RU2324434C1 - Method of surgical treatment of post-operational ventral hernia with median localisation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: separation of the hernia sac. The plastic surgery of hernial aponeurosis is performed with the net prosthesis. The net prosthesis is fixed to the posterior aponeurotic leaves of the rectus abdominal muscles. The longitudinal relaxing incisions are made upon the anterior aponeurotic leaves of the rectus abdominal muscles.

EFFECT: method reduces risk of seroma and in-surgery traumatism.

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Description

The invention relates to abdominal surgery and relates to the repair of hernia gate in case of postoperative ventral hernias of the abdomen (POVH) of large sizes of midline localization.

There are many methods for repairing hernia gates with large POVG; at present, most authors recognize the need for explants in this situation.

The following method of plastics is known. Cut the aponeurosis around the hernial defect in a circular incision. The posterior walls of their vagina are peeled off through an incision from the rectus muscles. Dissected next to the median line of the abdomen, where there is a fusion of both walls, the back wall of the vagina. Detachment is performed above and below the hernial defect, forming pockets in the preperitoneal space above and below the hernial defect at a distance of 3-4 cm.The lateral edges of the implant are located between the rectus muscles and posterior walls of the vagina, and the upper and lower edges are in the formed pockets in the preperitoneal space. The implant is fixed simultaneously with suturing of the aponeurosis incision with one row of interrupted sutures (RF Patent No. 2261051, А61В 17/00, 2005).

The disadvantage of this method of plasty is the inevitability of contact of the mesh prosthesis with subcutaneous fat, which significantly increases the risk of developing seromas in the postoperative period (Slavin L.E., Fedorov I.V., Sigal E.I. “Complications of surgery for abdominal hernias”, Moscow, Publishing house "Profile", 2005, 176 p., 68 p.)

Also known is the inlay alloplasty method, which is the closest to our proposed method. The operation begins with excision of the old postoperative scar. Subcutaneous fatty tissue is dissected before aponeurosis with simultaneous discharge of the hernial sac. The hernial sac stands out from the surrounding tissue to the gates, while they try not to open it. In case of accidental opening of the hernial sac, it is sutured. The hernial sac in preperitoneal tissue is separated from the aponeurosis with the creation of "pockets" at a distance of 3-4 cm from the edge of the hernia gate. Sometimes the hernial sac is separated along with the back sheet of the vagina of the rectus abdominis muscle and then the posterior surface of the rectus abdominis muscle becomes visible in the wound. The mesh is cut out according to the size of the hernia gate, plus the dimensions of the created "pockets". The mesh is placed behind the aponeurosis and the U-shaped sutures drawn through the rectus abdominis, sutured to it. The mesh appears to be a plate lying behind the aponeurosis. At this stage, plastic surgery is considered complete. The residual cavity is drained by two drains with active aspiration of the contents. Subcutaneous tissue and skin are sutured (Egiev V.N., Lyadov K.V., Voskresensky P.K. “Atlas of operative surgery of hernias.” Moscow, Medpraktika-M publishing house, 2003, p. 179).

The disadvantages of this method of plastics are: 1) the technical complexity of its implementation in connection with the existing adhesive process, which can lead to undesirable opening of the hernial sac, 2) the contact of a significant part of the implanted mesh with subcutaneous fatty tissue with large POVG, which in turn increases 3) the risk of developing seromas and local inflammatory complications and often necessitates drainage, 4) the high morbidity associated with through stitching of the rectus abdominis muscles. When stitching muscles, damage to blood vessels passing through the muscle tissue and the formation of hematomas are possible. In addition, with through stitching of the rectus abdominal muscles, it is possible to compress the nerve fibers with a ligature, which can result in neuritis causing persistent pain in the postoperative period and atrophy of the abdominal rectus muscles, leading to a violation of the biomechanics of the abdominal press.

The objective of the invention is a method of surgical treatment of postoperative ventral hernias of the abdomen of midline localization, which has less trauma and is simpler in technical design.

The problem in the method of surgical treatment of middle-localized abdominal POVH is solved by the fact that the hernial sac is isolated (without additional mobilization of the rectus abdominis muscles from the posterior wall of the vagina), the mesh explant is placed between the rectus abdominis muscles and the tissue layer consisting of the posterior leaf of their vagina with a fixed with a hernial sac, mesh fixation is performed around the perimeter to the posterior aponeurosis sheet, longitudinal laxative sections of the anterior aponeurosis sheets are performed over the rectus muscles and then their ssh vayut.

The absence of through stitching of the rectus abdominis muscles ensures minimal invasiveness of the method. In addition, stitching over the mesh of dissected anterior sheets of the vagina of the rectus abdominis muscles with or without grasping the underlying mesh into the suture line prevents contact of the mesh prosthesis with subcutaneous fat, which reduces the risk of seromas and other local purulent-septic complications.

The proposed method and features that distinguish it from the known, in the medical and patent literature are not found, which allows us to conclude that its criterion of "novelty".

The essence of the proposed method is as follows. Open the vagina of the rectus abdominis muscles along their medial edge. Between the rectus muscles and the posterior wall of their vagina, a mesh explant is placed over the hernial sac overlapping the hernial defect by 4-5 cm along the perimeter and fixed to the posterior leaf of the aponeurosis with separate interrupted sutures. The anterior leaf of the aponeurosis is sutured with the preliminary application of longitudinal laxative cuts to avoid tension. It is this way of fixing the mesh that allows you to significantly technically simplify the plastic surgery, achieve minimal trauma (there is no need for through stitching of the rectus abdominis muscles), and the location of the mesh in the muscular-aponeurotic case provides the minimum risk of developing seromas and local purulent-septic complications.

The following examples illustrate the method of the invention.

Example 1. Patient Suvorov N.Ya., 67 years old, medical history No. 701, was hospitalized 02.10.2006 in a planned manner for surgical treatment of postoperative ventral hernia. Complaints upon admission for the presence of hernial protrusion in the upper and middle parts of the abdomen, in the area of the postoperative scar.

From the anamnesis, it is known that four years ago, the patient simultaneously underwent cholecystectomy and hernia repair for an umbilical hernia. A week after the operation, the appearance of hernial protrusion in the area of the postoperative suture was noted. About 1.5 years ago there was an episode of infringement of a hernia, which the patient independently corrected. I did not contact the doctors. The hernial protrusion gradually increased in size, episodes of infringement were repeated.

Concomitant diseases: peptic ulcer in remission, fatty hepatosis, coronary heart disease, angina pectoris II FC, atherosclerotic cardiosclerosis, hypertension II degree, prostate adenoma.

The condition at admission is satisfactory. The skin and visible mucous membranes are pale pink. The vesicular breathing is carried out in all departments of the lungs, there are no rales. HELL - 140/90 mm Hg Pulse - 76 rpm The tongue is clean, moist. The abdomen is soft, not swollen, not tense, asymmetric due to hernial protrusion, participates in the act of breathing, painless on palpation in all departments. There are no symptoms of peritoneal irritation. Intestinal noises of normal sonority. Physiological administration is normal. Locally: on the anterior abdominal wall there is a postoperative scar after upper mid laparotomy. Along the entire length of the postoperative scar there is a hernial protrusion of 15.0 by 8.0 cm, painless, freely set into the abdominal cavity. The symptom of the “cough push” is positive.

An additional examination was performed in the department - endoscopy, in which acute erosive gastritis was detected, in the presence of which surgical intervention is contraindicated. The patient received antiulcer therapy, against the background of which erosions in the stomach healed. The patient was prepared for a planned surgical intervention.

02.21.2006 a planned operation was performed: hernia repair according to the proposed method. On operation: a hernial defect measuring 8.0 by 6.0 cm. The contents are a large omentum. The aponeurosis of the rectus abdominis muscle was opened, the posterior leaf was mobilized without opening it. Further, under the muscles, on top of the posterior leaf of the aponeurosis, there is a polypropylene mesh prosthesis measuring 15 by 30 cm, which is fixed with interrupted sutures to the posterior leaf of the aponeurosis of the rectus abdominis muscle. Superimposed 4 longitudinal laxative incisions on the anterior aponeurosis sheets of the rectus abdominis over the rectus muscles. On top of the prosthesis, the front sheets of the vagina of the rectus abdominis are sutured with a continuous suture.

The postoperative period was uneventful. The wound healed by first intention, the sutures were removed on the 13th day.

Example 2. Patient Bratsky V.A., 44 years old, medical history No. 1660, was hospitalized in a planned manner for surgical treatment of postoperative ventral hernia 04.04.2006. Complaints upon admission for the presence of hernial protrusion in the area of the old postoperative scar, periodically occurring pain in the area of hernial protrusion.

From the anamnesis it is known that 2 years ago the patient was operated on for a perforated ulcer of the duodenum (upper median laparotomy, suturing of the ulcer), 2 months after the operation, a hernial protrusion appeared in the middle part of the postoperative scar. Periodically there were pains in the area of hernial protrusion. Gradually, hernial protrusion increased in size.

Concomitant diseases: duodenal ulcer.

The condition at admission is satisfactory. The skin and visible mucous membranes are pale pink. The vesicular breathing is carried out in all departments of the lungs, there are no rales. HELL - 145/90 mm Hg Pulse - 76 rpm The tongue is clean, moist. The abdomen is soft, not swollen, not tense, asymmetric due to hernial protrusion, participates in the act of breathing, painless on palpation in all departments. Intestinal noises of normal sonority. Physiological administration is normal.

Locally: on the anterior abdominal wall in the middle part of the postoperative scar there is a hernial protrusion of 30.0 by 12.0 cm, which can be freely set into the abdominal cavity. The symptom of the “cough push” is positive.

An additional examination was carried out in the department, the patient was prepared for a planned operation. 04/06/2006 a planned operation was performed: hernia repair according to the proposed method. On the operation: a hernial defect measuring 20.0 by 10.0 cm. The contents are loops of the small intestine. The aponeurosis of the rectus abdominis muscle was opened, the posterior leaf was mobilized without opening it. Under the muscles, on top of the posterior leaf of the aponeurosis, there is a polypropylene mesh prosthesis measuring 25 by 15 cm, which is fixed with interrupted sutures to the posterior leaf of the aponeurosis of the rectus abdominis muscle. 6 longitudinal laxative sections were superimposed on the anterior leaf of the aponeurosis of the rectus abdominis muscles over the rectus muscles. On top of the prosthesis, the front sheets of the vagina of the rectus abdominis are sutured with a continuous suture.

The postoperative period is smooth. The postoperative wound healed by primary intention. Sutures were removed on the 11th day.

The proposed method allows to solve the problem - to reduce the invasiveness of the plastic, reduce the number of postoperative complications and simplify the surgical technique of fixation of the mesh.

The method was tested (clinical trials were conducted in the Department of Surgery for Emergencies of the Russian Academy of Medical Sciences) for 30 patients, no relapse of the disease was observed.

Claims (1)

A method for the surgical treatment of postoperative ventral hernias of a midline localization abdominal hernia, including the isolation of a hernial sac, plastic hernia defect of the aponeurosis with a mesh prosthesis located behind the rectus abdominis muscles and isolated from subcutaneous fatty tissue by stitching the front sheets of the aponeurosis of the rectus abdominus muscles, characterized in that the net is fixed the prosthesis is performed to the posterior sheets of the aponeurosis of the rectus abdominis muscles, and longitudinal laxatives are applied to the front sheets of the aponeurosis of the rectus abdominis muscles other sections.