RU2423933C1 - Method of hernial defect plasty in case of large ventral hernias - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgical methods in treatment of ventration hernias, tumours growing into anterior abdominal wall. Subcutaneous cellular tissue is separated within 6-7 cm from the edge of hernial orifice. Peritoneum is cut in a circular way at the distance 4-5 cm from defect. Peripheral part of peritoneum is separated on 2-3 cm. Endoprosthesis edges are placed between separated peripheral part and tissues of abdominal wall and fixed.

EFFECT: method makes it possible to close endoprosthesis edges.

1 ex, 1 dwg

Description

The invention relates to medicine, namely to surgical methods of treatment, and can be used in surgical treatment of patients with hernias, eventings, tumors growing in the anterior abdominal wall, that is, in all situations requiring the closure of a sufficiently large defect in the anterior abdominal wall.

The issue of extraperitonization of the endoprosthesis is very relevant and has not been resolved at present; this is confirmed by the discussion of this problem in the “Intraabdominal plastic” section of the All-Russian Conference of Herniology (Materials of the 2nd All-Russian Conference “Current State and Perspectives of Herniology” 2009), therefore, the development of new methods plastic hernia defect is relevant.

Contact of the endoprosthesis with abdominal organs can lead to serious complications, a rough scar-adhesion process, and sometimes to the formation of pressure sores in the intestinal wall and the formation of intestinal fistula (Local complications after surgical treatment in patients with postoperative ventral hernias using endoprostheses. Gogia B.Sh. , Adamyan A.A., Alyautdinov PP In Mat.1 of the International Conference "Modern Technologies and Possibilities of Reconstructive and Aesthetic Surgery." Edited by Prof. V.D. Fedorov, Prof. A.A. Adamyan. Mosk but Almanac Vishnevsky Surgery Institute, 2008; 2 (1). 111-112). Therefore, in some cases, surgeons try to isolate the endoprosthesis from the abdominal cavity with an omentum or hernial sac (Extraperitonization with a polypropylene mesh for plastic surgery of ventral hernias. Seidov VF Surgery 2004; 11: 26-29. Choice of the alloplasty method for the treatment of postoperative ventral hernias. .N: Abstract of the dissertation of the candidate of medical sciences: 14.00.27. Lower state medical academician N.Novgorod. 2007, 112).

However, in a number of cases it is not possible to use a hernial sac, for example, with a strangulated hernia with inflammation, the phlegmon of the hernial sac is excised (hernias of the abdominal wall. 2nd ed., Revised and supplemented. Toskin K.D., Zhebrovsky V.V. M.: Medicine, 1990, 272).

It is not possible to use an omentum for extraperitonization of the endoprosthesis if the patient has previously undergone interventions in the abdominal cavity, since the omentum in this case is tightly adhered to the area of the operation performed. However, with a large hernia defect, this is not possible.

The most reliable and modern method selected as a prototype is the known method for repairing a hernial defect in large ventral hernias, including mobilization of hernial gates, their processing with separation of the subcutaneous tissue from aponeurosis, and implantation of a mesh endoprosthesis from polypropylene using the inlay method (Egiev V.N. Lyadov K.V., Voskresensky P.K. Atlas of operative surgery of hernias. M: Medpraktika - M .: 2003, 228).

The known method is as follows.

Mobilize the hernia gate from the side of the abdominal cavity at least 5 cm from the edges of the hernia defect and process the hernia gate from the side of the wound with separation of the subcutaneous tissue from the aponeurosis. Then the polypropylene endoprosthesis is placed in the abdominal cavity. Sutures are applied starting from the aponeurosis, while a needle with a thread is inserted from the outside inward through the aponeurosis, muscles, peritoneum and then it is passed through the endoprosthesis. After this, the direction of the needle is changed to the opposite from the inside out through the endoprosthesis. the peritoneum, muscles, aponeurosis, after which the thread is tied with a knot. In this way, the endoprosthesis is fixed around the perimeter, and the aponeurosis is not sutured over it.

However, the known method has disadvantages.

As the material of the mesh, polypropylene is used. The tissue reaction to polypropylene proceeds as an aseptic inflammation, which leads to serious complications, a rough scar-adhesion process, and sometimes to the formation of pressure sores in the intestinal wall and the formation of intestinal fistula.

Currently, information has been received that the reparative process in the plastic zone proceeds differently. In the center of the implantation zone, the reparative process proceeds slowly, calmly, without a pronounced inflammatory component. At the same time, at the periphery of the plastic zone, where the edges of the mesh are fixed to the tissues of the anterior abdominal wall, a rapid course of the repair process with a pronounced inflammatory component is observed, which is the basis for the development of complications. This regularity does not depend on the material of the endoprosthesis itself.

The objective of the invention is the reduction and / or prevention of complications when performing an operation of atension grafting of the anterior abdominal wall due to large ventral hernias.

The problem is solved in that in the known method of plasticity of a hernial defect with large ventral hernias, including mobilization of hernial gates, their processing with separation of the subcutaneous tissue from the aponeurosis, placement of the mesh endoprosthesis in the abdominal cavity and its fixation, separation of the subcutaneous tissue is performed within 6-7 cm from the edge of the hernia gate, the peritoneum is circularly dissected at a distance of 4-5 cm from the edge of the defect, its peripheral part is separated by 2-3 cm, then an endoprot is placed in the abdominal cavity under the edges of the defect ez and fix the edges of the endoprosthesis between the separated peripheral part of the peritoneum and the tissues of the abdominal wall.

The present invention meets the criteria of "novelty" and "inventive step", as the patent information research did not reveal the sources of patent and scientific and technical information that would discredit the novelty of the proposed method, as well as technical solutions with essential features of the invention.

The proposed method allows to obtain when using the following positive effect.

The analysis of the immediate results revealed the following. The application of the proposed method provides a favorable course of the reparative process. Isolation of the edges of the mesh from the abdominal organs avoids the formation of gross scars and adhesions, intestinal obstruction. The mesh implanted by the proposed method eliminates the contact of hollow organs with sharp edges with a polypropylene endoprosthesis and solves the problem of dangerous complications from the organs of the abdominal cavity - pressure ulcers of the intestinal wall and intestinal fistula. The proposed method guarantees both reliability and safety of the operation. Thus, the proposed method reduces the risk of an adverse course of the postoperative period, postoperative complications.

The invention is illustrated in graphic materials.

Figure 1 schematically depicts the proposed method for plastic hernia defect of the anterior abdominal wall with large ventral hernias.

Figure 1 shows:

1- hernia gate

2 - peritoneum

3 - endoprosthesis

4 - endoprosthesis edges

5 - tissue of the abdominal wall

After mobilization of the hernia gate 1, the subcutaneous tissue is separated within 6-7 cm from the edge of the hernia gate. Peritoneum 2 is dissected in a circular manner at a distance of 4-5 cm from the edge of the defect, the peripheral part of the peritoneum is separated by 2-3 cm. An endoprosthesis 3 is placed in the abdominal cavity under the edges of the defect and the edges 4 of the endoprosthesis are fixed between the separated peripheral part of the peritoneum 2 and tissues of the abdominal wall 5.

The proposed method is as follows.

After opening the hernial sac, the hernial portal is mobilized, including from the side of the abdominal cavity within 6-7 cm from the edges of the hernial defect. At a distance of 4-5 cm from the edges of the defect of the abdominal wall, the peritoneum is circularly dissected, its peripheral part is separated by 2-3 cm. Next, an endoprosthesis from polypropylene is placed in the inlay position under the edges of the defect and the edges of the endoprosthesis are fixed between the separated peripheral part of the peritoneum and tissues the abdominal wall, thus isolating the edges of the mesh from the abdominal organs around the entire perimeter of the endoprosthesis, complete the plastic surgery and suture the wound.

A clinical example is given as an extract from a medical history.

Patient G., 75 years old, medical history No. 4345, had previously undergone surgery for a restrained postoperative ventral hernia. The intervention was completed with plastic according to the standard inlay method using a polypropylene mesh. I went to the clinic in June 2008. An examination revealed that there was no recurrence of a hernia. There is an abscess of the anterior abdominal wall in the plastic zone. The abscess is opened and drained, a course of antibiotic therapy is carried out. It was revealed that its bottom is a polypropylene mesh. I managed to stop the purulent process, the patient was discharged. In July 2008, she again appealed for a purulent para-prosthetic fistula in the same place. The fistula was sanitized, a course of antibiotic therapy, dressings, but the fistula did not close. Computed tomography revealed that in the area of previously performed plastic surgery there is a roughly expressed adhesion process, intestinal loops are soldered directly to the scar. On irrigoscopy, the tumor process is excluded. On fistulography, it was found that in the plastic zone, in the area of the endoprosthesis, a colonic fistula was formed. September 10, 2008 an extensive reconstructive operation was performed. During the intervention, the presence of a gross adhesion process in the abdominal cavity along the periphery of the zone of the previously performed operation was established. One of the edges of the mesh 8 previously implanted in the abdominal cavity caused a pressure sore of the transverse colon wall and the formation of an intestinal fistula. It is impossible to isolate the fistulous passage from the tissues of the abdominal wall, with excision of the abdominal wall along with the mesh and resection of the middle third of the transverse colon with a fistula transversotransversostomy. A significant portion of the abdominal wall was excised with resection of the transverse colon, end-to-end transversal transversoanastomosis was formed. The size of the defect in the abdominal wall is 15 × 15 cm. A decision was made on atension plastic using a synthetic material - a mesh. It is not possible to isolate the plastic zone and the mesh from the intestinal loops with the help of the peritoneum and omentum. The resulting extensive abdominal wall defect was replaced by the method proposed by the authors using a polypropylene mesh and extraperitonization of its edges.

The edges of the abdominal wall defect were mobilized, including from the side of the abdominal cavity within 7 cm from the edges of the hernial defect. At a distance of 5 cm from the edges of the abdominal wall defect, the peritoneum was circularly dissected, its peripheral part was separated by 2 cm, then an endoprosthesis from polypropylene was placed in the inlay position under the edges of the defect, then the edges of the endoprosthesis were fixed between the separated peripheral part of the peritoneum and the tissues of the abdominal wall, thus isolating the edges of the mesh from the abdominal organs along the entire perimeter of the endoprosthesis, they completed the plastic surgery and closed the wound.

The drug removed during the operation was examined, and it was established that it was the mesh with its sharp edge that caused the pressure sore of the colon wall and the formation of a fistula.

Smooth postoperative period. Discharged in satisfactory condition. Examined after a year, local inflammatory phenomena are absent, there are no fistulas. He feels well, makes no complaints, leads an active lifestyle. With ultrasound scanning of the abdominal cavity, the mesh is in situ, the adhesion process in the area of the operation is weakly expressed. There is no recurrence of a hernia. Quality of life indicators are excellent.

Claims (1)

A method for repairing a hernial defect in large ventral hernias, including mobilization of hernial gates, their processing with separation of the subcutaneous tissue from aponeurosis, placement of the mesh endoprosthesis in the abdominal cavity and its fixation, characterized in that the separation of the subcutaneous tissue is performed within 6-7 cm from the edge of the hernia gate, the peritoneum is circularly dissected at a distance of 4-5 cm from the defect, the peripheral part is separated by 2-3 cm, the edges of the endoprosthesis are placed between the separated peripheral part and the tissues of the abdominal wall and fix them.

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