RU2546927C2 - Method of hernioplasty in case of postoperative ventral hernias - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to abdominal surgery. After exposure of a hernia sac, a hernia orifice, the anterior leaves of the sheath are cut with the formation of medial and lateral leaves. After unfolding of the medial leaves, the first (internal) synthetic endoprosthesis, fixed to the medial leaves, is sewn into the defect. The second (external) synthetic endoprosthesis is sewn into the defect of the lateral leaves. The endoprostheses are fixed to each other on the entire diameter of the first endoprosthesis fixation.

EFFECT: method reduces postoperative complications: seromas, infarctions of the skin-fat flap, suppurations of postoperative wounds, which reduces the incidence of the hernia recurrences.

5 dwg, 1 ex

Description

The invention relates to medicine, namely to abdominal surgery.

Hernioplasty for postoperative ventral hernias is an urgent problem in modern surgery (2, 3). The increased amount of this pathology is due to an increase in the number of abdominal interventions and an increase in the volume of operations. However, with hernioplasty, complications are possible that worsen the results of surgical intervention, such as seromas of the postoperative wound, suppuration of the wound, infarcted skin-fatty flap and in the long-term period of hernia recurrence (4).

A known method of hernia repair according to V.I. Belokonev of the first type (1) by dissecting the front sheets of the vagina of the rectus abdominis muscles, deploying them 180 degrees and stitching them in the longitudinal direction, followed by the replacement of the aponeurosis defect with a synthetic prosthesis.

The disadvantage of this method is the wide, often up to the spigella line, mobilization of the anterior leaf of the vagina of the rectus abdominis muscles, especially with large and giant hernias, which can lead to impaired blood supply to the aponeurosis and, in some cases, the technical impossibility to compare the expanded medial sheets of the vagina of the rectus abdominis muscles.

A known method of hernia repair according to V.I. Belokonevu V.I. of the second type (1), by dissecting the front leaves of the vaginas of the rectus abdominis muscles, expanding them 180 degrees and if it is impossible to compare them, an aponeurosis defect is left with the covering of the latter with a synthetic prosthesis fixed to the lateral sheets of the dissected vaginas of the rectus abdominis muscles.

The disadvantage of this method is the wide mobilization of the flaps, which is performed involuntarily to reduce the area of the defect, which is formed in the center of the plastic, where the abdominal cavity is covered only by the shells of the hernial sac. To solve the problem aimed at reducing the area of detachment of the aponeurosis, allows the shift of the dissection line to the center of the white line of the abdomen. However, this will increase the size of the weak area located in the center, which contributes to the occurrence of relapses. This method is taken as a prototype.

The aim of the invention is to develop a method of hernioplasty with postoperative ventral hernias, providing a non-tensile nature of the plastic; reduction of ischemic disorders in skin-fat flaps and sheets of aponeurosis of the rectus abdominis muscles; a decrease in the incidence of postoperative complications, a decrease in the number of hernia relapses.

This goal is achieved by the fact that the first synthetic prolene endoprosthesis is sutured into the defect formed after 180 degrees of deployment of the medial leaves of the aponeurosis of the rectus abdominis, and the second synthetic prolene endoprosthesis is sewn into the defect formed by the lateral sheets of the aponeurosis, which is fixed to the first endoprosthesis in diameter its attachment to the medial sheets.

Comparison of the claimed method with others known in the field of medicine, showed its compliance with the criteria of the invention. The technical result of the claimed invention is the ability to perform this type of plastic, regardless of the size of the defect of the anterior abdominal wall; unstretched nature of plastic; reduction of ischemic disorders in mobilized skin-fat flaps and aponeurosis; reduction in the risk of complications (seromas, heart attacks of skin-fat flaps, suppuration of a postoperative wound); reduction in hernia recurrence rate. This allows you to perform this type of hernioplasty, regardless of the size of the hernial defect, reduce the frequency of local postoperative complications, reduce the time of initial hospitalization, and reduce the frequency of relapses in the long term.

The method of hernioplasty with postoperative ventral hernias is illustrated with graphic material.

The figure 1 shows the anterior abdominal wall after mobilization and processing of the hernial sac: skin-fat flaps (1) are mobilized, the abdominal cavity (6) is closed by the continuous shell suture (7) of the hernial sac shells (8). The dissection line (2) of the outer leaf of the vagina of the rectus abdominis muscles (5) is made at a distance of up to 1.5 cm from the edges of the hernial ring; Medial (3) and lateral (4) aponeurosis leaflets were identified.

The figure 2 shows the anterior abdominal wall with 180 degrees of medial flaps (9), sewn together until tension appears by a continuous seam (10). A synthetic endoprosthesis (11) with a continuous suture (12) is sewn into the formed defect of the medial sheets.

The figure 3 presents the option of closing the defect of the unfolded medial sheets with a synthetic endoprosthesis by a continuous suture (13) without matching sheets.

Figure 4 shows the anterior abdominal wall with a second synthetic endoprosthesis (14) fixed to the lateral sheets of the vagina of the rectus abdominis muscles with a continuous suture (15) and to the underlying first endoprosthesis in diameter of the last continuous suture (16).

The figure 5 shows the anterior abdominal wall after performing plastic in a transverse section.

The proposed method is implemented as follows.

After treatment of the surgical field with two incisions bordering the hernial protrusion with excision of the old postoperative scar, a hernial sac is secreted, the edges of the rectus abdominis muscles are at a distance of no more than 1.5 cm from the hernial collar and the white line of the abdomen. After opening the hernial sac, the contents of the latter are immersed in the abdominal cavity. The hernial sac is processed according to a generally recognized technique, the abdominal cavity is closed with hernial sac shells sewn with a continuous suture. Two semi-oval converging incisions at a distance of up to 1.5 cm from the hernia gate and the white line of the abdomen reveal the front sheets of the vagina of the rectus abdominis muscles. The medial sheets of the aponeurosis unfold 180 degrees. If possible, the medial sheets above and below the hernial gate are stitched together until tissue tension appears. The first prolene endoprosthesis without tissue tension is sutured into the defect of the unfolded medial sheets. The prosthesis is fixed to the medial sheets of the aponeurosis by a continuous suture with a non-absorbable suture material. The second prolene endoprosthesis is sewn into the defect formed by the lateral sheets of the vagina of the rectus abdominis muscles, without tensioning the tissues, a non-absorbable suture material with a continuous suture. The upper and lower endoprostheses are stitched together at the place of fixation of the lower endoprosthesis to the medial sheets of the vagina of the rectus abdominis muscles with a continuous suture. In the case where the medial leaves of the aponeurosis are sutured above and below the hernial portal, the upper endoprosthesis is additionally fixed to the stitched leaves with a continuous suture. Redon Subcutaneous Drainage. Mattress stitches. Subcutaneous tissue is sutured after absorbable suture material after installing through active drains. Stitches to the skin.

The method of hernioplasty in postoperative ventral hernias is illustrated by a clinical example.

A 43-year-old patient M. was admitted to the surgical department No. 1 of MMU GB No. 8 on 08.04.2009 in a planned manner with a diagnosis of giant postoperative ventral hernia. Condition after surgery for acute hemorrhagic pancreatic necrosis. 04/15/2009 the patient underwent surgery. After excision of the old postoperative scar, a hernial sac was distinguished, the anterior sheaths of the rectus rectus sheaths, hernia gate 25 cm by 18 cm. The hernial sac was opened, the contents were immersed in the abdominal cavity, and the excess membranes were excised. The abdominal cavity is closed by the remains of the hernial sac shells sewn with a continuous suture. At a distance of 1.5 cm from the hernia gate, two vaginal rectus muscles were opened by two semi-oval converging incisions. The medial sheets are rotated 180 degrees and sewn together above and below the main defect without tension. The defect formed 15 cm by 13 cm is closed with a prolene endoprosthesis fixed to the edges of the unfolded medial sheets with a continuous suture. In the defect formed by the lateral sheets of the anterior wall of the vagina of the rectus abdominis muscles 30 cm by 20 cm, the second prolene prosthesis 30 cm by 20 cm is sewn with a continuous suture. The upper and lower endoprostheses are fixed to each other by a continuous suture at the place of fixation of the first endoprosthesis. Mattress stitches are laid. The postoperative wound is drained by active suction drainage. The postoperative period without complications. Primary healing. 04/30/2009 was discharged in satisfactory condition under the supervision of a surgeon in the clinic.

The proposed method of hernioplasty for postoperative ventral hernias can be used in surgical departments that provide assistance to patients with surgical pathology of the abdominal organs.

Information sources

1. V.I. Belokonev, T.A. Fedorina, Z.V. Kovaleva et al. Pathogenesis and surgical treatment of postoperative ventral hernias // Samara, 2005

2. V.V. Zhebrovsky, F.N. Ilchenko. Atlas of operations for abdominal hernias // Simferopol, 2004

3. V.N. Egiev, K.V. Lyadov, P.K. Resurrection Atlas of operative hernia surgery // Medical practice - M, Moscow, 2003

4. Clinical surgery is a national guide. Volume 2. Edited by Acad. RAS and RAMS B.C. Savelyev, Corr. RAMS A.I. Kiriyenko // Moscow, 2009.

Claims (1)

The method of hernioplasty by dissecting the front leaves of the vagina of the rectus abdominis muscles around the entire perimeter of the hernial portal with the formation of the medial and lateral sheets, closing the defect in the abdominal wall due to the shells of the hernial sac, expanding the medial sheets 180 degrees, characterized in that they are sewn into the defect of the expanded medial sheets the first synthetic endoprosthesis, and in the defect formed by the lateral sheets, the second synthetic endoprosthesis, which is fixed to the first endoprosthesis according to the diameter of its Lenia to the medial layers.

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