RU2587646C1 - Method of autografting for abdominal wall at large epigastric hernias after laparotomy in pancreatonecrosis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to epigastric region hernia surgery. Method involves excision of hernial sac. Dissection of front wall of abdominal rectus muscles is carried out at distance of 3-3.5 cm from edge of hernial orifice. Dissection of abdominal external oblique muscle are bilaterally from costal arch to wing of ilium. Inner edge of rectus sheathes are sutured at distance 0.5-1.0 cm from wound edge. Skin graft is laid over seams and fixed to edges of dissected aponeurosis and outer edges of rectus sheathes continuous duplicating suture.

EFFECT: method reduces intra-abdominal pressure and tension of sutured tissues.

1 cl, 1 ex, 4 dwg

Description

The present invention relates to medicine, namely to surgery, and can be used to treat patients with large hernias of the epigastric region after laparotomy with pancreatic necrosis.

In recent years, pancreatic necrosis has become the most common. The main cause of pancreatic necrosis is a violation of the diet, as well as an increase in the etiological factors of pancreatic lesions, alcoholism, obesity, adverse environmental conditions and injuries (Danilov M.V., Fedorov V.D., 1995; Cavallini G. et al., 1996).

Plastic closure of large hernial defects of the epigastric region is associated with a number of technical difficulties caused by the anatomical features of hernias of a given localization - a small number of tissues between the costal arches and their scar-atrophic changes that limit the ability to reduce the edges of the hernial defect without significant tissue tension and increased intra-abdominal pressure, which leads to teething and hernia recurrence.

Currently, surgical interventions, accompanied by the creation of a laparostomy for conducting stage sanitations, except for the positive aspects, have one consequence - almost all patients in the epigastric zone form a hernial defect, which over time turns into a hernia. And it, as you know, can lead to a decrease in working capacity, and often - even to disability of patients. Only timely and adequately performed hernioplasty can in most cases ensure the full recovery of the patient. However, according to the observations of many authors, in a significant part of patients, surgery is performed only when the hernia reaches a large size, which affects the general condition of the patient, reduces his quality of life or leads to dangerous complications.

There is a method of plastic hernia gate with postoperative ventral hernias according to N.I. Napalkov (Zhebrovsky V.V., Ilchenko F.N. Atlas of operations for abdominal hernias. - Simferopol: Hellinho, 2004. - 315 p.), Which is as follows : after removal of the hernial sac, the edges of the aponeurosis are sutured edge to edge. Then, at the medial edge of the vagina of the rectus muscles, two parallel sections of the anterior leaf of the vagina are made. The length of the cut depends on the length of the section of the midline to be plastic reconstructed. The inner edges of the incisions of the anterior leaf of the aponeurotic vagina are sutured. When tying the seams, the front row is immersed. Then, in the same way, stitches are placed on the outer edges of the aponeurotic vagina.

The disadvantage of this method is its limited use in postoperative hernias of small and medium sizes, having an oval or slit-like shape. With large, giant recurrent postoperative hernias with pancreatic necrosis, it is not possible to sew the outer edges, because when attempting suturing, intra-abdominal pressure rises, which leads to cardiopulmonary failure, teething and hernia recurrence.

A known method of hernioplasty using an autodermal graft proposed by V.N. Yanov (Yanov V.N. Autodermal plasty of the abdominal wall with postoperative hernias / / Bulletin of Surgery. - 1974. - No. 7. - S. 68-71).

The known method is as follows. An elliptical incision along the hernial protrusion excised a flap with subcutaneous tissue and a postoperative scar. The epidermal surface of the flap is treated with physiological saline, heated to 90-94 ° C. Then the epidermal layer is removed with a scalpel. The subcutaneous tissue is excised using curved scissors. Thus prepared skin flap is placed in a solution of penicillin (200 thousand units per 50 ml of physiological saline), where it is stored until the start of autodermoplasty.

Autoplasty of hernial glands with pancreatic necrosis has a number of positive aspects: a skin autograft allows you to close a fairly large defect in the abdominal wall, an autograft has complete engraftment and does not give rise to a plastosis phenomenon (unlike xenomaterials).

The disadvantage of this method is its impracticability with large and giant postoperative hernias with pancreatic necrosis due to the large number of postoperative complications.

A known method of hernioplasty proposed by V.I. Belokonev (Patent No. 2123292, IPC АВВ 17/00, published on December 20, 2008). It is as follows. The method of hernioplasty for large and giant hernias involves longitudinal dissection of the anterior leaves of the vaginas of the rectus abdominis muscles and the use of a graft, which is first sutured to the lateral sheet, and then to the medial sheet of the aponeurosis around the circumference of the large and small perimeters.

The disadvantage of this method is the inability to close a hernial defect without a significant increase in intra-abdominal pressure when dissecting the vagina of the rectus abdominis muscles with large and giant epigastric hernias after laparotomy with pancreatic necrosis. In the case of using a polypropylene mesh as a graft, the conditions for its contact with subcutaneous fat are inevitably created, which is associated with a high probability of the formation of seromas, which, when activated, a dormant infection in the edges of the wound, inevitably fester. For the prototype of the invention, a well-known method for the treatment of postoperative is selected (Patent RU 2546927, IPC АВВ 17/00, publ. 04/10/2015).

The method is 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 white 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 vaginas of the rectus abdominis muscles, without tissue tension, by 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. Redon Subcutaneous Drainage. Mattress stitches. Subcutaneous tissue is sutured after absorbable suture material after installing through active drains. Stitches to the skin. The known method allows you to close the hernial defect of the epigastric region without a significant increase in intra-abdominal pressure.

The known method has the disadvantages of:

- the method involves closing the hernia gate with tissues of the hernial sac, which is not always possible with its cicatricial changes;

- fixation of the endoprosthesis to the medial sheets of the vaginas of the rectus abdominis muscles “edge to edge” without overlapping the edges of the hernia gate, which can lead to a hernia recurrence;

- the method is associated with a high risk of postoperative wound complications due to the contact of the prolene endoprosthesis with subcutaneous fat and the possibility of ascending infection by drainage.

The objective of the proposed method is to reduce postoperative complications, including a decrease in intra-abdominal pressure.

The problem is solved in that the method of autoplasty of the abdominal wall with large epigastric hernias after laparotomy with pancreatic necrosis includes excision of the hernial sac, plastic surgery of the abdominal wall, fixation of the autograft over the sutures and suturing of the rectus sheaths of the rectus muscles of the anterior wall, the anterior wall carried out at a distance of 3-3.5 cm from the edge of the hernia gate, the dissection of the aponeurosis of the external oblique muscle of the abdomen is carried out bilaterally from the costal arch to the wing p of the iliac bone, the inner edges of the vaginas of the rectus abdominis muscle are sutured at a distance of 0.5-1.0 cm from the edge of the wound, a skin autograft is placed over the sutures and fixed to the edges of the dissected aponeurosis and the outer edges of the vaginas of the rectus abdominis with a continuous duplicate suture.

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 technical effect. Due to laxative sections of the aponeurosis of the external oblique muscle of the abdomen with pancreatic necrosis, intra-abdominal pressure decreases, therefore, the frequency of cardiopulmonary failure in the postoperative period decreases and the tension of the stitched tissues decreases. Also, due to the use of a skin autograft, the frequency of wound complications during pancreatic necrosis in the postoperative period is reduced and the likelihood of developing inconsistency of the sutures of the anterior abdominal wall, respectively, and hernia recurrence is reduced. The method of preparing an autograft, unlike the known method according to V. N. Yanov, performs the separation of the flap from the tissue with a scalpel even during its excision and the method of fixation of the autograft is performed using a continuous duplicate suture (RU patent of the Russian Federation for invention No. 2180522, IPC А61В 17/00 , published on March 20, 2002), which makes it possible to tightly and firmly fix a skin autograft. The use of a skin autograft allows you to further strengthen the line of sutures and create a reliable protective case for the rectus abdominis muscles.

The invention is illustrated by graphic material (Fig. 1; Fig. 2, Fig. 3, Fig. 4), which demonstrate the steps of the method

The method is as follows:

Under endotracheal anesthesia using muscle relaxants, the postoperative scar and excess skin are excised with bordering incisions, then the hernial sac is excised with the release of the hernial portal (Fig. 1). After performing the intra-abdominal stage of the operation, they begin to repair the abdominal wall. Dissect the anterior wall of the rectus sheaths 2 3-3.5 cm from the edge of the hernial portal along their entire length 3 (Fig. 2). Then, an aponeurosis of the external oblique muscle of the abdomen is dissected bilaterally from the costal arch to the wing of the ilium 4. The internal edges of the vagina of the rectus abdominis muscle 5 are sutured with separate knotted nylon sutures at a distance of 0.5-1.0 cm from the edge of the wound 6 (Fig. 3 ) The cut skin autograft is placed over the sutures and fixed to the edges of the dissected aponeurosis and the outer edges of the rectus sheaths of the abdomen with a continuous duplicate suture of absorbable sutures (Polysorb No. 2) 7, which strengthens the suture line and creates a protective case for the rectus abdominis (Fig. 4). Then, the fascia, subcutaneous tissue and skin 8 are sutured, while all pockets and cavities are carefully sutured in the subcutaneous tissue without drainage being brought to the skin autograft, which we consider to be fundamentally important in view of preventing the possibility of ascending infection. All stages of hernia repair are performed under the control of intra-abdominal pressure (according to the sensor of the mechanical ventilation apparatus (IVL), dynamics in the bladder). At the end of the operation, the abdominal pressure is measured.

Examples of specific performance are given in extracts from the medical history.

Patient K., 54 years old, was admitted to the I surgical department of GBUZ NO GKB No. 40 in a planned manner with a diagnosis of Postoperative hernia of large sizes, uterine polyposis, chronic calculous cholecystitis, pancreatic necrosis. Concomitant diseases: lymphogranulomatosis, type 2 diabetes mellitus, ischemic heart disease, hypertension (2 tbsp.), Obesity 2 tbsp.

Anamnesismorbi: considers herself a patient for more than 10 years when, after marsupialization of the pancreatic cyst, she noticed a tumor in the area of the postoperative scar on the anterior abdominal wall, which gradually increased in size. Periodically there were pains in the protrusion, delayed stool. In 2007, hernia repair was performed with plastic mesh endoprosthesis. In the postoperative period, mesh rejection with suppuration of the surgical wound, which required the removal of the endoprosthesis.

Statuslocalis: hernial protrusion in the mesogastrium, correctable, measuring 18 × 25 cm (corresponding to a defect in the aponeurosis). Preparation for Borovkov S.A. within 15 days. The operation is cholecystectomy, supravaginal amputation of the uterus, hernia repair with an autodermal graft plastic surgery. Progress of the operation: from the xiphoid process to the bosom, two skin-flap cuts were cut with two sections bordering the hernial protrusion, which was processed according to the method of V.N. Yanova. An abdominal cavity was opened, a hernial sac 20x20 cm in size with a thin atrophic deformed wall was dissected. The extensive fusion of the hernia gate with the small intestine is divided. Gall bladder with calculi. Cholecystectomy from the neck with separate ligation of the cystic artery and cystic duct, suturing of the cystic bed. The uterus is small in size, appendages without inflammatory changes, the ovaries are atrophic. The uterus was mobilized from the appendages and the ligamentous apparatus, after which the uterine vessels were ligated and the uterus was cut off from the cervix. The latter was treated with chlorhexidine along the section line and sutured with catgut, with peritonization by nylon seams. Trapping drainage under the liver and into the pelvic cavity. Due to a large defect of 18 × 25 cm in the upper abdomen and the stiffness of the muscle-aponeurotic layer (due to previous radiation therapy and their cicatricial changes), it is not possible to bring the edges of the hernia gate closer. The aponeurosis of the external oblique muscle of the abdomen was dissected bilaterally from the costal arch to the iliac wing. However, even this would not allow the edges of the hernia gate to be seamed together. In this regard, the anterior wall of the rectus sheaths was dissected 3-3.5 cm from the edge of the hernial portal along their entire length. Only after that was it possible to suture the hernia gate with interrupted sutures with the reinforcement of these sutures with a skin flap that is fixed to the edges of the dissected aponeurosis, to the outer edges of the dissected vaginas of the rectus muscles and along the midline by a continuous duplicate suture. The area of the skin flap is 15 × 25 cm. Sutures on fiber and skin. The postoperative period was without wound complications and hernia recurrence. Sutures were removed on the 10th day. The wound healed initially, was discharged in satisfactory condition.

Claims (1)

The method of autoplasty of the abdominal wall with large epigastric hernias after laparotomy with pancreatic necrosis, including excision of the hernial sac, plastic surgery of the abdominal wall, fixation of the autograft over the sutures and suturing of the rectus muscles of the abdominal muscles with the straight muscles of the anterior wall at a distance of 3-3.5 cm from the edge of the hernial portal, dissection of the aponeurosis of the external oblique muscle of the abdomen is carried out bilaterally from the costal arch to the iliac wing stitches, the inner edges of the vaginas of the rectus abdominis muscles are sutured at a distance of 0.5-1.0 cm from the edge of the wound, the skin autograft is placed over the sutures and fixed to the edges of the dissected aponeurosis and the outer edges of the vaginas of the rectus abdominis muscles with a continuous duplicate suture.

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