RU2758180C1 - Umbilical ring plastic method for umbilic hernia - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery, herniology. An incision with a diameter of 1 cm is made within the umbilical ring with excision of a skin flap. The peritoneum is separated from the aponeurosis along the entire perimeter of the umbilical ring at a distance of 1 cm. A mesh endoprosthesis in the form of a four-pointed star is used as an implant. The endoprosthesis is positioned under the aponeurosis and fixed with a surgical needle, fixing the end of the beam in the eye of the needle, by passing the resulting beams of the mesh endoprosthesis under the aponeurosis with the withdrawal to the anterior surface of the aponeurosis with an indent of 1 cm at 3, 6, 9, 12 o'clock. The endoprosthesis is straightened in the subgaleal space by pulling on the indicated rays, after which the excess rays of the endoprosthesis are cut off and fixed with a prolene thread to the aponeurosis of the umbilical ring. A new navel is formed.

EFFECT: method allows improving the results of treatment of patients with umbilical hernias of small and medium size, allows preventing the risk of interposition of internal organs between the implant and the aponeurosis, reduces invasiveness and duration of surgery, provides a good cosmetic effect, is easy to implement.

1 cl, 10 dwg, 1 ex

Description

The invention relates to medicine and can be used in abdominal surgery for the treatment of umbilical hernias of small and medium sizes.

Hernias of the anterior abdominal wall are one of the most common diseases subject to surgical treatment [2]. Umbilical hernias occupy a solid third place, after inguinal and postoperative, among all external abdominal hernias, and the frequency of their occurrence is on average 17.5% of hernia carriers. The main operations that have so far been used to eliminate umbilical hernias in adults were autoplastic methods proposed at the beginning of the 20th century by K.S. Sapezhko (1900) and Mauo (1901). Known methods for eliminating umbilical hernias and by using mesh endoprostheses in various modifications. However, many modern methods have significant drawbacks. Firstly, plastic is often performed using pathologically altered local tissues. Secondly, there is no single standard in the choice of an implant and a method for eliminating a hernial defect. Third, the implementation of the operative aid on an outpatient basis limits its volume, which increases the risk of relapse. Fourth, the methods of surgical techniques used today often do not correspond to the pathogenetic mechanism of the formation of an umbilical hernia. And, fifthly, modern existing techniques do not meet the cosmetic criteria for preserving the navel. At the same time, there is no objective analysis of various approaches in the treatment of uncomplicated umbilical hernias, which determines the need to search for the most optimal ways to solve this problem.

Known technique of plastics for umbilical hernias according to Sapezhko, which consists in creating a duplication of the aponeurosis in the longitudinal direction (KD Toskin, VV Zhebrovsky. Abdominal hernia. M .: "Medicine", 1983 - S. 168-170). The disadvantage of this method is the high risk of relapse, unsatisfactory cosmetic result due to the large incision. Separation of the aponeurosis from the subcutaneous fat to create a duplication can lead to seromas.

A known method of treating umbilical hernias by applying and fixing a mesh implant over the hernial defect. In this case, after the isolation and reduction of the hernial sac, a mesh is cut out, in size exceeding the hernial orifice by 2-3 cm in all directions, and then fixed outward from the hernial orifice along the perimeter with a continuous suture (Atlas of hernia operative surgery. V.N. Egiev, K. V. Lyadov, P.K. Voskresensky. Medical practice - M., Moscow, 2003 - p. 156). The advantage of the method is its higher reliability compared to plastics with local tissues. The disadvantages are the high risk of seroma formation due to the location of the implant in the subcutaneous fatty tissue, the risk of the implant tearing off with excessive intra-abdominal pressure, and unsatisfactory cosmetic result due to the large incision.

The closest analogue to the claimed invention is a method of plastic surgery for umbilical hernias (RF patent No. 2504337). The method includes access through the umbilicus to the hernial sac, isolation and processing of the latter, exposure and repair of the hernial defect with the creation of a duplication of the aponeurosis using U-shaped polypropylene sutures with simultaneous stitching and attached to the umbilical ring along the circumference of the scar tissue. The advantage of the method is its simplicity, low invasiveness, good cosmetic result in comparison with the above methods, as well as the absence of contact with subcutaneous fat during the operation, which minimizes the risk of wound complications.

The disadvantage of the above method is the high risk of recurrence due to the tension of the edges of the hernial defect, especially in the case of their degradation.

The technical result of the present invention is to improve the results of treatment of patients with umbilical hernias of small and medium size by increasing the strength of the scar through the use of intra-umbilical prosthetics with umbilicoplasty in surgical practice.

To achieve this goal, the Umbilical RING PLASTIC METHOD has been developed, the tasks of which are:

1. Reliable fixation of the mesh endoprosthesis in the subgaleal space, which creates the basis for the formation of a strong connective tissue scar, which will minimize the risk of recurrence.

2. Good cosmetic result.

3. Minimal invasiveness and ease of execution.

4. Low financial costs for the implementation of the methodology.

The method consists in the fact that at first it is performed through the umbilical mini-access. The skin fold at the base (bottom) of the navel (Fig. 1) is clamped between the working jaws of the clamp and holding it in the clamped state, turned inside out and raised above the level of the surrounding skin (Fig. 2).

Then make a circular, bordering clamp, a 1 cm incision, necessarily within the umbilical ring, and with excision of the skin flap (Fig. 3). In order not to cause mechanical damage with wound dilating instrumentation, the skin edges of the resulting access are stitched with four ligatures. They should be located opposite each other (Fig. 4). This allows you to keep the intraoperative wound free and maintain the vitality of the skin.

After the formation of the access in the traditional blunt and sharp way, the hernial sac is isolated. If necessary, it is opened, and the existing contents are immersed in the abdominal cavity. This allows you to safely, under the control of vision, release the cavity of the hernial sac, and resect it at the neck, within healthy tissues. Then the peritoneum is separated along the entire perimeter of the umbilical ring, not exceeding 1 cm (Fig. 5) (Fig. 6).

After that, a flap in the shape of a four-pointed star is cut out of a polypropylene mesh endoprosthesis (Fig. 8), taking into account the shape and size of the formed umbilical ring after the aponeurosis is isolated, increasing the diameter of the central part of the flap (the distance between the bases of opposite "rays") by 2 cm. the implant is fixed with a surgical needle (the end of the beam is fixed in the eye of the needle) by passing the resulting "beams" of the mesh implant under the aponeurosis with the introduction to the anterior surface of the aponeurosis with an indent of one cm at 3, 6, 9, 12 o'clock. By pulling on the indicated "rays" of the mesh implant, the latter is straightened in the subgaleal space. Excess "rays" of the mesh implant are cut off and fixed with a 2-0 prolene suture to the aponeurosis at the sites of their conduction (Fig. 9), (Fig. 10). At the end of the operation, a new navel is formed by imposing an intradermal purse-string suture with a 2-0 absorbable monofilament suture material along the edge of the skin wound, while simultaneously grasping the edge of the umbilical aponeurosis into the suture. When tying a pouch, the skin sinks, imitating the navel.

Brief description of the drawings.

FIG. 1 - umbilical hernia.

FIG. 2 - capture of the skin fold.

FIG. 3 - excision of a skin fold area.

FIG. 4 - holders on the skin.

FIG. 5 - isolation of the hernial sac and aponeurosis.

FIG. 6 is a diagram of the isolation of the aponeurosis.

FIG. 7 - mesh implant pattern.

FIG. 8 - fixation of the implant.

FIG. 9 is a diagram of the fixation of the implant.

FIG. 10 - the formation of the navel.

1 - Skin fold of the umbilical ring.

2 - Subcutaneous fat.

3 - Aponeurosis of the white line of the abdomen surrounding the umbilical ring.

4 - Mesh implant.

5 - Fixing seams.

6 - Distance required for mesh implant placement.

7 - Separation of the peritoneum and aponeurosis.

The advantages of this method of suturing are:

1. Ease of performance of surgical intervention that does not require special training.

2. Reliable fixation of the implant due to its subgaleurotic location. The developed shape of the mesh implant in the form of a four-pointed star allows to prevent the risk of interposition of internal organs between it and the aponeurosis due to the tight fit of the implant along the entire circumference of the umbilical ring.

3. Reducing the invasiveness and duration of surgery allows umbilical hernioplasty to be performed on an outpatient basis, including under local anesthesia.

4. Good cosmetic effect - no postoperative scar.

5. Significant reduction in the cost of surgery compared to the use of umbilical herniosystems.

Clinical example

Patient O., 63, was admitted on 19.02.2018 in a planned manner with an umbilical hernia clinic. Hernia has been carried for 1.5 years, there were no episodes of infringement. Hernial protrusion 2.5 × 2.5 × 1.5 is painless, can be reduced into the abdominal cavity, the skin above it is not changed. From concomitant pathology - hypertension, signs of undifferentiated connective tissue dysplasia of moderate degree according to Smolnova. 02/19/18 under the MCA through the umbilical access according to the method described above, the hernial sac was isolated, opened - containing a strand of the greater omentum, suturing of the peritoneal defect. The preperitoneal space was mobilized along the perimeter of the umbilical ring, not exceeding 1 cm. The diameter of the hernial defect was 1.5 cm. A flap in the form of a four-pointed star was cut out of a polypropylene mesh implant. Taking into account the diameter of the hernial defect, the diameter of the central part of the obtained mesh implant flap was 3.5 cm. Further, the resulting flap was fixed using a surgical needle by passing the obtained “rays” of the mesh implant along the edges of the aponeurosis with an indent of 1 cm. In 3, 6, 9 and 12 hours. After pulling up the indicated "rays" of the mesh implant, the latter was fixed with a 2-0 prolene suture to the aponeurosis of the umbilical ring at the sites of their conduction. The operation was completed by shaping a new navel by placing a purse-string suture with Maxon 2-0 suture material on the edges of the skin wound with suturing to the edge of the umbilical ring. When tying the pouch, the skin sank, imitating the navel. The patient was discharged in satisfactory condition on the third day. The purse-string was not removed from the skin. Examined after 18 months. He has no complaints, notes a good cosmetic result, there is no recurrence of hernia.

Claims (1)

The method of plasty of the umbilical ring for umbilical hernias, including the implementation of a trans-umbilical mini-approach, an incision with a diameter of 1 cm within the umbilical ring with excision of a skin flap, isolation or cutting off of the hernial sac and immersion into the abdominal cavity, separation of the peritoneum from the aponeurosis along the entire perimeter of the umbilical ring at a distance 1 cm, fixation of the implant to the aponeurosis, the formation of a new navel by applying a purse-string suture with an absorbable monofilament suture material, characterized in that a mesh endoprosthesis in the form of a four-pointed star is used as an implant, which is placed under the aponeurosis and fixed with a surgical needle, fixing the end of the beam in the eye of the needle, by holding the received rays of the mesh endoprosthesis under the aponeurosis with the withdrawal to the anterior surface of the aponeurosis with an indentation of 1 cm at 3, 6, 9, 12 hours, the endoprosthesis is straightened in the subgaleal space by pulling the indicated rays, after which the excess rays of the endo the prosthesis is cut off and fixed with a prolene thread to the aponeurosis of the umbilical ring.

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