EA023684B1 - Method of combined plastic of greater and giant postoperative anterior abdominal wall hernia - Google Patents

Abstract

The invention relates to medicine, in particular, to surgery and can be used in operative treatment of greater and giant anterior abdominal wall hernia. The problem is solved by separating rectus muscle of stomach from posterior wall of its vagina, up to the muscle lateral edge, then from above the separation is performed of subcutaneous fat to the point where aponeurosis of external oblique muscle transforms to the vagina stomach rectum, the transition point of the aponeurosis of external oblique muscle to the vagina stomach rectum is positioned at medium-clavicular line, further the aponeurosis of external oblique muscle crosses in the longitudinal direction, then the Trabucco net with shape memory in the sub-lay position is laid in the retromuscular space, further the Uniflex nets are positioned between dissected medial and lateral flaps of the aponeuroses of dissected external oblique muscles in the on-lay position, after which the Uniflex nets are fixed to the Trabucco net by Π-shaped through seam on both sides, then the medial aponeuroses flaps of the anterior walls of vaginas of rectus muscle of stomach are sutured therebetween at medium line, remaining left and right free flaps of the Uniflex net are correspondingly sutured by a continuos seam to lateral flaps of the external oblique muscles.

Description

The invention relates to medicine, namely to surgery and can be used in surgical treatment of large and giant hernias of the anterior abdominal wall. As you know, postoperative ventral hernias comprise up to 20-26% of all external abdominal hernias, taking the second place in frequency after inguinal hernias. The greatest difficulties arise in the treatment of patients with large and giant ventral hernias. According to I.G. Gataulina (1994), the frequency of their relapses is 1.5 times higher than with hernias of small and medium sizes. The main causes of unsatisfactory results are technical and tactical errors in the fixation of an allograft, the development of purulent complications, the presence of concomitant diseases that adversely affect the course of the postoperative period. Thus, from the point of view of surgical tactics, the main issue is the location and method of fixation of the endoprosthesis.

A known method of combined hernioplasty without opening the abdominal cavity, proposed by Όβνΐίπ in 1993, the essence of this method is to place the explant in front of the muscular aponeurotic layer with minimal tension on the edges of the hernial defect. The size of the hernial defect is palpated, the scar and subcutaneous fat are excised above the hernial sac, 4-5 cm away from the edge of the hernial collar, the anterior wall of the rectus sheath is cut from both sides, the hernial sac is immersed into the abdominal cavity without opening, and then sutured the medial edges of the dissected leaves of the vagina of the rectus abdominis muscles; the graft is hemmed to the lateral edges of the dissected leaves.

This method has its drawbacks: 1) there are risks of complications that are characteristic of the subcutaneous location of the implant (seromas, hematomas, infiltrates); 2) this plastic cannot be used for postoperative ventral hernias with an aponeurosis defect of more than 10 cm across.

As a prototype for our method of treatment, we chose the Rapps / method, proposed in 1990. The method consists in crossing the tendon of the external oblique muscle of the abdomen from two sides, which allows to reduce the width of the hernial defect. Initially, the hernial sac and the front sheets of the vagina of the rectus abdominis are mobilized to the spigel lines on both sides. After that, along the edge of the muscular part, that is, OJK | 1SH5 ABBOTH with S1S5, its tendon part intersects along the entire length from the costal arch to the ilium. It is advisable to limit the plastic zone either with the help of hernia sac flaps, or with the help of a large omentum. Hernial gates reduce sutures, avoiding much tension.

The disadvantage of this method is 1) the frequent formation of accumulations of serous fluid due to the intersection of many lymphatic and blood capillaries as a result of detachment of the subcutaneous fat base; 2) data of foreign authors indicate that between the transverse and internal oblique muscles of the abdomen nerve endings pass and when excised they lose their properties; 3) wide contact of adipose tissue with the explant, which can lead to rejection of the endoprosthesis and in the future to hernia recurrence.

The objective of our invention is to improve the results of treatment after surgical hernias of the anterior abdominal wall and to reduce the number of relapses and complications.

The problem is solved due to the fact that in the method of surgical treatment of postoperative ventral hernias of the abdomen, comprising the fact that after longitudinal dissection of the anterior walls of the vagina of the rectus abdominis muscles and separation of the anterior leaf of the aponeurosis from the rectus abdominis to the point of attachment of the tendon of the external oblique, internal oblique and transverse abdominal muscles cut off the tendon of the external oblique, internal oblique and transverse abdominal muscles, the following differences are provided: in the retromuscular space A Trabucco mesh with shape memory in position 8i3-1au is placed, then Uniflex grids are placed between dissected medial and lateral aponeurosis flaps of dissected external oblique muscles in the op 1au position, after which Uniflex grids on the right and left through through U-shaped sutures are fixed to the Trabucco mesh, then the medial aponeurotic flaps of the anterior walls of the vagina of the rectus abdominis muscle are sutured together along the midline and without tension, the remaining left and right free edges of the Uniflex mesh are respectively sewn It is to the lateral flap of external oblique muscles with a continuous suture.

An advantage of our invention is that due to this plasty, there is no frequent accumulation of serous fluid due to the intersection of many lymphatic and blood capillaries as a result of wide detachment of the subcutaneous fat base; nerve endings located between the transverse and internal oblique muscles of the abdomen are not excised. Cases of hernia recurrence with this method of operation are not marked.

There is a causal relationship between the totality of essential features and the technical result achieved: through the use of nets with the memory of the Trabucco shape and the Uniflex mesh, an increase in the volume of the abdominal cavity is achieved, which, as a result, contributes to better tolerance of the increased intra-abdominal pressure, sometimes found in patients with large and giant hernias of the anterior abdominal wall in the postoperative period.

Also, with the help of such reconstruction, the biomechanical properties of the anterior

- 1,023,684 abdominal wall, the focus of which is the rectus abdominis muscles, reduced without tension to the midline and contributing to a better and more adequate resistance to intra-abdominal pressure, due to the preserved sufficient muscle contractility, which is of great importance in the prevention of relapse.

SUMMARY OF THE INVENTION

The skin and subcutaneous tissue are dissected. The hernial sac is opened, the contents are separated in a sharp and blunt way from the walls. If necessary, adhesiolysis and simultaneous operations on the abdominal organs are performed. The area of the hernial defect is determined. Then begins the plastic phase of the operation. The vagina of the rectus abdominis muscle is opened at the medial edge along the entire length of the hernial defect. The rectus abdominis muscle is separated from the posterior wall of its vagina, up to the lateral edge of the muscle. Then, subcutaneous fat is separated from the top to the point of transition of the aponeurosis of the external oblique muscle into the vagina of the rectus abdominis muscle. A technique is used to separate the components (construction of keratoyoi (seFoods). With transposition of the rectus muscle. On the midclavicular line is the transition point of the aponeurosis of the external oblique muscle into the vagina of the rectus abdominis muscle, and, retreating 1.5-2 cm laterally, a longitudinal incision is made, which continues up to the costal arches and down to the anterior superior iliac spine, depending on the length of the hernial defect. The rectus abdominis muscle is freed from contracture. The external oblique muscle is separated by separation with the internal oblique muscle. As a result, the liberated and mobilized rectus abdominis muscle is freely, without tension, pulled to the midline, the same procedure is performed from the opposite side.

Then they begin laying mesh implants. First, with a continuous polypropylene suture (No. 0), the posterior wall of the vagina of the rectus abdominis muscle is sutured, consisting of: above the navel - from the posterior leaf of the aponeurosis of the internal oblique muscle, aponeurosis of the transverse abdominal muscle, transverse fascia, peritoneum; below the navel - only from the transverse fascia and peritoneum. Sometimes, if necessary, an incompletely excised hernial sac is also used for this purpose. Hemostasis is performed. The mesh implant No1ga 0 of the Netshate company, which has a shape memory, which, according to the manufacturer, does not need to be stitched to the tissues, is removed from a sterile package of the right size. after installation in the retromuscular space, it lies flat on the tissues, does not wrinkle and does not fold (Trabukko mesh). The contractility of the Trabukko mesh in the long-term postoperative period is 2–5%, while conventional polypropylene nets are reduced already by 25–30% a year after implantation. The unusualness of the Trabucco nets is that although the nets themselves are composed of polypropylene monofilaments, they have a special form of weaving, for which manufacturers have an exclusive patent, as a result of which the mesh takes shape memory (Ermanno Trabucco Netchat, Turin, Italy). The Trabukko mesh is modeled in the shape of the retromuscular space so that there is neither a lack of mesh nor an excess that facilitates bending it in the middle, after suturing the anterior wall of the vagina of the rectus abdominis muscle. Then another mesh is removed, the right size, consisting of 100% polyvinylidene fluoride (PVDF) monofilaments (Lintex Uniflex mesh), which has better dynamic properties, pronounced resistance to infection, as well as less contractility (1-4%) due to cicatricial germination, unlike standard polypropylene endoprostheses, which are reduced in size by 25-30% after a year or more after implantation. The Uniflex mesh with one edge fits along the entire length of the dissected aponeurosis of the external oblique muscle, under its medial flap, until it contacts the outer edge of the vagina of the rectus abdominis muscle. Then, with a polypropylene monofilament 2.0, both grids (Trabucco and Uniflex) are sewn through the seam through one seam as follows. First, the medial flap of the dissected aponeurosis of the external oblique muscle of the abdomen is stitched, then the Uniflex mesh is grasped into the suture, retreating 1.0-1.5 cm from its edge, then the straight muscle selected from the posterior wall is taken and slightly stretched to the midline, then from the inside, the aponeurosis of the internal oblique muscle is stitched, while hitting the retromuscular space with a needle directly to the edge of the Trabukko mesh placed there, which is stitched with a U-shaped suture, and, retreating 0.5-0.7 cm from the previous injection, the needle is punctured arr Tnom direction, i.e. the aponeurosis of the internal oblique muscle is again stitched, now from the inside (the retromuscular space) to the outside. Then the Uniflex mesh is captured into the suture and the medial flap of the dissected aponeurosis of the external oblique muscle of the abdomen is also stitched. The thread is taken to the holder.

Depending on the length of the muscle-aponeurotic defect and the size of the nets, it is sufficient to lay three or a maximum of four such through sutures at an even distance from each other, which are tied after application. The same seams are laid on the opposite side. The upper and lower poles of the Trabucco grid are not stitched, because the grid has shape memory; it does not wrinkle or twist in a confined space. A vacuum drainage is installed above the Trabucco mesh, which is released onto the skin with a contra -perture.

Then, the medial edges of the rectus abdominis muscles with aponeuroses covering them on top of the Trabucco mesh are sutured without tension with a continuous polypropylene suture (No. 0) along the entire length of the defect. Next, the excess Uniflex nets are cut off at their lateral edge, both on the right and on the left side.

- 2 023684

The lateral edges of Uniflex nets simulated in this way without tension, are sewn with a continuous polypropylene suture (2/0) to the lateral flaps of the right and left dissected aponeurosis of the external oblique muscle of the abdomen, with the underlying soft tissues being captured into the suture. The upper and lower redundant grid poles are also trimmed and sutured to the underlying tissues with separate interrupted sutures.

A thorough hemostasis is performed. In the space between the subcutaneous tissue and aponeurosis, drainages are laid, which are removed to the skin by contrapertures. The wound is sutured in layers, an aseptic dressing is applied.

Thus, non-tensile plastic surgery of large and gigantic defects of the anterior abdominal wall is performed using the technique of separation of components (sotropep18 veratiope 1ceNp1cis) and transposition of the rectus abdominis muscles, followed by the installation and stitching of two mesh endoprostheses (Trabucco mesh and Uniflex mesh) using the original technique.

Thus, an increase in the volume of the abdominal cavity is achieved, which subsequently contributes to better tolerance of the increased intra-abdominal pressure, which is sometimes found in patients with large and giant hernias of the anterior abdominal wall in the postoperative period.

Also, with the help of this reconstruction, the biomechanical properties of the anterior abdominal wall are restored, the focus of which is the rectus abdominis muscles, reduced without tension to the midline and contributing to a better and more adequate resistance to intra-abdominal pressure, due to the preserved sufficient muscle contractility, which is of great importance in the prevention of relapses .

FIG. 1. Large ventral hernia

- hernial sac;

- rectus muscle;

- the rectus sheath.

FIG. 2. Muscles

- rectus muscle;

- the rectus sheath;

- external oblique muscle;

- internal oblique muscle;

- transverse muscle.

FIG. 3. The intersection of the aponeurosis of the external oblique muscle and its separation from the internal oblique muscle

- the intersection of the aponeurosis of the external oblique muscle and its separation from the internal oblique muscle.

FIG. 4. Separation of the rectus abdominis muscle from the posterior wall of its vagina

- separation of the rectus abdominis muscle from the posterior wall of its vagina.

FIG. 5. Suturing of the posterior sheets of the vagina of the rectus abdominis muscles

- back sheets of the vagina of the rectus abdominis muscles;

- the seam.

FIG. 6. The method of combined plastic surgery of large and giant postoperative hernias of the anterior abdominal wall

- mesh Trabucco;

- mesh Uniflex;

- through seams connecting the Trabucco grid with the Uniflex grid;

- continuous seam;

- suturing of the front sheets of the vagina of the rectus abdominis muscles.

Example. Patient R., 58 years old, medical history No. 2850, 05.05.2012 was admitted to the II surgical department of hospital No. 1 in Baku with a diagnosis of a huge recurrent median hernia of the anterior abdominal wall, sagging abdomen, obesity of II degree.

From the anamnesis it is known that in 2009 she underwent uterine extirpation, a few months after which a postoperative hernia appeared, and the patient underwent a second operation - hernioalloplasty with the implant in the op-1au position. A year after the operation, the patient again had a hernia, which gradually increased. In parallel with this, the patient had a pronounced saggy abdomen.

Upon admission, the condition is satisfactory, the skin and visible mucous membranes of normal color, the subcutaneous fat layer is overdeveloped. The vesicular breathing, without wheezing. Heart sounds are muffled, Ρδ - rhythmic, 86 beats. in minutes, A / D - 130/80 mm RT. Art. The abdomen is soft, painless on palpation. On the anterior abdominal wall there is a huge protrusion of 30x20 cm in size, a skin-fat apron hanging down to the upper 1/3 of the thighs is expressed. There are no phenomena of maceration in the skin-fat fold. The hernia gate could not be determined due to the presence of a dense scar conglomerate under the skin.

05/08/2012, a planned operation was performed: herniolaparotomy, adhesiolysis, removal of a scar-deformed mesh implant, the technique of separation of components according to the Rapigeh method. combined hernioplasty with Ttbieeo and Uniflex nets in the position kl-1au + op-1au, abdominoplasty.

Under endotracheal anesthesia in the transverse direction, two half-moon incisions were made with excision of the old scar and skin-fat apron over the protrusion. After separating the protrusion from the surrounding tissues, it turned out that the old mesh was scar deformed and was a conglomerate measuring 15x12 cm. The hernial protrusion significantly protruded through the upper edge of the mesh, bending the latter under its weight. The old implant is excised and removed, the hernial sac is opened, adhesions are highlighted. The length of the hernia defect is 17 cm, while the width, i.e. diastasis between aponeuroses of the rectus abdominis muscle reaches 14 cm. The vagina of the rectus abdominis muscle is opened along the entire length of the hernial sac. The rectus muscles are separated from their posterior walls. Then, the technique of component separation by the Cachelet method was performed with the movement of the rectus abdominis muscles to the midline without much tension. Next, the posterior abdominal rectus sheath walls were sutured with a continuous prolene suture together with the remaining hernial sac, and thus the abdominal cavity was closed, and then combined hernioplasty was performed with the required dimensions of the nets TgLisso and Uniflex in position kl-1au + op-1au according to the proposed method. The front walls of the vaginas of the rectus abdominis muscle are also sutured with a continuous prolene suture without tension. Excess skin and fat apron is completely excised. The area of the separated subcutaneous tissue is drained by Redon vacuum drainage. The skin wound is sutured, an aseptic dressing is applied.

In the postoperative period, within a few days, a small amount (70-80 ml) of serous fluid was separated through the drains. As the amount of detachable was reduced, the drains were removed on the 5th day. The wound healed by primary intention. The patient in satisfactory condition 05/17/2012 was discharged home.

Literature

1. Belokonev V.I. et al. Plastics of the abdominal wall with ventral hernias in a combined way. Surgery. 2000, No. 8, pp. 24-26.

2. 8aegg1apy 8. e! a1. // IB, 2004, yo1.8, No. 1, p. 42-46.

3. Ermolov A.S., Upyrev A.V. et al. Peculiarities of the course of the postoperative period with various technology of abdominal wall hernia repair // New technologies in hernia surgery: Proc. doc. scientific and practical. conferences. Saratov, 2006, p. 6-9.

4. Yeu1t N.V. Mapadetep! OG AYOT1PA1 Gettak. Biop: ViNGloPIK, 2000, 430 p.

5. Coughing / O.M., Kjak E., B11b. 'Sotropep! To kerataNop' teFoy Gog s1okige oG ayot1pa1-la11 eGes! K: up apa!

6. Koeg! R. VschIgoy !, Tatto 8., ye Upek KeShpdi, Apap Ma1uag e! a1. SotropeShk keragaiop TesIpksche! About teral 1 when MShte Netshak // Oretayue TesIpkschek sh Oepeta 8igdegu, Uo1 6, No 3 (8er! Etg), 2004, pp 179-188.

Claims (1)

A method of combined plastic surgery of large and giant postoperative hernias of the anterior abdominal wall, comprising the fact that after longitudinal dissection of the anterior walls of the vagina of the rectus abdominis muscles and separation of the anterior leaf of the aponeurosis from the rectus abdominis to the point of attachment of the tendon of the external oblique, internal oblique and transverse abdominal muscles cut off the tendon of the external oblique, internal oblique and transverse abdominal muscles, characterized in that the rectus abdominis is separated from the back wall of its vagina, right up to the lateral edge of the muscle, then subcutaneous fatty tissue is separated from the top to the point of transition of the aponeurosis of the external oblique muscle into the vagina of the rectus abdominis muscle, along the midclavicular line is the place of transition of the aponeurosis of the external oblique muscle into the vagina of the rectus abdominis muscle, then the aponeurosis of the external oblique abdominal muscle is crossed in the longitudinal direction, then in the retromuscular space, a Trabukko grid with shape memory in the position kb-1au is laid, then Uniflex grids are placed between the dissected medial with lateral and lateral aponeurosis flaps of dissected external oblique muscles in the op-1au position, after which the Uniflex nets to the right and left through the U-shaped sutures are fixed to the Trabukko mesh, then the medial aponeurotic flaps of the anterior walls of the vagina of the rectus abdominis muscles are sutured together along the midline and without tension, the remaining left and right free edges of the Uniflex mesh are respectively sewn to the lateral flaps of the external oblique muscles with a continuous suture.