RU2658161C1 - Method of surgical treatment of hernias in combination with abdominoplasty - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery. Conduct suturing of the medial edges of rectus abdominal muscles from the xiphoid process to the lower third of the hypogastric region. Hernial protrusion with hernial contents is immersed in the abdominal cavity. Mesh implant with the formation of a window under the umbilical stalk is placed on the aponeurosis in the zone of the umbilical ring, fixed with U-shaped seams from the nickel-titanium filament to the aponeurosis and in the umbilical cord transition zone into the aponeurosis of the rectus abdominis muscles. Dermalipectomy is performed to the level of the umbilicus excision. Perform the transposition of the navel.

EFFECT: method prevents postoperative complications and recurrence of a hernia; increases the effectiveness of hernioplasty in abdominoplasty, excludes dissection of musculo-aponeurotic structures of the anterior abdominal wall, and also allows to prevent complication and relapse of the disease by eliminating the muscular-aponeurotic defect, strengthen the anterior abdominal wall using a biocompatible nickel-titanium mesh implant, retain the umbilical ring, which is very important from an aesthetic point of view.

1 cl, 1 ex, 6 dwg

Description

The invention relates to medicine, namely to surgery, and can be used in herniology, plastic surgery.

A known method of simultaneous abdominoplasty and umbilical hernia repair, including hernioplasty, suturing of the medial edges of the rectus abdominis muscles with double thread PDS-2 with a thickness of USP 2 along the entire length and constriction of the umbilical ring trapezoidally with the small side up to 1.0 cm, and the larger side up to 2.5 cm with mandatory immersion of the hernial sac in the abdominal cavity, excision of skin-fat flaps of the anterior abdominal wall, drainage and suturing of the skin wound (RF application No. 2012152006, A61B 17/00, Bull. No. 16, 06/10/2014).

However, this method has disadvantages. Violation of the anatomical and functional state of the anterior abdominal wall leads to the need for simultaneous surgery: elimination of diastasis of the rectus abdominis muscles and hernial defect, followed by abdominoplasty. Diastasis of the rectus abdominis muscles is a hereditary predisposition to low collagen formation, leading to a violation of the muscular-aponeurotic structures of the anterior abdominal wall. (Leonov S.A. Private surgical aspects of abdominoplasty / S.A. Leonov // abstract for the degree. - Moscow, 2005). Thus, suturing the rectus abdominis muscle with a double thread of PDS-2 in the presence of diastasis in combination with a hernia of the white line, or with an umbilical hernia without plastic hernia defect of the anterior abdominal wall using an implant, can lead to relapse and the need for repeated surgery.

A known method of hernioplasty with lipoabdominoplasty with transposition of the umbilical cord for umbilical hernias, including suprapubic access, performing preperitoneal plastic of the hernia gate with a mesh implant while preserving perfusion from the perforating arteries of the rectus abdominis muscles, making a cruciate incision of the skin into the orthotic margin of the upper and left flanks along the navel dissection line, a suture going through the aponeurosis, creating a physiological depression, lateral skin triangles ovnogo flap excised and replaced sewn half of the navel (RF patent №2401073, A61B 17/00, Bull. №28, 10.10.2010 city).

The disadvantage of this method is the dissection of the aponeurosis of the rectus abdominis muscles and the violation of the anatomical structure due to the tension of the tissues of the anterior abdominal wall, which increases the risk of complications and relapses in the formation of a hernial defect, adhesions of the abdominal cavity when performing preperitoneal plastic hernia gate with a mesh implant (Deryugina M.S. Treatment of giant postoperative hernias / M.S. Deryugin // Surgery. - 2000. - No. 12. - P. 30-33). Although polypropylene or polytetrafluoroethylene implants used in herniology are chemically inert materials, they are devoid of biomechanical compatibility, (Zotov V.A., Clinical and morphological substantiation of the choice of implants in surgery of hernias of the anterior abdominal wall / V.A. Zotov, G.I. Veronsky , OV Vostrikov // Morphology and Surgery: Collection of Scientific Works. - Novosibirsk, 2000. - P. 88-91; Gunter, V.E. Properties of Mesh Titanium Nickelide Implants Used in Surgery / V.E. Gunter, A.A. Radkevich, I.I. Kuzmenko, G.Ts. Dambaev, V. A. Zotov // Biocompatible materials with shape memory and new technologies in medicine: Collection of scientific works, edited by professor V.E. Gunther. - Tomsk: IAP; NTL Publishing House 2004 - S. 276-277), thereby causing a pronounced inflammatory reaction of the surrounding body tissues during the replacement of defects, with the possible formation of seromas, abscesses, fistulas (Reparative desmogenesis in connective tissue defects after replacement with tissue implants made of titanium nickelide / A.A. Radkevich, N.A. Gorbunov, V.N. Khodorenko, D.M. Usoltsev // Implants with shape memory. - 2008 - No. 1. - S. 21-25). This method is taken as a prototype.

The objective of the proposed method is to increase the effectiveness of surgical treatment of hernias of the anterior abdominal wall in combination with abdominoplasty, preventing the development of complications and relapse of the disease.

The task is achieved due to the fact that they eliminate diastasis of the rectus abdominis muscles by suturing the fascial-muscular edge of the rectus muscle until they are completely touched by the PDS-2 thread, an implant based on titanium nickelide is installed on the muscle-aponeurotic layer, having previously formed a window in it according to the umbilical size legs, strengthen the suture line in the area of the white line of the abdomen and the umbilical ring, eliminate the hernial defect in the place of the umbilical ring, and fix with U-shaped seams around the perimeter to the aponeurosis and in the transition zone of the umbilical leg in the aponeurosis of the rectus abdominis muscles.

The method is as follows: perform a linear transverse cutaneous-subcutaneous incision between the anteroposterior spine of the ilium at the border of the hypogastric and pubic zones; detach the skin-subcutaneous flap in a blunt and sharp way to the level of the xiphoid process and costal arches above, laterally to the anterior axillary line on the right and left; the umbilical ring with a skin area rhomboid cut off from the skin of the anterior abdominal wall; diastasis of the rectus abdominis is eliminated by suturing the medial edges with a thread of PDS II - UPS2 from the xiphoid process to the lower third of the hypogastric region; hernial protrusion in the projection of the umbilical ring is immersed in the abdominal cavity; then a mesh implant made of nickel-titanium filament 60-90 μm thick, made in accordance with the configuration of the hernial defect and the hole for the umbilical leg, is fixed along the perimeter to the aponeurosis with U-shaped sutures, fixation in the zone of transition of the umbilical leg into the aponeurosis of the rectus abdominis with several seams with nickel-titanium thread 90-100 microns thick. Dermalipectomy is performed to the navel cut-off level, hypodermic sutures are applied. The navel is transposed by determining the projection on the skin of the anterior abdominal wall, dissection of the skin and the application of marginal skin sutures. The subcutaneous space is drained by suction drainage over the edge of the wound. Tissues of the anterior abdominal wall are sutured in layers.

Example 1

Patient N., 45 years old, was admitted with complaints of drooping abdominal skin. Diagnosis: Paraumbilical hernia. Diastasis of the rectus abdominis muscles. On examination: there is ptosis of the skin of the anterior abdominal wall, diastasis of the rectus abdominis muscles, hernial protrusion in the paraumbilical zone (Fig. 1). From the anamnesis it is known: the patient suffers from an umbilical hernia from birth, after the second birth the hernial defect in the umbilical ring has increased in size, diastasis of the rectus abdominis muscles has arisen. After repeated pregnancy, ptosis of the skin of the anterior abdominal wall appeared. Performed preoperative markup (Fig. 2).

Under intubation anesthesia, after processing the surgical field, a linear transverse cutaneous-subcutaneous incision was made between the anteroposterior iliac spines at the border of the hypogastric and pubic zones. A detachment of the skin-subcutaneous flap was performed in a blunt and sharp way to the level of the xiphoid process and costal arches at the top, laterally to the anterior axillary line on the right and left, the umbilical ring with a skin area was rhomboid cut off from the skin of the anterior abdominal wall. The medial edges of the rectus abdominis muscle are sutured together by applying muscle-aponeurotic sutures with a thread of PDS II - UPS2 from the xiphoid process to the lower third of the hypogastric region. A hernial protrusion in the navel is immersed in the abdominal cavity (Fig. 3). Then, a mesh implant made of nickel-titanium filament 60-90 μm thick, made in accordance with the configuration of the hernial defect and the hole for the umbilical leg, is fixed along the perimeter to the aponeurosis and in the region of the umbilical leg transition into the aponeurosis of the rectus muscles with a nickel-titanium thread 90-100 thick μm U-shaped seams (Fig. 4). Sutures were placed at a distance of 3 cm from each other (Fig. 5). Dermalectomy was performed to the level of navel excision, subcutaneous sutures were made. The navel was transposed by determining the projection on the skin of the anterior abdominal wall, dissection of the skin and the application of marginal skin sutures. The subcutaneous space is drained by suction drainage over the edge of the wound. Performed layer-by-layer suturing of the wounds of the anterior abdominal wall (Fig. 6).

The postoperative period was uneventful. Drainages removed after 24 hours. The patient was discharged from the hospital on the 3rd day in a satisfactory condition. When viewed after 1.5 years, no recurrence of the disease was noted, the function of the abdominal cavity and the anterior abdominal wall was not impaired.

The technical result of the proposed method is that the elimination of defects of the anterior abdominal wall in combination with abdominoplasty allows you to completely restore the anterior abdominal wall and prevent possible relapse of the disease in the future.

The advantages of the proposed method are that the dissection of the aponeurosis of the rectus abdominis is not performed, thereby their anatomical structure is not violated, the mesh nickel-titanium implant used as a plastic material for the reconstruction of diastasis of the rectus abdominis and hernial defects provides in shape, size and elasticity durable and reliable closure of the defect while maintaining the biomechanical properties of the anterior abdominal wall, thereby preventing the possibility of relapse of the disease. The proposed method of hernioplasty with abdominoplasty allows with a high degree of efficiency to fully replace defects in the tissues of the anterior abdominal wall. Due to superelasticity, biochemical and biomechanical compatibility of titanium nickelide with body tissues, the connective tissue from the side of the recipient zone grows through the implant structure, forming a connective tissue regenerate with the material, which ensures complete replacement of the defect tissue of the anterior abdominal wall. Cross dense disordered laying of the thread, placed in a mesh structure, allows you to give the structure elastic properties that are as close as possible to the features of the anterior abdominal wall. The mesh size of the cells ensures the preservation of a given implant shape and retention of tissue fluid.

The proposed method was carried out on 19 patients. When viewed for three or more years after surgery, there was no relapse of the disease, functional disorders of the anterior abdominal wall were not detected. The method is recommended for practical use.

Claims (1)

A method of surgical treatment of hernias in combination with abdominoplasty, including abdominoplasty, elimination of diastasis of the abdominal muscles, umbilical hernia repair, characterized in that the umbilical ring with a rhomboid section of the skin is cut off from the skin, the medial edges of the rectus abdominis are sutured from the xiphoid process to the lower third of the hypogastric region , hernial protrusion in the projection of the umbilical ring is immersed in the abdominal cavity, a mesh implant made of nickel-titanium thread in accordance with the configuration of the hernial The project and the hole for the umbilical leg are fixed along the perimeter to the aponeurosis with U-shaped sutures and nickel-titanium filament in the zone of transition of the umbilical leg into the aponeurosis of the rectus muscles, a dermalectectomy is performed to the navel cut-off level, subcutaneous sutures are applied, the projection of the navel on the skin of the anterior abdominal wall is applied, carry out the transposition of the navel into the skin incision, impose marginal skin sutures.

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