RU2435528C1 - Method of combined laparoscopic hernioplasty - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention relates to medicine, namely to laparoscopic hernioplasty. After application of pneumoperitoneum, two 5 mm trocars (in right and left hypochondrium) and one 12 mm trocar (in paraumbilical region) are installed. Hernial orifice is detected. In case of necessity adhesiolysis is carried out by blunt and sharp manner with application of bi- and monopolar coagulators. Hernia content is set into abdominat cavity. Via 12 mm trocar into abdominal cavity introduced is mesh implant, preliminarily folded in tube, which is unfolded and by means of endoherniosteppler fixed to anterior abdominal wall around hernial orifice in 8 points on perimetre. On medial line of mesh implant 2 ligatures for leveling are applied. After that, via 12 mm trocar into abdominal cavity introduced is folded lyophilised dura mater, which is unfolded and above synthetic implant from the side of abdominal cavity, overlaying it and overlapping it on 1.0 cm on perimetre, is fixed in 8 points. ^ EFFECT: method prevents commissural process of abdominal cavity organs, preserves vessels between peritoneum and aponeurosis. ^ 3 cl, 1 ex, 3 dwg

Description

The invention relates to medicine, namely to abdominal surgery, and may be applicable for laparoscopic hernioplasty in the treatment of hernias of the anterior abdominal wall.

Laparoscopic interventions in recent years are finding wider application and are rightfully considered a new chapter in surgery. Modern endoscopic technology has made possible radical changes in the method of surgical correction of external abdominal hernias. Characterized by low invasiveness and sufficiently high efficiency, in many cases they have become an alternative to traditional hernia repair methods [1, 4, 6, 9].

With laparoscopic hernioplasty, the main advantages of laparoscopic operations are preserved - an easier course of the postoperative period, early rehabilitation of patients [4-7]. An important argument in favor of laparoscopic surgery is the need for simultaneous intervention on the abdominal organs, especially if the hernia and the area of another operation are located on different floors of the abdominal cavity. Multiple localized hernias are also easier to operate laparoscopically. With paralytic hernias, especially located in the lateral abdomen, which is very difficult to close with local tissues, it is easier to laparoscopically identify surrounding unchanged tissues, bones and attach a prosthesis to them [5-9].

The application of the principle of “loose” hernioplasty and the use of synthetic materials have now made a revolution in herniology, allowing to reduce the number of relapses [1], but the intra-abdominal location of the synthetic implant is not ideal, since it implies its contact with intestinal loops, carries the risk of formation of intestinal adhesions and fistulas [4]. Toskim K.D. and Zhebrovsky V.V. [1, 2] developed an original method of application as an additional material for hernioplasty of the dura mater allograft. An important feature of which is a very low immunobiological activity, resistance to infection [2, 3, 10].

There is a method of transabdominal preperitoneal hernioplasty [8, 11], which consists in the fact that after applying a pneumoperitoneum, introducing a laparoscope and trocars, the hernial contents are inserted into the abdominal cavity, then the parietal peritoneum is cut, which, together with the hernial sac, is separated from the underlying structures. After isolation of the peritoneum, a mesh prosthesis is inserted into the abdominal cavity through the trocar, and is fixed into the preperitoneal space using a herniostapler. The final stage of the intervention is to compare the dissected edges of the peritoneum and stitch them using a ligature suture.

Known methods are technically difficult to implement, since it is necessary to strive for the complete isolation of the anatomical structures, wide detachment of the peritoneum, so that the mesh fits freely in the preperitoneal space. This increases the risk of damage to the vascular and nerve structures (for example, structures richly adjacent in the inguinal region - the lower epigastric, external femoral, seminal vessels, vas deferens, spermatic cord elements). In order to peritonize a synthetic prosthesis from the abdominal organs, it is necessary to compare the edges of the peritoneum with a ligature suture, which in most cases penetrates the peritoneum. The contact of the mesh implant with the abdominal cavity causes adhesions, leads to prolonged exudation in the wound, the formation of gray, and subsequently to the formation of external intestinal fistulas.

The technical result achieved by the implementation of the proposed method is to increase the efficiency of treatment of hernias of the anterior abdominal wall by reducing the invasiveness of the operation, reducing the risk of damage to surrounding structures, and reducing pain after surgery, due to the fact that peritoneal detachment is not required. In addition, the implementation of the claimed method allows to prevent the development of the adhesive process and the formation of external intestinal fistulas. This is ensured by the use of a lyophilized dura mater as an additional prosthesis, which makes it possible to limit the contact of a synthetic implant with abdominal organs and reduce the number of gross inflammatory and destructive changes in implants and abdominal tissues in the early stages after surgery (formation of infiltrate, suppuration, gray).

The method is as follows.

After application of the pneumoperitoneum with the Veress needle, two 5-mm trocars (in the right and left hypochondria) and one 12-mm trocar (in the paraumbilical region) are installed. Identified hernial gates (figure 1). If necessary (in the case of postoperative hernias), blunt and acute using bi- and monopolar coagulators, an adhesolysis is performed, the hernial contents are set into the abdominal cavity. Through a 12-mm trocar, a mesh implant is inserted into the abdominal cavity, pre-rolled up by a tube, straightened and fixed with the help of an endogerniostapler (Fig. 2) to the front abdominal wall around the hernial portal at eight points around the perimeter (going beyond the diameter of the hernial portal by 3-4 cm ) In postoperative ventral hernias, two ligatures are applied to align the midline of the mesh implant. Then, also through the 12-mm trocar, the convoluted lyophilized dura mater is introduced into the abdominal cavity, spreads and over the synthetic implant from the side of the abdominal cavity, blocking it and protruding 1.0 cm around the perimeter, is fixed at eight points using an endogeniostepler ( figure 3). Install double-lumen drainage in the pelvis. The trocars are removed. Perform a desulfurization. Sutures on three trocar wounds.

The proposed method performed hernioplasty in 6 patients. The postoperative period was uneventful, follow-up examination after 1 year - no hernia recurrence.

Example. Patient K., 58 years old.

Received in FDI SP named after P.V. Sklifosovsky with complaints of hernial protrusion. In 2001, she was operated on for uterine fibroids (a lower midline laparotomy was performed). At the beginning of 2007, the projection of the postoperative scar, in the lower third, noted the appearance of hernial protrusion, which over time began to increase in size.

The condition at admission is relatively satisfactory.

Local status: in the umbilical region, in the projection of the postoperative scar (in the lower third), in a standing and lying position when straining, a hernial protrusion of ~ 6.0 × 5.0 cm, soft-elastic consistency, freely set into the abdominal cavity, painless with palpation. The symptom of a cough push is positive. The patient underwent surgery: Videolaparoscopic hernioplasty using a synthetic implant and lyophilized dura mater, abdominal drainage

The postoperative period is smooth. During control ultrasound: Loops of the small intestine are not expanded, the walls are not thickened, the contents of medium echogenicity. Peristalsis can be traced in all departments. Free fluid in the abdominal cavity, soft tissues in the area of the operation was not detected. Drainages from the pelvis and hernial sac removed on the 3rd day. Sutures were removed on the 4th day. The wounds healed by primary intention. When viewed after 1 year, there is no recurrence of a hernia.

Literature

1. Zhebrovsky, VV, Mohammed Tom Elbashir. Surgery of abdominal hernias and eventrations / Simferopol: Business-inform, 2002. 440 p.

2. Zyablov V.I., Toskin K.D. The use of the dura mater for plasty of postoperative hernias. Surgery, 1975; 7: 109-110.

3. Meskhia A.A. Study of the immunological reaction of the recipient's organism during homotransplantation of the dura mater preserved by cold. Q. neurohir., 1971; 5: 58-60.

4. Lutsevich O.E., Gordeev S.A., Prokhorov Yu.A. Intraperitoneal laparoscopic hernioplasty. // Materials of the scientific conference "Laparoscopic surgery of the abdominal organs." Moscow, May 20-21, 1996. P. 48-49.

5. Timoshin A.D., Yurasov A.V., Shestakov A.L., Chernokov A.I. Experience in performing combined operations using laparoscopic techniques. // Russian Journal of Gastroenterology, Hepatology, Coloproctology. 1995. - Volume 5. - No. 3. - S.230. Appendix No. 1. Materials of the 1st Russian Gastroenterological Week in St. Petersburg, November 27 - December 2, 1995.

6. Ermolov A.S., Blagovestnov D.A., Alekseev A.K., Ilyichev V.A., Gorchakov V.K., Andreev V.G. "New technologies in the surgical treatment of median ventral hernias." Difficult patient, No. 10-11 - 2005.

6. Sedov V.M., Guslev A.B., Strizheletsky V.V. and others. Laparoscopic hernioplasty with inguinal hernias. St. Petersburg, 1995 (prototype).

7. Toy F.K., Smoot RT. Laparoscopic hernioplasty update. // J. Laparoendosc. Surg. 1992; 2: 197-205.

8. Corbitt J.D. Laparoscopic Herniorrhaphy: A preperitoneal tension-free approach. // Surg. Endosc. 1993; 7: 550-555.

9. Bower CE, Reade CC, Kirby LW, Roth JS (2004) Complications of laparoscopic incisional-ventral hernia repair: the experience of a single institution. Sum Endosc. 18: 672-675.

10. Michael S. Mason, M.D., John Raaf, M.D. "Use of Homologous Dura Mater in the Repair of Hernias." AMA Arch Surg. 1961; 82 (6): 856-862.

11. Arregui ME, Preperitoneal repair of direct inguinal hernia with mesh. Advanced laparoscopic Surgery: The international Experience. Indianapolis, Ind. May 20-22, 1991.

Claims (3)

1. The method of combined laparoscopic hernioplasty, characterized in that after applying with a Veress needle a pneumoperitoneum establish two 5-mm trocar in the right and left hypochondria and one 12-mm trocar in the paraumbilical region, reveal the hernia gate, the hernial contents are inserted into the abdominal cavity, through a 12-mm trocar, a mesh implant is introduced into the abdominal cavity, pre-rolled up with a tube, which is straightened and fixed with an endogerniostapler to the anterior abdominal wall around the hernia gate at 8 points ah around the perimeter, going beyond the diameter of the hernial gate by 3-4 cm, then through the 12-mm trocar a rolled lyophilized dura mater is introduced into the abdominal cavity, straightened and laid on top of the synthetic implant from the side of the abdominal cavity, blocking it and protruding beyond it 1.0 cm around the perimeter, fixed at 8 points using an endogeniostepler, after which a double-lumen drainage is placed in the pelvis, the trocars are removed, desufflation is performed and sutures are made on 3 trocar wounds. 2. The method according to claim 1, characterized in that in addition to postoperative hernias in a blunt and acute way, using bi- and monopolar coagulators, adhesolysis is performed. 3. The method according to claim 1, characterized in that in case of postoperative ventral hernias after fixation of the mesh implant, 2 ligatures are additionally applied to align along the midline of the mesh implant.

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