RU2502479C1 - Method of large ventral postoperative hernia plasty - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to surgery. Access to hernia sac is performed, it is separated and processed. Hernial defect is exposed, aponeurosis around hernial defect is dissected with formation of bed for placement of synthetic mesh prosthesis. Plasty is carried out with preperitoneal or axillary placement of rectangular synthetic mesh prosthesis. Rectangular synthetic mesh prosthesis is modelled, with making cuts from its four edges in direction to opposite edges, with cutting out straps, which are passed through muscular-aponeurotic edges of hernial gates from inside to outside with following tightening suturing of each strap with area of synthetic mesh prosthesis near the edge of hernial defect. Each strap is additionally fixed by sutures, passed through synthetic mesh prosthesis, to medial edge of aponeurosis, formed after transaction of aponeurosis around hernial defect.

EFFECT: synthetic mesh prosthesis is additionally fixed by sutures to medial edge of aponeurosis, formed after dissection of aponeurosis around hernial defect, which makes it possible to bring together edges of hernial defect, reduce possibility of sub-mesh space appearance with formation of seromas.

2 cl, 1 ex, 6 dwg

Description

The invention relates to medicine, namely to surgery, and is intended to increase the effectiveness of plastic surgery for large postoperative ventral hernias when it is impossible to reduce the edges of a hernial defect.

In recent years, the most common in the surgical treatment of postoperative ventral hernias are methods of alloplasty using synthetic mesh prostheses. The main advantage of the above methods is the reduction in the number of relapses.

A known method for the surgical treatment of large postoperative ventral hernias without suturing or narrowing of the hernia gate. The defect is closed with tissues of the hernial sac to isolate the prosthesis from internal organs. The prosthesis is fixed with a continuous seam around the perimeter, retreating 5 cm outward from the edge of the hernial gate. The edges of the prosthesis can be located both above the aponeurosis and below it (preperitoneally). In the latter case, the edge of the prosthesis is freely placed in the preperitoneal space, and fixation is carried out along the perimeter of the hernial portal. Drainages are installed on top of the prosthesis and a skin-subcutaneous flap is fixed (Timoshin A.D., Yurasov A.V., Shestakov A.L. The concept of surgical treatment of postoperative hernias of the anterior abdominal wall. / Gerniology, 2004, No. 1, p. 8).

The advantage of this method is that it can be used in cases of large hernial gates, when it is impossible to reduce their edges.

Along with the advantages of the above alloplastic method has disadvantages. So, as a result of the wrinkling effect of the mesh prosthesis, its dislocation is possible with the formation of a subsequent hernia recurrence.

The closest analogue to the claimed invention is a known method of plastic surgery for postoperative ventral hernias (Plastic surgery for postoperative ventral hernias: Pat. 2366367 Russian Federation. Federation: MKI A61B 17/00 / authors Shalashov S.V., Mikhailov A.L., Usoltsev Yu. K., Egorov I.A .; application 2007114707/14, application date 04/18/2007; publ. 10/27/2008; Bull. No. 25).

The known method of plastic surgery for postoperative ventral hernias is as follows. An incision of the skin and subcutaneous tissue, isolation and processing of the hernial sac are performed. Next, a hernial defect with a preperitoneal or axillary arrangement of a synthetic mesh prosthesis is exposed and made. In this case, a rectangular synthetic mesh prosthesis is modeled by making incisions from two opposite or from its four edges towards the opposite edges, cutting strips. Further, these strips are passed through the muscle-aponeurotic edges of the hernial portal from the inside out, followed by pulling together each stitch with a different strip or with a section of a synthetic mesh prosthesis at the edge of the hernia defect.

If it is possible to completely approach the edges of the hernial defect, the strips in the synthetic mesh prosthesis are cut out, making cuts from only two long opposite edges, pass them through the muscular-aponeurotic structures of the adjacent edges of the hernial defect, and, after pulling to the edges of the hernial defect, are sutured to the opposite strips .

If it is impossible to completely approach the edges of the hernial defect, the strips in the synthetic mesh prosthesis are cut out, making cuts from all four of its edges, while cutting the corners, and each of the cut strips, after passing it through the muscular aponeurotic structures, is sutured to the site of the synthetic mesh prosthesis at the edge hernial defect.

The strips cut in a synthetic mesh prosthesis have a width of 2-4 cm. They are passed through the muscle-aponeurotic structures, 2-4 cm from the edges of the hernial defect, at a distance of 2-4 cm from each other. The width of the synthetic mesh prosthesis between the cut strips, if it is possible to reduce the edges of the hernial defect, is 4-8 cm.The dimensions of the synthetic mesh prosthesis between the cut strips, if it is impossible to reduce the edges of the hernial defect, should be 2-4 cm larger in all directions than the hernia defect itself.

The method allows to close the hernial defect with ventral hernias of any size, including irreducibility of the edges of the hernial defect.

The negative side of the method is that if it is impossible to completely approach the edges of the hernial defect under the net, free space forms in which a hernia recurrence may occur or in which seroma may form.

In addition, in some cases, if it is not possible to completely approach the edges of the hernial defect, the sutures between the strips and the net itself along the edge of the hernial defect may not withstand the forces of intra-abdominal pressure and disperse, leading to a hernia recurrence.

The objective of the proposed technical solution is to develop an effective method of plastic surgery with a preperitoneal or axillary arrangement of a synthetic mesh prosthesis for large postoperative ventral hernias, when it is impossible to reduce the edges of the hernial defect.

The technical result of the proposed method is to increase the efficiency of surgical treatment of large postoperative ventral hernias with irreducibility of the edges of the hernial defect due to:

- additional fixation of strips cut along the edges of the synthetic mesh prosthesis at new points, eliminating the likelihood of subgrid space;

- additional attachment of the mesh prosthesis to the aponeurotic tissues.

The technical result is achieved by the fact that the method of plasty for large postoperative ventral hernias, when it is impossible to reduce the edges of the hernial defect, includes access to the hernial sac, its isolation and processing, exposure of the hernial defect, dissection of the aponeurosis around the hernial defect with the formation of a bed for the location of the synthetic mesh prosthesis, plastic with a preperitoneal or axillary arrangement of a rectangular synthetic mesh prosthesis. In this case, a rectangular synthetic mesh prosthesis is modeled by making incisions from its four edges toward opposite edges, cutting strips that pass through the muscular aponeurotic edges of the hernial portal from the inside out, followed by tightening of each strip with a section of the synthetic mesh prosthesis at the edge of the hernia defect .

A distinctive technique of the proposed method is that each strip cut from a rectangular synthetic mesh prosthesis is additionally fixed with sutures drawn through the synthetic mesh prosthesis to the medial edge of the aponeurosis formed after dissection of the aponeurosis around the hernial defect.

The difference of the method lies in the fact that the synthetic mesh prosthesis is additionally fixed with sutures to the medial edge of the aponeurosis formed after dissection of the aponeurosis around the hernial defect.

A comparative analysis of the proposed method and the prototype shows that the claimed method differs from the known above methods. These differences allow us to conclude that the claimed technical solution meets the criteria of the invention of "novelty."

From the analysis of patent and specialized literature, the authors found that the proposed technical solution has features that distinguish it not only from the prototype, but also from other technical solutions in this field of medicine. We have not found a method of plastic surgery for large postoperative ventral hernias containing the distinctive techniques of the proposed method.

In the proposed method of surgical intervention, each strip cut from a rectangular synthetic mesh prosthesis is additionally fixed with sutures drawn through the synthetic mesh prosthesis to the medial edge of the aponeurosis formed after cutting the aponeurosis around the hernial defect.

In this case, the sutures attract the synthetic mesh prosthesis to the medial edge of the aponeurosis, formed after dissection of the aponeurosis around the hernial defect, thereby eliminating the subgrid space.

With additional sewing of the synthetic mesh prosthesis with sutures to the medial edge of the aponeurosis, formed after cutting the aponeurosis around the hernial defect, a more reliable fixation of the synthetic mesh prosthesis to the tissues is achieved and the possibility of hernia recurrence is excluded.

All the signs of an independent claim of the claimed method are essential, since they are necessary to achieve the specified technical result.

Symptom: - "the method of plastic surgery for large postoperative ventral hernias, when it is impossible to reduce the edges of the hernial defect, includes access to the hernial sac" - it is known and determines access to the operative area.

Symptom: - “isolation and processing of the hernial sac” - is known, defines the actions in relation to the hernial sac.

Sign: - “exposure of a hernial defect, dissection of the aponeurosis around the hernial defect with the formation of a bed for the location of the synthetic mesh prosthesis, plastic with a preperitoneal or axillary arrangement of a rectangular synthetic mesh prosthesis” - it is known, it determines the preparatory stage before the plastic and the location of the synthetic mesh prosthesis.

Sign: - “a rectangular synthetic mesh prosthesis is modeled by making incisions from its four edges toward opposite edges, cutting strips” - it is known that determines the shape of the synthetic mesh prosthesis.

Symptom: “the strips are passed through the muscle-aponeurotic edges of the hernia gate from the inside out, followed by pulling together each stitch with a section of the synthetic mesh prosthesis at the edge of the hernia defect” - determines the nature of fixation of the synthetic mesh prosthesis. This feature increases the reliability of fixation of the synthetic mesh prosthesis and is known from the prior art.

Sign: - “each strip cut from a rectangular synthetic mesh prosthesis is additionally fixed with sutures drawn through the synthetic mesh prosthesis to the medial edge of the aponeurosis formed after cutting the aponeurosis around the hernial defect” - determines the nature of the additional fixation of the strips, which leads to the elimination of the subgrid space . This feature is not known from the prior art.

Sign: - “the synthetic mesh prosthesis is additionally fixed with sutures to the medial edge of the aponeurosis formed after cutting the aponeurosis around the hernial defect” - provides additional fixation of the synthetic mesh prosthesis, which increases the reliability of hernioplasty. This feature is not known from the prior art.

With the interaction of all the essential features, a new technical result is obtained, namely: increasing the efficiency of surgical treatment of large postoperative ventral hernias with irreducibility of the edges of the hernial defect.

Two of the seven distinctive features of the proposed method from the prior art are not known. Therefore, the claimed technical solution meets the criterion of "inventive step".

The method comprising the claimed invention is intended for use in healthcare. This method can be used in surgery in the treatment of large postoperative ventral hernias, when it is impossible to reduce the edges of the hernial defect. The possibility of its implementation is confirmed by the methods and means described in the application, therefore, the proposed solution meets the criteria of the invention "industrial applicability".

The essence of the proposed method is illustrated by six figures, reflecting the stages of its implementation, where: 1 - synthetic mesh prosthesis; 2 - strips cut from a rectangular synthetic mesh prosthesis; 3 - skin; 4 - subcutaneous fat; 5 - aponeurosis; 6 - edge of the hernial defect; 7 - a section line of an aponeurosis around a hernial defect; 8 - formed sutures between the cut strips and the medial edge of the aponeurosis, formed after dissection of the aponeurosis around the hernial defect, drawn through a synthetic mesh prosthesis; 9 - the medial edge of the aponeurosis, formed after dissection of the aponeurosis around the hernial defect; 10 - sutures between the synthetic mesh prosthesis and the medial edge of the aponeurosis formed after dissection of the aponeurosis around the hernial defect.

Figure 1 shows a hernial defect with a dissection line of the aponeurosis around it. Figure 2 - synthetic mesh prosthesis with cuts on the sides of the stripes. In Fig.3 - a synthetic mesh prosthesis is located axillary, strips cut along its sides are drawn through the muscular aponeurotic edges of the hernial portal from the inside out. Figure 4 - the synthetic mesh prosthesis is located axillary, the strips cut along its sides are drawn through the muscle-aponeurotic edges of the hernia gate from the inside out, the seams between the strips and the medial edge of the dissected aponeurosis are shown through the synthetic mesh prosthesis. Figure 5 - all strips are fixed by seams. Figure 6 shows the seams between the mesh prosthesis and the medial edge of the aponeurosis formed after dissection of the aponeurosis around the hernial defect, the plastic is finished.

The proposed method of surgery for postoperative ventral hernia, when it is impossible to reduce the edges of the hernial defect, is as follows. After processing the surgical field, under general anesthesia, in the projection of a hernial protrusion, access to the hernial sac is performed (not shown in the figures). A hernial sac is isolated (not shown in the figures), the edges of the hernial defect 6, aponeurosis 5. The hernial sac is excised or inserted into the abdominal cavity. Departing from the edge of the hernia defect 6, the aponeurosis 5 is cut along line 7, forming a bed for the synthetic mesh prosthesis 1 in the preperitoneal or axillary space. A synthetic mesh prosthesis 1 is modeled by cutting strips 2 along its sides. A synthetic mesh prosthesis 1 is placed in the prepared bed, cut strips 2 are passed through the muscular aponeurotic edges of the hernial portal 6 from the inside out. Subsequently, after pulling, each strip 2 is sutured with sutures 8 through the synthetic mesh prosthesis 1 with the medial edge 9 of the dissected aponeurosis 5. Next, the synthetic mesh prosthesis 1 with sutures 10 is sewn to the medial edge 9 of the dissected aponeurosis 1 located under the specified prosthesis 1.

After completion of the plasty, a drainage tube is installed in the operation zone (not shown in the figures). Subcutaneous tissue 4 and skin 3 are then sutured.

The essence of the proposed method is illustrated by an example of a specific implementation

Patient M., 62 years old, was in the surgery department of the NUZ “DKB at st. Irkutsk-Passenger ”JSC“ Russian Railways ”with a diagnosis of correctable postoperative median ventral hernia.

Surgical intervention: herniolaparotomy, plastic surgery by the present method. During the operation, it was found that it is not possible to reduce the edges of the hernial defect without significant tension. After isolation of the aponeurosis and its dissection, a bed is formed around the hernial defect for the location of the synthetic mesh prosthesis. Performed plastic hernial defect according to the claimed method. An additional fixation of the strips and mesh prosthesis to the medial edge of the dissected aponeurosis achieved the elimination of the subgrid space and more durable fixation of the mesh prosthesis in the tissues. A tubular drainage brought out through a separate puncture is brought to the area of the mesh prosthesis location.

The postoperative period was uneventful. Pain is not pronounced. On the 2nd day in the postoperative bandage, the patient began to walk independently. Drainage removed on the 4th day. The hospital stay was 9 days. Discharged under the supervision of a surgeon at a community clinic. Sutures were removed on the 12th day. Control examination every 6 months. After 6 months no complaints, local status without features. When viewed after 1 year, no relapse was noted.

According to the claimed method performed 10 herniasis in 7 men and 3 women. In all cases, postoperative ventral hernias were correctable in nature, were median. The edges of the hernial defect were either irreducible, or they could be reduced only with great tension, when an unacceptable increase in intra-abdominal pressure occurred. As a synthetic mesh prosthesis, standard and lightweight nets from Lintex were used.

The follow-up period for patients after surgery is up to two years. In all cases, after the operation, the pain was moderately expressed, the postoperative period was uneventful. No relapses were noted.

Thus, the inventive method can be used for plastic surgery of large postoperative ventral hernias when it is impossible to reduce the edges of the hernial defect or they are reduced with great tension.

The advantage of the proposed method from the known is that it achieves a strong closure of the hernial defect without the risk of wrinkling and displacement of the prosthesis.

Compared with the prototype, the advantage of the proposed method lies in the fact that additional fixation in the tissues of the synthetic mesh prosthesis is achieved and the possibility of the formation of a subgrid space is excluded.

The implementation of the proposed method of plastic surgery for large postoperative ventral hernias, when it is impossible to reduce the edges of the hernial defect, leads to an increase in the quality of hernioplasty.

Claims (2)

1. Plastic surgery for large postoperative ventral hernias when it is impossible to reduce the edges of the hernial defect, including access to the hernial sac, isolation and processing of it, exposure of the hernial defect, dissection of the aponeurosis around the hernial defect with the formation of a bed for the location of the synthetic mesh prosthesis, plastic with preperitoneal or axillary arrangement of a rectangular synthetic mesh prosthesis, which is modeled by making incisions from its four edges towards opposite edges, cutting strips that pass through the muscle-aponeurotic edges of the hernial portal from the inside out, followed by pulling together each strip with a section of synthetic mesh prosthesis at the edge of the hernia defect, characterized in that each strip cut from a rectangular synthetic mesh prosthesis is additionally fixed with sutures drawn through a synthetic mesh prosthesis to the medial edge of the aponeurosis formed after dissection of the aponeurosis around the hernial defect. 2. The method according to claim 1, characterized in that the synthetic mesh prosthesis is additionally fixed with sutures to the medial edge of the aponeurosis formed after dissection of the aponeurosis around the hernial defect.

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