RU2733039C1 - Method of surgical treatment of umbilical hernia - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery. Umbilical hernioplasty is performed with local tissues to form transverse duplicate of abdominal rectus aponeurosis. Access is performed by skin incision inside the umbilicus along its cranial contour, at distance of 3–4 mm from the skin of the anterior abdominal wall. Length of the skin incision corresponds to half the length of the umbilicus circumference, and the umbilical hernioplasty is performed with a double-row suture of the transverse duplication of the abdominal rectus aponeurosis using an atraumatic monofilament non-absorbable material. First row of the suture is formed from the inside to the outside along the lower layer of the above duplicate and in the reverse direction along its upper layer, and the seam assemblies are fastened between the duplicate sheets. Second line of the suture is formed outside the previous one similarly. That is followed by umbilicoplasty, which is performed by forming a surface and three internal circular sutures with non-traumatic monofilament absorbable material, followed by suturing the skin wound by immersing the suture inside the umbilicus. Umbilicoplasty is then formed by forming a superficial and three internal circular sutures with an absorbable atraumatic monofilament suture with subsequent suturing of the skin wound by immersing the suture inside the umbilicus.

EFFECT: method enables providing minimally invasive cutaneous access inside the umbilicus, leaving the external skin without intervention; eliminating diastasis of rectus abdominis muscles; prevent formation of palpable under skin scars and seams in duplicate area of aponeurosis of rectus abdominis muscle in patients with non-expressed subcutaneous fat on anterior abdominal wall.

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Description

The invention relates to medicine, namely to surgery and can be used in the surgical treatment of umbilical hernias when indicated with the elimination of diastasis of the rectus abdominis muscles and reconstruction of the umbilical region in women with the formation of an umbilical hernia and severe deformation of the umbilical region, after pregnancy and childbirth.

The share of umbilical hernias among all hernias of the anterior abdominal wall is about 40-45%. At the same time, there is a slight advantage of the number of women over the number of men (57.5 and 42.5%, respectively). However, the frequency of the formation of umbilical hernias during pregnancy and childbirth increases significantly (about 60-65% according to various sources), and in patients with umbilical hernia, diastasis of the rectus muscles occurs in 60% of cases. They occur mainly in women (80.4-90%) at a young age (25-35 years), as a result of stretching the umbilical ring, atrophy of the surrounding tissues, a decrease in the resistance of the abdominal wall to an increase in intra-abdominal pressure during pregnancy [1, 2, 3].

The most common are small and medium-sized hernias (61-74%), which are infringed in 30.3% of cases [1].

The high recurrence rate (15-40%) after the plasty of umbilical hernias by existing methods prompted a wide search for new methods of plasty of umbilical hernias that can improve the results of their surgical treatment [1, 4].

In 1900 K.M. Sapezhko proposed the so-called “frock coat” plastic, by analogy with the hem of a frock coat, which are fastened one on top of the other. With this method, a longitudinal incision is performed with bypassing the navel on the left, it is assumed that the entire white line of the abdomen is restructured, U-shaped stitches are applied to the aponeuroses with the capture of the medial edges of the rectus abdominis muscles, while creating a duplicate of the aponeurosis and rectus abdominis muscles, which is also accompanied by traumatization of the latter [5 ].

In 1901, the American physician Mayo proposed a method for treating umbilical hernias, the idea of which is to create a duplicate of the white line of the abdomen with a suture that is applied in the transverse direction [5]. In this case, access is located near the navel. If it is necessary to expand the access, it is necessary to cross the muscles, blood vessels and nerves of the umbilical region, a pronounced skin scar is formed on the anterior abdominal wall. In addition, it should be noted that this method does not eliminate diastasis of the rectus muscles [6].

With the described methods, a pronounced cutaneous scar of the anterior abdominal wall is formed. Both methods are significantly traumatic and non-cosmetic [1, 2, 7].

There are prosthetic methods with supra- and subgaponeurotic arrangement of the mesh implant.

Endovideosurgical methods of IPOM plastic have been developed. Endovideosurgical methods are indicated for large hernia sizes and are inappropriate for small and medium ones (according to the classification of the European Herniological Society).

All traditional methods of umbilical hernioplasty do not imply restoration of the anatomy of the navel and umbilical region and are accompanied by the appearance of additional scars, which further worsen the cosmetic effect.

During pregnancy, the likelihood of developing an umbilical hernia increases when the anterior abdominal wall is stretched by the pregnant uterus. In this case, the skin of the anterior abdominal wall is also stretched, accompanied by deformation of the navel and the umbilical region. Diastasis (divergence) of the rectus abdominis muscles is also quite common. The category of patients with the development of umbilical hernia and diastasis of the rectus abdomen after pregnancy and childbirth are young or middle-aged women, for whom cosmetic is an important aspect. Often it is a cosmetic defect that makes them see a doctor. Elimination of only hernia and diastasis of the rectus abdominis muscles is not a full-fledged care for this category of patients.

As analogues are presented:

1. Method of eliminating umbilical hernia according to Mayo: umbilical hernioplasty with the formation of a transverse duplication of the aponeurosis of the rectus abdominis muscles. A negative aspect of the operation is a higher recurrence rate compared to prosthetic methods of surgery (up to 20-30%) [5, 6].

As well as a non-cosmetic surgical approach, which is performed paraumbilically and borders the umbilical region along the periphery, creating an additional scar.

2. Prosthetic hernioplasty. It is characterized by a lower recurrence rate: 1-5% [1, 5, 8, 9]. The access is also performed paraumbilically. There are several hernioplasty methods depending on the mesh arrangement. The "sub-lay" method - the mesh endoprosthesis is located under the aponeurosis or retromuscularly in front of the posterior aponeurosis leaf of the rectus abdominis muscles. At the same time, it is necessary to further expand the operational access. Method "on-lay" location of the mesh over the aponeurosis. The downside is the higher incidence of complications and the formation of postoperative seromas.

3. Elimination of diastasis of the rectus abdominis muscles. To eliminate diastasis of the rectus abdominis muscles, both the prosthetic method according to the "sub-lay" or "on-lay" methods, and the Shampioner method, when a continuous suture of the medial edges of the divergence of the rectus abdominis muscles is made and diastasis along the white line is eliminated. The surgical approach is traditionally located along the entire length of the diastasis along the midline of the abdomen and is distinguished by a large length.

4. Minimally open sublay-method of hernioplasty "MILOS" (mini / less open sublay technique) and endoscopic version of this operation "EMILOS". Using the MILOS concept, the mesh can be placed in a retromuscular position without opening the abdomen or without the need to make a large skin incision. The dissection of the retromuscular plane can be performed by open technique (MILOS) or endoscopically (EMILOS), while the mesh prosthesis is installed without fixation [10].

5. Restoration of the navel is traditionally performed after the described methods by fixing the bottom with one or several sutures to the aponeurosis. In this case, a cone is created, the dimensions advising the initial deformation or stretching of the skin.

Traditionally, for hernioplasty with local tissues and the elimination of diastasis of the rectus abdominis muscles, as well as fixation of the navel, nylon thread 3 / 0-5 / 0 is used, while the suture is formed outward.

As a prototype for the closest technical essence, the Mauo operation method was chosen, which consists in performing a wide skin access along the outer semicircle of the umbilical region, that is, paraumbilically, followed by the elimination of the umbilical hernia and performing umbilical hernioplasty with the formation of a transverse duplication of the aponeurosis of the rectus abdominis muscles with interrupted sutures with a thick thread with the formation of nodes over the aponeurosis.

The disadvantages of the method we have chosen as a prototype include:

• non-cosmetic surgical approach, which borders the umbilical region along the periphery, creating a visible scar;

• impossibility of performing the elimination of diastasis of the rectus abdominis muscles when the surgical access is located on the side or below the navel;

• presence of scar and suture nodes palpable under the skin in the area of duplicate aponeurosis of the rectus abdominis muscles in patients with unexpressed subcutaneous fat on the anterior abdominal wall;

• impossibility of restoring the normal anatomy of the navel.

The objective of the invention is to increase the cosmetic effect of the method of surgical treatment of umbilical hernias, as well as to restore the normal anatomy of the navel.

The technical result of the invention is:

• performing an internal minimally invasive skin access inside the navel, leaving the outer skin without intervention;

• the possibility of eliminating diastasis of the rectus abdominis muscles;

• absence of scar and suture nodes palpable under the skin in the area of duplicate aponeurosis of the rectus abdominis muscles in patients with unexpressed subcutaneous fat on the anterior abdominal wall.

The technical result of the invention is achieved in that the method for the surgical treatment of umbilical hernias consists in performing umbilical hernioplasty with local tissues with the formation of a transverse duplication of the aponeurosis of the rectus abdominis muscles. Access is carried out by cutting the skin inside the navel along its cranial contour, departing from the plane of the skin of the anterior abdominal wall into the depth of the navel by 3-4 mm, while the length of the skin incision corresponds to half the circumference of the navel. Umbilical hernioplasty is performed with a two-row suture of a transverse duplication of the aponeurosis of the rectus abdominis muscles, using atraumatic monofilament non-absorbable material. In this case, the first row of seams is formed from the inside to the outside along the lower layer of the above duplicate and in the opposite direction along its upper layer, and the suture knots are tied between the leaves of the duplicate. The second row of suture is formed outwardly of the previous one in the same way, after which umbilicoplasty is performed by forming a superficial and three internal circular sutures with an absorbable atraumatic monofilament suture, followed by suturing the skin wound by immersing the suture inside the navel.

The method is carried out as follows:

The operation is performed in the supine position of the patient under general anesthesia after treatment of the operating field (the entire abdomen) with antiseptic solutions.

Access is carried out by cutting the skin inside the navel along its cranial contour, departing from the plane of the skin of the anterior abdominal wall into the depth of the navel by 3-4 mm, while the length of the skin incision corresponds to half the circumference of the navel.

Next, layer by layer, the umbilical hernia and the surrounding aponeurosis are isolated 2 cm along the periphery of the umbilical ring. The hernial sac is not opened and is immersed in the abdominal cavity. In the presence of diastasis of the rectus abdominis muscles, the operative skin access is raised up and the aponeurosis is additionally isolated at the level of diastasis of the rectus abdominis muscles and along the periphery of it so that when the rectus abdominis muscles are brought together, a subcutaneous "roller" does not form. For this, an electrocoagulator with an elongated attachment of the working surface of the electrodissection is used. Using long instruments, the edges of the rectus abdominis muscles are brought together at the level of diastasis, starting from the top according to the Shampioner method with a continuous suture with atraumatic monofilament Vicryl 1/0 thread. The suture knot is formed under the aponeurosis of the umbilical ring.

For subsequent duplicates of the aponeurosis transversely on both sides of the umbilical ring, 0.5 cm incisions are made on each side bilaterally. Umbilical hernioplasty is performed with a double-row suture of a transverse duplication of the aponeurosis of the rectus abdominis muscles, using atraumatic monofiloment non-absorbable material, while the first row of suture is formed from the inside to the outside along the lower layer of the above duplicate and in the opposite direction along its upper layer, and the suture knots are tied between the second knots a row of seams is formed outside the previous one in the same way.

The final stage of the operation is umbilicoplasty and restoration of the normal anatomy of the umbilical region and navel. Umbilicoplasty is performed by forming a superficial and three internal circular sutures with an absorbable atraumatic monofilament suture, creating a uniform umbilical cone with fixation of the bottom of the navel slightly above the aponeurosis suture line. The supraumbilical (cranial) edge of the umbilicus is brought in 2-3 mm cranially under the plane of the skin of the anterior abdominal wall with the formation of a skin "visor". Monocril or Vicryl 4/0 is used as suture material.

The skin suture is formed in two rows. The first row is the absorbable suture material Monocril or Vicryl 4/0 according to the Ebadi method from the inside out with the immersion of the knot inside. In this case, the upper skin edge is 1 mm longer than the lower one. Use single sparse stitches for the first row. The second row - along the edge intradermally continuously without fixing the proximal and distal edges.

After that, the skin is treated with an antiseptic and an aseptic bandage with a gauze ball in the navel. An obligatory stage is putting on the postoperative bandage on the abdomen immediately on the operating table, covering the anterior abdominal wall in the area of the performed operation.

Distinctive essential features of the invention and the cause-and-effect relationship between them and the result achieved:

• Access is performed by incision of the skin inside the umbilicus along its cranial contour, departing from the plane of the skin of the anterior abdominal wall deep into the umbilicus by 3-4 mm in order to additionally hide the suture line and, in the future, the postoperative scar, while the length of the skin incision corresponds to half the circumference of the navel, this length is sufficient to perform the operation and does not cause ischemic disorders of the umbilicus when using excessively large incisions, and a smaller incision is insufficient to perform the entire volume of the operation.

• Umbilical hernioplasty is performed with a double-row suture of the transverse duplication of the aponeurosis of the rectus abdominis muscles, using atraumatic monofiloment non-absorbable material, while the first row of sutures is formed from the inside to the outside along the lower layer of the above duplicate and in the opposite direction along its upper layer, and the suture knots are tied between the sheets the second row of the seam is formed outside the previous one in the same way.

When forming a duplication of the aponeurosis of the rectus abdominis muscles, a two-row suture is performed using atraumatic monofiloment non-absorbable material with the formation of suture nodes inside the duplicator between its sheets. The suture material used differs from the usual nylon in high strength, minimal tissue reaction, and the formation of knots inward excludes further palpable seals around the sutures through the skin, which is determined in patients with poorly expressed subcutaneous tissue of the anterior abdominal wall;

• After that, umbilicoplasty is performed, which is performed by forming a superficial and three internal circular sutures with an atraumatic absorbable atraumatic monofilament thread, followed by suturing the skin wound by immersing the suture inside the navel.

The prototype method of umbilical hernipoplasty does not include restoring the normal anatomy of the navel and the umbilical region, which is achieved in the claimed method by performing umbilicoplasty on frame circular purse string sutures with atraumatic monofiloment absorbable material, the threads of which are absorbed, forming a frame, without rough scars.

All stages of the operation are performed through a single access, which is significantly smaller than in the prototype and is located inside the navel, and the closure of the skin incision with the immersion of the suture inside the navel allows precise matching of the skin edges, which further improves the cosmetic properties of the access.

Here are clinical examples: Example 1. Patient A., 29 years old, on January 14, 2019, was admitted to the surgical department No. 2 of the Peter the Great Hospital in a planned manner after preliminary consultation and outpatient examination. On admission, the patient complained of protrusion in the navel, asymmetric deformation of the navel, hyperextension of the skin of the umbilical region, periodic pain in the area of this formation during physical exertion. Considers himself sick for about two years, when a protrusion in the navel area first appeared during pregnancy. During this time, the hernia almost doubled and in the last 2 months pains in this area began to bother. In addition, diastasis of the rectus abdominis muscles was revealed up to 3 cm in the lower half of the white line of the abdomen of the epigastric region. History of 2 births. When viewed in the area of the umbilical ring, a hernial protrusion measuring 3.5 × 2.5 × 2.5 cm in diameter is determined. On palpation, the contents of a soft-elastic consistency, painless, reduced into the abdominal cavity, the skin over the formation is not changed, a cough push is performed. In addition, diastasis of the rectus abdominis muscles was revealed up to 3 cm in the lower half of the white line of the abdomen of the epigastric region. Taking into account the wishes of the patient, it is necessary to perform the elimination of the umbilical hernia with the correction of the deformity of the umbilical region. The patient is planning a second pregnancy in the future, therefore, the use of prosthetic hernia repair methods is contraindicated. After standard preparation, on January 15, 2019, a complex operation was performed through the umbilical access, retreating 3 mm deep into the navel, and umbilical hernioplasty with local tissues was performed with the creation of a transverse duplication of the aponeurosis of the rectus abdominis muscles with 2/0 prolene sutures, elimination of diastasis of the rectus abdominis muscles with Vicryl thread 1 / 0 continuous suture, completed the operation to restore the normal anatomy of the navel and umbilical region through a single access according to the original method. The wound healed by primary intention, the stitches were removed after 7 days. There were no complications. Immersion 3 mm deep in this patient was enough to completely hide the line of the postoperative scar from view. Examined after 2 and 6 months. No complaints. Performs any physical work 1 month after surgery. There are no signs of relapse. A good cosmetic effect has been achieved by reducing the size of the navel to the original and eliminating the deformities of the umbilical region. The patient is satisfied with the cosmetic effect. Repeated births are planned.

Example 2. Patient P., 33 years old. A history of 2 births, after which a protrusion appeared in the umbilical region with a change in the shape and size of the umbilicus, with these complaints, the patient turned to an outpatient consultation. Diagnosed with an umbilical hernia 3 × 3 × 2 cm, freely reducible into the abdominal cavity, the umbilical ring expanded to 2 cm, diastasis of the rectus abdominis muscles 2 cm wide at the level of the navel. In addition, the umbilical region is visually deformed, the navel skin is turned outward, expanded to 3 cm. Earlier, the patient noted that the navel was 1.5 cm in diameter. The patient is planning another pregnancy in the future. The use of mesh endoprostheses for hernioplasty is contraindicated. The patient is hypersthenic, height 174 cm. Indications for surgery according to the proposed original method are presented and planned hospitalization is planned. A standard preoperative examination was carried out and contraindications to hospitalization and surgery were excluded. She was hospitalized on January 21, 2019, the operation was performed on January 22, 2019.The umbilical approach was performed, retreating 4 mm into the navel according to the patient's constitutional features, and umbilical hernioplasty was performed with local tissues with the creation of a transverse duplication of the aponeurosis of the rectus abdominis muscles with 2/0 prolene sutures, eliminated diastasis of the rectus abdominis muscles with the Vicryl thread 1/0 continuous suture, the operation was completed by restoring the normal anatomy of the navel and the umbilical region through a single access using the original method. The navel was reduced in size to its original 1.5 cm due to continuous circular sutures, its fixation was restored. The wound healed by primary intention, the stitches were removed after 7 days. There were no complications. Immersion 4 mm deep in this patient was enough to completely hide the line of the postoperative scar from view. Examined after 3 and 6 months. No complaints. Performs any household physical work 1 month after surgery. There are no signs of relapse. A good cosmetic effect has been achieved by reducing the size of the navel to the original and eliminating the deformities of the umbilical region. The patient is satisfied with the cosmetic effect. Repeated births are planned.

According to the developed method, 18 patients were operated on. All patients were satisfied with the cosmetic result of the operation, were followed up after 6-12 months. No relapses were found.

The inventive method for the surgical treatment of umbilical hernias provides:

• performing an internal minimally invasive skin access inside the navel, leaving the outer skin without intervention;

• elimination of diastasis of the rectus abdominis muscles;

• absence of scar and suture nodes palpable under the skin in the area of duplicate aponeurosis of the rectus abdominis muscles in patients with unexpressed subcutaneous fat on the anterior abdominal wall,

which increases the cosmetic effect of the method of surgical treatment of umbilical hernias, and also restores the normal anatomy of the navel.

Literature

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3. Voskresensky, P.V. Abdominal wall hernia surgery / P.V. Voskresensky, S.L. Gorelik // M .: Medicine. - 1965 .-- P. 326.

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Claims (1)

A method of surgical treatment of umbilical hernias, including performing umbilical hernioplasty with local tissues with the formation of a transverse duplication of the aponeurosis of the rectus abdominis muscles, characterized in that the access is carried out by incision of the skin inside the navel along its cranial contour, departing from the plane of the skin of the anterior abdominal wall deep into the navel by 3-4 mm, while the length of the skin incision corresponds to half the circumference of the navel, and the umbilical hernioplasty is performed with a two-row suture of the transverse duplication of the aponeurosis of the rectus abdominis muscles using atraumatic monofiloment non-absorbable material, while the first row of suture is formed from the inside to the outside along the lower layer of the above-mentioned duplicate and in the opposite direction along its top layer, and the suture knots are tied between the sheets of duplicate, the second row of the seam is formed outside the previous one in the same way; after which umbilicoplasty is performed, which is performed by the formation of a superficial and three internal circular sutures with an atraumatic monofilament absorbable material, followed by suturing the skin wound by dipping the suture inside the navel, after which umbilicoplasty is performed by forming a superficial and three internal circular sutures with absorbable atraumatic monofilament suture with subsequent suturing inside the navel.