RU2604046C1 - Method for prevention of postoperative "trocar" hernia (versions) - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery. In one version of the method skin is incised with semilunar, crosswise or lengthwise periomphalic incision, pneumoperitoneum is applied, trocar with stylet is inserted through skin incision. Through skin incision and subcutaneous fat trocar is inserted at an angle of 90°, relative to the anterior abdominal wall, then in position of inclination at an angle of 45°, relative to the anterior abdominal wall, it is displaced laterally on 1.0-1.5 cm, and puncture of underlying tissues of the anterior abdominal wall is made through the abdominal rectus muscle. In another version of the method skin is also incised, pneumoperitoneum is applied, trocar with stylet is inserted through skin incision. When performing laparoport in lateral regions of abdomen, insertion of trocar through skin incision, subcutaneous fat and puncture of the external aponeurosis leaf are performed at an angle of 90°, relative to the skin in the area of insertion, then underlying muscles are punctured, trocar is inserted laterally at an angle of 30-45° in relation to the skin in the area of insertion, then trocar is turned and puncture of the underlying tissues of the abdominal wall is made, moving it medially at an angle of 30-45° in relation to the skin in the area of insertion.

EFFECT: disclosed method is aimed to prevention of postoperative "trocar" hernias due to absence of serial "direct" channel after removal of trocar, which is achieved due to overlap of skin wound defects, aponeurosis, muscles and peritoneum in relation to each other, thus excluding the probability of hernia defect.

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Description

The invention relates to medicine, namely to surgery.

The use of laparoscopic access does not exclude the possibility of the formation of postoperative ventral hernias, although their frequency is significantly lower than with laparotomy and reaches an average of 0.34% [1, 2]. Postoperative hernias in places of laparoscopic access are called “trocar”. The frequency of their occurrence depends on the diameter of the trocar and is 0.23% at the installation site of the 10 mm port, in 1.9% of cases after using the 12 mm port and in 6.3% of cases at the site of the 20 mm port. These figures significantly increase (up to 12%) in obese patients with a body mass index greater than 30 kg / m ² [3, 4].

The most significant factors in the formation of “trocar” hernias include: the age of patients older than 60 years, the presence of obesity, functional insufficiency of connective tissue, suppuration of the surgical wound, an inferior method of suturing a trocar wound. As reasons contributing to the development of the inflammatory process, the authors draw attention to the excessive use of electrocoagulation for hemostasis on the anterior abdominal wall, the use of reactogenic suture material [5].

Currently, different authors propose similar methods for the prevention of the formation of “trocar” hernias: excluding contact of the wound canal with a destructively changed gall bladder or appendix, careful treatment of tissues, preventive use of prosthetic materials in the area of a postoperative wound, use of antibiotics [2, 4].

The proposed methods for the prevention of hernia formation are based on the use of prosthetic materials (polypropylene nets), which always lengthens the operation time and is an additional source of infectious complications (6).

Tools are also used for less trauma when suturing wounds and better matching edges (using an anterior abdominal wall lift, devices for suturing trocar openings under conditions of applied pneumoperitoneum; Endo CloseTM (USSC, Norwalk, CT), SuturePasser (Storz, Tuttlingen, Germany) brands ), InletCloseSure System (Inlet Medical Inc, MN 55344, USA). (3 - prototype).

The problem solved by the present invention is the development of a trocar placement method that allows to achieve displacement of the trocar channel with a disposition of defects of the aponeurosis, muscles and peritoneum relative to each other, which eliminates the formation of a "weak spot" after the placement of the trocar.

Achievable technical result is the prevention of postoperative “trocar” hernias due to the lack of a consistent “direct” channel after trocar removal, which is ensured by overlapping wound defects of the skin, aponeurosis, muscles and peritoneum relative to each other, thereby eliminating the likelihood of a hernia defect forming.

The developed solution can be implemented in several ways:

1. When staging a trocar in the paraumbilical region:

In the position of the patient on the back under combined endotracheal anesthesia (ETN), a skin incision is performed in a semilunar, transverse or longitudinal incision paraumbilical (top, bottom, left, right), departing 1.0-1.5 cm from the umbilical ring 1.5-2 cm long The Veress needle creates pneumoperitoneum (standard technique).

After that, through the skin incision and subcutaneous fatty tissue, the trocar is injected at an angle of 90 ° with respect to the anterior abdominal wall. Further, in the tilt position at an angle of 45 ° with respect to the anterior abdominal wall, it is laterally displaced by 1.0-1.5 cm and the underlying tissues of the anterior abdominal wall are punctured through the rectus abdominis muscle.

Thus, the trocar channel looks like a broken line.

2. When staging a trocar in the lateral regions of the abdomen:

A skin incision is performed, pneumoperitoneum is applied, and a trocar with a stylet is inserted through a skin incision. When performing a laparoport in the lateral regions of the abdomen, the introduction of the trocar through a skin incision, subcutaneous fatty tissue and puncture of the outer leaf of the aponeurosis is carried out at an angle of 90 ° relative to the skin in the injection area, then the underlying muscles are punctured by conducting the trocar laterally in an inclined position at an angle of 30-45 ° in relation to the skin in the injection area, after which the trocar is deployed and the underlying tissues of the abdominal wall are punctured, conducting it medially at an angle of 30-45 ° in relation to the skin in the injection area.

Thus, the puncture points of the parietal peritoneum and aponeurosis do not coincide, and the trocar channel passes diagonally through the internal and external oblique muscles of the abdomen.

Clinical example No. 1.

Patient: N, 45 years old. Clinical diagnosis: Gallstone disease. Acute calculous cholecystitis. He entered the institute with a clinical and instrumental picture of acute calculous cholecystitis. Ultrasound of the abdominal cavity shows signs of acute calculous cholecystitis (gall bladder measuring 8.0 × 6.5 cm, walls 0.4-0.5 cm, layered, multiple lumps of various sizes in the lumen giving an acoustic shadow). Given the short time from the onset of the disease, it was decided to perform surgical treatment. Under ETN, video laparoscopic cholecystectomy was performed. 10 mm trocars were installed in the paraumbilical and epigastric regions as described above. The postoperative period is smooth. In satisfactory condition, the patient was discharged from the hospital.

The control was carried out after 12 and 36 months, postoperative hernia was not detected.

Clinical example No. 2.

Patient: K, 59 years old. Clinical diagnosis: Cancer of the ascending colon. T2NxM0. Held intestinal bleeding. He entered the institute with a clinical and instrumental picture of intestinal bleeding, prepared for planned surgical treatment. Under ETN, a laparoscopic right-sided hemicolonectomy was performed with intra-abdominal hardware formation of ileotransverse anastomosis with a side-to-side circular apparatus. 12 mm trocars were installed in the epigastric, paraumbilical and right iliac regions according to the described technique. The postoperative period was uneventful. In satisfactory condition, the patient was discharged from the hospital.

The control was carried out after 12 and 36 months, postoperative hernia was not detected.

Bibliography

1. Di Lorenso N., Coscarella G., Lirosi F., Gaspari A. Port-site closure: a new problem, an old device JSLS 2002; 6: 2: 181-183.

2. Agapov M.A., Prevention of postoperative ventral hernias after laparoscopic cholecystectomy // Author. diss. honey. sciences. Moscow 2008; p. 2-3.

3. Akilov F.A., Kasumyan S.A., Snytko N.P. and others. On the prevention of postoperative trocar hernias // Endoscopic surgery, 2012; 1: p. 35-36

4. Fedorov I.V., Valiullin I.N., Agliullin A.F. Prevention of trocar complications in laparoscopy // Textbook / Kazan: Publishing House, 2010. - pp. 6-8.

5. Oskretkov V. I., Litvinova O. M., Skripitsina O. V. The causes and methods of prophylaxis of trocar hernias after video laparoscopic cholecystectomy // Endoscopic surgery 2008; 2.

6. Butorina OV Prevention of the formation of ventral hernias after laparoscopic interventions diss. Cand. honey. sciences. Moscow 2008; p. 3-4.

Claims (2)

1. A method for the prevention of postoperative “trocar” hernias, including performing a skin incision with a semilunar, transverse or longitudinal incision paraumbilical, applying a pneumoperitoneum, introducing a trocar with a stylet through a skin incision, characterized in that the trocar is inserted through a skin incision and subcutaneous fatty tissue at an angle of 90 ° in relation to the anterior abdominal wall, then in a tilt position at an angle of 45 ° with respect to the anterior abdominal wall, it is laterally displaced by 1.0-1.5 cm and the underlying tissues are punctured the abdominal wall through the rectus abdominis muscle. 2. A method for the prevention of postoperative "trocar" hernias, including performing a skin incision, applying a pneumoperitoneum, introducing a trocar with a stylet through a skin incision, characterized in that when performing a laparoport in the lateral regions of the abdomen, introducing the trocar through a skin incision, subcutaneous fat and puncture of the external leaflet aponeurosis is carried out at an angle of 90 ° with respect to the skin in the area of administration, then the underlying muscles are punctured by conducting a trocar laterally in an inclined position at an angle of 30-45 ° with respect to in the injection area, after which the trocar is deployed and the underlying tissues of the abdominal wall are punctured, conducting it medially at an angle of 30-45 ° with respect to the skin in the injection area.

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