RU2261663C2 - Method for plasty in case of hernia of diaphragmatic esophageal foramen - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: one should perform laparotomy, remove hernial content and replace it into abdominal cavity, isolate esophageal-diaphragmatic ligament, dissect its excessive parts, perform posterior crurorhaphy, overlap the defect with netted implant applied around abdominal esophageal department to be fixed with separate interrupted sutures to esophagus along internal contour and simultaneously with the same interrupted sutures - along external contour to sutured diaphragmatic pedicles without tension.

EFFECT: decreased complexity and traumatism of operation.

6 dwg, 1 ex

Description

The invention relates to medicine, in particular to surgery, and can be used in the treatment of hiatal hernia.

Known methods of plastic hernia of the esophageal opening of the diaphragm (1), including fixing:

- the esophagus to the edges of the esophageal opening of the diaphragm with the capture of the remains of the esophageal-diaphragmatic ligament and the addition of U-shaped sutures on the legs of the diaphragm;

- lesser curvature of the stomach (and fundus) to the anterior abdominal wall;

- to the anteritoneal wall of the U-shaped skin flap held around the cardia;

- cardia using the round liver ligament drawn around it;

- cardia to the preaortic fascia.

However, when using these methods, reliable fixation of the abdominal part of the esophagus and cardia in the abdominal cavity is not ensured while maintaining the cardiac closure function, which contributes to hernia recurrence and the development of postoperative complications, for example, in the form of reflux esophagitis.

There is also known a method for plastic surgery of a hernia of the esophageal opening of the diaphragm (2), including the allocation of the esophageal-diaphragmatic ligament, excision of its excess and suturing of the remaining part to the legs of the diaphragm, followed by posterior crurography.

However, this method is traumatic, difficult to perform and also does not exclude the development of hernia recurrence.

The objective of the invention is to develop a method of plastic hernia of the esophageal opening of the diaphragm, which reduces the complexity and invasiveness of the operation, as well as increasing its effectiveness by creating an artificial esophageal-diaphragmatic ligament.

This problem is solved by the fact that in the method of plastic hernia of the esophageal aperture of the diaphragm, including performing laparotomy, removing the hernial contents with moving it to the abdominal cavity, isolating the esophageal-diaphragmatic ligament, excising its excesses, followed by performing posterior cruraraphy, the defect formed is blocked by a connective germination tissue mesh implant installed around the abdominal esophagus and fixed without tension to the esophagus and diaphragm. It is provided that the mesh implant is made of nickel-titanium wire.

The invention is illustrated by a description, an example of clinical use, as well as schemes for performing specific techniques.

The attached diagrams show:

Figure 1 - mesh implant, General view;

Figure 2 - diagram of the mobilization of the esophagus and esophageal-diaphragmatic opening;

Figure 3 - diagram of the implementation of rear crurography;

Figure 4 - diagram of the fixation of the mesh implant to the esophagus and diaphragm.

The method is as follows.

After the upper middle laparotomy and extraction of the hernial contents with its movement into the abdominal cavity, the esophagus is mobilized with the intersection of the esophageal-diaphragmatic ligament (Fig. 2). The esophageal opening of the diaphragm and the preaortic fascia are isolated. After this, the rear crurography is performed - the application of one nodal suture on the legs of the diaphragm (Fig. 3). Following this, a mesh implant is installed around the esophagus, made of material that is capable of germination by connective tissue, for example, nickel-titanium wire with a diameter of 0.07 mm (Fig. 1), which, departing from the esophago-gastric junction by 3-4 cm, with separate interrupted sutures fixed to the esophagus along the inner contour.

At the same time, the same interrupted sutures along the outer contour without tension are fixed to the diaphragm and to its legs (Fig. 4).

The operation is completed by suturing the wound and applying an aseptic dressing.

In the postoperative period, the mesh implant, sprouting connective tissue, forms an artificial esophageal-diaphragmatic ligament, which has sufficient mechanical strength to hold the abdominal esophagus in the abdominal cavity.

The practical use of the method is illustrated by the following clinical example.

Patient Sh., 67 years old, was admitted to the hospital with a diagnosis of sliding hernia of the esophageal opening of the diaphragm (photo 1). After appropriate preoperative preparation, the operation was performed: laparotomy, plastic of the hernia of the esophageal opening of the diaphragm with a mesh implant of titanium nickelide.

During the operation, initially, after performing a laparotomy and extracting the hernial contents with its movement into the abdominal cavity, the esophageal-diaphragmatic ligament was excised, its excess was excised, followed by posterior cruroraphy. After that, the defect formed was blocked by a mesh implant capable of connective tissue germination, which was placed around the abdominal esophagus and fixed without tension to the esophagus and diaphragm (photo 2).

The postoperative period was uneventful. When a fluoroscopy of the stomach was performed on the 13th day after the operation, it was found that the cardia is located in the abdominal cavity, the angle of His is sharp, the gas bubble is pronounced, there is no hernia of the esophageal opening of the diaphragm.

On the control examination after one year, the reliability of the formed artificial esophageal-diaphragmatic ligament is noted; there are no signs of relapse.

Thus, the proposed method for plastic surgery of a hernia of the esophageal opening of the diaphragm reduces the complexity and invasiveness of the operation, and also increases its effectiveness by reconstructing the artificial esophageal-diaphragmatic ligament and prevents relapse of the disease.

Sources of information

1. Petrovsky B.V., Kanshin N.N., Nikolaev N.O. Diaphragm Surgery.// L .: Medicine, 1966, 336 p.

2. Shalimov A.A., Polupan V.N. Atlas of operations on the esophagus, stomach and duodenum. // M .: Medicine, 1975, p. 40.

Claims (1)

Method for plastic surgery of a hernia of the esophageal opening of the diaphragm, including performing laparotomy, extracting the hernial contents with moving it to the abdominal cavity, isolating the esophageal-diaphragmatic ligament, excising its excess, followed by performing posterior crurography, characterized in that after performing cruraraphy, the defect is covered by a germinating tissue mesh implant installed around the abdominal esophagus and fixed with separate interrupted sutures to the esophagus along the inner contour ru, at the same time with the same interrupted sutures along the outer contour to the stitched legs of the diaphragm without tension.

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