RU2629803C1 - Method for intra-abdominal hypertension prevention in case of medial ventral hernioplasty - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: after opening of rectus abdominal muscles sheaths back sheets, clamps are aplied onr every 20-30 mm of the back sheet of the rectus abdominal muscle sheath. They are subjected to traction in the medial direction until aponeurosis microfractures appear near the tips of the clamps applied to the tissue. This position is maintained for at least four minutes. In the same way, correction of the myofascial structures of the transverse muscle is performed alternately from one side and from the other. Next, similar traction of the front sheet of the rectus muscle sheath is performed. After tractions, the back sheets of the rectus abdominal muscle sheath are sutured. Retro-muscular plasty of the anterior abdominal wall is performed with an endoprosthesis and the front sheets of the sheaths are sutured.

EFFECT: method reduces pain syndrome severity in the early postoperative period.

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Description

The invention relates to medicine, namely to surgery and can be used for hernioplasty in patients with median ventral hernias.

In patients with large median ventral hernias, part of the abdominal organs is in the hernial sac, and the anterior abdominal wall has an extensive tissue defect. During a surgical operation, the contents of the hernial sac are transferred to the abdominal cavity, and the defect of the anterior abdominal wall is closed by one of the methods. At the same time, an increase in intra-abdominal pressure occurs to one degree or another.

The development of the syndrome of intra-abdominal hypertension negatively affects both early complications and the long-term result of treatment. Therefore, the prevention of intra-abdominal hypertension in hernioplasty is one of the most important aspects of the surgical treatment of patients with large ventral hernias.

There are methods of separation hernioplasty. The most common method is Ramirez surgery (Ramirez OM, Ruas E., Dellon L., Components separation method for closure of abdominal wall defects: an anatomic and clinical study // Plastic and Reconstructive Surgery. - 1990. - Vol. 86. - No. 3. - p. 519-526), which consists in the intersection of the aponeurosis of the external oblique muscle of the abdomen lateral to the spigel line from the costal arch to the ilium. The method allows to avoid the occurrence of intra-abdominal hypertension, but has significant disadvantages. In particular, the method involves the intersection of muscles, which leads to deformation of the anterior abdominal wall and the formation of the so-called "frog stomach". The external oblique muscle of the abdomen, devoid of one of the attachment points, atrophies. The operation is very traumatic, since it involves extensive mobilization of skin flaps. In some patients, implantation of additional fragments of the mesh endoprosthesis is required to close the defect in the aponeurosis of the external oblique muscle of the abdomen.

There is a method of posterior separation plastic proposed by Novitsky (Novitsky YW, Elliott HL, Orenstein SB, Rosen MJ Transversus abdominis muscle release: a novel approach to posterior component separation during complex abdominal wall reconstruction // Am J Surg. 2012 Nov; 204 (5) : 709-16). The operation consists in crossing the transverse abdominal muscle medially to the spigel line after the posterior leaf of the vagina of the rectus abdominis is isolated. The intersection is also carried out from the costal arch to the ilium.

However, the method increases the invasiveness of the operation. After crossing, the transverse abdominal muscle loses its function to a large extent. In the presence of a hernia gate in one of the sections of the anterior abdominal wall, extensive mobilization of the crossed muscle is required to complete the operation, which dictates the need for a total midline incision, not limited to the localized area of the hernia.

A known method of hernioplasty according to Belokonev (RU 2137432 C1, 09/20/1999), which consists in dissecting the front sheets of the vaginas of the rectus abdominis muscles and suturing the mesh endoprosthesis along the perimeter to the medial and lateral aponeurosis flap. The disadvantage of this method is that the mesh endoprosthesis is located in the subcutaneous tissue and anterior to the rectus abdominis muscles, which can cause hernia recurrence and the formation of seroma.

There is a hardware-based method for surgical treatment of postoperative ventral hernias (RU 2215484 C2, 10/10/2003). The essence of the method is to reduce the edges of the aponeurosis with a spoke device. The device allows you to immobilize the edges of the aponeurosis and control intra-abdominal pressure. Upon reaching the optimal values of intra-abdominal pressure, intraoperative hardware reduction of the edges is stopped and plastic surgery is performed in one way or another. The spoke device is removed 5-6 days after surgery. The disadvantage of this method is the need to use a complex spoke device that remains in the wound for several days, which can lead to infection of the wound, the development of necrosis adjacent to the spokes of the tissues.

The technical result of the invention is to improve the results of surgical treatment of a large median ventral hernia.

The essence of the method lies in the fact that they perform excision of the hernial sac, scar tissue, if any. Open the back leaves of the vaginas of the rectus abdominis muscles along the diameter of the hernial collar and additionally up and down not less than 6 cm, as close as possible to the white line of the abdomen. The rectus muscle is separated from the dissected posterior leaf as laterally as possible. Next, they take on the Kocher clamps the back sheet of the vagina of the rectus abdominis muscle, one clamp for every 20-30 mm of the aponeurosis, and carry out traction in the medial direction until the aponeurosis shows microcracks in the region of the ends of the clips applied to the tissue. Then hold in this position for at least four minutes. Thus, the myofascial structures of the transverse abdominal muscle are redressed alternately from one and the other. In this case, the correction of existing contracture associated with the presence of a hernia occurs. Next, perform a similar traction procedure for the anterior leaf of the vagina of the rectus abdominis muscle. Thus, the contracture of the oblique muscles of the abdomen is eliminated. So, with the help of layer-by-layer reduction, the transverse length of the lateral abdominal muscles is increased. After this, the posterior vaginal sheets of the rectus abdominis muscle are sutured, the retromuscular plastic surgery of the anterior abdominal wall is performed with a polypropylene mesh endoprosthesis and the anterior vaginal sheet of the rectus abdominis is sutured.

The advantages of the method are as follows.

1. Due to the layering of redress, the effectiveness of the applied effort for traction of the aponeurosis increases

2. The lateral abdominal muscles with this method do not lose their function, since the points of attachment of the muscles are not destroyed.

3. In the early postoperative period, the severity of the pain syndrome decreases, the volume of surgical injury does not increase.

The study involved patients with postoperative ventral median hernias. Of these, 10 were included in the control group, they underwent retromuscular plastic surgery with a mesh endoprosthesis with suturing of the posterior and anterior sheets of the vagina of the rectus abdominis muscles in the traditional way. The main group consisted of 10 patients operated on by the proposed method.

In the control group, the width of the hernia gate was from 4 to 9 cm, on average 5.4 ± 2.4 cm. In the main group, the width of the hernia gate was from 5 to 10 cm, on average 5.7 ± 2.6 cm. According to gender, the age composition and concomitant pathology of the group did not differ statistically significantly.

Evaluation of the results was carried out on the second day after the intervention using the following indicators. Kron intra-abdominal pressure and visual assessment of pain syndrome. In the control group, the indicators of intra-abdominal pressure averaged 6.5 ± 1.6 cm of water column. In the comparison group, this indicator was 5.4 ± 1.1 cm water column.

The inventive step of the proposed method characterizes the decrease in the severity of pain in the early postoperative period, the absence of relapse for at least two years from the time of surgery.

Example 1. Patient W., 59 years old. Received as planned for the surgical treatment of postoperative large median ventral hernia. Operation completed. The hernial sac and hernial gates 18 × 10 cm in size were highlighted. Forcibly reducing the edges of the hernial gates, the intra-abdominal pressure was 13 cm of the water column. The back sheet of the vagina of the rectus abdominis was opened. Reduction was done layer by layer for the posterior and anterior sheets of the vagina of the rectus abdominis muscles. The back sheets of the aponeurosis are sutured with a continuous suture. The mesh endoprosthesis is laid retromuscularly and fixed to the aponeurosis. The front sheets of the vagina of the rectus abdominis muscle are sutured. Control of abdominal pressure - 9 cm of water. The course of the postoperative period without features. Examined after 12, 24 months. There is no relapse, active body movements are not limited, no complaints.

Example 2. Patient K., 56 years old. Received complaints about the presence of a tumor-like formation in the area of the postoperative scar. At the operation, the size of the hernia gate is 20x12 cm. When reducing the edges of the hernia gate, the intra-abdominal pressure is 14 cm of the water column. The back sheet of the vagina of the rectus abdominis was opened. Reduction by the described method was performed, retromuscular plastic by mesh endoprosthesis with suturing of the front and rear sheets of the vagina of the rectus abdominis muscles. Control of abdominal pressure - 9 cm of water. The course of the postoperative period without features. Examined after 6, 12, 24 months. No relapse; no complaints.

Claims (1)

A method for the prevention of intra-abdominal hypertension in median ventral hernioplasty, including the isolation of a hernial sac, hernial collar, retro-muscular plastic of the anterior abdominal wall with an endoprosthesis, characterized in that after opening the posterior sheets of the vagina of the rectus abdominis muscles, clamps are applied to every 20-30 mm of the posterior sheath of the rectus sheath carry out their traction in the medial direction until the appearance of aponeurosis micro-ruptures in the region of the ends of the clips applied to the tissue, hold in this position and for at least four minutes, in the same way, the myofascial structures of the transverse muscle are redressed alternately on one side and on the other hand, then they perform the same traction of the anterior sheet of the rectus sheath, after the traction is performed, the posterior sheets of the rectus sheath are sutured, and the retromuscular plastic of the anterior abdominal wall is performed endoprosthesis and sutured the front sheets of the vagina.