RU2392877C1 - Method of plastics of giant post-operational ventral hernia in anterior abdominal wall - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, particularly to hernia surgery. Hernial sac is separated and dissected lengthwise along the central line from hernial oprifices upwards to form two large flaps. Further both flap sides are cut across up to hernial orifices into 3 strips. Then a linear orifice is made in the first and third strips at the side over 5 cm inwards from strip edge. At the right side, linear orifice is made in the second strip. Then first and third right strips are put through orifices in first and third left strips, and second left strip is put through orifice of second right strip. A lock is made in each strip, and four knots are made tension-free in each lock. Further an Alloplant graft out of firm connective tissue mass of 15x20 size, 2-3 mm thickness, with rounded corners and 3 mm diametre holes perforated at 0.5 cm distance from each other over the whole graft surface is placed on fixated strips without fixation to surrounding tissues. Aponeurosis is closed by continuous suture over the graft, sutures are made ono hypoderm and skin.

EFFECT: prevention of rough connective tissue growth and commissure process.

1 ex, 1 dwg

Description

The present invention relates to medicine, in particular to surgery, and for the surgical treatment of giant postoperative ventral hernias of the abdominal wall.

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 operations account 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% on average (Hollinsky S., 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 have appeared, in which the relapse rate is about 1% (Mitin S.E., Peshekhonov S.I., Chistyakov DB, 2002; Egiev V.N., Lyadov K .V., Resurrection P.K., 2003).

A known method of treatment of median ventral hernias, including moving back the dissected medial leaves of the aponeurosis of the rectus abdominis muscles, stitching them along the midline along with the peritoneum and the remains of the hernial sac, stitching with U-shaped ligatures the remains of the hernial sac and the posterior wall of the vagina of the rectus abdominis muscles at their inner edge laying autodermal graft in place of the defect and conducting previously applied ligatures through the entire thickness of the autodermal flap. The disadvantage of this method is the possibility of relapse due to the low strength properties of the tissues forming the anterior abdominal wall.

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 plastic surgery of the anterior abdominal wall in patients with postoperative ventral hernias (Patent RU 2220667, 2004). The authors excised a skin flap of the anterior abdominal wall in the projection of a hernial protrusion. The epidermal surface of the flap was heated up to 90-94 ° C with physiological solution, followed by its de-epithelization. The excess hernial sac was dissected to the hernial portal. The peritoneal defect and the muscle-aponeurotic layer were plasticized with a skin flap. After plastic surgery of the anterior abdominal wall, granules of porous titanium nickelide with a particle size of 100 to 2000 μm in an amount of 5 to 45% of the wound surface were applied to the near-defective tissue and flap. The skin and subcutaneous tissue were sutured. The method allows to prevent relapse of the ventral hernia.

A significant disadvantage of this method is its invasiveness due to de-epithelialization of the epidermal surface of the flap, multi-stage operation, which increases the time of surgery. The use of granules made of porous titanium nickelide, which is a non-physiological tissue and in most cases causes complications, such as flap rejection and the occurrence of a hernia recurrence, leads to repeated surgery. One of the disadvantages is the high cost of the material, which does not allow its use in everyday practice. Excision of the hernial sac to the hernial gate contributes to the anatomical violation of the integrity of the abdominal wall, which also leads to its weakening and relapse of the hernia.

The disadvantages of this method are: the lack of elasticity and rigidity of the prosthesis, which lead to damage to the surrounding tissue during implantation, as a result of which the damaged tissue soon develops into coarse connective tissue, which in turn leads to the appearance of a painful scar and patient discomfort. Also, when the flap and titanium nickelide are fused with the surrounding tissues, not the fibers grow through the prosthesis cells, but their capsulation, which subsequently, with a possible relapse, adversely affects the preparation.

The technical result when using the present invention is the prevention of complications associated with relapse of hernias, the prevention of postoperative growth of coarse connective tissue, the postoperative adhesion process, the preservation of the anatomical structure of the anterior abdominal wall, the reduction of hospital stay, and the reduction in the cost of the operation.

The proposed method is as follows. Under general anesthesia, the processing of the surgical field is performed. Cut the skin, subcutaneous tissue, exfoliate the aponeurosis of the anterior abdominal muscle. The hernial sac is isolated, dissected longitudinally in the middle to the hernial portal from the bottom up, forming two large leaves of the hernial sac. Then, both sides of the leaves are cut across to the hernial gate into 3 strips. After that, a linear hole is made on the first and third strips on the left side, departing from the edge of the strip by 5 cm inwards. And on the right side perform a linear hole on the second strip. Then, the right first and third strips are carried out in the hole of the first and third strips of the left side, and the left second strip is carried out in the hole of the second right stripe. At the same time, they create a “lock” on each strip and impose four knots on each “lock” without tension. The creation of such strips allows you to save the anatomical tissue of the hernia gate without violating their integrity, while creating a strengthening of the anterior abdominal wall with its own tissue. Then, a rectangular implant from Alloplant biomaterial is placed in the preperitoneal space onto the created fixed strips. The proposed implant is a biomaterial from a dense connective tissue formation of size 15 × 20, rectangular in shape with rounded corners, the thickness of which is 2-3 mm. Perforated holes were made over the entire area of the prosthesis at a distance of 0.5 cm from each other with a diameter of 3 mm. The implant is placed without fixation to surrounding tissues. The aponeurosis is sutured with a continuous suture over the prosthesis. Then suture on the subcutaneous tissue and skin.

The proposed biomaterial for hernioplasty is prepared based on the requirements for corset plastics. Donor material for the preparation of biomaterial are 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, additionally reinforced with elastic fibers (Essays on tissue transplantation. - R.T. Nigmatullin, Ufa 2003, p. 95).

The proposed invention of treatment is illustrated by a drawing, which shows a diagram of the operation, where 1 denotes the creation of strips and locks from a hernial sac; 2 - the trajectory of the implant overlay on top of the created strips and locks (perforated holes are not shown over the implant area to visualize the created strips and locks from the hernial sac).

Clinical example. Patient M., 52 years old (medical history No. 22556/07), was admitted to the hospital with a diagnosis of Postoperative ventral hernia of gigantic abdominal wall. He had a history of surgery for cholelithiasis. After examination and preoperative preparation, surgical intervention was performed. Under general anesthesia, the surgical field was treated. We made a dissection of the skin, subcutaneous tissue, exfoliated aponeurosis of the anterior abdominal muscle. The hernial sac was isolated, dissected longitudinally in the middle to the hernial portal from the bottom up, forming two large leaves of the hernial sac. Then, both sides of the leaflets were cut across to the hernia gate into 3 strips. After that, a linear hole was cut on the first and third strips on the left side, departing from the edge of the strip by 5 cm inwards. And on the right side, a linear hole was cut on the second strip. Then, the right first and third stripes were drawn into the hole of the first and third stripes of the left side, and the left second strip was drawn into the hole of the second right strip. At the same time, they created a “lock” on each strip and imposed four knots on each “lock” without tension. After that, in the preperitoneal space on the created fixed strips, a rectangular implant of Alloplant biomaterial with a size of 15x20 with rounded corners, 2-3 mm thick, over the entire area of which perforated holes were made at a distance of 0.5 cm from each other with a diameter of 3 mm, was placed. The implant was placed without fixation to surrounding tissues. The remains of the aponeurosis were sutured with a continuous suture over the implant. 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 giant postoperative ventral hernias of the anterior abdominal wall. No complications using the method have been identified.

Thus, the results of clinical studies show that the proposed method with preserving the hernia sac leaves and forming strips with “locks” from them and applying an implant from Alloplant biomaterial prevents the complications associated with hernia recurrence, prevents the growth of coarse connective tissue due to the high density of collagen bundles fibers of 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. In addition, the material is available in everyday practice and is economically viable for the general population.

Claims (1)

A method for surgical treatment of giant postoperative ventral hernias of the anterior abdominal wall, including the isolation of a hernial sac, its dissection, closure of a defect, subsequent closure of a defect with an implant, characterized in that the hernial sac is cut longitudinally in the middle to the hernial portal from the bottom up, forming two large leaves, both sides of the sheets are cut across to the hernia gate into 3 strips, after which a linear hole is made on the first and third strips on the left side, 5 cm kn from the edge of the stripe three, and on the right side a linear hole is made on the second strip, the right first and third cavities are carried out in the hole of the first and third stripes of the left side, and the left second strip is carried out in the hole of the second right strip, forming a “lock” on each strip, without Four knots of tension are applied to each “lock”, then Alloplant implant from a dense connective tissue formation 15 × 20 cm in size, rectangular with a rounded shape is placed on the created fixed strips without fixing to the surrounding tissues and corners, 2-3 mm thick, over the entire area of which perforated holes are made at a distance from each other of 0.5 cm with a diameter of 3 mm.

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