RU2393790C1 - Method of hernioplasty with mesh implant of ventral hernias - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, in particular to abdominal surgery. After isolation of hernia sac, it is cut longitudinally to aponeurosis defect. Formed flaps are turned with mesothelium upwards and placed on edges of aponeurosis defect in such a way that they 1.5-2.0 cm do not reach the edge of mobilised part. Excess of flaps is dissected. Flap edges are fixed by means of separate interrupted sutures to aponeurosis. Aponeurosis defect is sewn edge-to edge through flaps with separate interrupted sutures with distance 1 cm - 1.5 cm. Above flaps mesh implant overlapping their surface area with covering aponeurosis on 2-3 cm. Mesh implant is fixed to aponeurosis on perimetre with uninterrupted suture. Central part of mesh implant is fixed with separate interrupted sutures with gripping aponeurosis of anterior abdominal wall through flaps.

EFFECT: method ensures prevention of formation of seromes in wounds resulting from inflammatory response of organism to mesh implant and reduces percentage of suppurations in wound, which reduces number of hernia recurrences.

1 ex, 6 dwg

Description

The invention relates to medicine, namely to abdominal surgery.

The introduction of mesh implants into clinical practice radically changed the tactics of surgical treatment of ventral hernias. Plastic methods based on the implantation of synthetic nets allowed to significantly reduce the percentage of hernia recurrence and to achieve a significant improvement in treatment results. Hernioplasty with a mesh implant allows you to eliminate almost any hernia, regardless of their size and the anatomical state of the tissues. The relapse rate for ventral plastics with preperitoneal and subaponeurotic prosthesis is 1.7-10.4%, with supraponeurotic - 4.4-19.3%.

A known method of subaponeurotic (retromuscular and preperitoneal) fixation of the prosthesis ("sublay"). The edges of the aponeurosis after fixing the prosthesis to the peritoneum or to the posterior wall of the vagina of the rectus abdominis are sutured edge to edge. Timoshin A.D., Yurasov A.V., Shestakov A.L. Surgical treatment of inguinal and postoperative hernias of the abdominal wall. - M .: Triad-X, 2003, pp. 96-99.

The disadvantages of the method are that this method is technically complicated, traumatic and sometimes it is not feasible to separate the parietal peritoneum from the aponeurosis over a long period, which significantly increases the duration of the operation.

A known method of plastic hernia with the closure of the defect of the abdominal wall with synthetic material ("inlay"). This technique includes open “non-tensioning” hernioplasty, in which a mesh endoprosthesis covers an indelible aponeurosis defect and is fixed along the perimeter of the hernial portal. Chugunov A.N., Slavin L.E., Zamaleev A.Z. Annals of Surgery, 2007, No. 4, pp. 14-17.

The disadvantages of this method are frequent complications - degeneration and atrophy of the rectus abdominis muscles, frequent relapses.

A known method of intraperitoneal fixation of the prosthesis ("intraab-dominal"). In this case, the prosthesis is fixed to the peritoneum without delimitation from the internal organs. The main condition for this type of plastic is the use of non-adhesive multilayer mesh prostheses (Sepramesh, Composix, Seprafilm, Proceed). B. B. Zhebrovsky, F. N. Ilchenko. - Atlas of hernia surgery: Semfiropol, 2004, pp. 195-200.

The disadvantages of the method are the probability of contact of the prosthesis with internal organs, the high cost of materials and equipment, the technical complexity of the operation. The closest is the nadaponeurotic method of fixation of the prosthesis (“onlay”). Surgical treatment of inguinal and postoperative hernias of the abdominal wall. Timoshin A.D., Yurasov A.V., Shestakov A.L. - M .: "Triad-X", 2003, pp. 91-96.

In this method, after a skin incision and a hernia sac, the subcutaneous tissue around the hernia gate is separated from the aponeurosis by a width of up to 6 cm. The hernia sac is excised. The defect of the abdominal wall is sutured edge to edge by local tissues with a continuous suture through all layers, the peritoneum and aponeurosis are sutured in the longitudinal direction. The stitches are made, 1.5 cm from the edge, the distance between the stitches is not more than 1 cm. The prosthesis should be 8 cm longer and the first row of seams 9-10 cm wide. The prosthesis is pulled along the length and width in the process of fixation and seamed with seams . The prosthesis is fixed around the circumference by a continuous seam. Fixation of the prosthesis with separate interrupted sutures along the entire surface with the capture of the aponeurosis of the anterior abdominal wall.

This method has several disadvantages:

1. When separating subcutaneous tissue from aponeurosis, tissues are injured, blood and lymph vessels supplying subcutaneous fatty tissue intersect.

2. Separation of subcutaneous fat creates residual cavities in which wound is accumulated.

3. Residual cavities require additional drainage.

4. Contact of the polypropylene endoprosthesis with subcutaneous tissue promotes the formation of seromas.

5. Frequent occurrence in the early postoperative period of seromas and suppuration of the postoperative wound.

6. There is a risk of infection of the accumulated wound discharge, the formation of abscesses and ligature fistulas, which can lead to rejection of the mesh implant and further to hernia recurrence.

The objective of the invention is to improve the quality of hernioplasty with ventral hernias by reducing the amount of inflammatory exudate in the residual cavities due to their absorption by the surface of the peritoneum.

The task is achieved by the method of hernioplasty with a mesh implant of ventral hernias, including performing a skin incision, isolating a hernial sac, suturing an aponeurosis defect, preparing a bed for a mesh implant, installing a mesh implant and fixing it for aponeurosis. After isolation of the hernial sac, it is cut longitudinally to the aponeurosis defect. The formed flaps are turned upside down by the mesothelium and laid along the edges of the aponeurosis defect so that they do not reach the edge of the mobilized area by 1.5-2.0 cm, the excess flaps are excised. The edges of the flaps are fixed with separate interrupted sutures to the aponeurosis. The aponeurosis defect is sutured edge to edge through the flaps with separate interrupted sutures with a distance of 1-1.5 cm.The mesh implant is placed on top of the flaps, covering their surface area with 2-3 cm approach to the aponeurosis. A mesh implant for the aponeurosis is fixed along the perimeter with a continuous suture. The central part of the mesh implant is fixed with separate interrupted sutures with the capture of the aponeurosis of the anterior abdominal wall through flaps.

The novelty of the invention:

1. The dissection of the hernial sac longitudinal to the defect of the aponeurosis allows you to save blood vessels in the layers of the bag and not disturb the blood supply of the flaps.

2. The formed flaps are turned upside down by the mesothelium and laid along the edges of the aponeurosis defect so that they do not reach the edge of the mobilized area by 1.5-2.0 cm. The hernial sac is not excised, which makes it possible to leave and use the area of the suction surface of the peritoneum in the form flaps.

3. The excision of the excess flaps of the hernial sac along the periphery allows you to adjust the contact area of the mesh implant with the area of the hernial sac and aponeurosis. This makes it possible to contact the mesh implant with both the peritoneum and aponeurosis.

4. Fixing the edges of the flaps with separate interrupted sutures to the aponeurosis facilitates the subsequent suturing of the mesh implant to the aponeurosis. Corrugation of the flap of the hernial sac is excluded, which eliminates the formation of cavities and improves the process of tissue fusion.

5. Suturing of the edges of the aponeurosis defect edge to edge through the flaps of the hernial sac with separate interrupted sutures with a distance of 1-1.5 cm, which allows the vascular system to be preserved in the flaps of the hernial sac.

6. A mesh implant is placed on top of the flaps, covering the surface area with aponeurosis approaching by 2-3 cm. The edges of the mesh implant are fixed to the aponeurosis along the perimeter with a continuous suture, which ensures a tight fit of the mesh implant to the peritoneum of the hernia sac flaps. This contributes to better connective tissue germination of the pores of the mesh implant and the rapid formation of scar tissue.

7. Additional fixation of the central part of the mesh implant by separate interrupted sutures with the capture of the aponeurosis of the anterior abdominal wall through the flaps does not allow the mesh implant to be displaced with respect to the peritoneum and aponeurosis.

Result

By creating a suction surface of the peritoneum, turned by mesothelium to the mesh implant, the formation of seromas in the wound arising from the inflammatory reaction of the body to the mesh implant is prevented, and the percentage of suppuration in the wound is reduced, which reduces the number of hernia recurrences.

Due to the ability of the surface of the peritoneum, turned to the mesh implant to adhesion, there is a rapid germination of the mesh implant and its fixation to the anterior abdominal wall, which leads to accelerated formation of scar tissue.

The invention is illustrated by drawings, presented in Fig.1.-6.

Figa shows a top view of the hernial sac.

On figb shows a side view of the hernial sac.

On figa opening the hernial sac, top view.

On Figb opening the hernial sac, side view.

On figa fixation of the flaps of the hernial sac to the aponeurosis, top view.

On figb fixation of the flaps of the hernial sac to the aponeurosis, side view.

4a, suturing of an aponeurosis defect, top view.

On figb suturing of the defect of the aponeurosis, side view.

On figa fixation of the mesh implant with a continuous seam around the perimeter, top view.

On figb fixation of the mesh implant with a continuous seam around the perimeter, side view.

On figa fixation of the Central part of the mesh implant separate interrupted sutures, top view.

On figb fixation of the Central part of the mesh implant separate interrupted sutures, side view.

The method is as follows. The position of the patient on the operating table on the back. After processing the surgical field, a skin incision is made over the ventral hernia. The length of the skin incision is determined by the size of the hernia and should be slightly larger. After the discovery of the hernial sac 1, it is extracted from the subcutaneous fat and cicatricial adhesions until the hernial gates are exposed on all sides of Fig. 1a, Fig. 1b. The hernial sac cannot be opened, which allows the aponeurosis to be prepared for plastic surgery and the installation of a mesh implant without contact with the abdominal cavity. Subcutaneous fat is separated from the aponeurosis by a distance of 5-6 cm from the edges of the defect of the anterior abdominal cavity. Crossing and coagulation of blood vessels of the anterior abdominal wall is performed. Remediation of the wound, control of hemostasis. The hernial sac is opened by incision 2 longitudinally to the hernial defect of Fig. 2a, Fig. 2b. The joints between the walls of the hernial sac with intestinal loops and the omentum are separated. An audit of the abdominal cavity is performed, interintestinal adhesions are separated. The area of the flaps of the 3 hernial sac is determined. The edges of the hernia sac flaps should not reach the edge of the mobilized aponeurosis by 1.5-2 cm. Excess flaps 3 of the hernia sac 1 are excised. The prepared edges of the hernial sac flaps are fixed to the aponeurosis by separate interrupted sutures 4 in areas without vessels. Figa, Fig.36. The defect 5 of the aponeurosis is sutured edge to edge through the flaps of the hernial sac. Separate interrupted sutures 6 are superimposed, departing from the edge of the defect by 1.5 cm, the distance between the stitches is 1-1.5 cm. Fig. 4a, Fig. 4b. Cut out a mesh implant 7 of the required size. It should be longer than the row of sutures imposed on the aponeurosis defect by 8 cm and a width of 9-10 cm. The mesh implant 7 is placed on top of the flaps 3 of the hernial sac 1 and on the aponeurosis. The mesh implant 7 is fixed with a continuous upholstery suture 8 starting from the lower corner of the wound with the transition to the opposite side of the hernia gate from the surgeon along the entire perimeter of Fig. 5a, Fig. 5b. In the process of fixation, the thread goes along the edge of the mesh implant 7 counterclockwise to the starting point. During fixation of the mesh implant 7, they are stretched both in length and in width to exclude corrugation. The central part of the mesh implant 7 is fixed with separate interrupted sutures 9 with the capture of the aponeurosis of the anterior abdominal wall through the flaps 3 of the hernial sac in places without vessels. The operation ends with suturing of the skin. A postoperative wound is drained by rubber graduates. Aseptic dressing.

Example.

Patient A. 54 years. Received as planned with a diagnosis of Relapse of postoperative ventral hernia. From the anamnesis, she was operated on in 2001 for a perforated ulcer of the duodenal bulb. After 6 months the patient had a hernial protrusion in the middle third of the postoperative scar. In 2003, she applied for planned treatment for a postoperative ventral hernia. The operation was performed - hernia repair, hernioplasty with local tissues. The early postoperative period proceeded safely. A year later, the patient again appeared hernial protrusion in the middle third of the postoperative scar. In 2007, the patient turned to the surgical department No. 1 of FGLPU NKTsOZSh for planned surgical treatment. When viewed from the midline of the abdomen, a postoperative scar is formed. In the middle third of the scar, a hernial protrusion of 15 cm by 15 cm is determined, soft-elastic, moderately painful, and is inserted into the abdominal cavity. An aponeurosis defect of size 4 by 4 cm is determined. After examination and preoperative preparation, the patient is taken to the operating room. For the purpose of prevention of iv cefatoxime 2 gr. SMA. The surgical field is treated with alcohol chlorhexidine twice. A skin incision was made above the ventral hernia. The length of the skin incision is 20 cm. After the discovery of the hernial sac, it was isolated from subcutaneous fat and cicatricial adhesions until the hernial portal was found on all sides. The size of the hernial sac is 15 by 15 by 10 cm. The hernial gate is 6 cm by 4 cm. The subcutaneous fat is separated from the aponeurosis by a distance of 5-6 cm from the edges of the anterior abdominal defect. Made the intersection and coagulation of blood vessels of the anterior abdominal wall. Wound debridement, control of hemostasis. The hernial sac is opened longitudinally to the aponeurosis defect. The joints between the walls of the hernial sac by intestinal loops and the omentum are separated. The abdominal cavity was revised, inter-intestinal fusion separated. The preliminary area of the hernia sac flaps 18 by 16 cm was determined. The excess hernia sac was excised, the remaining area of the flaps was 10 by 8 cm. The prepared edges of the hernia sac flaps were fixed to the aponeurosis by separate interrupted sutures in areas without vessels. Produced suturing of the aponeurosis defect edge to edge through flaps. Separate interrupted sutures were applied, 1.5 cm from the edge of the defect, the distance between the stitches was 1-1.5 cm. A mesh implant 12 by 10 cm in size was cut. The mesh implant was placed over the hernia sac flaps on an aponeurosis, fixed to the aponeurosis with a continuous upholstery starting from the lower corner of the wound with the transition to the opposite side of the aponeurosis defect from the surgeon along the entire perimeter. In the process of fixation, the thread goes along the edge of the prosthesis counterclockwise to the starting point. During fixation, the mesh implant is stretched both in length and in width to prevent corrugation. The central part of the mesh implant is fixed with separate interrupted sutures to the aponeurosis through the flaps of the hernial sac in places without vessels. The operation ended with suturing of the skin. A postoperative wound is drained by rubber graduates. Aseptic dressing. The operation time was 145 minutes. In the early postoperative period, the patient received cefatoxime 2 g × 2 times iv 5 days, trental 10 ml iv 5 days, heparin 5 thousand × 4 times subcutaneously, UHF No. 7. From the first day, the patient was selected a bandage. Rubber graduates removed on the 2nd day. Sutures were removed on the 8th day. The patient was discharged for outpatient aftercare in satisfactory condition. Result: there was no suppuration, control after 1 month, six months and a year of relapse did not reveal. The length of stay in the hospital was reduced by 2 days.

This technique is used in the surgery department No. 1 of the Federal Medical and Prophylactic Institution Scientific and Clinical Center for Miners' Health, 6 patients were operated on.

Claims (1)

A method of hernioplasty with a mesh implant of ventral hernias, including performing a skin incision, isolating a hernial sac, suturing an aponeurosis defect, preparing a mesh bed for a mesh implant, installing a mesh implant and fixing it to an aponeurosis, characterized in that after isolation of the hernial sac, the defect is dissected longitudinally to it the formed flaps are turned upside down by the mesothelium and laid along the edges of the aponeurosis defect so that they do not reach the edge of the mobilized area by 1.5-2.0 cm, excess flaps and cut off, the edges of the flaps are fixed with separate nodal sutures to the aponeurosis, the aponeurosis defect is sutured edge to edge through the flaps with individual nodal sutures with a distance of 1-1.5 cm, a mesh implant is placed on top of the flaps, covering the surface area with 2-3 cm approach to the aponeurosis fix the mesh implant to the aponeurosis along the perimeter with a continuous suture, fix the central part of the mesh implant with separate interrupted sutures with the capture of the aponeurosis of the anterior abdominal wall through the flaps.

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