RU2573794C2 - Method for diaphrogmocruroplasty in surgical management of giant paraoesophageal hernias - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method refers to medicine, namely surgical management of giant paraoesophageal hernias. A retroesophageal crurorhaphy is performed. A diaphragm opening is closed with a synthetic mesh implant. The implant is placed on pre-sutured fibred cruses of diaphragm in the lateral direction from an oesophagogastric junction. A fragment of a hernial sac left on an anterior oesophageal wall after the separation is fixed to the diaphragm on top of the mesh implant.

EFFECT: method prevents postoperative complications.

1 ex, 6 dwg

Description

The invention relates to medicine, namely to surgery, and can be used for surgical treatment of giant paraesophageal hernias in a laparoscopic manner.

The literature describes numerous life-threatening complications of patients using synthetic mesh prostheses to strengthen the legs of the diaphragm in the surgical treatment of hiatal hernia. Among them: erosion of visceral organs (Arpad J. et al. 2011, Carlson MA, Condon RE, Schult WJ 1998), mesh migration into the esophagus (M. Jansen, J. Otto et al. 2007, Schauer PR, Ikramuddin S. Et al. 1998), pseudo-achalasia of the esophagus (L. Bonavia, D. Bona et al. 2007, Little A. Correnti F. et al. 1986), gastroesophageal fistula (Baladas HG, Smith GS, 2000) and others. In addition, according to some foreign authors, scarring processes that intensify during the reaction of body tissues to foreign material make repeated intervention impossible in case of a hernia recurrence.

However, with giant paraesophageal hernias, when due to the large area of the hiatal opening, the tension between the legs of the diaphragm is aggravated by dystrophy of the legs, reliable cruroraphy without the release of muscle fibers is hardly possible. The stitches placed on the ragged legs of the diaphragm erupt, which as a result leads to a relapse of the hernia (Egiev V.N. et al., 2009).

According to the literature, the recurrence of paraesophageal hernia when performing crurography to eliminate a hernia gate without implanting a mesh prosthesis is 42% (Hashemi M, Peters HJ, DeMeester TR. Et al. 2000).

The prototype of the invention is the Huntington T.R method, in which a laxative incision is applied to the diaphragm of the lateral right leg in order to overcome the tension when stitching the diaphragmatic legs and then close the resulting diaphragm defect with a rectangular rectangular mesh prosthesis [Huntington TR. Laparoscopic mesh repair of the oesophageal hiatus. J Am Coll Surg 1997; 184: 399-401. Horgan S, Eubanks TR, Jacobsen G, Omelanczuk P, Pellegrini CA. Repair of paraesophageal hernias. Am J Surg 1999; 177: 354-58]. The advantage of the Huntington T.R method is the location of the mesh implant at a certain distance from the esophagus-gastric junction, which avoids the complications arising from direct contact of the mesh implant with the esophagus: erosion of the esophagus wall, migration of the mesh into the lumen of the esophagus, cicatricial process in the area of the esophagus transition.

The disadvantage of the Huntington T.R method is the lack of peritonization of the mesh implant, resulting in complications: adhesions in the abdominal cavity, erosion of the stomach wall, erosion of the wall of the small intestine, migration of the mesh into the lumen of the esophagus or stomach.

The technical result when using the invention is to increase the reliability of closing the opening of the diaphragm, preventing postoperative complications.

The proposed method of diaphragmocroroplasty in the surgical treatment of giant paraesophageal hernias is as follows. After performing back crurography, the mesh implant is placed on the fibrous legs of the diaphragm laterally to the esophagus-gastric junction, then a fragment of the hernial sac is fixed to the diaphragm over the mesh implant.

The advantage of this method is the peritonization of a mesh implant located at a distance from the esophagus-gastric transition, as a result, there are no complications in the postoperative period: adhesions in the abdominal cavity, erosion of the stomach wall, erosion of the wall of the small intestine, migration of the mesh into the lumen of the esophagus or stomach, process scarring in the esophageal-gastric junction.

The invention is illustrated by the following figures: figure 1 shows a panoramic x-ray of the abdominal organs of patient K. according to an example; figure 2 is a view of a hernia of the esophageal opening of the diaphragm with laparoscipia; figure 3 - selected legs of the diaphragm; figure 4 - post-esophageal crurography, fibrous legs of the diaphragm; figure 5 - diaphragmocroroplasty polypropylene mesh implant; figure 6 - fixing a fragment of the hernial sac to the diaphragm on top of the implant.

Clinical example.

Patient K., 71 years old, was admitted to the hospital in an emergency in serious condition with complaints of repeated profuse vomiting, lack of stool for 3 days, decreased diuresis, severe weakness, convulsive syndrome, moderate pain in the left chest region. According to fluoroscopy revealed a significant part of the stomach above the diaphragm with a horizontal liquid level (Figure 1).

Diagnosed with Restrained Antral Paraesophageal Hernia. After preoperative preparation, an emergency laparoscopic posterior cruroraphy, prosthetic diaphragmocroroplasty, and Nissen-Rozzetti fundoplication were performed. The area of the esophageal opening of the diaphragm was about 6 cm ² (Figure 2).

After isolation and complete excision of the hernial sac, the stomach is reduced to the abdominal cavity, the legs of the diaphragm are highlighted (Figure 3).

With technical difficulties due to tension, 3 interrupted sutures were placed on the legs of the diaphragm behind the esophagus using Vikril 2.0 thread (Figure 4).

A cuff is formed from the bottom of the stomach on the anterior wall of the esophagus with 3 interrupted sutures with Vikril 2.0 thread, the latter with the capture of the adventitia and muscular membrane of the esophagus.

Then, on the fibrous fibers of the diaphragm lateral to the right leg, a rectangular polypropylene mesh 4 × 3 cm in size was laid, fixed with a herniostapler (Figure 5). On top of the polypropylene implant, a fragment of the hernial sac left on the front wall of the esophagus is laid. A fragment of the hernial sac is also fixed to the diaphragm with staples along the perimeter (Figure 6).

The patient was discharged from the hospital on the 10th day after surgery in a satisfactory condition. The function of the gastrointestinal tract is fully restored. There were no complaints of dysphagia, heartburn, chest pain in the immediate postoperative period.

Claims (1)

The method of diaphragmocroroplasty in the surgical treatment of giant paraesophageal hernias, including posterior-esophageal krurorafiya, closing the opening in the diaphragm with a synthetic mesh implant, characterized in that the implant is placed on the pre-stitched fibrous legs of the diaphragm later than the esophageal-gastric ductal junction duct, left on the front wall of the esophagus during discharge.

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