RU2254819C1 - Method for plasty of median ventral hernias - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: one should isolate and dissect hernial sac, suture in muscular-aponeurotic edges of hernial porta or residues of hernial sac's peritoneum to fix the explant above the sutures of aponeurosis or peritoneum. The explant should be covered with aponeurotic fragments out of anterior walls of sheathes of rectus muscles of abdomen being adjacent to the explant that, in its turn, prevents infectioning, migration and detachment of the explant mentioned.

EFFECT: higher efficiency of plasty.

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Description

The invention relates to medicine, namely to surgery, and can be used for plastic surgery of median ventral hernias.

The high relapse rate (10–40%) after plastic surgery of the median ventral hernias with local tissues prompted the widespread use of explants.

There is a method of plastic surgery of median ventral hernias, in which after excision of the hernial sac and suturing of the peritoneum, the prolene mesh is fixed to the parietal peritoneum, the edges of the scar-modified aponeurosis are excised and the aponeurosis is sutured over the mesh (A. G. Kirpichov and N. A. Surkov. Using a mesh from prolena with plastic surgery of the anterior abdominal wall. M., 2001, p. 18-22).

However, this method has its drawbacks. Subponeurotic placement of the mesh requires separation of the parietal peritoneum from the aponeurosis over a large area, which is not always possible due to intimate fusion of tissues and their cicatricial changes after previous operations. In addition, there is a limitation of the area of the anterior abdominal wall covered by the prosthesis due to the technical difficulties of its fixation under the aponeurosis. The method is not feasible with large sizes of hernial gates.

A known method of plastic surgery of median ventral hernias without tissue tension (V.N. Egiev, M.N. Rudakova, M.D. Svetkovsky. Hernioplasty without tissue tension in the treatment of postoperative ventral hernias. Surgery. No. 6, 2000, p. 18 -22). The authors distinguish aponeurosis around the hernial sac. The polypropylene mesh is fixed around the hernia gate with a margin of 2-3 cm. With this method, the mesh is in wide contact with the subcutaneous tissue, which contributes to the development of the inflammatory process in the wound.

A known method of plasticity of the median ventral hernias is that, with small hernial gates, they are plastic edge to edge and an explant is placed over the aponeurosis in the area of hernial gates (A.G. Kirpichyov and N.A. Surkov. Use of prolene mesh for plastic anterior abdominal wall. M., 2001, p. 18-22).

This method has a number of significant disadvantages. With large sizes of hernial gates, stitching their edges leads to tissue tension and teething. The placement of the mesh above the aponeurosis is the least rational. A mesh that is not integrated into the layers of the anterior abdominal wall may exfoliate from the aponeurosis and fail to fulfill its function of strengthening the abdominal wall. The wide contact of the explant with subcutaneous fat increases the risk of developing a purulent-inflammatory process in the wound and infection of the mesh.

The objective of the invention is to provide a method of plasticity of the middle ventral hernia, used for any size of hernia gate, providing reliable fixation of the explant along the entire line of the primary scar, preventing infection, migration and rejection of the explant by eliminating contact of the explant with subcutaneous tissue.

The problem is solved in that in the known method of plastic surgery of the median ventral hernias, including an incision of the anterior abdominal wall with excision of the scar, excess skin and adipose tissue, isolation and excision of the hernial sac, suturing of the muscular aponeurotic edges of the hernial collar or remnants of the peritoneal hernia sac and fixation over the seams of the aponeurosis or peritoneum, according to the invention, the explant is closed with flaps of aponeurosis from the front walls of the vagina of the rectus abdominis adjacent to the explant.

Studies have shown that the closure of the explant with aponeurosis grafts from the anterior vaginal walls of the rectus abdominis adjacent to the explant eliminates the contact of the explant with subcutaneous tissue and thereby prevents infection of the explant. An explant placed under the aponeurosis integrates reliably into the layers of the anterior abdominal wall. Plastic surgery using aponeurosis flaps from adjacent adjacent tissues allows closing hernial gates of any size. The proposed method was performed plastic surgery of ventral hernias in 6 patients.

In FIG. 1 shows a diagram of fixation of the explant and cutting out of aponeurosis flaps.

In FIG. 2 shows a diagram of the closure of the explant with cut aponeurosis flaps.

The proposed method can be implemented as follows. Cut the anterior abdominal wall with excision of the entire postoperative scar, excess skin and fatty tissue. Gap and excise (with large hernial gates partially) hernial sac. The abdominal cavity is sutured by suturing the edge to the edge of either the muscular-aponeurotic edges of the hernial portal, or, with large hernial portal, the remaining peritoneum. Explant 1 is placed over the seams of the aponeurosis or over the peritoneum in the form of a Proline or Esfil polypropylene mesh so that it overlaps the line of hernia gate by 3-5 cm in all directions and is located along the entire previous postoperative scar. The explant 1 is hemmed at the edges to the aponeurosis in the area of the hernial gate with a continuous suture of 2/0 or 0 proline. To the right and left of the explant 1, two flaps 2 are cut from the aponeurosis of the anterior wall of the vagina of the rectus abdominis muscles, the bases of which are located at the lateral edges of the explant 1, and the width is half its width. Flaps 2 of the aponeurosis are deployed in the medial direction, placed over the mesh and sutured to each other edge to edge along the white line 3. The postoperative wound is sutured, leaving active drainage according to Redon.

The method can be illustrated by the following examples.

Example 1. Patient B. 56 years old, diagnosis: postoperative ventral hernia. Obesity I-II Art. Diastasis of the rectus abdominis muscles. Appointed plastic surgery. Three hernial sacs 7 × 8, 6 × 7 and 6 × 6 cm were revealed during the operation; in addition, many small defects of the aponeurosis along the entire line of the previous aponeurotic scar after the upper middle laparotomy. The hernial sacs were excised, the soldered large omentum was resected. After joining the hernia gate of all three hernias, the resulting defect of the anterior abdominal wall measuring 12 × 9 cm is sutured edge to edge with Kuntz sutures. After seams along the entire line of the musculo-aponeurotic scar after the previous operation, a polycropylene mesh was installed Prolic of Ethikon company measuring 15 × 7 cm and fixed along the edges with a continuous prolene suture 0. Then two aponeurotic flaps were cut from the front walls of the vagina of the rectus abdominis muscles, the base of the flaps are located along the lateral the walls of the grid. The flaps are deployed in the medial direction and sewn over the grid in a white line. The wound was sutured in layers, leaving two PVC drainages according to Redon. The postoperative course is smooth. Primary healing. The patient was discharged 12 days after surgery.

Example 2. Patient G., 67 years old, diagnosis: recurrent postoperative ventral hernia. Obesity II tbsp. Diastasis of the rectus abdominis muscles. She was previously operated on three times for a hernia and its relapses. Plastic surgery was performed. In the course of the entire postoperative scar, after an upper midline laparotomy, multiple hernias from 5 × 5 to 1 × 1 cm were revealed. After the hernia gate was connected, a defect of 12 × 10 cm was formed. The hernial sacs were partially excised and the peritoneum was sutured. Above it is a polypropylene mesh Prolen of Ethikon company with dimensions of 15 × 10 cm and fixed with interrupted prolene seams. Muscle-aponeurotic edges of the defect are sutured above the mesh. In the upper right quadrant, the muscular aponeurotic edge is scarred, very thinned, and it was not possible to cover them with a mesh. A 8x6 cm flap was cut from the front wall of the vagina of the right rectus abdominis muscle and the mesh was covered with it. The postoperative course is smooth. Healing by first intention. The patient was discharged on the 17th day after surgery.

Example 3. Patient D., 48 years old, diagnosis: giant postoperative ventral hernia. In the area of the scar, after the upper midline laparotomy, there is a hernia of -20 × 25 cm, hernial gates -15 × 15 cm. A plastic surgery is prescribed. During plastic surgery, the postoperative scar along with the skin over the hernial protrusion and the umbilicus is partially excised. A hernial sac 20 × 22 cm in size was opened, containing a large omentum soldered to its walls. The oil seal is separated. The hernial sac is partially excised, the peritoneum is sutured. Esfil polypropylene mesh 15 × 15 cm was sewn over the peritoneal peritoneum along the perimeter of the hernial collar with a continuous 2/0 suture suture. Two aponeurotic flaps were cut from the front walls of the rectus sheaths, the bases of which are located at the edges of the hemmed mesh. The flaps are deployed medially and stitched with each other above the grid. The subcutaneous tissue is drained by two active drains. Stitches are applied to the skin. The postoperative course is smooth. Healing by first intention. The patient was discharged for outpatient treatment on the twelfth day after surgery.

The proposed method is simple and fast implementation. The combination of plastic with the explant and local tissues ensures the reliability of the operation. The method can be used with any size of hernial gates.

The subponeurotic location of the explant enhances its action strengthening the anterior abdominal wall. The method allows the explant to strengthen the entire line of the primary scar. Covering the explant with aponeurosis prevents infection, migration, and rejection. The method can be used in combination with other plastic methods.

Claims (1)

The method of plastic surgery of median ventral hernias, including an incision of the anterior abdominal wall with excision of the scar, excess skin and adipose tissue, isolation and excision of the hernial sac, suturing of the muscular-aponeurotic edges of the hernial collar or remnants of the peritoneum of the hernial sac, and fixation of the explant above the aponeurosis seams that the explant is closed with flaps of aponeurosis from the front walls of the vagina of the rectus abdominis adjacent to the explant.

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