RU2716620C1 - Method for prevention of postoperative ventral hernias after medial laparotomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to abdominal surgery. Operating access marking is performed on the operating table. Median laparotomy is performed with incision of umbilicus and umbilical ring along marking line. "Sutures-beacons" are applied on the edges of the aponeurosis on each side of the dissected umbilical ring. After the main stage, operations are performed to layer wound closing. Before suturing the peritoneum, "sutures-holders" are applied on both sides of the wound aponeurotic angles. In paraumbilical region "sutures-beacons" are replaced with "suture-holder". Peritoneum closure is performed with traction upwards by "sutures-holders". Aponeurosis is closed on the same principle. Hemostasis is monitored. Subcutaneous fat is closed with interrupted sutures. Skin is closed.

EFFECT: method enables preventing the formation of postoperative ventral hernias, forming a low-traumatic approach, excluding opening and injuring a rectus muscle and its vagina; to create symmetrical edges of skin and aponeurosis at umbilical ring level with observing principle of homogeneous tissues suturing; evenly distribute load over entire length of seam; preserve umbilical area aponeurosis blood supply; eliminating weak areas of aponeurosis with umbilical ring closure; reducing laparotomy and wound closing time; enhance cosmetic effect.

1 cl, 3 dwg, 1 ex

Description

The invention relates to medicine, namely to abdominal surgery, gynecology, proctology, oncology and can be used in surgical treatment of patients with diseases localized in the abdominal cavity and retroperitoneal space, both in patients with planned and emergency pathology in general surgical and oncological hospitals.

Traditionally, laparotomy means prompt access to the abdominal organs, carried out by layerwise dissection of the abdominal wall and opening the abdominal cavity. (Topographic anatomy and operative surgery: textbook / I.I. Kagan, S.V. Chemezov. - M.: GEOTAR-Media, 2011. P. 551-552) A lot of laparotomic accesses have been proposed for abdominal operations, which can classify along the section direction as longitudinal, transverse, oblique and combined (angular) (ImreLittmann, Abdominal Surgery. M: fourth edition, Hungarian Academy of Sciences Publishing House, 1970, pp. 22-37). Of the longitudinal laparotomic accesses, median laparotomy is most common. The incision is carried out along the white line of the abdomen with a bypass of the umbilical ring on the left. (Nikolaev A.V., Topographic anatomy and operative surgery: a textbook. M.: 3rd edition, revised as amended, GEOTAR-Media Publishing House - 2016 S. 439-450). Obviously, this access has several advantages: technical simplicity, convenience and speed of execution. Median laparotomy makes it possible to freely approach almost any organ of the abdominal cavity and retroperitoneal space without crossing the muscles, large vessels and nerves of the abdominal wall. The cut itself can be extended up or down if necessary to expand access. (Big Medical Encyclopedia / Ch. Ed. A.N. Bakulev. - 2nd ed. - M.: Soviet Encyclopedia, 1960. - T. 15. S. 235-251).

In traditional median laparotomy, the umbilical ring is bypassed on the left to prevent injury to the round ligament of the liver, which goes to the visceral surface of the liver to the right of the umbilical ring and is an obliterated umbilical vein. (Laparotomy and the layered structure of the anterior abdominal wall / N.S. Gorbunov, I.V. Kirgizov, P.A. Samotesov; Ministry of Health of the Russian Federation [and others]. - Krasnoyarsk: CLARETIANUM, 2002. - S. 47-48, 68-69.).

However, the risk of injury to these structures has lost its importance thanks to modern methods of hemostasis (Pantelic M., Ljikar J., Devecerski G., Karadzic J. .. Energysystemsinsurgery. MedPregl. 2015 Nov-Dec; 68 (11-12): 394-9.) .

Currently, median laparotomy with a bypass of the umbilical ring is considered optimal access during abdominal operations.

However, in the available descriptions of the technique for conducting median laparotomy there is no unequivocal indication of the method of suturing tissues (layering, direction, type of suture, step between sutures and distance from injection to the edge, suture material). At the same time, diametrically opposed opinions are encountered regarding a continuous or interrupted suture, suture material and other aspects. (Patel SV, Paskar DD, Nelson RL, Vedula SS, Steele SR. Closure methods for laparotomy incisions for preventing incisional hernias and other wound complications. Cochrane Database of Systematic Reviews 2017, Issue 11. Art. No .: CD005661. DOI: 10.1002 /14651858.CD005661.pub2.).

One of the late complications of median laparotomy is postoperative ventral hernia. The incidence of postoperative ventral hernias after median laparotomy reaches 28.3%, despite various methods of preventing their formation. They consist in stimulating the regenerative processes of the connective tissue of the suture line, strengthening the area of the surgical wound with local tissues, creating duplicates to ensure tissue strength, using mesh implants during wound closure, prevention of suppuration of postoperative wounds, etc. (Fedosev A.V., Muravyov S.Yu., Budarev V.N., Inyutin A.S., Zatsarinny V.V. / Morphological and functional characteristics of the white line of the abdomen from the position of a herniologist // Young Science - Eruditio Juvenium.- 2015 - No. 4- S.73-81.). Most of the listed methods of prevention require significant financial costs, special material and technical support, which complicates their application.

With all the advantages of traditional median access, it has several disadvantages associated with the technique of the operation and the possible development of complications from the wound, leading to the formation of postoperative ventral hernias. (Belokonev V.I., Fedorina T.A., Kovaleva Z.A., Pushkin S.Yu., Nagapetyan S.Yu., Supilnikov A.A. / Pathogenesis and surgical treatment of postoperative ventral hernias. Samara: GP Prospect. 2005; S. 30-61). The following factors contribute to the occurrence of postoperative ventral hernias:

1) Access bypassing the umbilical ring entails opening the front and back sheets of the vagina of the rectus abdominis muscle with frequent damage to the muscle itself and an increased risk of developing wound complications with the formation of postoperative hernias.

2) The formation of asymmetric edges of the skin and aponeurosis at the level of the umbilical ring makes it difficult to clearly differentiate the anatomical structures when suturing the wound. The asymmetry of tissues is aggravated by the use of retractors, unevenly stretching the wound. This ultimately can lead to improper consolidation of the edges of the wound and failure to comply with the principle of stitching homogeneous tissues. As a result, the formation of an inferior scar is possible, which increases the risk of developing postoperative ventral hernias.

3) The use of an arcuate incision to the left of the umbilical ring creates conditions for uneven loading on the seam line. In FIG. 1 illustrates a median laparotomy with a bypass of the umbilical ring on the left,

Where

1 umbilical ring;

2-arc incision;

3-seams transition zone;

4 muscle traction.

As can be seen from figure 1, the arcuate incision (2) to the left of the umbilical ring (1) creates conditions for an uneven load on the suture line in the umbilical region due to muscle traction (4) of the anterior abdominal wall. At the same time, the seams of the transition zone (3) of the arc-shaped section into the linear one experience the greatest load. Uneven loading leads to eruption and inconsistency of the suture line, which entails the formation of postoperative ventral hernias.

4) The use of an arcuate incision with its subsequent suturing contributes to the deterioration of the blood supply to the area of the right leaf of the aponeurosis located between the umbilical ring and the incision line. This, in turn, can be one of the main factors in the development of postoperative ventral hernias.

5) A paraumbilical arcuate incision in the umbilical ring region leads to the formation of weak spots in the aponeurosis and the possible development of hernial defects. (Fedosev A.V., Muravyov S.Yu., Budarev V.N., Inyutin A.S., Zatsarinny V.V. / Morphological and functional characteristics of the white line of the abdomen from the position of a herniologist // Young Science - EruditioJuvenium.- 2015 - No. 4- P.73-81).

In addition to hernia factors, the disadvantages of the median laparotomy with the bypass of the umbilical ring on the left are:

6) Increase in the total time for access and suturing of the wound due to the need to perform an arcuate incision in the umbilical region.

7) Scar formation in the umbilical region with a low aesthetic result.

Actual in our opinion is the improvement of the technique of median laparotomy and wound closure, taking into account the identified deficiencies.

In order to prevent the formation of postoperative ventral hernias of the anterior abdominal wall, we have for the first time proposed a method of median laparotomy with dissection of the umbilical ring and suturing of the wound with an exact comparison of tissues of opposite anatomical structures.

The progress of the operation is illustrated in FIG. 2

Where:

1 umbilical ring;

5-leather;

6-subcutaneous fat;

7-aponeurosis;

8-peritoneum;

9- "seams-beacons";

10- “seams-holders”.

The method is as follows:

Prior to the planned laparotomy, the umbilical ring area is sanitized with hygienic detergents and antiseptics (using soap, cleaning with a tuffer moistened with chlorhexidine solution for external use 0.05%) to mechanically clean and reduce the microbial number of the navel zone.

On the operating table, the surgical field is marked with a surgical marker using a ruler from the xiphoid process to the bosom. Due to the often existing scoliosis in patients, the marking is carried out in two stages - from the xiphoid process to the navel and from the navel to the womb. This avoids lateral displacement of the skin incision relative to the white line of the abdomen.

After processing the surgical field with antiseptic solutions, a median laparotomy is performed with the umbilical ring dissected along the marking line. The dissection of the skin (5) is carried out in the direction from the epigastric (epigastric) region to the navel and from the navel in the direction of the hypogastric (suprapubic) region, for example, with a disposable abdominal scalpel. Then the navel and the umbilical ring (1) are dissected. The surgeon and assistant with two tweezers stretch the skin of the umbilical region in the transverse direction. This manipulation avoids the displacement of the incision from the white line of the abdomen and eliminates injury to the vagina of the rectus muscle, and also facilitates the dissection of the dense tissue of the navel. Next, an electrosurgical monopolar knife is used for the purpose of hemostasis and precision dissection of tissues. The next stage is dissected subcutaneous fat (6) to the white line of the abdomen with the preparation of the latter from subcutaneous tissue up to 5 mm wide. The navel is dissected in layers: skin, scar tissue, transverse fascia, peritoneum. If bleeding from the umbilical vein occurs, it is ligated or coagulated. Entrance to the abdominal cavity is performed just above the navel level using standard safety principles (visual control, opening the peritoneum into the lumen, etc.). The peritoneum (8) is dissected using a monopolar electric knife. A digital audit of the parietal peritoneum of this area is performed to exclude the presence of fixed organs. Suture beacons (9) are placed on the edges of the aponeurosis (7) on each side in the middle of the semicircle of the dissected umbilical ring (1) with an umbilical ring diameter of up to 8 mm. The number of “beacon seams” depends on the size of the umbilical ring. As can be seen from FIG. 3 with an umbilical ring size (1) of more than 8 mm, we additionally impose 2 pairs of “beacon seams” (9) on the aponeurosis (7) in the region of the umbilical ring (1). An additional overlay of “beacon seams” is determined by the step performed between the nodal seams of the aponeurosis equal to 5-8 mm. So, for example, with a umbilical ring diameter of more than 8 mm, the length of the semicircle will be more than 12 mm, which requires suturing of the umbilical ring with additional ligatures in order to comply with the selected step. These sutures are used to indicate opposite anatomical structures for further accurate matching of tissues in the umbilical ring. Often when performing the main stage of operations, it becomes necessary to install a retractor (such as Seagal) for better visualization of one or another organ. This leads to asymmetric traction by hooks of the contralateral sides of the abdominal wall. There is an asymmetric extension of the tissues of the anterior abdominal wall from two sides. In this regard, the correct consolidation of umbilical tissue for the prevention of postoperative ventral hernias is important. This is achieved through the use of "beacon seams" on both sides.

After the main stage of the operation, they begin to layered wound closure. In doing so, adhere to the following principles. Before suturing the peritoneum, a “suture-holder” (10) is applied to each aponeurotic angle, capturing both edges of the wound, which are taken into the clamps. One “suture-holder” is located in the epigastric region, the second in the hypogastric region. “Suture-holders” (10) are applied only to the tissue of the aponeurosis (7), since the strength of the aponeurotic tissue due to the presence of collagen and elastic fibers allows traction of sufficient strength for these sutures without the risk of eruption. In the umbilical region, “suture-beacons” (9) is replaced by a “suture-holder” (10), combining the edges of the aponeurosis (7) of the dissected umbilical ring (1). Suturing of the peritoneum is carried out in two stages. At the first stage, the peritoneum is sutured in the direction from the epigastrium to the umbilical ring with simultaneous traction upwards for the “suture-holders” located in the epigastric and umbilical regions. In the second stage, the peritoneum is sutured in the direction from the pubic joint to the umbilical ring with simultaneous traction for the “suture-holders” located in the hypogastric and umbilical regions. In this case, the transverse fascia and the parietal peritoneum below the douglas line are captured in one suture due to the absence of a posterior leaf of the vagina of the rectus abdominis muscle. Suturing of the aponeurosis is carried out according to the same principle with traction for the corresponding "suture-holders". This technique allows the peritoneum to be sutured without the risk of suturing the internal organs and more accurately match the edges of the aponeurosis due to the linear extension of the wound. The peritoneum is sutured, for example, with a round needle with non-absorbable synthetic threads of metric size 3 (0.300-0.339 mm) with interrupted sutures. The aponeurosis is sutured with round needles with non-absorbable synthetic threads of metric size 4 (0.400-0.499 mm) with interrupted sutures. The step between the seams is 5-8 mm, the indentation is from the edge of the aponeurosis 5-8 mm. The last to tie all the “stitches-holders”, previously imposed in the epigastric, umbilical and hypogastric areas. Control hemostasis. Subcutaneous tissue is sutured with interrupted sutures. Suturing of the skin is done, for example, with non-absorbable sutures of metric size 3 (0.300-0.339 mm) or a skin stapler according to standard principles. In the prevention of postoperative ventral hernias, the combination of the technique for accessing and suturing the median laparotomy is important. When making access with dissection of the umbilical ring, strict adherence to the sequence of actions of suturing a laparotomy wound is of great importance.

In the period from October 2016 to October 2017, at the Department of Faculty Surgery and Oncology, Saratov State Medical University named after IN AND. Razumovsky was analyzed 57 patients operated on from mid-access using the proposed method for the prevention of postoperative ventral hernias. Patients were observed for up to 36 months. Control inspection was carried out in 1,3,6,9,12,24,36 month after the operation. To identify hernial defects, anamnestic data and complaints were collected, the patient's current condition was assessed, a physical examination was performed with palpation and percussion of the postoperative scar zone. If abdominal wall defects were suspected, an ultrasound scan of the anterior abdominal wall was performed. In complex cases, CT of the anterior abdominal wall was performed. The occurrence of postoperative ventral hernia was recorded in 2 cases (3.5%), while hernial defects did not exceed 3 cm in diameter and were localized in the epigastric region. It should be noted that both patients had grade III obesity (BMI of more than 30%).

Example. Patient K., 61 years old, was admitted to the proctology department of the Clinical Hospital named after Mirotoretseva S. R. with a diagnosis of Cancer of the hepatic bend of the colon T ₃ N ₀ M ₀ . Surgical intervention: right-sided hemicolectomy, total mesocolonectomy with central vascular ligation, drainage of the abdominal cavity.

Prior to the planned laparotomy, the umbilical ring was sanitized with hygienic detergents and antiseptics (using soap, cleaning with a tuffer dipped in a chlorhexidine solution for external use 0.05%).

The operation was performed under general anesthesia. The patient was supine. After the patient was placed on the operating table and the general anesthesia began, markings were applied to the skin with a surgical marker using a ruler from the xiphoid process to the womb. The marking was carried out in two stages - from the xiphoid process to the umbilical ring and from the umbilical ring to the bosom. After processing the surgical field with antiseptic solutions, a median laparotomy was performed with the umbilical ring dissected along the marking line. In this case, skin dissection was performed with a disposable abdominal scalpel in the direction from the epigastric (epigastric) region to the umbilical ring and from the umbilical ring in the direction of the hypogastric (suprapubic) region. Then the navel and the umbilical ring were dissected. The surgeon and assistant with two tweezers stretched the skin of the umbilical region in the transverse direction. Then, an electrosurgical monopolar knife was used for hemostasis and precision dissection of tissues. The next step was dissected subcutaneous fat to the white line of the abdomen with the preparation of the latter from subcutaneous tissue up to 5 mm wide. The navel was dissected in layers: skin, scar tissue, transverse fascia, peritoneum. Entrance to the abdominal cavity was performed just above the umbilical ring using standard safety principles (visual inspection, opening the peritoneum into the lumen, etc.). The peritoneum was dissected using a monopolar electric knife. A finger revision of the parietal peritoneum was performed. They placed “seams-beacons” on the edges of the aponeurosis on each side in the middle of the semicircle of the dissected umbilical ring. The umbilical ring in this case was less than 8 mm. Installed a retractor type Seagal. The main stage of the operation was performed: right-sided hemicolectomy, total mesocolonectomy with central vascular ligation. Then proceeded to layered wound closure. At the same time, before suturing the peritoneum, each aponeurotic angle was stitched with a “suture-holder” capturing both edges of the wound. One “suture-holder” was located in the epigastric region, the other in the hypogastric region. In the umbilical region, “suture-beacons” was replaced by a “suture-holder” combining the edges of the aponeurosis of the dissected umbilical ring. All “suture-holders” were applied with a round needle with non-absorbable synthetic thread of metric size 4 (0.400-0.499 mm), taking them in the clamps. The peritoneum was sutured in two stages. First, the peritoneum was sutured in the direction from the epigastrium to the umbilical ring with simultaneous traction upwards behind the “suture-holders” of the epigastric and umbilical regions. Then, in the direction from the pubic joint to the umbilical ring with simultaneous traction for the “suture-holders” located in the hypogastric and umbilical regions. The transverse fascia and parietal peritoneum below the douglas line were sutured, capturing in one seam. The peritoneum was sutured with a round needle with non-absorbable synthetic threads of metric size 3 (0.300-0.339 mm) with interrupted sutures. The aponeurosis was sutured according to the same principle with traction for the corresponding “suture-holders”. Used round needles with non-absorbable synthetic threads of metric size 4 (0.400-0.499 mm) nodal joints. The step between the seams is 5-8 mm, the indentation is from the edge of the aponeurosis 5-8 mm. Thanks to the use of “suture-holders”, hemming of the internal organs was excluded, the edges of the wound were more precisely matched, and an even, straight-line suture was formed. The last to be tied are the “suture-holders”, which were previously applied in the epigastric, umbilical and hypogastric regions. Control of hemostasis. Suture of subcutaneous tissue with interrupted sutures. The skin was sutured using a skin stapler according to standard principles. The patient was discharged on the 8th day after surgery in a satisfactory condition. The brackets were removed on an outpatient basis on the 10th day. Postoperative wound without signs of inflammation, healed by primary intention. After 36 months of observation of hernial defects was not detected.

As can be seen from the description and the above example, the proposed method has the following advantages:

1. When an incision is made through the umbilical ring, less traumatic access is formed along the white line of the abdomen, excluding the opening of the vagina of the rectus abdominis muscle and damage to the muscle itself. The decrease in the traumatic injury to the umbilical region is due to the fact that the involvement of the subcutaneous fat, the vagina of the left rectus abdominis muscle and the rectus muscle itself in the subcutaneous fat incision is excluded, and thereby reduces the likelihood of wound complications and hernia formation.

2. The negative consequences of the arcuate incision are leveled: symmetrical edges of the skin, aponeurosis at the level of the umbilical ring are formed. This contributes to good visualization and comparison of homogeneous anatomical structures when suturing the wound. An exact comparison of the edges of the wound is achieved through the imposition of "seams, beacons" and "seams, holders." Compliance with the principle of stitching homogeneous tissues reduces the likelihood of an inferior scar forming, leading to the formation of postoperative hernias.

3. There is a uniform load distribution over the entire length of the seam line. At the same time, all sutures experience the same traction of the muscles of the anterior abdominal wall on both sides.

4. The blood supply to the umbilical region aponeurosis is not disturbed.

5. The weak areas of the aponeurosis in the umbilical region are completely eliminated when the umbilical ring is sutured. This allows you to reduce the incidence of postoperative hernia defects.

6. The total time of laparotomy and suturing of the wound is reduced due to a simpler technique of operations.

7. Improved cosmetic results due to the symmetry of the skin incision.

Claims (1)

A method for the prevention of postoperative ventral hernias after median laparotomy, including dissection of the skin, subcutaneous fat, aponeurosis, peritoneum, characterized in that prior to the operation, markings are made using a ruler and marker, direct lines are drawn from the xiphoid process to the navel and from the navel to the womb tissue is dissected in layers along the lines obtained with dissection of the umbilicus and the umbilical ring, the umbilical ring is dissected, stretching the skin of the umbilical region with two tweezers in the transverse direction, ayaks on the edges of the aponeurosis on each side in the middle of the semicircle of the dissected umbilical ring, after performing the main stage of the operation, before suturing the peritoneum, a suture-retainer is applied to each aponeurotic angle, capturing both edges of the wound, the suture-holders are clamped, in the umbilical region, the suture beacons replaced by a suture-holder, combining the edges of the aponeurosis in the center of the navel, and the peritoneum is sutured first in the direction from the epigastric region to the navel, then from the pubic region to the navel while traction Pi for the respective seams-taped, then sutured the fascia on the same principle with the traction of the joints-taped, the latest tie-taped seams, imposed earlier in the epigastric, umbilical and hypogastric regions, control hemostasis, sutured the subcutaneous tissue with interrupted sutures, the skin is sutured.

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