RU2724486C1 - Non-stretching hernioplasty of hernia belly lines, recurrent postoperative ventral hernias - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, namely to surgery. Hernial sac is exposed. Aponeurosis is mobilized from subcutaneous fat at distance of 3 cm along the circumference from the border of the hernial orifice. White belly line is incised up and down by 3 cm from the edge of hernial opening. Parietal peritoneum is mobilized from the white line and aponeurosis of abdominal rectus muscle by 3 cm. Mesh prosthesis is cut out of polypropylene mesh esphyl standard. Size of the mesh implant is selected so that its external edges from the border of the hernial defect are spaced at a distance of not less than 3 cm. Mesh prosthesis is dissected in a vertical direction into two equal parts. Mesh prosthesis is placed between the peritoneum and the posterior leaf of the belly aponeurosis on the left side. Vertical U-sutures are fixed with an atraumatic needle non-absorbable by suturing filament of size 0. Suture is started from an upper angle of the wound at distance of 2.5 cm in the distal direction from an edge of a hernial defect. Suture is advanced from the top downwards, through the front leaf of the aponeurosis of the abdominal rectus muscle, then through the abdominal rectus muscle, through the posterior leaf of the abdominal rectus aponeurosis, through the mesh prosthesis, through the peritoneum, return to the front sheet of abdominal rectus aponeurosis sheet. Above tissues are stitched in the reverse order, 1 cm from a peritoneal peritoneum in the caudal direction, the interval between sutures is 1 cm. In the same way, the mesh prosthesis is fixed on the opposite side. Peritoneum defect is closed with a continuous suture with an atraumatic needle, which is not absorbed by a suture of size 2\0. Mesh prosthesis is sutured with an atraumatic needle, non-absorbable by a suture of size 2\0 at distance of 0.3 cm from the edge of the mesh prosthesis. Anterior and posterior leaves of the aponeurosis of rectus abdominal muscles are combined with an atraumatic needle non-absorbable by a sutured suture of size 0. Suture is started from the upper angle of the wound at distance of 0.5 cm from the aponeurosis edge. Subcutaneous fat and the skin are closed.EFFECT: method enables minimizing a risk of recurrent hernia, minimizing the risk of serum formation, infection, that is improving clinical effectiveness.1 cl, 2 dwg, 1 ex

Description

The invention relates to medicine, namely to surgery, can be used in the surgical treatment of hernias of the white line of the abdomen, recurrent postoperative ventral hernias.

A known method of non-tensile preperitoneal hernioplasty of umbilical paraumbilical hernias of the white line of the abdomen (Patent RU No. 2291670, publ. 20.01.2007, IPC: A61B 17/00).

The method is as follows. Operation Technique. The skin incision is transverse under the navel. At the base of the hernial sac, the aponeurosis is separated from the subcutaneous tissue at a distance of 2.5-3 cm from the edge of the hernial opening around the circumference. Perform thorough hemostasis. The hernial sac is not opened if there is no need to revise its contents. The following techniques are used to place the mesh implant in the preperitoneal space. With hernias of a relatively large size (3-4 cm), in which the hernial sac, entering the hernial defect, displaces the parietal peritoneum, and its peeling is not difficult. Pull the hernial sac into the wound in one direction, in the opposite direction - the edge of the defect, lift it, dissect the peritoneum from the white line and aponeurosis of the rectus abdominis muscles at the same distance as the subcutaneous tissue. In cases where the hernial sac in the area of the hernial portal is intimately fused with the umbilical ring (usually with small hernias), and the allocation of the preperitoneal space is difficult, use the following technique. Retreating from the edge of the hernia gate by 0.3-0.5 cm, the aponeurosis is dissected to the peritoneum and without any difficulties stupidly peel off the cut off umbilical ring with the peritoneum soldered to it. Then the hernial sac is immersed in the abdominal cavity. Between the peritoneum and the abdominal wall, a suitable size polypropylene mesh implant is placed in the prepared space. The principles of cutting and fixing are the same for all operations using polypropylene implants, taking into account a decrease in its subsequent area. The size of the mesh implant is selected so that its outer edges from the edge of the hernial defect are at a distance of at least 2.5-3 cm. The angles of the mesh implant and its lateral edges are fixed through the interrupted sutures at the level of the middle part of the hernial defect, i.e. maximally 6-8 seams are used. Seams are made as follows. Having departed from the edge of the net at least 0.8-1 cm, the needle is injected and punctured from the side opposite from the peritoneum. Then both threads are inserted into the eye of a large-sized needle, which pierces the muscle-aponeurotic part of the abdominal wall from the abdomen to the outside in a place corresponding to the size of the mesh. The outer sheet of the rectus sheath is stitched with one of the threads (in order to fix the suture to the abdominal wall) and the suture is tied. Then, in a similar manner, the next grid angle is fixed. The lateral edges of the mesh are fixed last at the level of the middle of the hernial defect. To do this, they are preliminarily taken onto the holders so that when tightening the last seam at the corners, not to lose the edge of the grid.

The above method has significant disadvantages:

1. It is impossible to use with large sizes of hernial protrusions.

2. A possible relapse due to the lack of fixation of the mesh implant to the peritoneum.

A known method of treating postoperative ventral hernias in a combined way with suturing of the aponeurosis and the location of the mesh explant above it [Egiev V.N., Lyadov K.V., Voskresensky P.K. Atlas of operative hernia surgery. - Medical practice. - M. - Moscow. - 2003. - 228 p.].

The above method has significant disadvantages:

1. The occurrence of inflammatory complications associated with infection and the occurrence of seromas is not ruled out.

2. Relapse of hernias above or below the implant location.

The objective of the invention is to provide a method of non-tension hernioplasty of hernias of the white line of the abdomen, recurrent postoperative ventral hernias, preventing relapses and inflammatory complications.

The task is achieved by the method of non-tight hernioplasty of hernias of the white line of the abdomen, recurrent postoperative ventral hernias, including access to the hernial sac, mobilization of the aponeurosis from the subcutaneous fat at a distance of 3 centimeters around the circumference of the edge of the hernial foramen, opening the hernial sac upward and dissecting the white line up and down 3 centimeters from the edge of the hernial foramen, mobilization of the parietal peritoneum from the white line and aponeurosis of the rectus abdominis by 3 centimeters, the mesh prosthesis is cut out from the Esfil standard polypropylene mesh, the size of the mesh implant is selected so that its outer edges from the edge of the hernial defect stand on a distance of at least 3 cm, dissection of the mesh prosthesis in two equal parts in the vertical direction, laying of the mesh prosthesis between the peritoneum and the posterior sheet of the aponeurosis of the white line of the abdomen on the left, fixation with vertical U-shaped sutures with an atraumatic needle, non-absorbable suture thread size 0 , the suture starts from the upper corner of the wound at a distance of 2.5 centimeters in the distal direction from the edge of the hernial defect, the thread runs from top to bottom, injected through the front sheet of the aponeurosis of the rectus abdominis muscle, then through the rectus muscle of the abdomen, through the posterior sheet of the aponeurosis of the rectus abdominis muscle, through mesh prosthesis, through the peritoneum, return to the anterior leaf of the aponeurosis of the rectus abdominis muscle, stitching the above tissues in the reverse order, 1 cm off from the puncture in the peritoneum in the caudal direction, the interval between the sutures is 1 cm. In this way, the fixation of the mesh prosthesis from the opposite side. Suturing of the peritoneal defect with a continuous suture with an atraumatic needle, non-absorbable suture thread size 2 \ 0. Stitching of the mesh prosthesis with an atraumatic needle, non-absorbable thread of prolene size 2 \ 0, the seam begins from the upper corner at a distance of 0.3 centimeters from the edge of the mesh prosthesis. Joint suturing of the anterior and posterior aponeurosis sheets of the rectus abdominis muscles with an atraumatic needle, non-absorbable suture thread size 0, the suture begins from the upper corner of the wound at a distance of 0.5 centimeters from the edge of the aponeurosis. Subcutaneous tissue and skin are sutured.

The novelty of the invention:

Dissection of the prepared mesh prosthesis from Esfil standard polypropylene mesh into two equal parts in the vertical direction.

Fixation of the mesh prosthesis with U-shaped sutures with an atraumatic needle, a non-absorbable suture thread of size 0 on both sides of the hernial defect. The suture begins from the upper corner of the wound at a distance of 2.5 centimeters in the distal direction from the edge of the hernial defect, the thread runs from top to bottom, injected through the front sheet of the aponeurosis of the rectus muscle, then through the rectus muscle, through the posterior sheet of the aponeurosis of the rectus muscle, through the reticular prosthesis, through the peritoneum, return to the anterior leaf of the aponeurosis of the rectus abdominis muscle, stitching the above tissues in the reverse sequence, 1 cm backward from the puncture in the peritoneum in the caudal direction, 1 centimeter between the sutures. In this way, the fixation of the mesh prosthesis from the opposite side. Suturing of the peritoneal defect with a continuous suture with an atraumatic needle, non-absorbable suture thread size 2 \ 0. Stitching of the mesh prosthesis with an atraumatic needle, non-absorbable thread of prolene size 2 \ 0, the seam begins from the upper corner at a distance of 0.3 centimeters from the edge of the mesh prosthesis. Joint suturing of the anterior and posterior aponeurosis sheets of the rectus abdominis muscles with an atraumatic needle, non-absorbable suture thread size 0, the suture begins from the upper corner of the wound at a distance of 0.5 centimeters from the edge of the aponeurosis.

The set of essential features of the invention allows to obtain a new technical result:

Minimize the risk of hernia recurrence.

Minimize the risk of seromas, infection, i.e. increase the effectiveness of treatment.

The invention is illustrated in the schematic drawings in FIG. 1; FIG. 2.

In FIG. 1 is a schematic illustration of the method in the frontal plane after the application of U-shaped seams.

In FIG. 1 are shown:

1 - peritoneum;

2 - polypropylene mesh

3 - the back sheet of aponeurosis of the rectus abdominis muscle;

4 - rectus abdominis muscle;

5 - front sheet of aponeurosis of the rectus abdominis muscle;

6 - subcutaneous fat;

7 - skin;

8 - U-shaped seam.

In FIG. 2 final appearance after tightening and tying the seams.

9 - a seam of the peritoneum;

10 - seam polypropylene mesh;

11 - suture of the leaves of the aponeurosis of the rectus abdominis muscles.

The method is as follows.

They access the hernial sac, mobilize the aponeurosis from the subcutaneous fat at a distance of 3 centimeters around the circumference of the edge of the hernial foramen. The hernial sac is opened, a white line is cut up and down 3 centimeters from the edge of the hernial opening. The parietal peritoneum is mobilized from the white line and aponeurosis of the rectus abdominis muscles by 3 centimeters. The mesh prosthesis is cut out from the Esfil standard polypropylene mesh, the mesh implant size is selected so that its outer edges from the edge of the hernial defect are at least 3 cm apart. The mesh prosthesis is dissected in the vertical direction into two equal parts, the mesh prosthesis is placed between the peritoneum and back sheet of aponeurosis of the white line of the abdomen on the left. They are fixed with vertical U-shaped sutures with an atraumatic needle, a non-absorbable suture thread of size 0, the suture begins from the upper corner of the wound at a distance of 2.5 centimeters in the distal direction from the edge of the hernial defect, the thread moves from top to bottom. Injection through the front sheet of the aponeurosis of the rectus abdominis muscle, then through the rectus abdominis muscle, through the posterior sheet of the aponeurosis of the rectus abdominis muscle, through the mesh prosthesis, through the peritoneum, return to the front sheet of the aponeurosis of the rectus abdominis muscle. Sewing the above fabrics in the reverse order, retreating 1 centimeter from the puncture in the peritoneum in the caudal direction. The interval between the seams is 1 centimeter. In this way, the mesh prosthesis is fixed on the opposite side. The peritoneal defect is sutured with a continuous suture with an atraumatic needle, non-absorbable suture thread size 2 \ 0. The mesh prosthesis is sutured with an atraumatic needle, a non-absorbable 2/0-size prolene thread, the seam begins from the upper corner at a distance of 0.3 centimeters from the edge of the mesh prosthesis. Together, the front and rear sheets of the aponeurosis of the rectus abdominis are sutured with an atraumatic needle, a non-absorbable suture thread of size 0, the suture starts from the upper corner of the wound at a distance of 0.5 cm from the edge of the aponeurosis. Subcutaneous tissue and skin are sutured.

Example 1

Patient B., 51 years old, was admitted to the KGBUZ Ulchi district hospital on 06.08.18 with a diagnosis of hernia of the white line of the abdomen. Sick for more than 10 years. The onset of the disease is due to a rise in severity, after which it notes the appearance of a tumor-like protrusion in the epigastric region in the projection of the white line of the abdomen, which over time began to increase in size.

The skin and visible mucous membranes of normal color, clean. Peripheral lymph nodes are not palpable. In the lungs, vesicular breathing, no wheezing. NPV = 16 per min. Cor-tones are clear, rhythmic. Heart rate = 70 per min; HELL = 130/80 mm RT. Art. The abdomen is soft, painless on palpation. Liver on the edge of the costal arch. There are no symptoms of peritoneal irritation. The chair is regular. Urination is free, painless. St.loc: In the epigastric region in the projection of the white line of the abdomen, a hernial protrusion of 7 × 3 cm in size, of soft elastic consistency, is easily fixed in the abdominal cavity in the supine position.

General blood test: Er - 4.4 × 10 12 / l; Hb - 130 g / l; CPU - 0.9; ESR - 10 mm / h; L - 5.9 × 10 9 / L. Coagulogram: PTI - 100%; fibrinogen A - 4.5 g / l; APTTV - 32 s; O / b - 69.9 g / l; creatinine - 59.6 mmol / l; ALT - 27.1; ACT 25.2; sugar - 5.6. General urine analysis: beats. weight - 1023, protein - neg, L - 4-5-6 in s / z .; ECG - sinus rhythm, heart rate = 75 per min, left EOS deviation, left ventricular hypertrophy.

On the 2nd day after hospitalization, the patient underwent surgery - hernia repair, plastic surgery of the anterior abdominal wall with a mesh prosthesis.

Under endo-tracheal anesthesia, a hernial sac was isolated from the surrounding tissues through midline access. Bag 6 * 3 centimeters. The aponeurosis defect is 4 cm in diameter. The aponeurosis was mobilized from subcutaneous fat at a distance of 3 centimeters around the circumference from the edge of the hernial foramen. The hernial sac is opened, no contents. A white line was cut up and down 3 centimeters from the edge of the hernial foramen. Mobilization of the parietal peritoneum from the white line and aponeurosis of the rectus abdominis by 3 centimeters. A mesh prosthesis was cut from an Esfil standard polypropylene mesh, measuring 10 * 10 centimeters. The mesh prosthesis is dissected in the vertical direction into two equal parts. The mesh prosthesis is laid between the peritoneum and the posterior leaf of the aponeurosis of the white line of the abdomen on the left. Fixation with vertical U-shaped sutures with an atraumatic needle, a non-absorbable suture thread of size 0, a suture from the upper corner of the wound at a distance of 2.5 centimeters in the distal direction from the edge of the hernial defect, thread advancement from top to bottom. Injection through the front sheet of the aponeurosis of the rectus abdominis muscle, then through the rectus abdominis muscle, through the posterior sheet of the aponeurosis of the rectus abdominis muscle, through the mesh prosthesis, through the peritoneum, return to the front sheet of the aponeurosis of the rectus abdominis muscle. Sewing the above fabrics in the reverse order, retreating 1 centimeter from the puncture in the peritoneum in the caudal direction. The interval between the seams is 1 centimeter. Overlay of 5 U-shaped seams was completed. The seams are tied. In this way, the fixation of the mesh prosthesis from the opposite side. The peritoneal defect is sutured with a continuous suture with an atraumatic needle, non-absorbable suture thread size 2 \ 0. The mesh prosthesis was stitched with an atraumatic needle, a non-absorbable 2 \ 0 length prolene thread, a suture was made from the upper corner at a distance of 0.3 centimeters from the edge of the mesh prosthesis. Together, the front and rear sheets of the aponeurosis of the rectus abdominis are sutured with an atraumatic needle, a non-absorbable suture thread of size 0, a suture from the upper corner of the wound at a distance of 0.5 cm from the edge of the aponeurosis. Hemostasis. Account of material, tools. Suturing of subcutaneous tissue and skin. Rubber graduate. Aseptic dressing.

P \ o diagnosis: hernia of the white line of the abdomen.

The duration of the operation is 1 hour 10 minutes.

Sutures were removed on the 9th day, wound healing by primary intention. Discharged from the hospital after 7 days.

During the follow-up examination after 3 months, there are no complaints, the postoperative scar without features. During the follow-up examination after 9 months there were no complaints, the postoperative scar without features.

The claimed method has made it possible to minimize postoperative complications and reduce the rehabilitation time, i.e. increase the effectiveness of treatment.

Claims (1)

The method of non-tension hernioplasty of white line abdominal hernias, recurrent postoperative ventral hernias, including access to the hernial sac, mobilization of aponeurosis from subcutaneous fat at a distance of 3 centimeters from the edge of the hernial opening, dissection of the white line of the abdomen up and down by 3 centimeters from the edge openings, mobilization of the parietal peritoneum from the white line and aponeurosis of the rectus abdominis by 3 centimeters, cutting out the mesh prosthesis from the Esphil standard polypropylene mesh, the size of the mesh implant is selected so that its outer edges from the edge of the hernial defect are at least 3 cm apart, dissection of the mesh prosthesis in the vertical direction into two equal parts, laying of the mesh prosthesis between the peritoneum and the posterior sheet of the aponeurosis of the white line of the abdomen on the left, fixation with vertical U-shaped sutures with an atraumatic needle, non-absorbable suture thread size 0, the suture starts from the upper corner of the wound at a distance of 2, five centimeter in the distal direction from the edge of the hernial defect, advance the thread from top to bottom, inject through the front sheet of the aponeurosis of the rectus abdominis muscle, then through the rectus muscle of the abdomen, through the posterior sheet of the aponeurosis of the rectus abdominis muscle, through the mesh prosthesis, through the peritoneum, return to the front sheet of the aponeurosis of the rectum abdominal muscles, flashing the above-mentioned tissues in the reverse order, departing 1 centimeter from the puncture in the peritoneum in the caudal direction, the seam interval is 1 centimeter, in the same way fixing the mesh prosthesis from the opposite side, suturing the peritoneal defect with a continuous suture with an atraumatic needle, non-absorbable 2-meter length proline \ 0, stitching the mesh prosthesis with an atraumatic needle, non-absorbable 2/0 length proline thread at a distance of 0.3 centimeters from the edge of the mesh prosthesis, joint suturing of the anterior and posterior aponeurosis sheets of the rectus abdominis muscle with an atraumatic needle, non-absorbable prolene thread size 0, the suture begins with the upper angle p Ana at a distance of 0.5 cm from the edge of the aponeurosis, suturing of the subcutaneous tissue, skin.

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