RU2496427C1 - Method of alloplasty of medium ventral hernia - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery of treating patients with medium ventral hernias. Method reduces early and late postoperative complications, reduces risk of development of new ventral hernias and improves quality of patient's life. Method includes carrying out midline laparotomy, section of postoperative scar with parts of skin above hernia protrusion, dissection of hernia sac and separation of parietal peritoneum to external edge of recti abdomini, cutting out prosthesis from propylene mesh. Two rectangular prostheses are cut out from propylene mesh and placed on anterior and posterior surfaces of recti abdomini from both sides, reaching external edges. Prosthesis is covered with parts of preserved hernia sac from upper surface, and with parietal peritoneum. "П"-shaped sutures are applied on external and internal edge of recti through all layers of abdominal wall and prosthesis, covered with parietal peritoneum and part of hernia sac at 3-4 cm distance from each other; 1 cm wide free edge of prosthesis duplicature is left, duplicature is formed from free edges of prosthesis, covered with peritoneum, by means of interrupted sutures.

EFFECT: method reduces early and late postoperative complications, reduces risk of development of new ventral hernia.

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Description

The present invention relates to medicine, namely to surgery, and can be used to treat patients with secondary ventral hernias.

Modern statistics indicate that postoperative hernias occur in 5-14% of patients undergoing laparotomy.

Among ventral hernias, hernias located along the white line are most frequently found (Ermolov A.S., Alekseev A.K., Upytreva A.V., Ilyichev V.A. et al. Choice of method for plastic surgery of postoperative abdominal hernias with propylene endoprostheses, w . "Surgery", 2005; 8: 16-21).

Currently, there are a number of controversial issues related to the lack of a unified approach to the application of one or another method of hernia defect plasty, which would meet the optimal conditions for the functioning of the abdominal press. Full adaptation of the anatomical elements of the abdominal wall restores function and increases its strength during physical tests by 40%.

For the prototype of the present invention, the known method of alloplasty of middle hernias is selected, including performing median laparotomy, excising a postoperative scar with skin over the hernial protrusion, dissecting the hernial sac and detaching the parietal peritoneum to the outer edge of the rectus abdominis muscles, cutting the prosthesis from the propylene mesh and fixing the prosthesis tissue abdominal wall (Moshkova T.A. Alloplasty of median ventral hernias with polypropylene nets, J. "Herald of Surgery", 2008; 4: 36-39).

In the known method, a prosthesis consisting of a main part and two lateral legs, which surround the rectus abdominis muscles on both sides, is cut out of a polypropylene mesh. On the rear sheets of the rectus sheath that are sutured with interrupted sutures, a cut prosthesis is laid. Under the front sheets of the aponeurosis of the rectus muscles, tunnels form at the level of the prosthesis legs, exfoliating the aponeurosis of the underlying muscles. The legs of the prosthesis are passed through the formed tunnels from the outer edges of the rectus abdominis to the medial edges. By stitching the edges of both legs with threads of nodal sutures on the aponeurosis of the posterior sheets of the vagina of the rectus abdominis, the rectus abdominis are moved and fixed.

The disadvantage of this method is that there is subaponeurotic exfoliation of the rectus abdominis muscle from the sheets of tendon sheaths, which is an additional trauma. The legs of the alloprosthesis cover the rectus abdominis muscles in areas corresponding to their width, which leads to their uneven displacement to the center. Thus, the known method does not allow to restore the functions of the abdominal press.

The task of the invention is to reduce early and late postoperative complications by eliminating diastasis of the rectus abdominis muscles and restoration of abdominal functions.

The problem is solved in that in the known method of alloplasty of middle ventral hernias, including performing median laparotomy, excising a postoperative scar with patches of skin above the hernial protrusion, dissecting the hernial sac and detaching the parietal peritoneum to the outer edge of the rectus abdominis muscles, cutting out the propylene mesh prosthesis the prosthesis to the tissues of the abdominal wall, from the polypropylene mesh, two rectangular prostheses are cut out, placed on the front and back surfaces of the rectus abdominis muscles with reaching their outer edges, from the front surface of the prosthesis cover the areas of the saved hernial sac, from the back of the parietal peritoneum, along the outer and inner edges of the rectus muscles through all layers of the abdominal wall and the prosthesis covered with the parietal peritoneum and part of the hernial sac, impose U-shaped sutures at a distance of 3-4 cm from each other, along the inner edge of the rectus muscles leave a free edge of the duplicate of the prosthesis 1 cm wide of the free edges of the prosthesis covered with the peritoneum, using duplicate sutures form a duplicate.

The present invention meets the criteria of "novelty" and "inventive step", since in the process of conducting patent information research, no sources of scientific, technical and patent information were found discrediting the novelty of the proposed invention, as well as technical solutions containing essential features of the proposed method.

The proposed method allows using the following positive effect.

Rectangular dentures cut from a propylene mesh with a length exceeding the length of the hernial collar by 5 cm allow the front and back walls of the vagina of the rectus muscles to form, reaching the spigel line. The tissues of the hernial sac and the parietal peritoneum cover the prosthesis along its entire length. Through U-shaped sutures securely fix the prosthesis to the tissues of the abdominal wall. The double inner edge of the prosthesis, covered with a parietal peritoneum, creates a duplicate, forming a white line of the abdomen. Thus, the anatomical integrity of the structures of the abdominal wall is restored with the strengthening of the vaginas of the rectus abdominis muscles and ensuring an even distribution of lateral traction on both walls of the vagina. The method allows to create optimal anatomical and physiological conditions for the functioning of the rectus abdominis muscles and restore the function of the abdominal press, which adapts the intra-abdominal pressure, the activity of the gastrointestinal tract and other body systems. The method allows to reduce early and late postoperative complications, reduce the risk of new ventral hernias and improve the quality of life of the patient.

The invention is illustrated by graphic materials. Figure 1, 2 shows the stages of the proposed method.

In figure 1, 2 is indicated

1 - hernial sac;

2 - parietal peritoneum;

3 - the outer edge of the rectus abdominis muscles;

4 - dentures made of propylene mesh;

5 - the front surface of the rectus abdominis muscle;

6 - the back surface of the rectus abdominis muscles;

7 - U-shaped seams;

8 - free edge of the duplicate.

The method is as follows.

Perform median laparotomy. Two semi-oval incisions excise a postoperative scar with patches of skin above the hernial protrusion. A hernial sac 1 is isolated (Fig. 1), dissected in the longitudinal direction. Separate the parietal peritoneum 2 to the outer edge of the rectus abdominis muscles 3. Cut two rectangular prostheses from the propylene mesh 4, which are placed along the front 5 and posterior 6 surfaces of the rectus abdominis muscles on both sides, reaching their outer edges 3. From the front surface, the prosthesis is covered with sections of the stored a hernial sac 1, from the back side of the parietal peritoneum 2. On the outer and inner edge of the rectus muscles through all layers of the abdominal wall and the prosthesis covered with the parietal peritoneum and part of the hernial sac, impose U-shaped you 7 at a distance of 3-4 cm from each other. On the inner edge of the rectus muscles, the free edge of the duplicate of the prosthesis 4 (Fig. 3) is left with a width of 1 cm. Then, from the free edges of the prosthesis covered with the peritoneum, duplicate is formed using nodal sutures and the white line of the abdomen is restored.

An example of a specific implementation is given in the form of extracts from medical records.

Patient S., 57 years old, was operated on in a district hospital for acute calculous cholecystitis. In the postoperative period, partial suppuration of the postoperative median wound was noted. Six months later, noted the appearance of hernial protrusion in the epigastric region, which gradually increased. The patient was admitted to the General Surgery Clinic them. A.I. Kozhevnikova (IB No. 0867786) in satisfactory condition with the presence of a large postoperative hernia. Concomitant diseases: coronary heart disease, angina pectoris 2KFK, hypertension 2 tbsp., Risk 4, CHF 2A (2FK), obesity 3 tbsp. In the epigastric region there is a postoperative scar from the median laparotomy. In a standing position, a hernial protrusion of 20 × 15 cm is determined. The defect in the muscle-aponeurotic layer is 9 × 6 cm. After preoperative preparation, the patient is operated on by the proposed method. A median laparotomy was performed, postoperative scars with patches of skin above the hernial protrusion were dissected. The hernia sac was excised and the parietal peritoneum was detached to the outer edge of the rectus abdominis muscles. Two rectangular prostheses are cut from the propylene mesh, which are placed on the front and back surfaces of the rectus abdominis muscles on both sides, reaching the outer edges. From the front surface, the prosthesis was covered with sections of the preserved hernial sac, on the back side of the parietal peritoneum. On the outer and inner edges of the rectus muscles through all layers of the abdominal wall and the prosthesis covered with the parietal peritoneum and part of the hernial sac, U-shaped sutures were applied at a distance of 3-4 cm from each other. On the inner edge of the rectus muscles, the free edge of the duplicate of the prosthesis was left with a width of 1 cm. A duplicate was formed from the free edges of the prosthesis covered with the peritoneum using nodal sutures. The postoperative period was uneventful, the wound healed by first intention. Discharged in satisfactory condition.

Claims (1)

The method of alloplasty of middle ventral hernias, including performing median laparotomy, excising a postoperative scar with skin over the hernial protrusion, dissecting the hernial sac and detaching the parietal peritoneum to the outer edge of the rectus abdominis muscles, cutting out the propylene mesh of the prosthesis and fixing the prosthesis to the abdominal tissues that two rectangular prostheses are cut out of a polypropylene mesh, placed on the front and back surfaces of the rectus abdominis muscles on both sides, reaching the outer edges, from the front surface of the prosthesis cover the areas of the saved hernial sac, from the back side of the parietal peritoneum, along the outer and inner edges of the rectus muscles through all layers of the abdominal wall and the prosthesis covered with the parietal peritoneum and part of the hernial sac, impose U-shaped sutures at a distance of 3- 4 cm apart, along the inner edge of the rectus muscles leave the free edge of the duplicate of the prosthesis 1 cm wide of the free edges of the prosthesis covered with the peritoneum, using duplicate sutures form a duplicate.

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