RU2715095C1 - Method of surgical treatment of patients with large and giant ventral hernias - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgery, herniology. It is followed by hernioparotomy. Medial edges of sheath of both abdominal rectus muscles are dissected. Retro-muscular dissection of the abdominal rectus muscles is performed from a back plate of their vagina. Elongation of the layers of the anterior abdominal wall is created by mobilizing a posterior plate of the vagina of both rectus abdominis muscles by cutting the medial and posterolateral edges, layer-by-layer mobilization of external and internal mobilization of internal oblique muscle from transverse and external oblique muscles. Internal oblique muscle is dissected away from the vagina of the rectus muscle by the own aponeurosis. Internal oblique muscle is separated from the transverse and external oblique muscles. That is followed by creating a new line of internal oblique muscle attachment by free suture of the internal oblique muscle with the suture along the entire length.

EFFECT: method enables to restore layer-by-layer anatomical structure of the anterior abdominal wall with its own tissues without abdominal deformities, preserve and restore functions of all muscular structures of the abdominal wall.

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Description

The invention relates to medicine, specifically to surgery, herniology. It is intended for surgical treatment, and can be used for reconstruction of the anterior abdominal wall with large and giant hernias of the anterior abdominal wall.

A known method of surgical treatment of extensive defects of the anterior abdominal wall - Anterior Component separation technigue (technique of separation of the anterior components), developed by Ramirez O.M. (Ramirez OM, Ruas E, Dellon AL. “Components separation” method for closure of abdominal-wall defects: an anatomic and clinical study / Plast Reconstr Surg. 1990.-Sep; 86 (3): 519-26). Anterior separation plastic surgery of the anterior abdominal wall according to Ramirez O.M. carried out by herniolaparotomy, excision of the hernial sac, separation of subcutaneous fat from aponeurosis laterally 3-4 cm spigel line; then the dissection of the aponeurosis of the external oblique muscle of the abdomen, retreating 1-1.5 cm lateral to the spigel line, from the costal arch to the ilium; dissection of the external oblique muscle of the abdomen and its detachment from the internal oblique muscle of the abdomen.

However, the method has serious drawbacks that limit its use in reconstruction of the anterior abdominal wall, given its high morbidity and the predicted postoperative complications due to the extensive detachment of the skin-subcutaneous flap with impaired blood supply and innervation. Significant disadvantages are manifested in a large (up to 50-70% according to various sources) number of dangerous complications: skin necrosis, suppuration of a postoperative wound, and a long rehabilitation period.

A known method of Transversus Abdominis Release - the release of the transverse muscle of Novitsky (Novitsky Y.W. et al, 2012), related to the Posterior Component separation separation technigue - the technique of separation of the rear components (Novitsky Y.W., Elliott H.L., Orenstein S.B., Rosen M.J. 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 method consists in the fact that through the median laparotomy, the posterior sheet of the rectus sheath is dissected vertically 0.5-1.0 cm medially from its lateral edge. This is usually done at the navel level. The posterior muscular space opens at the level of the lunar line, visualizing the connection between the posterior and anterior aponeurosis leaves. Starting from the upper third of the abdominal cavity, approximately 0.5 cm medial to the junction of the anterior and posterior aponeurosis leaves, the posterior leaf is dissected to expose the transverse abdominal muscle. Then the muscle is divided along the entire medial edge using an electrocoagulator. This step begins with the upper third of the abdomen, where the medial fibers of the transverse abdominal muscle are most easily identified and separated from the fascia. This step allows you to penetrate into the space between the transverse fascia and the transverse abdominal muscle, which is in contact with the retroperitoneal space and, if necessary, can be expanded to the lumbar muscle. The retromuscular dissection plane can be enlarged in the cranial direction to the costal margins and dorsally to the sternum by separating the peritoneum / transverse fascia from the diaphragm. The underlying space in front of the bladder is opened to get to the pubic symphysis and both Cooper ligaments. Under the arcuate Douglas line, only the transverse fascia and peritoneum are defined. After a similar selection is done on both sides, the posterior leaf of the aponeurosis is sutured along the midline with a continuous suture. The mesh implant is placed Sublay in the retro-muscular space and secured with nodal, transabdominal sutures using a Reverdin needle. In addition, the lower edge of the mesh is attached to both Cooper ligaments using 2 to 4 single nodal joints. Suction drains are installed above the net. Then sutured the front sheet of the aponeurosis of the rectus abdominis muscle along the midline to restore the white line of the abdomen above the mesh.

The known method is selected by us as the closest analogue (prototype).

However, this method has serious drawbacks consisting in a * barrel-shaped * change in the shape of the anterior abdominal wall associated with intersection of the transverse abdominal muscle and loss of abdominal function, loss of stabilization of the spine.

The objective of the invention is to develop a method that allows to increase the efficiency of reconstruction of the anterior abdominal wall with extensive defects due to the layered separation of the muscle and aponeurotic layers of the anterior abdominal wall during surgical treatment of large and giant ventral, including postoperative hernias of the anterior abdominal wall (muscle-aponeurotic layer) without detachment of subcutaneous fat and skin with the creation of a new line of fixation of the internal oblique muscle of the abdomen.

 The technical result of the proposed method for surgical treatment of large and giant ventral hernias is the restoration of the layer-by-layer anatomical structure of the anterior abdominal wall with its own tissues without abdominal deformities, preservation and restoration of the function of all muscle structures of the abdominal wall.

The inventive method allows to prevent the formation of a "barrel-shaped" abdomen and loss of function of the transverse muscles in the form of unstable fixation of the spine due to the lack of intersection of the transverse muscle; the internal oblique muscle is cut off by its own aponeurosis from the vagina of the rectus muscle and is separated from the external oblique and transverse muscles, and the implant is laid on the inner layer retromuscularly. In order to prevent atrophy of the internal oblique muscle and preserve the function of the abdominal press and the shape of the abdomen, a new line of attachment of the internal oblique muscle is created by continuously fixing the free edge of the internal oblique muscle to the implant throughout. This preserves its function, prevents muscle atrophy, preserves the shape of the abdomen, abdominal function and stabilization of the spine.

The method of surgical treatment of large and giant ventral hernias, including hernia laparotomy, dissection of the medial edges of the vagina of the rectus abdominis muscles, retromuscular dissection of the rectus abdominis muscles from the posterior plate of their vagina, dissection of the walls of the vagina of the rectus abdominis muscles along the posterior lateral the line, the separation of the transverse muscle from the internal oblique muscle, mesh prosthesis implantation,

characterized in that it creates an extension of the layers of the anterior abdominal wall by mobilizing the posterior plate of the vagina of both rectus abdominis muscles by dissecting the medial and posterolateral edges, layer-by-layer mobilization of the external and internal mobilization of the internal oblique muscle from the transverse and external oblique muscles; the internal oblique muscle is cut off according to its own aponeurosis from the rectus sheath, the internal oblique muscle is separated from the transverse and external oblique muscles, then a new line of attachment of the internal oblique muscle is created by fixing the free edge of the internal oblique muscle to the implant by suture along the entire length.

 The invention is illustrated by illustrations.

 Figure 1 shows the beginning of the separation, where: 1 is the posterior plate of the vagina of the rectus abdominis muscle, 2 is the rectus abdominis muscle, 3 is the transverse abdominal muscle, 4 is the internal oblique muscle, 5 is the hernial sac, 6 is the external oblique muscle. The posterior plate of the rectus sheath vagina 1 is separated from the rectus abdominis muscle 2. The posterior lateral wall of the rectus sheath is dissected and the entrance between the transverse muscle 3 and the internal oblique muscle 4 is made.

 Figure 2 shows the separated internal oblique muscle 4 from the transverse abdominal muscle 3 and the created interfascial space. By increasing muscle distensibility, the volume of the abdominal cavity increases.

Figure 3 shows the crossed intrinsic aponeurosis of the internal oblique muscle 4 and the separated internal oblique muscle 4 from the external oblique muscle 6 and the transverse muscle 3. One edge of the internal oblique muscle lost its attachment site. Created interfascial spaces. By increasing muscle distensibility, the volume of the abdominal cavity increased.

Figure 4 shows how the muscles are separated, interfascial spaces are created, and an implant is installed, where: 2 - the rectus abdominis muscle, 3 - the transverse abdominal muscle, 4 - the internal oblique muscle, 6 - the external oblique muscle, 7 - the implant. An implant 7 is installed under the rectus, external and internal oblique muscles. The implant is fixed to the transverse muscle 3. The free edge of the internal oblique muscle 4 is fixed to the implant 7 to recreate the line of attachment.

Figure 5 shows how the free edge of the internal oblique muscle 4 is fixed to the implant 7, the internal oblique muscles are separated from the transverse and external oblique muscles throughout in interfascial space, without intersecting the transverse muscle. 8 - costal arch. Muscle function saved.

The method is carried out in the following way.

A patient with a large or giant ventral hernia is carried out:

- herniolaparotomy - opening of the abdominal cavity through the hernia gate with hernia repair,

- dissection of viscero-parietal adhesions,

- complete excision of the hernial sac,

- dissection of the medial edges of the vagina of both rectus abdominis muscles, retreating 0.5-1 cm lateral to its medial edge,

- retromuscular dissection of the rectus muscles from the posterior plate of the vagina of the rectus muscles up to its lateral edge;

- retreating 0.5 cm medial from the connection line of the anterior and posterior vaginal plates of the rectus muscle, dissection of the walls of the vagina of the rectus abdominis muscles along the posterior lateral line is performed to access the intermuscular space between the transverse and internal oblique muscles. This procedure is performed in the epigastric region, where it is easiest to identify the fibers of the medial edge of the transverse muscle (Figure 1). This stage differs from the prototype in which the transverse muscle is dissected to the transverse fascia and the transverse muscle is further separated from the transverse fascia + peritoneum complex,

- then the transverse muscle is separated from the internal oblique muscle throughout in the interfascial space, without crossing the transverse muscle. (Fig. 2)

- cutoff of the internal oblique muscle from the vagina of the rectus abdominis muscle is carried out according to its own aponeurosis of the internal oblique muscle,

- separation of the internal oblique muscle from the external oblique muscle throughout in interfascial space (Fig. 3),

- carrying out similar manipulations with muscle-aponeurotic structures on the other hand,

- the formation of the first (inner) layer of the closure of the defect of the anterior abdominal wall by continuous stitching of the posterior sheets of the vagina of the rectus abdominis muscles along the midline,

- laying the mesh implant on the inner layer, formed from sutured along the midline of the posterior sheets of the vagina of the rectus muscles and transverse muscles - retro-muscular sublay,

- the formation of the second (middle) layer of the closure of the defect of the anterior abdominal wall by fixing the mesh implant with separate sutures to the transverse muscle,

- fixation by a continuous suture of a non-absorbable thread of the free edge of the internal oblique muscle to the implant throughout is carried out by medialization of the free (cut off) edge of the internal oblique muscle, but with minimal tension, i.e. creates a new line of attachment of the internal oblique muscle, which preserves the functional consistency of the muscle, prevents its atrophy (Figure 4),

- installation of low vacuum drains in the lateral pockets between the external oblique muscle and the implant,

- the formation of the third (outer) layer of closing the defect of the anterior abdominal wall by stitching continuously the external plates of the vagina of the rectus abdominis muscles along the midline with the formation of the outer layer of the outer plates of the own aponeurosis of the rectus muscles, the rectus muscles themselves and the external oblique muscles with their own aponeurosis and cutaneous fat layer

- suturing of subcutaneous fat,

- suturing of the skin.

The layer-by-layer separation of the muscle and aponeurotic layers of the anterior abdominal wall is carried out from the medial line medially to the lumbar muscles laterally, from the costal arches and diaphragm cranially to the pubic joint and inguinal ligaments caudally, followed by layer-by-layer stitching along the midline and implantation of a mesh implant.

Clinical examples.

Example 1. Patient E., 65 years old. IB No. 17967. A working pensioner. Diagnosis: Giant recurrent postoperative ventral hernia MW4R2. A history of 3 operations: hysterectomy, then surgery for postoperative and then recurrent postoperative hernia. The formation of hernias within 1 year after surgery.

She was hospitalized in a planned manner in May 2016.

Operation - hernia repair with separation plastic according to the claimed method from reconstructions of the anterior abdominal wall with the location of the sub-lay mesh implant.

Intraoperatively: the size of the hernial sac is 35 * 42 cm, the defect in the muscle-aponerotic layer of the anterior abdominal wall is 30 * 30 cm (S-900 cm2) with the absence of most of the rectus abdominis muscles. Excision of the * old * implant. There is no increase in intra-abdominal pressure when suturing the abdominal cavity.

The postoperative period without complications. Low-vacuum drainage of the para-prosthetic and subcutaneous fat layer for 24 days. After removal of the drains, an ultrasound test was performed: with sulfur and no infiltrates. Wound healing by primary intention. Discharged in satisfactory condition. Control examination after 3, 6, 18 months - no relapse. Well-being and activity are good. Still working.

Example 2. Patient U., 62 years old. IB№2466. Senior citizen not working. Diagnosis: Giant recurrent postoperative ventral hernia MW4R2. A history of 3 operations: laparotomy for penetrating stab wounds of the abdominal cavity, then surgery for postoperative and then recurrent postoperative hernia. Formation of hernias within 6 months after surgery. Both herniotomy were complicated by suppuration of postoperative wounds. Smokes.

He was hospitalized in a planned manner in July 2017.

Operation - hernia repair with separation plastic according to the claimed method from reconstructions of the anterior abdominal wall with the location of the sub-lay mesh implant.

Intraoperatively: the size of the hernial sac is 30 * 35 cm, the defect in the muscular-aponerotic layer of the anterior abdominal wall is 20 * 20 cm (S-400 cm2). It required excision of the * old * implant with ligature fistulas. There is no increase in intra-abdominal pressure when suturing the abdominal cavity.

The postoperative period without complications. Low-vacuum drainage of the para-prosthetic and subcutaneous fat layer for 12 days. After removal of the drains, an ultrasound test was performed: with sulfur and no infiltrates. Wound healing by primary intention. Discharged in satisfactory condition. Control examination after 3, 6, 12 months - no relapse. Well-being and activity are good. Continues to smoke.

Thus:

- due to the separation of muscles in interfascial spaces and the intersection of the internal oblique muscle, the walls of the abdominal cavity are lengthened,

- lengthening the walls allows you to increase the volume of the abdominal cavity, which eliminates viscero-abdominal imbalance and freely immerse the contents of the hernial sac in the abdominal cavity without increasing intra-abdominal pressure, position the implant retro-muscular sublay,

- restore the anatomical and functional viability of the abdominal press,

- maintain the function of the internal oblique muscle by creating a new line of attachment,

- the proposed method of surgical treatment involves the reconstruction of the anterior abdominal wall with its own tissues and a mesh implant without increasing intra-abdominal pressure with large and giant ventral hernias.

Claims (3)

A method for the surgical treatment of patients with large and giant ventral hernias, including hernia, consisting in herniolaparotomy, dissection of the medial edges of the vagina of both rectus abdominis, retromuscular dissection of the rectus muscles from the posterior plate of the vagina of rectus abdominis, dissection of the walls of the vagina of rectus muscle abdomen along their posterolateral line, separation of the transverse muscle from the internal oblique muscle, implantation of a mesh prosthesis, characterized in that it creates an extension of the layers of the anterior abdominal wall by mobilizing the posterior plate of the vagina of both rectus abdominis muscles by dissecting the medial and posterolateral edges, layer-by-layer mobilization of the internal oblique muscle from the transverse and external oblique muscles;  the internal oblique muscle is cut off according to its own aponeurosis from the rectus sheath, the internal oblique muscle is separated from the transverse and external oblique muscles, then a new line of attachment of the internal oblique muscle is created by fixing the free edge of the internal oblique muscle to the implant by suture along the entire length.

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