RU2367359C1 - Sutureless combined prosthetics of anterior abdominal wall in combined injuinal hernias - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, particularly to surgery. That involves dissection of skin and hypoderm, separation of aponeurosis of abdominal external oblique muscle. A hernial sac is separated and dipped in abdominal cavity without opening, suturing and excision. A preperitoneal space wherein a rectangular implant of biomaterial Alloplant is pre-applied on spermatic cord is created. The implant represents a biomaterial of consistent adhesive formation of the size 3×4 cm, of rectangular shape with the rounded-off angles. At the distance 1-1.5 cm to the middle, there is an opening of diametre 1 cm that is connected to the external rectangle border owing to a radial incision performed. The prosthesis thickness is 2-3 mm. In the entire area of the prosthesis, there are perforations of diametre 3 mm that are spaced 0.5 cm. The implant is positioned on posterior wall of inguinal canal without being fixed to surrounding tissues. Aponeurosis is sutured over the prosthesis and under spermatic cord.

EFFECT: application of the invention prevents complications associated with recurrent hernias, postoperative growth of coarse connecting tissue and spermatic cord stenosis.

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Description

The present invention relates to medicine, in particular to surgery, and for the surgical treatment of defects of the abdominal wall of the inguinal region.

Hernia of the anterior abdominal wall is one of the most common human diseases. In approximately 75% of cases, we are talking about inguinal and femoral hernias and 15–20% account for ventral hernias (Kuzin M.I., 1986; Emelyanov S.I., Protasov A.V., Rutenburg G.M., 2000) . This pathology is traditionally referred to as a surgical profile, since only the abdominal wall plastic is capable of ensuring the full recovery of the patient. Hernia surgery accounts for almost a quarter of all surgical interventions, and 35% of them perform emergency procedures for infringement with a mortality rate of at least 3% (Hollinsky C, Sandberg S, Kocijan R, 2007). A low percentage of hernia recurrences can be obtained only in specialized herniological centers. A new generation of synthetic prostheses was created. Due to this, methods for surgical treatment of inguinal hernias with the use of modern materials appeared, at which the relapse rate is about 1% (Mitin S.E., Peshekhonov S.I., Chistyakov D.B. 2002; Egiev V.N., Lyadov K. V., Voskresensky P.K., 2003).

Inguinal hernias are congenital (non-shortening of the process of the peritoneum) and acquired. Congenital hernias are often combined with other diseases - dropsy of the testicle, cryptorchidism, spermatic cord cysts. Depending on the place of exit (localization of the hernia gate), oblique and direct inguinal hernias are distinguished. An operation for inguinal hernias consists of providing operative access to the hernia (incision of the superficial tissues), isolating the hernial sac from surrounding tissues, opening it, disconnecting from the joints, and placing the organs in the hernial sac into the abdominal cavity.

Surgical treatment of hernias refers to reconstructive surgery, which always requires a special constructive approach and the search for better, different from the usual methods of surgery.

The prototype of the invention is a method for seamless implantation of a prosthesis according to the Trabucco method, which consists in implanting a rigid polypropylene prosthesis in the area of the peritoneal space, which does not require stitching of the mesh to the tissues with threads. To obtain this effect, the Italian company Herniamesh developed rigid monofilament mesh polypropylene prostheses (www.semashko.com/services/surgery). For all the positive aspects of this technique, there are a number of significant drawbacks. The disadvantages of this method are: the lack of elasticity and rigidity of the polypropylene prosthesis leads to damage to the spermatic cord and surrounding tissues during implantation, as a result of which the damaged tissues soon grow into coarse connective tissue, which in turn leads to the appearance of a painful scar and patient discomfort, and damage to areas of the spermatic cord lead to proliferation in the area of the opening of the prosthesis of fibrous tissue and narrowing of the spermatic cord. Also, when the polypropylene prosthesis is fused with the surrounding tissues, it is not the fibers that grow through the prosthesis cells, but their capsulation, which subsequently, with a possible relapse, adversely affects the preparation due to the rough and random growth of the connective tissue.

The technical result is the prevention of complications associated with recurrence of hernias, the prevention of postoperative proliferation of coarse connective tissue, stenosis of the spermatic cord, and the reduction of hospital stay.

The proposed method is as follows. Under general anesthesia, the processing of the surgical field is performed. The operation is carried out in stages, starting with an oblique hernia. Cut the skin, subcutaneous tissue, exfoliate the aponeurosis of the external oblique muscle of the abdomen. The hernial sac is isolated, then immersed in the abdominal cavity without opening, suturing and excision. During the operation, with an oblique inguinal hernia, a preperitoneal space is created with a finger in the projection of the internal inguinal ring, in which a rectangular implant from Alloplant biomaterial is placed, previously worn on the spermatic cord, closing the inner inguinal ring. The proposed implant is a biomaterial of a dense connective tissue formation of size 3 × 9, rectangular with rounded corners, on one side, departing from the edge 1-1.5 cm to the middle, a hole with a diameter of 1 cm is made, communicating due to the radial section from the outside the border of the rectangle. The thickness of the prosthesis made is 2-3 mm. Perforated holes were made over the entire area of the device at a distance of 0.5 cm from each other with a diameter of 3 mm. After that, a hernial sac of a direct hernia is isolated and immersed in the abdominal cavity without opening, flashing and excision.

Then, an oval-shaped implant of the Italian company Herniamesh is placed on the back wall of the inguinal canal without fixation to surrounding tissues. The implant is located in a closed anatomical space under the aponeurosis of the external oblique muscle of the abdomen, without fixation to surrounding tissues. The aponeurosis is sutured with a continuous suture over the prosthesis and under the spermatic cord, which as a result is located under the skin. Then suture on the subcutaneous tissue and skin.

The proposed biomaterial for hernioplasty is prepared based on the requirements for corset plastics. The donor material for the preparation of biomaterial is allogens, dense connective tissue formations. Processing and preservation is carried out according to Alloplant technology (Patent No. 2189257), on the basis of the All-Russian Center for Ophthalmic and Plastic Surgery. This biomaterial for corset plastic has high strength and elastic properties.

The tensile strength is: 7.16 ± 0.2 MPa, the modulus of elasticity is 31.68 ± 1.18 MPa (Essays on tissue transplantation. - R.T. Nigmatullin, Ufa, 2003, p-58). These properties are provided by a high density of bundles of collagen fibers. This allows, if necessary, to simulate the biomaterial and adapt to the tissue bed. After transplantation, the biomaterial does not cause an inflammatory local and general reaction. It is gradually replaced by a dense connective tissue regenerate, which provides high tissue strength in the inguinal canal. The structural organization of the fibrous structures of the implant made of allogens, connective tissue formations is specific. The collagen fibers of the implant form a dense three-dimensional network of additionally reinforced elastic fibers. (Essays on tissue transplantation. - R.T. Nigmatullin, Ufa, 2003, p.95.)

Clinical example. Patient L., 48 years old (medical history No. 17356/07), was admitted to the hospital with complaints of pain, a protrusion in the right inguinal region 3 × 4 cm in size and a scrotum of 6 × 6 cm in the abdominal cavity. The disease is associated with lifting heavy loads and injuring the inguinal canal with a blunt object. After examination and preoperative preparation, surgical intervention was performed. Under general anesthesia, the surgical field was treated. They made a dissection of the skin, subcutaneous tissue, exfoliated aponeurosis of the external oblique muscle of the abdomen. After the audit, a direct and oblique inguinal hernia was revealed. The operation was carried out in stages, starting with an oblique hernia. The hernial sac was isolated, then immersed in the abdominal cavity without opening, flashing and excision. During the operation, a preperitoneal space was created with a finger in the projection of the internal inguinal ring, in which a rectangular implant from Alloplant biomaterial was placed, previously put on the spermatic cord, closing the inner inguinal ring. After that, a hernial sac of a direct hernia was isolated and immersed in the abdominal cavity without opening, flashing and excision. The implant was placed in a closed anatomical space under the aponeurosis of the external oblique muscle of the abdomen without fixation to surrounding tissues. The aponeurosis was sutured with a continuous suture over the prosthesis and under the spermatic cord, which as a result was located under the skin. Then sutured the subcutaneous tissue and skin.

In the postoperative period, the course is smooth, the patient was discharged on the 8th day after the operation.

The proposed method was used in a clinic in 10 patients with oblique hernia combined with direct inguinal hernia. No complications using the method have been identified.

Thus, the results of clinical studies show that the proposed method for the combined use of an implant from Alloplant biomaterial and an Herniamesh implant prevents the complications associated with relapse of hernias, prevents the growth of coarse connective tissue, stenosis of the spermatic cord due to the high density of bundles of collagen fibers of the biomaterial. This allows, if necessary, to simulate the biomaterial and adapt to the tissue bed. After transplantation, the biomaterial does not cause an inflammatory local and general reaction. Gradually, the biomaterial is replaced by a dense connective tissue regenerate, which ensures high tissue strength in the inguinal canal.

Claims (1)

A method of surgical treatment of combined inguinal hernias, including general anesthesia, revision of the inguinal canal, implantation of a rigid polypropylene prosthesis in the peritoneal space without hemming, suturing of the subcutaneous tissue and skin, characterized in that an implant made of Alloplant biomaterial made of Alloplant biomaterial is first placed in the peritoneal space dense connective tissue formation 3 × 9 cm in size, 2-3 mm thick, rectangular in shape with rounded corners, on one side of which, departing from the edge and 1-1.5 cm to the middle, a hole with a diameter of 1 cm is made, communicating thanks to a radial cut with the outer border of the rectangle, over the entire area of which perforated holes are made at a distance of 0.5 cm from each other with a diameter of 3 mm, previously worn on the spermatic cord .