RU2618651C1 - Method for postoperative ventral hernias surgical treatment - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: after postoperative scar excision, hernial sac and aponeurosis selection, simultaneous dissection of anterior and posterior aponeurosis leaflets to the peritoneum is performed as cuts, 2-2.5 cm apart from the hernial orifice. The hernial sac and its contents are immersed into the peritoneal cavity without opening by aponeurosis medial edges stitching with interrupted sutures. Then the aponeurosis lateral edge are peeled from the peritoneum. The implant is applied, covering the previous aponeurosis sutures, and directed under its lateral edges at a distance of 1-1.5 cm with implant fixation to the aponeurosis with U-shaped sutures and directly to the aponeurosis edge with interrupted sutures, creating the same level of relief.

EFFECT: method prevents postoperative complications and recurrence of hernias by double fixation of the implant to the aponeurosis, exclusion of its partial separation and possible infringement of abdominal cavity organs in the defect.

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Description

The invention relates to medicine, namely to surgery, and can be used for plastic surgery of the anterior abdominal wall in the treatment of postoperative ventral hernias.

A known method of combined hernioplasty without opening the abdominal cavity by fixing the mesh implant in front of the rectus abdominis muscles, after peeling the aponeurosis and suturing it to the crossed tendon of the external oblique, internal oblique and transverse abdominal muscles on both sides. The hernia sac without opening is immersed in the abdominal cavity and covered with an implant. In the midline above the rectus, the medial flaps of the anterior leaf of the aponeurosis of the rectus abdominis muscle are sutured together without tension [3].

The disadvantages of this method is its invasiveness, the need for a wide detachment of the anterior leaf of the aponeurosis from the rectus abdominis, the intersection of the unchanged, normally functioning tendon of the external and internal oblique, as well as the transverse abdominal muscles. This disrupts their blood supply, venous and lymphatic drainage, leads to prolonged exudation in the wound, the formation of seromas and necrosis of the subcutaneous tissue and skin with the possible subsequent development of purulent wound complications and long-existing fistulas [1].

A known method proposed by Devlin in 1993. The essence of this method is to place the explant in front of the muscle-aponeurotic layer with minimal tension on the edges of the hernial defect. The size of the hernial defect is palpated, the scar and subcutaneous fat are excised above the hernial sac, 4-5 cm away from the edge of the hernial collar, the anterior wall of the rectus sheath is cut from both sides, the hernial sac is immersed into the abdominal cavity without opening, and then sutured the medial edges of the dissected leaves of the vagina of the rectus abdominis muscles; the transplant is hemmed to the lateral edges of the dissected leaves (prototype) [4].

However, the disadvantages of this method of hernioplasty are the risk of complications with the subcutaneous location of the implant (seroma, hematoma, infiltrates) and the inability to use this plastic with postoperative ventral hernias with an aponeurosis defect of more than 10 cm across [2, 4]. A common drawback of both methods is that with hernioplasty, a pathologically changed anterior leaf of the aponeurosis is corrected, and a thinned posterior leaf of the aponeurosis that is stretched with a defect is not corrected.

The objective of the invention is to increase the effectiveness of treatment of postoperative ventral hernias by reducing the number of relapses and complications.

This goal is achieved by the fact that according to the method of surgical treatment of postoperative ventral hernias, including excision of the postoperative scar, isolation of the hernial sac and aponeurosis, directing the hernial sac and its contents into the abdominal cavity without opening and cutting the hernia gate with dissection of the anterior aponeurosis, the simultaneous dissection of the anterior aponeurosis is performed, simultaneously and the posterior leaf of the aponeurosis to the peritoneum with semilunar incisions, retreating 2-2.5 cm from the hernial portal, immerse the hernial sac and its contents in the abdominal without opening by stitching the medial edges of the aponeurosis with nodal sutures, then the lateral edges of the aponeurosis are peeled from the peritoneum, then the implant is laid, covering the previous aponeurosis seams, and it is placed under the lateral edges of the aponeurosis at a distance of 1.5-2 cm with fixation of the implant by U-shaped seams to the aponeurosis and interrupted sutures directly to the edge of the aponeurosis, creating a single level of relief.

Improving the treatment of postoperative ventral hernias is achieved by reducing the number of relapses and complications. This is facilitated by a new procedure and additional elements of the method, namely, simultaneous dissection of the front and back leaves of the aponeurosis to the peritoneum, flaking of the lateral edge of the aponeurosis from the peritoneum, insertion of the implant under the lateral edge and fixation with U-shaped and interrupted sutures to create a single relief level. Quantitative parameters are also necessary to achieve the claimed effect. The new procedure allows you to strengthen the anterior abdominal wall above the hernia gate and thereby reduce the risk of relapse. Distinctive features of the claimed method are necessary and sufficient to achieve the task.

The method is as follows. After excision of the old postoperative scar (Fig. 1), a hernial sac (2) is isolated from the subcutaneous tissue (1) to its gates and the aponeurosis is 3-4 cm from the edge of the hernial sac. Retreating 2-2.5 cm from the hernia gate, two frontal and posterior aponeurosis sheets to the peritoneum are cut simultaneously with two half-moon incisions (3) around the hernia gate. The hernial sac and its contents (Fig. 2) without opening are immersed in the abdominal cavity by stitching the medial edges of the aponeurosis flaps with nodal sutures (4). The lateral edges of the aponeurosis (5) stupidly exfoliate from the peritoneum. A mesh implant (6) is brought under the lateral edges of the aponeurosis (Fig. 3) and fixed at a distance of 1-1.5 cm from the edge of the aponeurosis with U-shaped sutures, and then interrupted sutures to the edge of the aponeurosis (7), creating a single relief level. Layer wound closure with 1-3 drainages (depending on the size of the implant) for active aspiration.

An example of the method.

Patient K., 46 years old, was hospitalized on March 19, 2014 in a planned manner for surgical treatment of recurrent postoperative ventral hernia. Upon admission, he complained of the presence of hernial protrusion in the area of the old postoperative scar, periodically occurring pain in the area of hernial protrusion.

From the anamnesis it is known that four years ago the patient underwent a resection of the stomach for gastric ulcer complicated by bleeding. Seven months after the operation, the appearance of hernial protrusion in the area of the postoperative scar was noted. He was operated on for a hernia 1 year after the resection of the stomach, but after six months the hernial protrusion appeared again. It gradually increased in size, episodes of short-term infringement appeared. Concomitant diseases: hypertension I-II degree.

The condition at admission is satisfactory. The skin and visible mucous membranes are pale pink. The vesicular breathing is carried out in all pulmonary fields, no wheezing. HELL - 140/90 mm Hg Pulse - 76 rpm The tongue is clean, moist. The abdomen is soft, not swollen, not tense, asymmetric due to hernial protrusion, participates in the act of breathing, painless on palpation in all departments. There are no symptoms of peritoneal irritation. Intestinal noises of normal sonority. Physiological administration is normal. Locally: on the anterior abdominal wall from the xiphoid process to the navel there is an old postoperative scar. In the middle third of the postoperative scar, a hernial protrusion is determined, measuring 15 × 10 × 4 cm, painless, soft-elastic consistency, and then straightened into the abdominal cavity. The symptom of the “cough push” is positive.

03/20/2014, the planned operation was performed: hernia repair according to the proposed method. On the operation: the postoperative scar and subcutaneous fat over the hernial sac were excised, 2 cm back from the edge of the hernial collar (10 × 5 cm), the aponeurosis of the vagina of the rectus abdominis muscles on both sides was cut with 2 lunate incisions to the peritoneum, the hernial sac was immersed without opening into the abdominal cavity after suturing the medial leaves of the aponeurosis. Ethicon mesh implant 12 × 7 cm in size is sewn to the lateral edges of the aponeurosis that are detached from the peritoneum by U-shaped sutures 1.5 cm from the edge of the aponeurosis and is additionally fixed with interrupted sutures to the edge of the aponeurosis. Two drainages were established for active aspiration through separate puncture incisions. The skin wound is sutured tightly. Iodine. Aseptic dressing.

The postoperative period was uneventful. The wound healed by first intention, the drains were removed on the 6th day, the sutures were removed on the 8th day.

Control examinations of the patient after 6 months and 1 year of recurrence of hernia were not revealed.

The claimed method of plastic surgery of postoperative ventral hernias increases the effectiveness of treatment, reduces the number of relapses and complications, since it is less traumatic and simple to perform. There is no need for detachment and movement of the aponeurosis, which reduces the time of the operation. Mesh implants can be used without a special coating that prevents adhesion of the abdominal organs to the implant, since the hernial sac is immersed without opening. This reduces the cost of the operation, eliminates intra-abdominal complications, and helps to restore the motor-evacuation function of the gastrointestinal tract in the shortest possible time. For reliable fixation of the mesh implant, not a thinned edge of the aponeurosis adjacent to the hernial sac is used, but a thick and dense aponeurosis. Double fixation of the implant to the aponeurosis excludes its partial detachment and possible pinching in the resulting abdominal organ defect. The proposed method does not lead to an increase in intra-abdominal pressure, since there is no tension of the mesh implant. This method is universal and can be used for any localization of postoperative abdominal hernias.

Information sources

1. Belokonev V.I. et al. Plastics of the abdominal wall with ventral hernias in a combined way. Surgery. 2000, No. 8. - S. 24-26.

2. Egiev V.N. Lightweight hernioplasty. - M .: Medpraktika - M, 2002 .-- 148 p.

3. Patent No. 2391924 of the Russian Federation, IPC A61B 17/00. The method of surgical treatment of postoperative ventral hernia of the abdomen / Yu.S. Vinnik, Yu.A. Nazaryants, S.I. Petrushenko, N.S. Gorbunov, S.V. Miller GOU VPO Krasnoyarsk State Medical University named after Professor V.F. War-Yasenets Ministry of Health and Social Development of the Russian Federation. ” - No. 2009106903/14; Claim 02/26/2009; Publ. 06/20/2010, Access mode:

http://www1.fips.ru/fips_servl/fips_servlet?DB=RUPAT&rn=939&DocNumber=2391924&TvpeFile=html. Date of treatment 11/26/2015.

4. Timoshin A.D., Yurasov A.V., Shestakov A.L. Surgical treatment of inguinal and postoperative hernias of the abdominal wall. - M .: Triad - X, 2003; - 144 p.

5. Devlin N.V. Management of abdominal hernias. - London: Butterworths, 2000 .-- 430 p.

Claims (1)

A method of surgical treatment of postoperative ventral hernias, including excision of the postoperative scar, isolation of the hernial sac and aponeurosis, reduction of the hernial sac and its contents into the abdominal cavity without opening and plastic hernia gate with dissection of the anterior leaf of the aponeurosis, characterized in that the anterior and posterior sections are simultaneously dissected. aponeurosis to the peritoneum with semilunar incisions, retreating 2-2.5 cm from the hernia gate, immerse the hernial sac and its contents into the abdominal cavity without opening the put m stitching with interrupted sutures of the medial edges of the aponeurosis, then the lateral edges of the aponeurosis are peeled from the peritoneum, then the implant is laid, covering the previous joints of the aponeurosis, and it is placed under the lateral edges of the aponeurosis at a distance of 1-1.5 cm with fixation of the implant by U-shaped seams to the aponeurosis and interrupted sutures directly to the edge of the aponeurosis, creating a single level of relief.

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