoprosthesis should cover the hernial orifice by 5 cm in all directions. Due to the more extensive contact of the endoprosthesis with the abdominal wall, the area of its integration increases and, consequently, more reliable fixation is ensured. This prevents the development of relapse in the postoperative period [All-Russian Society of Herniologists. National Clinical Guidelines for Herniology (Postoperative Ventral Hernia). Moscow: 2017. 25 p.].

A method of surgical treatment of large and giant hernias of the anterior abdominal wall is known [RU 2284762], according to which plastic surgery of the hernial orifice is performed by installing a mesh implant made of titanium nickelide, previously grown with autoconnective tissue, into the abdominal cavity, a second titanium nickelide implant is placed on the outer surface of the hernial defect, then both implants are fixed as a single block along the edges of the peri-defective tissues by 3-5 cm with a titanium nickelide thread 90-100 μm thick with U-shaped sutures through the thickness of the fascial-muscular layer.

The disadvantage of the method is the complexity of its implementation and long treatment periods, since hernioplasty is carried out in two stages, the first of which includes the installation of a nickel-titanium implant in the subcutaneous tissue, then 10-14 days after the autoconnective tissue has grown in, the implant is removed and the second stage is carried out, in which the hernial defect is repaired. Also, metal endoprostheses break and fragment, which creates a risk of injury to internal organs by the ends of the wire and the occurrence of a relapse of the hernia, which has been noted in a number of publications. In this regard, the use of metal endoprostheses to close the hernial orifices of the anterior abdominal wall is currently not recommended.

A method for surgical treatment of giant postoperative ventral hernias is known [Valenzuela Alpuche, Héctor Alí. Sandwich or double mall technique for repair of large hernia defects in adulthood: review of a series of cases. Cir. Gen. 2019, vol. 41, n. 2, pp. 105-110], which includes double prosthetics of the anterior abdominal wall using the technique of separating the components of the anterior abdominal wall, after which a composite endoprosthesis is installed in the intraperitoneal position, which is fixed with 8 transfascial sutures. Then, without suturing the edges of the hernial orifice, a second polypropylene endoprosthesis is installed supraponeurotically above the endoprosthesis in the "Onlay" position.

The disadvantage of the method is excessive trauma and the risk of postoperative wound complications due to the use of the component separation method. Another disadvantage of the method is the fixation of the composite endoprosthesis with 8 transfascial sutures, which increases the risk of chronic pain syndrome in the postoperative period, as well as the risk of intestinal loop migration between the endoprosthesis and the anterior abdominal wall due to insufficient fixation of the endoprosthesis at the edges, which can lead to intestinal obstruction. Of the number of patients operated on using this method (3 cases), one patient developed "complete mechanical occlusion of the small intestine".

The closest to the claimed solution is a method of surgical treatment of complex postoperative ventral hernias [Moreno-Egea A, Mengual-Ballester M, Cases-Baldó MJ, Aguayo-Albasini JL. Repair of complex incisional hernias using double prosthetic repair: single-surgeon experience with 50 cases. Surgery. 2010 Jul;148(1):140-4], including double prosthetics of the anterior abdominal wall. In this case, the first composite endoprosthesis is installed intraperitoneally at a distance of 6 cm from the edges of the hernial orifice, fixing it with 6-8 non-absorbable spiral metal staples (Protack) to the peritoneal surface of the abdominal wall. The edges of the hernial orifice are not sutured over the endoprosthesis to avoid tissue tension. The second polypropylene endoprosthesis measuring 30 x 30 cm is installed supra-aponeurotically in the “Onlay” position.

The disadvantage of this method, as well as the previous one, is insufficient fixation of the composite endoprosthesis to the peritoneal surface of the abdominal wall, which can cause migration of intestinal loops into the space between the endoprosthesis and the abdominal wall. Also, the installation of a second polypropylene endoprosthesis measuring 30x30 cm requires a wider mobilization of the subcutaneous fat flap and intersection of perforating vessels, which leads to a high risk of developing postoperative complications from the wound (seroma, skin necrosis, wound suppuration, etc.).

The technical problem is the development of a method of hernioplasty in patients with large and giant postoperative ventral hernias that eliminates the above-mentioned shortcomings.

Disclosure of the essence of the invention

The technical result of the invention is an increase in the effectiveness of treating large and giant postoperative ventral hernias with closure of the hernial orifice without a significant increase in intra-abdominal pressure, while reducing the risk of relapse, development of local wound complications, chronic pain syndrome, migration of intestinal loops between the endoprosthesis and the anterior abdominal wall and the risk of developing intestinal obstruction in the postoperative period for at least up to three years.

The technical result is achieved by the fact that during surgical treatment of large and giant postoperative ventral hernias (with a hernial orifice width of ≥ 10 cm, “domain loss”, i.e. the ratio of the hernia volume to the volume of the abdominal cavity ≥ 20%), double strengthening of the hernial orifice is performed by installing two endoprostheses in different layers of the anterior abdominal wall: a composite endoprosthesis with an anti-adhesive coating (hereinafter referred to as the composite endoprosthesis) and a mesh endoprosthesis made of polypropylene; the composite endoprosthesis is installed intraperitoneally (in the "IPOM" position) and fixed to the anterior abdominal wall with four transfascial sutures, wherein the first suture is placed in the upper part of the composite endoprosthesis, the second suture is placed in the lower part of the composite endoprosthesis, the third and fourth sutures are placed in the right and left parts of the composite endoprosthesis, after which the edges of the composite endoprosthesis are sutured to the anterior abdominal wall with a continuous suture along the perimeter of the endoprosthesis, consisting of four sections between the transfascial sutures, with the placement of threads between the intraperitoneally located endoprosthesis and the peritoneum, wherein the continuous suture is formed, starting with the injection of a needle into the peritoneum from the side of the abdominal cavity next to the already applied transfascial suture, then the needle is moved from top to bottom, capturing only the peritoneum, after being punctured from the peritoneum, an injection is made into the composite endoprosthesis at a distance of at least 0.5 cm from its edge, the needle is passed through the composite the endoprosthesis into the abdominal cavity towards the center of the endoprosthesis, the needle is punctured at a distance of 1 cm from the puncture on the outer part of the composite endoprosthesis not covered with an anti-adhesive coating, a knot is tied between the outer part of the composite endoprosthesis and the parietal peritoneum, while leaving a thread to continue applying a continuous suture in a similar manner at the next section between the transfascial sutures, after which a continuous suture is performed in the direction of the next transfascial suture along the perimeter of the composite endoprosthesis;

after installing a composite endoprosthesis with an anti-adhesive coating, the hernial orifice above the first endoprosthesis is closed using a hernial sac without tension, forming a bridge connection, and the second one is installed - a mesh endoprosthesis made of polypropylene (hereinafter referred to as the mesh endoprosthesis) supraponeurotically (prefascially) (in the "Onlay" position) with suturing the latter with a continuous suture to the surrounding tissues locally above the site of the bridge connection without wide mobilization of the subcutaneous fat flap at a distance of no more than 5 cm from the edges of the hernial orifice, while the mesh endoprosthesis is fixed with continuous sutures in two rows along the perimeter of this endoprosthesis with the second row located at a distance of 1.5-2 cm from the first row.

Compared with the known methods, the claimed method is less traumatic, characterized by a reduced risk of local postoperative complications due to the installation of the second - mesh polypropylene endoprosthesis subcutaneously prefascially (supraponeurotically) without wide mobilization of the skin-fat flap to the "bridge connection" zone of the first - composite endoprosthesis located intraperitoneally. In this case, essential for achieving the technical result is the fixation of the composite endoprosthesis with four transfascial sutures in combination with additional suturing of the edges of the endoprosthesis to the peritoneum at a distance of at least 0.5 cm, for example, at a distance of 0.5 - 0.7 cm, from the edge of the endoprosthesis with four continuous sutures along the perimeter, performed between the transfascial sutures, with the location of the threads for fixation between the intraperitoneally located composite endoprosthesis and the peritoneum. This technique helps prevent intestinal loop migration into the space between the composite endoprosthesis and the anterior abdominal wall and reduces the risk of chronic pain syndrome in the postoperative period. The installation of a second mesh endoprosthesis made of polypropylene, subcutaneously prefascially (supraponeurotically) (the "Onlay" technique) without extensive mobilization of the skin-fat flap as a reinforcement of only the area of the bridge connection of the intraperitoneally located composite endoprosthesis allows for an increase in the reliability of the formed block of endoprostheses, thereby reducing the frequency of relapses.

The second endoprosthesis is a polypropylene mesh in a subcutaneous prefascial (supraponeurotic) position. It is necessary to strengthen the “weak spots” of the anterior abdominal wall, namely, the area of the bridge connection of the first intraperitoneally located composite endoprosthesis, since this area is the most common site of hernia recurrence. In addition, the installation of the second endoprosthesis in a subcutaneous prefascial (supraponeurotic) position without wide mobilization of the subcutaneous fat flap at a distance of no more than 5 cm from the edges of the hernial orifice and its fixation with continuous sutures in two rows along the circumference of the endoprosthesis, allows to reduce local wound complications in the postoperative period. In addition to the strengthening function, the first intraperitoneally located composite endoprosthesis prevents the development of adhesions in the abdominal cavity due to the anti-adhesive coating.

Brief description of the drawings

The invention is explained by drawings, where Fig. 1 shows a diagram of the first endoprosthesis arrangement in the "IPOM Bridging" position. Fig. 2 shows a diagram of the second endoprosthesis arrangement in the "Onlay" position locally above the "bridge connection" zone, without wide mobilization of the skin-fat flap. Fig. 3 shows a method of applying a continuous suture for fixing the intraperitoneally located first endoprosthesis along its circumference to the peritoneum, wherein the fixation threads are located between the intraperitoneally located endoprosthesis and the peritoneum. Fig. 4 shows a method of fixing the second endoprosthesis in the "Onlay" position with continuous sutures in two rows along the circumference of the endoprosthesis. Fig. 5 - 7 show intraoperative photographs demonstrating an example of the implementation of the claimed method, namely, Fig. 5 shows the stage of installing the first composite endoprosthesis (intraperitoneally in the “IPOM” position), Fig. 6 shows the sutured edges of the hernial orifice using a hernial sac (the “bridge” method) over the first composite endoprosthesis, Fig. 7 shows the installed second mesh endoprosthesis made of polypropylene subcutaneously prefascially (supraponeurotically) (in the “Onlay” position).

The following positions are indicated on the figures: 1 – the first endoprosthesis, located intraperitoneally, 2 – interrupted transfascial sutures, 3 – continuous sutures around the circumference of the first endoprosthesis, 4 – sutured edges of the hernial orifice, 5 – hernial sac, 6 – sutured edges of the hernial sac, 7 – the second endoprosthesis, located subcutaneously supraponeurotically, 8 – peritoneum, 9 – continuous sutures around the circumference of the second endoprosthesis.

Implementation of the invention

The method is carried out as follows.

A circumferential longitudinal incision is made over the hernial protrusion to dissect the skin and subcutaneous tissue, with excision of the old postoperative scar. After opening the hernial sac and immersing its contents into the abdominal cavity, the viscero-parietal adhesions are dissected at a distance of up to 10 cm from the edges of the hernial orifice. The composite endoprosthesis with an anti-adhesive coating is placed into the abdominal cavity and fixed with four transfascial sutures evenly distributed along the perimeter of the endoprosthesis and four continuous sutures (Fig. 5). Transfascial sutures are applied at four opposite points of the endoprosthesis, one opposite the other, as shown in Fig. 1. In this case, the sutures are applied in the following sequence: the first suture is placed in the upper part of the endoprosthesis, the second suture is placed in the lower part of the endoprosthesis, the third and fourth sutures are placed in the right and left parts of the endoprosthesis. Continuous sutures fixing the endoprosthesis to the peritoneum are applied between the transfascial sutures, as shown in Fig. 1, along the perimeter of the endoprosthesis, with the fixation threads placed between the intraperitoneally located endoprosthesis and the peritoneum. The following technique for applying continuous sutures is used to fix the first endoprosthesis in the "IPOM" position (Fig. 3): initially, the needle is punctured into the peritoneum from the side of the abdominal cavity next to the already applied transfascial suture, with a movement from top to bottom, the needle is inserted shallowly, capturing only the peritoneum. After puncture from the peritoneum, an injection is made into the endoprosthesis at a distance of at least 0.5 cm from its edge, the needle is inserted through the endoprosthesis into the abdominal cavity towards the center of the endoprosthesis. The puncture is performed at a distance of 1 cm from the puncture on the outer part of the endoprosthesis, not covered with an anti-adhesive coating. The knot is tied between the outer part of the endoprosthesis and the parietal peritoneum, leaving a long thread to continue the application of a continuous suture in a similar manner at the next section between the transfascial sutures. Next, a continuous suture is made in the direction of the next transfascial suture along the perimeter of the endoprosthesis. Three subsequent continuous sutures are made in a similar manner. The endoprosthesis bed is drained with two safety drains through additional punctures in the abdominal wall. Subsequently, the edges of the hernial orifice are sutured over the composite endoprosthesis using a hernial sac (Fig. 6). Next, a second endoprosthesis is installed above the bridge connection area – a polypropylene mesh, subcutaneously prefascially (supraponeurotically) (the “Onlay” technique) by suturing the latter with a continuous suture to the surrounding tissues (as shown in Fig. 7), avoiding wide mobilization of the subcutaneous fat flap, at a distance of no more than 5 cm from the edges of the hernial orifice (Fig. 2). The second endoprosthesis is fixed with continuous sutures in two rows around the circumference of the endoprosthesis, as shown in Fig. 4. A safety drain is installed in the subcutaneous tissue, after which the subcutaneous tissue and skin are sutured.

During the period from 2015 to 2022, 11 patients were operated on using the declared method. The average observation period for patients after surgery was 3 years or more. There were no cases of relapse, development of local infectious complications, chronic pain syndrome, intestinal obstruction in patients in the postoperative period.

The claimed method of surgical treatment of large and giant postoperative hernias of the anterior abdominal wall is illustrated by the following clinical example.

Patient S., 53 years old, was admitted on a planned basis with the diagnosis: giant median postoperative ventral hernia, M₁₋₃W₃R₀, the ratio of the hernia volume to the volume of the abdominal cavity is 20%. From the anamnesis it follows that in 2019 the patient underwent multiple surgeries for acute infected total pancreatic necrosis. Two months after the last operation, a hernial protrusion appeared in the area of the postoperative scar, which began to increase in size over time. Concomitant diseases include stage I hypertension, type II diabetes mellitus, stage I obesity, post-thrombophlebitic syndrome after previously suffered bilateral thrombosis of the common femoral veins. The general condition of the patient upon admission is satisfactory. Locally on the anterior abdominal wall there is a median postoperative scar up to 30 cm long and up to 15 cm wide. In the area of the postoperative scar there is a hernial protrusion measuring 23×22 cm, partially repositioned into the abdominal cavity. The hernial orifice is up to 16 cm wide.

The patient underwent surgery. Under general anesthesia, framing the hernial protrusion with a longitudinal incision from the xiphoid process to the suprapubic area, the skin and subcutaneous tissue were dissected to the hernial sac with excision of the stretched thinned old postoperative scar measuring 30 x 15 cm. During revision of the abdominal cavity, pronounced viscero-visceral and viscero-parietal adhesions were noted, in places with an increase in the width of the small intestinal loops. With technical difficulties, partial dissection of the viscero-visceral adhesions and viscero-parietal adhesions was performed at a distance of up to 10 cm from the edges of the hernial orifice. The hernial orifice measures 22 x 16 cm (width 16 cm). The edges of the hernial orifice are cicatricially altered and atrophic. The first composite endoprosthesis with an anti-adhesive coating, mesh, (Ventlalight ST, Bard) measuring 20 x 25 cm was placed in the abdominal cavity and fixed with four transfascial sutures of size 1 polypropylene thread at a distance of 6 cm from the edges of the hernial orifice. Subsequently, the edges of the endoprosthesis were sutured to the peritoneum with size 2/0 polypropylene thread with four continuous sutures around the circumference at a distance of 0.5 cm from the edge of the endoprosthesis, while the fixation threads were located between the intraperitoneally located endoprosthesis and the peritoneum. The endoprosthesis bed was drained with two safety drains through punctures in the suprapubic area. Subsequently, the edges of the hernial orifice were sutured, while a hernial sac measuring 12 x 4 cm was used to close the hernial orifice in the epigastric region and partially in the umbilical region. Taking into account the atrophic changes in the hernial orifice, especially in the epigastric and umbilical regions, as well as the use of a hernial sac to close the hernial orifice, the anterior abdominal wall was additionally strengthened by suturing a second endoprosthesis - a polypropylene mesh one measuring 30 x 10 cm, subcutaneously prefascially (supraponeurotically) (the “Onlay” technique), minimally mobilizing the subcutaneous fat flap at a distance of 5 cm from the edges of the hernial orifice and fixing the endoprosthesis with continuous sutures in two rows around the circumference of the endoprosthesis. Two safety drains were left in the subcutaneous tissue. The subcutaneous fat tissue is sutured with a continuous suture.

The postoperative period was uneventful. Drains were removed on the 7th day. Sutures were removed on the 12th day. The wound healed by primary intention, local infectious complications, chronic pain syndrome were absent. At the control examination after 1 year, and then after 3 years, there was no relapse, no cases of intestinal obstruction were recorded in the patient.

As can be seen from the data provided, the claimed method used in the plastic surgery of large and giant postoperative hernias is highly reliable, reduces the risk of hernia recurrence and chronic pain syndrome, reduces the frequency of local postoperative complications, prevents the migration of intestinal loops into the space between the endoprosthesis and the anterior abdominal wall, and prevents the development of compartment syndrome.

Claims (1)

A method of surgical treatment of large and giant postoperative ventral hernias, including the installation of two endoprostheses in different layers of the anterior abdominal wall: a composite endoprosthesis with an anti-adhesive coating and a mesh endoprosthesis made of polypropylene; wherein the composite endoprosthesis is installed intraperitoneally and fixed to the anterior abdominal wall with four transfascial sutures, wherein the first suture is placed in the upper part of the composite endoprosthesis, the second suture is placed in the lower part of the composite endoprosthesis, the third and fourth sutures are placed in the right and left parts of the composite endoprosthesis, after which the edges of the composite endoprosthesis are sutured to the anterior abdominal wall with a continuous suture along the perimeter of the endoprosthesis, consisting of four sections between the transfascial sutures, with the placement of threads between the intraperitoneally located composite endoprosthesis and the peritoneum, wherein the continuous suture is formed, starting with the injection of a needle into the peritoneum from the side of the abdominal cavity next to the already applied transfascial suture, then the needle is moved from top to bottom, capturing only the peritoneum, after the injection from the peritoneum, an injection is made into the composite endoprosthesis at a distance of at least 0.5 cm from its edge, the needle is inserted through the composite endoprosthesis into the abdominal cavity towards its center, the needle is punctured at a distance of 1 cm from the puncture on the outer part of the composite endoprosthesis, not covered with an anti-adhesive coating, the knot is tied between the outer part of the endoprosthesis and the parietal peritoneum, while leaving a thread to continue applying a continuous suture in a similar manner on the next section between the transfascial sutures, after which a continuous suture is performed in the direction of the next transfascial suture along the perimeter of the endoprosthesis; after installing the composite endoprosthesis, the hernial orifice is closed above the first endoprosthesis using a hernial sac without tension, forming a bridge connection, and a polypropylene mesh endoprosthesis is installed supraponeurotically with suturing the latter with a continuous suture to the surrounding tissues locally above the site of the bridge connection without wide mobilization of the subcutaneous fat flap at a distance of no more than 5 cm from the edges of the hernial orifice, while the fixation of the polypropylene mesh endoprosthesis is carried out with continuous sutures in two rows along the perimeter of this mesh endoprosthesis.