RU2698415C2 - Method for reconstruction of combined iliac region defect - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely to surgery, and can be used for reconstruction of combined iliac defect. Framework of the abdominal wall is formed with a prolene-vicryl net. Prolene-vicryl mesh is screw-fixed in the wing of the ilium bone by means of three or more titanium anchor needles at distance of 2 cm from each other and from the edges of the operating defect.EFFECT: method enables effective elimination of extensive postoperative defects.1 cl, 2 dwg

Description

The invention relates to medicine, in particular to oncology, namely reconstructive surgery.

The desire to improve the radicalness of surgical treatment in oncology leads to an increase in the volume of surgical interventions, often combined with resection of adjacent organs and structures, and the achievement of adequate anatomical, functional and cosmetic results is possible only by using simultaneous or delayed reconstruction and plastic surgery. The term “plastic” summarizes the name of surgical methods for restoring the shape and (or) function of individual parts of the body by moving, transplanting and implanting biological tissues that replace them. Modern methods of plastic surgery based on microsurgical transplantation of multicomponent flaps and bioengineered complexes, in some cases allow adequate social and labor rehabilitation in the most complex group of patients.

The method of plasty with locally displaced flaps is used to restore a small organ or tissue defect in area using homogeneous tissues located near the defect. The excision of a tumor of the skin or soft tissues without causing a functional defect ends with the mobilization of the edges of the wound with cutting out of them triangular or trapezoidal flaps and sheltering the wound defect.

The implantation method is based on the use of various artificial materials based on metals, synthetic polymers, etc., from which various fragments of human tissues and organs are made that can replace their function. Using this method allows you to perform extensive resections and replace defects of large sizes.

In plastic surgery of defects located in the iliac region, a locally displaced flap is most often used, which does not always allow preserving the skeleton of the abdominal wall and preventing the formation of postoperative hernias.

The advantage of using proleno-vicryl mesh as a plastic material is the possibility of reconstructing a complex postoperative defect, thereby expanding the possibilities of organ-preserving treatment for both locally advanced and recurrent tumors located in the iliac region (Couto Netto at al., 2016).

However, in the case of combined resections of the abdominal wall with the ilium wing, when it is involved in the tumor process, restoration of the skeleton of the abdominal wall is extremely difficult. This is due to the complexity of fixing the prolene mesh to the ridge of the resected bone.

A known method for the reconstruction of an acetabulum defect (RU 2422109 C1). The acetabulum defect is covered with a biosynthetic non-absorbable mesh, the size of which corresponds to the area of the defect. A layer of bone cement is applied to the mesh, which, after hardening, is covered with a second layer of mesh. The edges of both layers of the mesh are hemmed to the edges of the acetabulum defect and cover the structure with the rectus abdominis muscle displaced from the lesion side by adapting it to the defect area.

However, the disadvantage of this method is the lack of the possibility of reliable fixation of the prolen-vicryl mesh to the bone, while in our original method the fixation is provided by anchor needles and ensures the greatest tightness of the operational defect.

The technical result of the claimed method is the development of an ileal plasty method, which improves the efficiency of elimination of extensive postoperative defects, including in cases where isolation of vital structures is necessary.

The main result achieved by using the proposed method is to increase the capabilities of the reconstructive component of surgical intervention and reduce the risk of forming a hernia of the abdominal wall.

The specified technical result in the implementation of the invention is achieved due to the fact that, as in the known method with plastic, a pro-vinyl-acrylic network, an abdominal wall frame is formed.

A feature of the proposed method lies in the fact that the pro-vicryl mesh is screw-shaped fixed in the iliac wing using three or more titanium anchor needles at a distance of 2 centimeters from each other and from the edges of the surgical defect.

Anchor needles are used in orthopedic practice to fix the ligamentous apparatus of the shoulder and knee joints and are made by ARTHREX from titanium alloy. The novelty of our method is the use of the above-described helical-shaped anchor needles, previously not used in such surgical interventions and allowing fixation of the prolen-vikrilnoy mesh in the ilium wing.

The invention is illustrated by a detailed description, clinical example and illustrations, which depict:

FIG. 1 - MRI of the pelvic organs, patient P.

FIG. 2 - plastic defect shelter with a prolen-vikrilnoy mesh, which is attached to the ilium with the help of three anchor needles, screw-shaped fixed in the iliac wing.

The method is as follows.

In the patient's position on the back with a roller placed under the operated buttock under intubation anesthesia in the iliac region, a longitudinal incision of the skin and subcutaneous tissue is made in the projection of the palpable formation. The edges of the wound are parted to the sides. Gradually, with the help of an electric knife, stepping back from the palpation of the edges of the tumor 2 cm begin to mobilize the tumor from the surrounding tissues. Enter the abdominal cavity. Using a bit, retreating 2 cm from the edge of the tumor, the iliac wing is resected. The drug is removed and sent to a planned morphological study.

Next, plastic defect is covered with a prolen-vikrilnoy mesh, which is attached to the ilium with the help of three anchor needles screw-shaped into the ilium wing (Fig. 2). Hemostasis. The wound is sutured in layers. An aseptic dressing is applied to the wound and one silicone drain is left on active aspiration.

Clinical implementation example.

Patient P., 34 years old, was undergoing treatment at the Department of Oncology Orthopedics of Moscow P.A. Herzen with a diagnosis of desmoid fibroma of the anterior abdominal wall on the right with spread to the wing of the right ilium. Condition after combined treatment in 2010 in Samara (Surgical treatment + RT SOD 46 Gy). Relapse of the disease. Condition after non-radical surgical treatment at the Moscow P.A. Herzen (06/29/17 Removing relapse of desmoid fibroma of the anterior abdominal wall with plastic composite mesh).

Considers herself a patient since 2010, when she independently discovered a tumor in the soft tissues of the anterior abdominal wall. At the place of residence in Samara, desmoid fibroma of the anterior abdominal wall was diagnosed, combined treatment was performed (surgical treatment with postoperative RT SOD 46 Gy), then the patient was left under dynamic observation. During the follow-up examination in April 2017: in the area of the postoperative scar in the projection of the internal oblique muscle of the abdomen to the right with spread to the suprapubic region, the formation of an irregular shape with clear contours, dimensions 85 * 77 mm, 90 mm high is determined. A similar formation is determined on the right in the area of the ilium wing, size 76 * 43 mm, height 80 mm. The patient was hospitalized in the thoracoabdominal ward for the implementation of the treatment plan. During the operation, an additional tumor component was discovered, horseshoe-shaped, covering the right wing of the ilium. A decision was made to separate the surgical stages. At the first stage, they decided to remove the relapse of the anterior abdominal wall. It was decided to consider the removal of the desmoid fibroma of the projection of the wing of the right ilium after rehabilitation of the patient.

MRI of the pelvic organs from 10.11.17. d. (Fig. 1): on the right, in the projection of the posterior superior contour of the iliac crest with spreading along the anterior contour of the transverse muscle into the right iliac region, a multinodular formation was detected with total dimensions of 55.3 × 97.1 mm in the maximum axial section. Additional formations similar in MP characteristics to the above were found in the region of the internal contour of the iliac wing on the right at the level of the superior spine and on the right in the region of the pubic region, in the surgical area. The dimensions of the formations are 16.1 × 17.3 mm and 6.4 × 8.5 mm.

The patient underwent surgical treatment: removal of a soft tissue tumor of the right iliac region with a resection of the right iliac bone with plastic prolene-vikrilovoy mesh with fixation to the ilium with anchor needles.

Operation protocol.

In the patient's position on the back with a roller placed under the right buttock under intubation anesthesia in the right iliac region, a longitudinal incision of the skin and subcutaneous tissue was made in the projection of the palpable formation. The edges of the wound are spread apart. Tumor visualized. Using the electric knife, step by step, departing from the palpation of the edges of the tumor 2 cm, the mobilization of the tumor from the surrounding tissues was started. Entered into the abdominal cavity. During the audit, the tumor mufto covers the wing of the right ilium. Using a chisel, 2 cm backward from the edge of the tumor, a resection of the wing of the right ilium was performed. The drug is removed and directed to a planned morphological study. Next, plastic defect was covered with a pro-vincrylic mesh. The mesh was attached to the ilium using three titanium anchor needles at a distance of 2 centimeters from each other and from the edges of the surgical defect (for example, ARTHREX) screw-shaped into the iliac wing (Fig. 2). Hemostasis. Layered suture of the wound. Aseptic dressing, iodine for wounds. Left 1 silicone drain on active suction.

The postoperative period was uneventful. Drainage was removed on the second day after surgery, the patient is activated on the third day. The wounds healed by first intention, the sutures were removed on the 14th day. During the follow-up examination after 3 and 6 months - data for progression were not obtained, the formation of a hernia of the abdominal wall was not noted.

The use of the proposed method in clinical practice makes it possible to increase the efficiency of eliminating extensive postoperative defects, including in cases where isolation of vital structures is necessary and to reduce the risk of formation of a hernia in the abdominal wall.

Claims (1)

A method for reconstructing a combined ileal defect, including the formation of an abdominal wall framework with a pro-ven-acrylic network, characterized in that the pro-ven-acrylic network is screw-shaped fixed to the iliac wing using three or more titanium anchor needles at a distance of 2 centimeters from each other and from the edges of the operating room defect.

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