RU2758557C1 - Method for fixing composite mesh endoprostheses in laparoscopic intra-abdominal parastomal hernia repair - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery, herniology. The endoprosthesis is fixed with spiral endoclips along the perimeters of the hernial defect and the endoprosthesis to be repaired. Spiral endoclips are placed at a distance of 3 diameters of clips from the edges of the endoprosthesis and at a distance of 5 diameters from each other along the fixation line.

EFFECT: method improves the reliability of fixation, reduces the risk of recurrence of parastomal hernia, eliminates the likelihood of displacement and detachment of the endoprosthesis from the anterior abdominal wall, prevents the development of implant shear syndrome, and also prevents intestinal loops from getting between the abdominal wall and the endoprosthesis.

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Description

The proposed invention relates to medicine, namely to surgery, and can be used in the treatment of patients with parastomal hernia for fixation of composite mesh endoprostheses in laparoscopic intra-abdominal hernia repair.

An intestinal stoma is often necessary to drain intestinal contents during surgery for rectal cancer, Crohn's disease, or ulcerative colitis. After operations of this kind, due to the weakening of the abdominal wall in the stoma area, a hernia may develop [1]. For the treatment of parastomal hernias, it is proposed to use synthetic mesh endoprostheses designed to strengthen the abdominal wall. Implantation of this category of products is performed in the area of the hernial defect, that is, in the area of the enlarged stomal canal, and can be performed both extraperitoneally between the layers of the anterior abdominal wall, and intraperitoneally with direct contact with the abdominal organs [2]. Plasty of parastomal hernias with transabdominal mesh placement has theoretical advantages over traditional open interventions, since the same intra-abdominal forces responsible for protrusion of the hernia, in this case, contribute to the best fixation of the implant [3].

This type of plastic is performed using multilayer synthetic mesh endoprostheses, one of the layers of which is an inert synthetic base, and the other is made of a resorbable material with antiadhesive properties. As a rule, the underlying layer is biologically inert, has greater strength, and has a cellular structure necessary for tissue germination. The second layer serves as an anti-adhesive barrier, which reduces the likelihood of development and the severity of the adhesion process.

When performing intraperitoneal laparoscopic hernioplasty for parastomal hernia, the “Keyhole” technique is used, a feature of which is the use of composite endoprostheses specially designed for this purpose with a hole in the center, designed to hold a segment of the intestine carrying a stoma [4].

Several methods are known for fixing the above-mentioned composite mesh endoprostheses with an opening for the intestine carrying the stoma during intra-abdominal implantation for parastomal hernia.

There is a way to fix the endoprosthesis using transmural sutures. In this case, after the introduction and positioning of the endoprosthesis in the abdominal cavity, 5 mm long incisions are made on the skin of the anterior abdominal wall, through which the device is fixed with suture material with the capture of all layers of the abdominal wall. The frequency and localization of sutures in relation to the bowel loop carrying the stoma is at the discretion of the surgeon [5]. This method of fixing an endoprosthesis for parastomal hernia repair has the following disadvantages:

- a significant increase in the operation time;

- the presence of additional incisions in the skin of the anterior abdominal wall in the immediate vicinity of the intestinal stoma, the imposition of transmural sutures for positioning the mesh, the risk of damage to the bowel loop that carries the stoma when the needle is passed increase the likelihood of developing infectious complications in the implantation zone;

- severe and prolonged pain syndrome;

- a significant risk of developing hematomas of the anterior abdominal wall;

- lack of standardization of the methodology.

Known laparoscopic method of fixing mesh endoprostheses for plastics of postoperative ventral hernias "double crown technique" - the technique of "double crown", in which endoclips fixing the endoprosthesis to the anterior abdominal wall are not randomly placed, but along the perimeters of the hernial defect and the endoprosthesis to be repaired [6]. However, this technique has been developed and is used only for fixation of the endoprosthesis in the repair of postoperative ventral hernia. In addition, when using this method, the order of application and the location of the fixing elements is not taken into account, which not only means the lack of standardization, but in some cases leads to excessive use of fixing elements, the creation of overstress in the main material of the implant, or, on the contrary, insufficiently reliable fixation of the endoprosthesis and as a result of its separation from the anterior abdominal wall.

It is known that in a number of branches of mechanical engineering, for example, in aircraft and shipbuilding, as well as when connecting metal products with non-metallic materials, such a method of joining elements as riveting is used. At the same time, depending on the functional purpose, when connecting thin metal sheets, single-row, two-row and multi-row types of riveted seams or options for the location of rivets are used. According to the basic rules of riveting, the centers of the rivets should be located on straight lines, parallel and perpendicular to the axis of the structure to be fixed. The distance between the rivets in the joint, as well as the distance from the edge of the joint to the rivet axis, is selected depending on the type of joint. So, when forming a single-row rivet seam, the distance between the axes of the fixing elements (the step of placing the fixing element) can be equal to five diameters of the rivet (5d), and the distance from the center of the rivet to the edge of the product can be equal to three diameters of the rivet 3d [7]. These parameters are determined by the strength conditions of the elements to be joined, as well as by the need for the fixed components not to lose stability in the gap between the rivets, and the parts stretched between them are sufficiently firmly connected. However, as mentioned above, the described connection method was developed and used primarily in mechanical engineering. The endoprosthesis and the anterior abdominal wall, like the combination of metal and non-metal parts, are heterogeneous in structure. Endoclips, like rivets, are fixing elements and when placing them, it is also necessary to take into account the requirements of strength and transfer of force from the abdominal wall to the endoprosthesis.

The objective of the invention is to improve the method for fixing an endoprosthesis in intra-abdominal laparoscopic repair of a parastomal hernia using the Keyhole method.

The technical result consists in increasing the reliability of fixation, which helps to reduce the risk of recurrent parastomal hernia and the occurrence of infectious complications associated with fixation of the endoprosthesis caused by its possible displacement or separation from the anterior abdominal wall, damage to the section of the intestine carrying the stoma, during the imposition of transmural sutures, reduction total operation time, using the optimal number of fixing elements.

The technical result is achieved by the fact that in the method of fixing composite mesh endoprostheses in laparoscopic intra-abdominal repair of a parastomal hernia, including fixing the endoprosthesis with spiral endoclips along the perimeters of the hernial defect and endoprosthesis to be repaired, spiral endoclips are placed at a distance of 3 diameters of the clips from each endoprosthesis edges and 5 friend along the line of fixation.

Preferably, endoclips with a spiral diameter of 4 mm and a height of 3.8 mm are used.

The proposed method is illustrated by graphic materials.

Fig. 1 is a diagram of the location of fixing endoclips (1) on a composite endoprosthesis (2) with an opening for a segment of the intestine carrying a stoma (3) during laparoscopic intra-abdominal repair of a parastomal hernia using the Keyhole method.

The method is carried out as follows.

After creating a carboxyperitoneum using a Veress needle, three trocars are placed in one line opposite the stoma and the parastomal hernia itself (optical port and two manipulators). Then the revision of the abdominal cavity and adhesiolysis are performed, the parastmoal defect and the loop of the intestine carrying the stoma are identified. Depending on the size of the stomal canal, in some cases it is sutured using 2-3 transmural sutures. Then, through one of the trocars, the previously prepared endoprosthesis is inserted into the abdominal cavity. The endoprosthesis is positioned in such a way that it encloses the segment of the intestine and also overlaps the parastomal aperture by 5 cm, after which the implant is fixed with the Covidien ProTack endoherniostepler. This device is widely used in endovideosurgery and is preloaded with thirty titanium spiral non-absorbable endoclips with a spiral diameter of 4 mm and a height of 3.8 mm. The first step is to fix the endoprosthesis with spiral endoclips along the perimeter, retreating at a distance of three diameters of the spiral clip from its outer edge. The distance between the fixing elements (the step of placing the endoclips) is set equal to 5 diameters of the endoclips. The next step is to form the stoma canal, while using the Covidien ProTack herniostepler, spiral endoclips are placed along the perimeter of the intestine supporting the stoma, retreating from it at a distance equal to three diameters of the fixing element. The distance between the fixing elements (the step of placing the endoclips) is set equal to 5 diameters of the endoclips.

This fixation method has been successfully introduced into clinical practice when performing laparoscopic parastomal hernia repair and is illustrated by an example.

Clinical example.

Patient G., 58 years old, was hospitalized routinely with a diagnosis of large irreducible parastomal hernia type III according to the classification of the European Society of Coloproctology. In 2018, after a course of preoperative chemotherapy, the patient underwent laparoscopic abdominal-perineal rectal extirpation for pT3N0M0G2 rectal cancer with the formation of an intraperitoneal unilateral sigmoidostomy in the left iliac region. No adjuvant chemotherapy was given. 7 months after the operation, she noted the appearance of a hernial protrusion in the area of the sigmostoma. Subsequently, the hernia increased in size, there were several episodes of severe pain in the stoma area, and difficulties in fixing the colostomy bag were noted. At the time of hospitalization, the patient was suffering from hypertension of the 1st degree, 2nd stage, risk 1. According to laboratory and instrumental studies, no information for the progression of the oncological process was revealed. Colonoscopy revealed no organic pathology. In a planned manner, laparoscopic parastomal hernia repair was performed using a Parietex Composite Parastomal mesh endoprosthesis with a diameter of 15 cm, fixed with a Covidien Protack endogerniostepler according to the Keyhole technique using the claimed method. After the creation of carboxyperitoneum using a Veress needle, three trocars were installed in one line opposite the stoma and the parastomal hernia itself (optical port and two manipulators). A revision of the abdominal cavity and adhesiolysis were performed, and a parastomal defect and a bowel loop carrying the stoma were identified. The diameter of the parastomal (hernial) defect was 6 cm and its suturing using transmural sutures was not performed. Then, through the optical port, a pre-prepared endoprosthesis with a diameter of 15 cm is inserted into the abdominal cavity, which has an opening for a segment of the intestine carrying a stoma with a diameter of 3.5 cm. endogerniostepler Covidien Protack with spiral non-absorbable endoclips with a spiral diameter of 4 mm and a height of 3.8 mm, retreating 12 mm from the outer edge, after 20 mm, the endoprosthesis was fixed along the perimeter. A total of 19 endoclips were spent. Using a Covidien ProTack herniostepler, the endoprosthesis was fixed along the perimeter of the intestine carrying the stoma, at a distance of 12 mm after 20 mm. A total of 9 endoclips were used. A thorough revision of the zone of formation of the new stoma canal was performed - no damage or compression of the segment of the intestine carrying the stoma with the mesh implant was found. Installed trapping drainage in the small basin. The carboxyperitoneum was eliminated, the wounds were sutured with intradermal sutures. The postoperative period was uneventful. She was discharged in satisfactory condition. Examined after three months. There were no data for hernia recurrence, the stoma is functioning, there are no phenomena of leakage of intestinal contents past the colostomy bag, evacuation of intestinal contents is free. During digital revision of the colostomy, the inner edge of the endoprosthesis is not determined, there is no data for the migration of the endoprosthesis, perforation of the segment of the intestine supporting the stoma.

The proposed method for laparoscopic fixation of the endoprosthesis uses the principles of forming the imposition of riveted sutures. This arrangement of the endoclips determines the strength of fixation, sufficient density and compactness of the connection, and at the same time excludes the creation of overstrain in the material of the endoprosthesis. The use of the method increases the reliability of fixation, reduces the risk of recurrence of parastomal hernia, eliminates the likelihood of displacement and separation of the endoprosthesis from the anterior abdominal wall, prevents the development of implant shear syndrome, and also prevents intestinal loops from getting between the abdominal wall and the endoprosthesis.

Sources of information

1. Hotouras A. et al., The persistent challenge of parastomal herniation: a review of the literature and future developments // Colorectal Disease. - 2013. - T. 15. - No. 5. - S. e202-e214.

2. Hansson, Birgitta ME, et al., "Surgical techniques for parastomal hernia repair: a systematic review of the literature." Annals of surgery 255.4 (2012): 685-695. Faylona J. M. V. Invited comment to: European Hernia Society guidelines on prevention and treatment of parastomal hernias // Hernia. - 2018. - T. 22. - No. 1. - S. 203-203.

3. LeBlanc K.A., Kingsnorth A., Sanders D.L. (ed.). Management of abdominal hernias. - Springer, 2018.

4. Hansson B. M. E., Bleichrodt R. P., De Hingh I. H. Laparoscopic parastomal hernia repair using a keyhole technique results in a high recurrence rate // Surgical endoscopy. - 2009. - T. 23. - No. 7. - S. 1456-1459.

5. DeAsis, Francis J., et al., "Current state of laparoscopic parastomal hernia repair: a meta-analysis." World journal of gastroenterology: WJG 21.28 (2015): 8670.

6. Morales-Conde S. et al., Laparoscopic ventral hernia repair without sutures - double crown technique: our experience after 140 cases with a mean follow-up of 40 months // International surgery. - 2005. - T. 90. - No. 3 Suppl. - S. S56-62.

7. Mukhanov K.K. Design of steel structures // Mukhanov K.K. Moscow: State Publishing House of Literature on Building Architecture. - 1956 .-- 382 p.

Claims (2)

1. A method of fixing composite mesh endoprostheses in laparoscopic intra-abdominal plastics of a parastomal hernia, including fixing the endoprosthesis with spiral endoclips along the perimeters of the hernial defect to be repaired and the endoprosthesis, characterized in that the spiral endoclips are placed at a distance of 3 clip diameters from the edges of the endoprosthesis diameter and at a distance of 5 along the line of fixation. 2. The method according to claim 1, characterized in that endoclips with a spiral diameter of 4 mm and a height of 3.8 mm are used.

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