RU2725069C2 - Method for anterior abdominal wall plasty in desmoid fibroma of abdominal external oblique muscle - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely to surgical management of anterior abdominal wall desmoid soft tissue fibroma. Anterior abdominal wall is incised. Mobilization is performed on the side of involved muscle lateral than level of vagina of abdominal rectus muscle by 3 cm to create a site for fixation of mesh above lateral edge of rectus abdominis muscle. Subtotal resection of the abdominal external oblique muscle is performed together with the anterior and posterior leaves of the aponeurosis. Outer and internal oblique muscles and the transverse muscle are sutured along with continuous suturing along the resection side of the absorbable suture, as well as the lateral edge of the abdominal rectus muscle to form a single line for fixing the mesh. Mesh edge is bent to the intended fixation line of the internal sutures and an internal line of sutures is formed between the fold of the mesh and the aponeurosis on the side of the unleavened rectus by separate interrupted sutures that remain under the sieve. Similarly, the mesh edge is bent on the opposite side and an internal row of sutures is formed between the mesh and the aponeurosis on the side of the resected muscle. Further, the mesh is fixed on the upper and lower edges of the defect to the residues of the aponeurosis, the anterior superior crest of the wing of the ilium, and previously folded edges of the mesh are returned into place, laying them on top of the mobilized from cellular aponeurosis, and forming an external row of sutures along the perimeter of the mesh.EFFECT: method enables performing an anterior abdominal wall plasty when the abdominal external oblique muscle is removed by the desmoid fibroma by the declared methods of the method.1 cl, 1 ex, 7 dwg

Description

The invention relates to medicine, namely to surgical treatment of desmoid fibroma of soft tissues of the anterior abdominal wall.

Massive resections of the soft tissues of the anterior abdominal wall are accompanied by the formation of extensive defects requiring their replacement, so the choice of the method for reconstruction also seems to be no less significant.

In general, most authors are currently leaning toward alloplasty, that is, the use of synthetic materials to restore the integrity of the abdominal wall. Moreover, completely different reconstruction options are given in the literature, from plastic surgery with local tissues and displaced muscle aponeurotic flaps to complex multicomponent or multi-stage reconstructions using synthetic or biological materials, this leads to unsatisfactory results of surgical treatment associated with impaired frame function of the anterior abdominal wall after removal of the desmoid fibroma of the external oblique muscle of the abdomen. The problem of the reconstructive stage of the anterior abdominal wall with subtotal removal of the affected muscle remains open.

A known method of plastic Inlay (Mayorov R.V., Naumov A.M., Zaikin A.V., Bulletin of medical Internet conferences. 2016. T. 6. No. 6. S. 1326-1328) - the implant is placed under the muscular-aponeurotic layer. After excision of the hernial sac and excision of the scars, the peritoneum is peeled off from the muscle-aponeurotic layer for 5-6 cm. The edges of the peritoneum are sutured (Fig. 1.). In cases where it is not possible to seal the abdominal cavity with the parietal peritoneum, the abdominal organs are separated from the plastic zone with a large omentum flap. An implant is placed in the prepared space without wrinkling and creasing, which is fixed with U-shaped slowly absorbable ligatures, carried through the muscle-aponeurotic layer and tied under the skin. In order for the implant to be well extended and remain in a taut state, all the sutures are simultaneously tightened and then tied.

However, the application of this technique is possible only with preserved rectus muscles of the anterior abdominal wall and is used as additional sealing and strengthening of the muscular aponeurotic framework of the anterior abdominal wall.

There is a method when it is possible to use combined plastic surgery of the anterior abdominal wall (Inlay-Onlay technique) (Mayorov R.V., Naumov A.M., Zaikin A.V., Bulletin of medical Internet conferences. 2016. V. 6. No. 6 S. 1326-1328). The hernia gate is strengthened by hemming the implant over autoplasty (Onlay technique). At the same time, the edges of the hernial defect are connected with a continuous or nodal suture until they are in close contact or with the formation of a duplicate. Then the front surface of the muscle-aponeurotic layer is separated from the subcutaneous tissue at a distance of 5-6 cm from the suture in both directions. The implant is sutured from above to the muscle-aponeurotic layer of the abdominal wall and is in direct contact with the subcutaneous fat layer (Fig. 2).

The disadvantage of this method is the unreliable and not sufficiently effective technique for attaching a synthetic mesh to the muscle-aponeurotic layer and, like the previous method, involves the presence of rectus abdominis, which play a key role in the formation of the skeleton of the anterior abdominal wall.

A known method of plastic surgery of extensive defects of the anterior abdominal wall (RU 2066125 C1). The method is as follows: after excision of the scar tissue, the defect of the anterior abdominal wall is closed with a flap cut out from its large omentum on a wide vascular pedicle, fixed with its own lavsan sutures to the defect tissues, without grabbing the edges of the aponeurosis, then plastic is performed: on top the flap is laid on a fine-mesh dacron mesh and fixed with a three-row continuous lavsan suture to the edges of the aponeurotic defect and for 2.5-3.5 cm, around it is laid on top of the fine-mesh mesh coarse dacron mesh, the edges of which are fixed within the aponeurosis of the anterior abdominal wall by individual dacron sutures and in the center - with MK-6 medical glue, and the connection of all layers of plastic material in the zone of an extensive defect is performed by separate U-shaped lavsan seams and MK-6 medical glue. The invention relates to methods of plastic surgery for extensive defects of the anterior abdominal wall.

However, the big disadvantage of this method is the use of the lavsan mesh and the use of a large amount of alloplastic material, namely, as the above example demonstrates the method of applying a coarse mesh dacron mesh to a fine-mesh dacron mesh. As you know, the use of lavsan mesh leads to a large number of local complications, such as suppuration of the wound, the formation of seromas, the formation of fistulas and infiltrates. The lack of strength of the lavsan mesh explains a significant number of local relapses of ventral hernias.

Closest to the claimed invention is a method of plastic surgery of the anterior abdominal wall with desmoid fibroma of the rectus abdominis muscle (RU 2581249 C1). A skin incision is made along the midline along the white line of the abdomen with a bypass of the umbilical ring, subcutaneous fatty tissue is dissected and separated to expose the case of the right or left rectus abdominis muscles throughout the latter, on the side of the affected muscle mobilization is carried out 3 cm lateral of the vagina of the rectus abdominis muscle for create a fixation area for the mesh over the external oblique muscle of the abdomen, the umbilical ring is cut off from aponeurosis, the affected muscle is mobilized in a single block with the tumor along the entire length from the costal arch to the pubic symphysis without opening the parietal peritoneum, subtotal resection of the rectus muscle along with the anterior and posterior leaves is performed aponeurosis with a transverse fascia below the umbilical ring, the edges of the external, internal oblique and transverse muscles on the resection side are sheathed with a continuous entwining suture with absorbable suture, forming a single line for fixing the mesh, the mesh edge is bent to the intended fixation line of the inner row of sutures, form a the pit inner row of sutures between the fold of the mesh and the aponeurosis from the side of the not removed rectus muscle with separate nodal sutures that remain under the mesh, similarly bend the edge of the mesh on the opposite side and form an arcuate inner row of sutures between the mesh and the aponeurosis from the resected muscle, the mesh is fixed on the upper and lower edges of the defect to the remnants of the aponeurosis, periosteum of the pubic bone and costal arch, and the previously bent edges of the mesh are returned into place, laying them on top of the aponeurosis mobilized from fiber, then form the outer row of sutures along the perimeter of the mesh, the umbilical ring is fixed to the mesh in the same place (FIG. 3).

However, this technique is used for tumor lesions of desmoid fibroma of the right or left rectus abdominis muscles, in the case when it is necessary to replace an extensive postoperative defect of the anterior abdominal wall, the disadvantage of this method is a longer postoperative period, which lengthens the patient's hospitalization. Also, the disadvantage of this method is that when mobilizing the affected muscle, a wider mobilization with cutting off the umbilical ring is necessary, this in turn can lead to a violation of the blood supply to the above zone and lead to umbilical ring necrosis, which can significantly affect the cosmetic result and lead to to reoperation. In addition, for the above methods, median access is used, the cosmetic result is satisfactory, but the length of the skin incision is much longer, in contrast to the proposed method for plastic surgery of the anterior abdominal wall.

The objective of the proposed technical solution is to develop a method of plastic surgery of the anterior abdominal wall when removing the affected external oblique muscle of the abdomen with desmoid fibroid.

This problem is solved by the fact that, as in the known method, an incision of the anterior abdominal wall is performed, a tumor is removed, a synthetic mesh is attached to the muscle-aponeurotic layer with layer-by-layer wound closure.

A feature of the proposed method is that mobilization is carried out on the side of the affected muscle lateral to the vaginal level of the rectus abdominis muscle by 3 cm to create a mesh fixation pad over the lateral edge of the rectus abdominis muscle, subtotal resection of the external oblique abdominal muscle along with the anterior and posterior aponeurosis sheets is performed, sheathed continuous twisted seam of the edges of the external and internal oblique muscles and the transverse muscle on the resection side of the absorbable suture, as well as the lateral edge of the rectus abdominis muscle, forming a single line for fixing the mesh, the mesh edge is bent to the intended fixation line of the inner row of sutures and form the inner row of sutures between by folding the mesh and aponeurosis from the side of the non-removed rectus muscle with separate nodal sutures that remain under the mesh, similarly bend the edge of the mesh on the opposite side and form the inner row of seams between the mesh and the aponeurosis from the resected muscle, then fix the mesh along the upper and the lower edge of the defect to the remnants of the aponeurosis, the anteroposterior crest of the ilium wing, and the edges of the mesh bent earlier are returned to their place, laying them on top of the aponeurosis mobilized from fiber and form the outer row of sutures around the perimeter of the mesh.

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

FIG. 1 - Layout of the implant above the muscle-aponeurotic layer: 1 - skin; 2 - subcutaneous fat layer; 3 - prolene mesh; 4 - muscle-aponeurotic layer; 5 - peritoneum.

FIG. 2 - Layout of a mesh of proline in the subaponeurotic space: 1 - skin; 2 - subcutaneous fat layer; 3 - prolene mesh; 4 - muscle-aponeurotic layer; 5 - peritoneum.

Figure 3 - Scheme of plastics of the anterior abdominal wall with desmoid fibroma of the rectus abdominis muscle: a - skin; b - subcutaneous fat layer; c - prolene mesh; g - muscle-aponeurotic layer; d - peritoneum; e is the line of the inner seam.

FIG. 4 - a diagram of the plasty of the anterior abdominal wall with desmoid fibroma of the external oblique muscle of the abdomen: a - skin; b - skin incision; in - subcutaneous fat; g - the outer row of individual nodal joints; d - the inner row of individual nodal joints; e - rectus abdominis muscle; f - peritoneum; h - iliac crest; and - transverse muscle of the abdomen; K - internal oblique muscle of the abdomen; l - composite mesh.

FIG. 5 - the appearance of patient C: preoperative marking of desmoid fibroma of the external oblique muscle of the abdomen; the arrow indicates the location of the desmoid fibroma in the affected external oblique muscle of the abdomen.

FIG. 6 - operation stages: a - tumor mobilization, subcutaneous fatty tissue is separated with exposure of the aponeurosis of the external oblique muscle of the abdomen; b - subtotal resection of the external oblique muscle of the abdomen; c - reconstructive stage with the formation of a single-row twisted seam; g - reconstruction of the postoperative defect using a composite mesh.

FIG. 7 - Appearance of the patient 6 months after removal of the desmoid fibroma of the external oblique muscle of the abdomen (cosmetic result, arrows indicate the skin incision line); a - front view; 6 is a side view.

The method is as follows.

The patient is preoperatively labeled (Fig. 5) and the operation is performed according to the scheme (Fig. 4). They make surgical access according to Volkovich-Dyakonov. A skin incision is performed through the Mc Burney point located on the border between the outer and middle third lines connecting the navel to the anterior superior awn of the right ilium. A skin incision is performed perpendicular to the above line. A skin incision is made, subcutaneous fatty tissue is dissected and separated to expose the sheath of the external oblique muscle of the abdomen and the fascia is dissected, beyond which the fibers of the external oblique muscle of the abdomen are exposed (Fig. 4 a). The tumor is mobilized on the affected side in a single block with the external oblique muscle (Fig. 6). Subtotal resection of the external oblique muscle is performed (Fig. 6 b). The medial border of the resection is the lateral edge of the muscle-aponeurotic case of the right or left rectus abdominis muscle, while creating a platform of about 3 cm to fix the composite mesh. The lateral border of the resection is along the edge of the oblique muscles (in the absence of invasion). The edges of the external and internal oblique muscles and the transverse muscle on the resection side are sheathed with a continuous entwining suture with an absorbable suture (Fig. 6 c) (for example, vicryl 1.0), forming a single line for fixing the mesh (lateral edge of the resection). In accordance with the size of the defect, the required mesh size is selected and plastic defect is started. The edge of the mesh is bent to the intended line of fixation of the inner row of seams. An inner row of sutures is formed between the fold of the mesh and the aponeurosis from the side of the unremoved rectus muscle with individual nodal sutures with non-absorbable suture (Fig. 4 e) (for example, nurolon 0). The seam line is straight. The distance between the ligatures is 1.0-1.5 cm. The nodes are left under the grid.

Similarly, the edge of the mesh is bent on the opposite side. An inner row of sutures is formed between the mesh and the aponeurosis from the side of the resected muscle. The distance between the seams is 1.0-1.5 cm. The line of seams corresponds to the configuration of the removed muscles. During mesh fastening, the edges of the resection are brought together to the width of the removed muscle 5.0-6.0 cm. The mesh is fixed along the upper and lower edge of the defect to the remnants of the aponeurosis, the anterior superior crest of the iliac wing. The distance between the seams is not more than 1.0 cm. Previously bent edges of the mesh are returned to place, laying them on top of the aponeurosis mobilized from fiber. An outer row of seams is formed around the perimeter of the mesh (Fig. 4 g). The distance between the seams is 2.0-2.5 cm. In case of incomplete adherence of the mesh to the underlying tissues, additional joints are formed, stitching them through the mesh and fixing to the aponeurosis. Hemostasis is carried out, the subcutaneous pocket is treated with an antiseptic solution, dried with tampons and drained with active drainage with a microprofile. Drainage is introduced from the side of the ileo-inguinal region and placed over the mesh.

Clinical example

Patient S., 26 years old, was admitted with a diagnosis of Desmoid fibroma of the left external oblique muscle of the abdomen. A comprehensive examination according to computed tomography, as well as the results of ultrasound examination in the thickness of the left external oblique muscle of the abdomen, tumor formation is determined up to 45 mm in size.

The patient underwent surgical treatment by preoperative marking (Fig. 5): a soft tissue tumor was removed with the anterior abdominal wall (Fig. 6 a) with subtotal resection of the external oblique muscle of the abdomen (Fig. 6 b), the mesh was fixed along the perimeter of the defect to the aponeurosis of the lateral edge of the left rectus abdominis muscle. The lateral border of the resection is made along the edge of the oblique muscles. The edges of the external and internal oblique muscles and the transverse muscle on the resection side are sheathed with a continuous twisting seam (Fig. 6 c), a single line is formed for fixing the mesh. An inner row of sutures has been formed between the fold of the mesh and the aponeurosis from the side of the unremoved rectus muscle by separate interrupted sutures with non-absorbable suture.

Similarly, on the opposite side, the inner row of sutures between the mesh and the aponeurosis from the resected muscle is formed. The suture line corresponds to the configuration of the removed muscles. The mesh is fixed along the upper and lower edge of the defect to the remnants of the aponeurosis, the anteroposterior crest of the iliac wing. Previously bent edges of the mesh are returned to place, laying them on top of the aponeurosis mobilized from fiber. Formed outer row of seams around the perimeter of the mesh (Fig. 6 g). Implemented hemostasis. Then performed layer-by-layer suturing of the anterior abdominal wall.

On examination, 6 months after removal of the desmoid fibroma of the external oblique muscle of the abdomen, a good functional and cosmetic result was obtained (Fig. 7 a, b).

Using the proposed method using a synthetic mesh developed at the Moscow P.A. Herzen in the thoracoabdominal oncological surgery department, achieved good direct, functional and cosmetic results.

Claims (1)

A method for plasty of the anterior abdominal wall with desmoid fibroma of the external oblique muscle of the abdomen, including an incision of the anterior abdominal wall, removal of a tumor with a synthetic mesh attached to the muscle-aponeurotic layer and layered suturing of the wound, characterized in that the mobilization is carried out on the side of the affected muscle lateral to the level of the rectus sheath 3 cm abdomen to create a mesh fixation pad over the lateral edge of the rectus abdominis muscle, subtotal resection of the external oblique muscle of the abdomen together with the anterior and posterior aponeurosis leaves, sheathed with a continuous twisting seam of the edges of the external and internal oblique muscles and transverse muscle on the resection side of the absorbable suture, as well as the lateral edge of the rectus abdominis muscle, forming a single line for fixation of the mesh, the edge of the mesh is bent to the supposed line of fixation of the inner row of sutures and form the inner row of sutures between the fold of the mesh and aponeurosis from the side of the unremoved rectus muscle with separate nodal sutures which remain beneath the mesh, similarly bend the edge of the mesh on the opposite side and form the inner row of seams between the mesh and the aponeurosis from the side of the resected muscle, then the mesh is fixed along the upper and lower edges of the defect to the remnants of the aponeurosis, the anterior superior crest of the iliac wing, and the edges bent earlier the mesh is returned to the place, laying them on top of the aponeurosis mobilized from fiber, and form the outer row of seams around the perimeter of the mesh.

Images