RU2645610C1 - Method for laparoscopic ventral hernia repair - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgical methods for treating patients with ventral hernias. Introduce trocar in the left hypochondrium and on the left side of the abdominal wall. Conduct pneumoperitoneum, overview laparoscopy, dissection of adhesions, determination of the size of the hernial gates, implantation and fixation of the mesh on the abdominal wall with a hernia gate closure 3-5 cm. After dissection, the adhesions are transposed into the abdominal cavity of the hernial sac until its cavity is eliminated. Then peritoneal tissues of hernial sac are fixed along the part or along the perimeter of the hernial gates, and the mesh is additionally fixed to the peritoneum of the hernial sac.

EFFECT: method reduces postoperative complications, prevents the formation of sulfur.

1 cl, 2 ex, 5 dwg

Description

The invention relates to medicine, namely to surgical methods for treating patients with ventral hernias.

A known method of laparoscopic hernioplasty of umbilical hernias and hernias of the white line of the abdomen (RF Patent No. 2326581, IPC АВВ 1/313, A61N 5/067, publ. 2008), including cutting a U-shaped flap of the peritoneum in the area of the hernial defect with the base facing the head the patient; separating it from the aponeurosis together with the hernial sac using high-intensity laser radiation contact. Coagulation of bleeding vessels. Suturing of an aponeurosis defect. Placing a mesh prosthesis between the aponeurosis and the peritoneum, followed by fixation and suturing of the defect of the peritoneum and skin using endoscopic sutures using intracorporeal endoscopic nodes. During the operation, three trocars are introduced.

The disadvantage of this method is the difficulty of its implementation due to the use of endoscopic sutures using intracorporeal endoscopic nodes, as well as a high risk of seroma in the hernial sac.

A known method of hernioplasty (RF Patent No. 2226992, IPC АВВ 17/00, publ. 2004), including suturing of the hernia gate with percutaneous interrupted suture sutures, ligature with a needle, inserted along the edge of the hernial defect into the abdominal cavity and re-piercing the opposite edge defect, and the withdrawal of the ligature outward under the control of a laparoscope. In addition, an instrumental trocar is introduced through a puncture at a distance of 10-20 cm from the edge of the hernial portal from the same side with respect to the hernial defect as the laparoscope. The end of the ligature is fed into the abdominal cavity through a hollow straight needle and is held with endo-clamp fed through the instrumental trocar, the distal end of the needle is removed into the subcutaneous tissue, the needle is inserted through the subcutaneous tissue, bypassing the hernial sac, and the wire loop is inserted into the opposite edge of the hernia gate, and the wire loop is inserted into the needle , the end of the ligature, held by the end clamp, is fed into the loop and the loop with the ligature is removed, the needle is removed.

The disadvantage of this method is that the edges of the aponeurosis are reduced with tension, which can lead to a hernia recurrence.

The closest is the method of laparoscopic plastic surgery of ventral hernias (The author's method of treatment of ventral hernias by the laparoscopic method. K.V. Puchkova, http://www.puchkovk.ru/obschaya-hirurgiya/posleoperatsionnye-gryzhi/avtorskaya-metodika-lecheniya/), including the introduction of trocars into the left hypochondrium and on the left side of the abdominal wall, pneumoperitoneum, survey laparoscopy, determination of the size of the hernia gate and dissection of adhesions, implantation and fixation of the mesh on the abdominal wall with an overlap of the hernia gate by 3-5 cm.

The disadvantage of this method is the high risk of seroma formation in the hernial sac, as well as the risk of hernial pseudo-relapse, in which the abdominal wall tissue is protruded outward along with the mesh.

The task of the invention is to remedy these disadvantages, increase the effectiveness of treatment, reduce the likelihood of postoperative complications, prevent the formation of seroma.

To solve the problem with laparoscopic plastic surgery of ventral hernias, including the introduction of trocars into the left hypochondrium and on the left side of the abdominal wall, pneumoperitoneum, laparoscopy, dissection of adhesions, determination of the size of hernial gates, implantation and fixation of the mesh on the abdominal wall with an overlap of the hernia gate by 3- 5 cm, it is proposed after dissection of adhesions to transpose into the abdominal cavity of the hernial sac until its cavity is eliminated. Then, it is recommended that the tissues of the peritoneum of the hernial sac be fixed along part or all of the perimeter of the hernial portal, and the mesh should be additionally fixed to the peritoneum of the hernial sac.

The fact that before the fixation of the graft, the peritoneum of the hernial sac is fixed to the unchanged abdominal wall, eliminates the hernial cavity, thereby eliminating the possibility of seroma formation in the postoperative period, and eliminating the recurrence of hernia.

The invention is illustrated by the operation diagram shown in the photo. In FIG. 1 - visualization of a hernial defect; in FIG. 2 - removal of the peritoneum from the hernial sac; in FIG. 3 - fixation of the peritoneum of the hernial sac to part of the abdominal wall with a herniostapler; in FIG. 4 - view of the abdominal wall after the elimination of the hernia; in FIG. 5 is a view of the abdominal wall after fixing the mesh.

The method is as follows.

Under endotracheal anesthesia, a 10 mm trocar is placed under the left costal arch using the open method or the Veress needle, pneumoperitoneum is formed, and then the abdominal cavity is revised. In the left lateral region of the abdomen, an additional 1-2 trocars are installed, more if necessary. Dissections of adhesions are carried out using scissors or the Harmonic electrosurgical scalpel, a hernial defect is visualized. The clamp captures the peritoneum of the hernial sac and performs its transposition into the abdominal cavity with subsequent fixation along the entire perimeter or part of the hernial portal until the hernial cavity is eliminated. In cases where the volume of the peritoneum of the hernial sac is sufficient, fixation is performed along the entire perimeter, with a deficiency and large size of the hernial defect - its part until the hernia cavity is eliminated.

A mesh with a release coating is selected so that it overlaps the edges of the hernia gate by 3-5 cm, stitched with monofilament absorbable ligatures 15-20 cm long from 4 sides at the edges so that the edges of the ligatures exit the mesh from the side opposite to the release coating them.

Then, with the help of an endoscopic clamp, having previously rolled the transplant around, enter it through a 10 mm trocar into the abdominal cavity, and deploy it there. The next stage, using a needle for suturing trocar wounds, passes through the abdominal wall and grabs the ligatures step by step, leads to the front abdominal wall in those places so that the graft is placed on the abdominal wall with a 3-5 cm overlap of the hernial defect. ligatures, carrying out its preliminary fixation to the abdominal wall. Then carry out the final fixation of the mesh with herniostapler absorbable or titanium clips. First, the mesh is fixed from the installation side of the trocars, then from the opposite side. With a transplant size of 15 × 20 cm, 25-30 staples are used, placing them, for example, in a checkerboard pattern, making sure that the mesh does not sag, but is tightly fixed to the peritoneum of the hernial sac and the abdominal wall without space between them and the mesh.

Control hemostasis, gas and instruments are removed. Heal the wounds.

Example 1

A 66-year-old patient P. was admitted to the surgical department of the FNCC FMBA with a diagnosis of postoperative ventral hernia M3W1. A history of umbilical hernia surgery.

The operation is performed - laparoscopic plastic surgery of the anterior abdominal wall according to the proposed method.

Under general anesthesia, a 10 mm trocar is installed in the left hypochondrium, and a 5 mm trocar is located on the left side of the abdominal wall. A hernia defect of 5.5 cm in size was visualized, in which a lock of a large omentum was fixed.

During the operation according to the proposed method, a composite polypropylene graft was fixed to the abdominal wall and hernial sac tissue - mesh size 15 × 20 cm. During the operation, the peritoneal tissue of the hernial sac was fixed to the part of the perimeter of the base of the hernial sac.

During the postoperative period without complications, the patient was discharged from the hospital on the 2nd day after surgery in a satisfactory condition.

Example 2

Patient A., aged 36, was admitted to the surgical department with a diagnosis of correctable umbilical hernia M3W1. The operation is performed - laparoscopic plastic surgery of the anterior abdominal wall according to the proposed method. Under general anesthesia, a 10 mm trocar is installed in the left hypochondrium, and a 5 mm trocar in the left lateral region. A hernial defect of 5 cm in diameter was visualized. The peritoneum from the hernial defect is fixed around the perimeter of the hernial portal with a herniostapler, thereby eliminating the hernial cavity, then a composite polypropylene graft of 15 × 20 cm is fixed to the abdominal wall.

According to this method, 5 patients with ventral hernias were operated on; there were no complications associated with the use of this method.

The application of the proposed method allowed to increase the effectiveness of treatment of patients with ventral hernias by preventing the formation of seromas in the postoperative period, to reduce the likelihood of postoperative complications, hernia recurrence.

Claims (1)

The method of laparoscopic plastic surgery of ventral hernias, including the introduction of trocars into the left hypochondrium and on the left side of the abdominal wall, pneumoperitoneum, laparoscopy, dissection of adhesions, determination of the size of the hernia gate, implantation and fixation of the mesh on the abdominal wall with an overlap of the hernia gate by 3-5 cm, different the fact that after determining the size of the hernial portal, the transposition into the abdominal cavity of the hernial sac is carried out until its cavity is eliminated, then the peritoneal tissue of the hernial sac is fixed along part or all of the the diameter of the base of the hernial sac, and the mesh is additionally fixed to the peritoneum of the hernial sac.

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