RU2597278C1 - Method of operation in ventral hernias - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, specifically to herniology. Method involves incising skin and subcutaneous fat, extraction and processing of hernial sac, exposure of hernia defect and repair with location of synthetic mesh prosthesis in prepared bed. Rectangular synthetic mesh prosthesis is modelled to form from four edges towards opposite edges strips which extend through muscular-aponeurotic edges of hernia orifice inside-out with subsequent, after stretching, suturing of each strip with a section of synthetic mesh prosthesis at edge of hernia defect. Edge of hernial orifice is sutured to synthetic mesh prosthesis, and operation is finished by draining wound and layered closure thereof. Bed for location of synthetic mesh prosthesis is created from whole hernial sac, tucked into abdominal cavity, and strips, formed on periphery of synthetic mesh prosthesis also extends through wall of hernia sac at 2-3 cm from edge of hernial orifice. Strips are pulled and fixed to aponeurosis at points their exit from musculo-aponeurotic tissues. Incisions with length of 2-3 cm are on wall of hernial sac from its neck towards an apex in an amount of 4-8 at equal distance from each other. At distance of 2-3 cm from edge of hernia defect in projections of made incisions of hernial sac through muscular-aponeurotic structures U-sutures are applied with underruning of edges of sections of wall of hernia. Edge of hernial orifice is sutured to synthetic mesh prosthesis throughout with gradual tightening of sewen tissues towards centre of hernia defect.

EFFECT: method is less invasive and prevents onset of pain syndrome.

6 cl, 1 ex, 8 dwg

Description

The invention relates to medicine, namely to surgery, and is intended to increase the effectiveness of surgery for ventral hernias.

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

A known method for the surgical treatment of 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 where it is impossible to reduce the edges of the hernia gate, possibly, but with significant tension, or undesirable due to the somatic state of the patient. Along with the advantages, the above alloplastic method has several disadvantages, since as a result of the wrinkling effect of the mesh prosthesis, it can be dislocated with subsequent formation of a hernia recurrence.

The closest analogue to the claimed invention is the known method of plastic surgery for postoperative ventral hernias (Plastic method for large postoperative ventral hernias: Pat. 2458640 Russian Federation. Federation: MKI A61B 17/00 / authors Kulikov L.K., Buslaev O.A., Shalashov S.V., Egorov I.A., Mikhailov A.L .; application 2011111966/14, application date March 29, 2011; published on August 20, 2012; Bull. No. 23). An incision is made in the skin and subcutaneous tissue, a hernial sac is isolated and treated. An aponeurosis is cut along its edge and plastic with a preperitoneal or axillary arrangement of a synthetic mesh prosthesis. A rectangular synthetic mesh prosthesis is modeled by making incisions from its four edges towards the opposite edges, cutting strips. The strips are passed through the muscle-aponeurotic edges of the hernial collar from the inside out, followed by pulling together each stitch with a section of a synthetic mesh prosthesis at the edge of the hernial defect. At the same time, an aponeurosis along the periphery of the hernial defect is also sutured to the synthetic mesh prosthesis at the edge of the hernial defect.

The method allows you to reliably close the aponeurosis defect in cases of ventral hernias of any size, including irreducibility of the edges of the hernia gate. The negative side of the method is that with it, the formation of the bed for the mesh prosthesis is quite traumatic. This is not always justified with large umbilical, epigastric hernias, Spigelia hernias, and secondary postoperative ventral hernias with a single hernial sac.

The objective of the proposed technical solution is to develop a less traumatic method of operation for ventral hernias with one hernial sac when using a synthetic mesh prosthesis.

The technical result of the proposed method is to increase the efficiency of surgical treatment of ventral hernias with one hernial sac due to:

- creating a bed for the location of the synthetic mesh prosthesis from a single hernial sac inserted into the abdominal cavity, followed by strips formed along the edges of the synthetic mesh prosthesis through its wall;

- holding strips formed along the edges of the synthetic mesh prosthesis through the wall of the hernial sac and the muscular-aponeurotic edges of the hernia gate, 2-3 cm from the edge of the hernia gate;

- pulling and fixing the strips formed along the edges of the synthetic mesh prosthesis, after passing them through the wall of the hernial sac and the muscular aponeurotic edges of the hernial portal, to the aponeurosis in the places of their exit from the muscular aponeurotic tissues;

- making incisions 2-3 cm long of the wall of the hernial sac from its neck towards the apex in the amount of 4-8 at the same distance from each other;

- making incisions 2-3 cm long of the wall of the hernial sac from its neck towards the apex in an amount of 4-8 at the same distance from each other, and subsequently during the operation at a distance of 2-3 cm from the edge of the hernial defect in the projections of the incisions made a hernial sac overlay through the muscle-aponeurotic structure of the U-shaped sutures with stitching the edges of the incisions of the wall of the hernial sac and tying;

- Sewing the edge of the hernial portal to the synthetic mesh prosthesis along the entire length with a gradual contraction of the sewn tissue towards the center of the hernial defect.

The technical result is achieved by the fact that the method of operation for ventral hernias includes an incision in the skin and subcutaneous tissue, isolation and processing of the hernial sac, exposure of the hernial defect and plastic with the location of the synthetic mesh prosthesis in the prepared bed. In this case, a rectangular synthetic mesh prosthesis is modeled, forming from its four edges towards the opposite edges of the strip. The strips are passed through the muscle-aponeurotic edges of the hernia gate from the inside out, followed by pulling together each strip with a section of the synthetic mesh prosthesis at the edge of the hernia defect, and, in addition, the edge of the hernia gate is sewn to the synthetic mesh prosthesis. The operation is completed by draining the wound and suturing it in layers.

The difference between the method is that the bed for the location of the synthetic mesh prosthesis is created from a solid hernial sac inserted into the abdominal cavity, and the strips formed along the edges of the synthetic mesh prosthesis are also passed through the wall of the hernial sac.

The difference of the method also lies in the fact that the strips formed along the edges of the synthetic mesh prosthesis are passed through the wall of the hernial sac and the muscular aponeurotic edges of the hernial portal, 2-3 cm from the edge of the hernial portal.

A distinctive technique of the proposed method is that the strips formed along the edges of the synthetic mesh prosthesis, after passing them through the wall of the hernial sac and the muscle-aponeurotic edges of the hernia gate, are pulled and fixed to the aponeurosis at the points of their exit from the muscle-aponeurotic tissues.

The difference of the method is also that they make incisions 2-3 cm long of the wall of the hernial sac from its neck towards the apex in the amount of 4-8 at the same distance from each other.

The difference of the proposed method is that they make incisions 2-3 cm long of the wall of the hernial sac from its neck towards the apex in the amount of 4-8 at the same distance from each other, and subsequently during the operation at a distance of 2-3 cm from the edges of the hernial defect in the projections of the incisions of the hernial sac through the muscle-aponeurotic structures impose U-shaped sutures with the stitching of the edges of the incisions of the wall of the hernial sac and tying.

The difference of the method lies in the fact that the edge of the hernia gate is sutured to the synthetic mesh prosthesis along the entire length with a gradual contraction of the sewn tissue towards the center of the hernia 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 ventral hernias containing the distinctive techniques of the proposed method.

In the proposed method of surgical intervention, the bed for the location of the synthetic mesh prosthesis is created from a solid hernial sac inserted into the abdominal cavity, and the strips formed along the edges of the synthetic mesh prosthesis are also passed through the wall of the hernial sac. In this case, there is no need to form a special bed for the placement of a synthetic mesh prosthesis, the need for the preparation of tissues. Holding the strips additionally through the wall of the hernial sac does not increase the injury.

The strips formed along the edges of the synthetic mesh prosthesis are passed through the wall of the hernial sac and the muscular aponeurotic edges of the hernia gate, 2-3 cm from the edge of the hernia gate. Such a distance is sufficient for reliable fixation of the synthetic mesh prosthesis.

The strips formed along the edges of the synthetic mesh prosthesis, after passing them through the wall of the hernial sac and the muscle-aponeurotic edges of the hernia gate, are pulled and fixed to the aponeurosis in the places where they exit the muscle-aponeurotic tissues. Such fixation is necessary in order for the synthetic mesh prosthesis to fit tightly from the inside to the anterior abdominal wall at the places where the strips pass through the tissues.

In the proposed method, incisions are made 2-3 cm long of the wall of the hernial sac from its neck towards the apex in an amount of 4-8 at the same distance from each other. Such incisions are necessary in order to visually control the location of the strips of the mesh prosthesis through the tissues, to avoid damage to internal organs.

In the claimed method of operation, incisions are made 2-3 cm long of the wall of the hernial sac from its neck towards the apex in an amount of 4-8 at the same distance from each other, and subsequently during the operation at a distance of 2-3 cm from the edge of the hernial defect in the projections of the incisions of the hernial sac through the muscular aponeurotic structures impose U-shaped sutures with the stitching of the edges of the incisions of the wall of the hernial sac and tying. With the help of U-shaped sutures, the incisions of the hernial sac are eliminated, and the hernial sac is additionally fixed from the inside to the anterior abdominal wall.

In the presented method of operation, the edge of the hernia gate is sutured to the synthetic mesh prosthesis along the entire length with a gradual retraction of the sewn tissue towards the center of the hernia defect. This technique allows to reduce the area of contact of the synthetic mesh prosthesis with subcutaneous fat, which reduces the risk of seromas.

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

Sign: - “the method of operation for ventral involves an incision in the skin and subcutaneous tissue” - it is known and determines the nature of access to the area of operative influence and the structure through which it passes.

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 and plastic with the location of the synthetic mesh prosthesis in the prepared bed” - 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 forming from its four edges towards the opposite edges of the strip” - 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 place and 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: - “the edge of the hernia gate is sewn to the synthetic mesh prosthesis” - determines the fixation of the edge of the hernia gate to the synthetic mesh prosthesis, which allows to increase the reliability of the plastic. This feature is known in the art.

Sign: - "complete the operation by draining the wound and suturing it in layers" - determines the nature of the completion of the operation. This feature is also known in the art.

Symptom: - “the bed for the location of the synthetic mesh prosthesis is created from a solid hernial sac inserted into the abdominal cavity, and the strips formed along the edges of the synthetic mesh prosthesis are also passed through the wall of the hernial sac” - determines the nature of the bed for the placement of the synthetic mesh prosthesis and additional structure through which strips of mesh prosthesis are passed. This feature is not known from the prior art.

Symptom: - “strips formed along the edges of the synthetic mesh prosthesis are passed through the wall of the hernial sac and the muscular aponeurotic edges of the hernia gate, 2-3 cm from the edge of the hernia gate” - determines the area of the prosthesis strips through the tissue. The indicated feature is also not known from the prior art.

Symptom: - “strips formed along the edges of the synthetic mesh prosthesis, after passing them through the wall of the hernial sac and the muscle-aponeurotic edges of the hernial portal, are pulled and fixed to the aponeurosis in the places of their exit from the muscle-aponeurotic tissues” - is unknown from the prior art and determines additional fixation of strips of mesh prosthesis to tissues.

Sign: - “make incisions 2-3 cm long of the wall of the hernial sac from its neck towards the apex in an amount of 4-8 at the same distance from each other” - is also unknown from the prior art and determines the incisions of the wall of the hernial sac to visualize intra-abdominal actions operation time.

Sign: - “make incisions 2-3 cm long of the wall of the hernial sac from its neck towards the apex in the amount of 4-8 at the same distance from each other, and subsequently during the operation at a distance of 2-3 cm from the edge of the hernial defect in the projections of the incisions of the hernial sac through the muscle-aponeurotic structures impose U-shaped sutures with the stitching of the edges of the incisions of the wall of the hernial sac and tying "- determines the incisions of the wall of the hernial sac to visualize intra-abdominal manipulations with a way to eliminate these zrezov. The indicated characteristic is not known from the prior art.

Symptom: “the edge of the hernia gate is sutured to the synthetic mesh prosthesis along the entire length with a gradual retraction of the sutured tissue towards the center of the hernia defect” - it is also unknown from the prior art and determines the nature of the edge of the hernia gate to be sewn to the synthetic mesh prosthesis.

With the interaction of all the essential features, a new technical result is obtained, namely: increasing the efficiency of surgical treatment of ventral hernias with one hernial sac.

Six of the thirteen distinctive features of the proposed method from the prior art are unknown. 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 for the treatment of ventral hernias. 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 eight figures, reflecting the stages of its implementation, where: 1 - synthetic mesh prosthesis; 2 - stripes cut out on the sides of the synthetic mesh prosthesis; 3 - hernial sac; 4 - hernial defect; 5 - the edges of the hernia gate; 6 - strips cut along the edges of the mesh prosthesis are sewn to the mesh prosthesis at the edge of the hernial defect; 7 - a seam between the edge of the hernia gate and a synthetic mesh prosthesis at the edge of the hernia defect; 8 - a seam with which each strip is fixed to the aponeurosis at the place of its exit from the muscle-aponeurotic tissues; 9 - sections of the wall of the hernial sac; 10 - U-shaped sutures in the projections of the incisions of the hernial sac imposed through the muscle-aponeurotic structures with suturing the edges of the incisions of the wall of the hernial sac; 11 - aponeurosis.

In FIG. 1 shows a synthetic mesh prosthesis with stripes cut on the sides. In FIG. 2 - a synthetic mesh prosthesis is placed in a bed formed from a solid hernial sac inserted into the abdominal cavity, and the strips are drawn through the edges of the hernial portal and are fixed to the aponeurosis at the exit points. In FIG. 3 - hernial sac with cuts made in its wall. In FIG. Figure 4 shows the procedure for placing and fixing a synthetic mesh prosthesis in a bed represented by a single hernial sac. In FIG. 5 synthetic mesh prosthesis placed in the bed, the procedure for applying U-shaped sutures in the projections of the incisions of the hernial sac. In FIG. 6, a synthetic mesh prosthesis is placed in the bed, a suture is made between the edge of the hernia gate and a synthetic mesh prosthesis, fixation of strips of the mesh prosthesis to it at the edge of the hernia defect, U-shaped sutures are applied. In FIG. 7 strips are fixed to the synthetic mesh prosthesis at the edge of the hernial defect, U-shaped sutures are applied. In FIG. 8, the edge of the hernial portal is sewn to the synthetic mesh prosthesis along its entire length with a gradual contraction of the sutured tissue towards the center of the hernial defect.

The proposed method of operation for ventral hernia is as follows. After processing the surgical field under general anesthesia in the projection of hernial protrusion, an incision is made in the skin (not shown in the figures) and subcutaneous tissue (not shown in the figures). The hernial sac 3 is isolated, the edges of the hernial defect 5. The hernial sac 3 is inserted into the abdominal cavity. The hernia sac 3 inserted into the abdominal cavity acts as a bed for a synthetic mesh prosthesis 1. In this method, incisions 9 are made 2-3 cm long of the wall of the hernia sac 3 from its neck towards the apex in an amount of 4-8 at the same distance from each other . Through the performed incisions 9, visual inspection of the anterior abdominal wall from the inside around the hernial defect 4 is carried out and they are convinced of the absence of internal organs soldered to it. A synthetic mesh prosthesis 1 is modeled by cutting strips 2 along its four edge. A synthetic mesh prosthesis 1 is placed in a prepared bed — a hernial sac 3. The cut strips 2 are passed through the wall of the hernial sac 3, the muscular aponeurotic edges of the hernia gate 5 are inside outwards under visual control through incisions of the hernial sac 9. Next, after pulling, each strip 2 is sutured to the aponeurosis 11. At a distance of 2-3 cm from the edge of the hernial defect 5 in the projections of the incisions 9 of the hernial sac 3 through the muscular apone rhotic structure superimposed U-shaped seams with stitching edges 10 cuts the wall 9 of the hernial sac 3. Then, these seams 10 knotted. With a continuous suture 7, the edge of the hernia gate 5 is sewn to the synthetic mesh prosthesis 1 along the entire length with a gradual retraction of the sewn tissue towards the center of the hernia defect 4. The next step is to sew each strip 2 to the synthetic mesh prosthesis 1 at the edge of the hernia defect 4. After the plastic is finished, the area of operation is installed drainage (not shown in the figures), subcutaneous tissue and skin are sutured (not shown in the figures).

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

Patient I., 56 years old, was in the surgery department of the NKZ “DKB at st. Irkutsk-Passenger ”JSC“ Russian Railways ”with a diagnosis of correctable postoperative (trocar) median ventral hernia.

Surgical intervention: herniolaparotomy, plastic surgery by the present method. During the operation, it was revealed that the hernial defect was 9 × 9 cm, the contents of the hernial sac freely set into the abdominal cavity. 8 incisions of a hernia sac 3 cm long were made in the direction from the neck to the apex. An audit through performed incisions revealed that there is no adhesion process in the abdominal cavity near the hernial defect. Performed plastic hernial defect according to the claimed method. During the audit, the synthetic mesh prosthesis adheres closely to the anterior abdominal wall along the entire perimeter. After stitching the edge of the hernial defect with the mesh, the dimensions of the mesh prosthesis not covered by aponeurosis are 5 × 5 cm. A tubular drainage is installed to the mesh prosthesis. 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 3rd day. The hospital stay was 9 days. Discharged under the supervision of the surgeon of the clinic at the place of residence. Sutures were removed on the 12th day. Control examination every 6 months. After 6 months, no complaints, local status without features. When viewed after 1.5 years, no relapse was noted.

According to the claimed method performed 16 hernia repair in 6 men and 10 women. In all cases, hernias were correctable. In nine patients, hernias were umbilical, in one hernia of a Spigel line, in six trocar midline postoperative hernias. As a synthetic mesh prosthesis, standard and lightweight nets from Lintex were used.

The follow-up period for patients after surgery is up to 1.5 years. In all cases, after performing plastic surgery by the proposed method in the early stages, the pain syndrome was moderately expressed. The postoperative period in all patients proceeded without complications. The drainage was removed in the period from 2 to 4 days. No relapses were noted.

The inventive method can be used in the treatment of ventral hernias when there is one hernial sac. The advantage of the proposed method from known methods using nets is that it is performed without forming a special bed in the tissues to accommodate the prosthetic structure. Compared with the prototype method, the advantage of the proposed method lies in the fact that it is less traumatic.

The implementation of the proposed method of plastic surgery for ventral hernias leads to an increase in the quality of surgical treatment.

Claims (6)

1. The method of operation for ventral hernias, including an incision in the skin and subcutaneous tissue, isolation and processing of the hernial sac, exposure of the hernial defect and plastic with the location of the synthetic mesh prosthesis in the prepared bed, while the rectangular synthetic mesh prosthesis is modeled, forming from its four edges in the direction to the opposite edges of the strip, which is passed through the muscular-aponeurotic edges of the hernial portal from the inside out, followed by pulling together each stitch with a section of synt a mesh mesh prosthesis at the edge of the hernial defect, and, in addition, the edge of the hernia gate is sewn to the synthetic mesh prosthesis, and the operation is completed by draining the wound and suturing it in layers, characterized in that the bed for the location of the synthetic mesh prosthesis is created from a solid hernia bag, inserted into the abdominal cavity, and strips formed along the edges of the synthetic mesh prosthesis are also passed through the wall of the hernial sac. 2. The method according to p. 1, characterized in that the strips formed along the edges of the synthetic mesh prosthesis are carried out through the wall of the hernial sac and the muscular aponeurotic edges of the hernia gate, 2-3 cm from the edge of the hernia gate. 3. The method according to p. 1, characterized in that the strips formed along the edges of the synthetic mesh prosthesis, after passing them through the wall of the hernial sac and the muscle-aponeurotic edges of the hernia gate, are pulled and fixed to the aponeurosis at the points of their exit from the muscle-aponeurotic tissues. 4. The method according to p. 1, characterized in that they make incisions 2-3 cm long of the wall of the hernial sac from its neck towards the apex in the amount of 4-8 at the same distance from each other. 5. The method according to p. 1, characterized in that the incisions are made 2-3 cm long of the wall of the hernial sac from its neck towards the apex in an amount of 4-8 at the same distance from each other, and subsequently during the operation at a distance of 2 -3 cm from the edge of the hernial defect in the projections of the incisions of the hernial sac through the muscle-aponeurotic structures impose U-shaped sutures with the stitching of the edges of the incisions of the wall of the hernial sac and tying. 6. The method according to p. 1, characterized in that the edge of the hernia gate is sutured to the synthetic mesh prosthesis along the entire length with a gradual tightening of the sewn tissue towards the center of the hernial defect.

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