RU2772220C1 - Method for treatment of postoperative ventral hernias after operations by kocher approach - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely surgery, hernioplasty. The old postoperative scar is excised. A hernial sac is isolated and immersed into the abdominal cavity without opening. Aponeurosis of the external oblique abdominal muscle and the anterior leaf of the rectus sheath are separated from the underlying tissues by up to the 9^th rib. Next, a mesh prosthesis 10 cm long and 5 cm wide is placed under the aponeurosis of the external oblique abdominal muscle. The lower edge of the prosthesis and the sides are fixed with nodular sutures to the aponeurosis of the internal oblique abdominal muscle. The remaining upper edge of the prosthesis is fixed with nodular sutures to the external intercostal muscle, after which nodular sutures are applied to the anterior leaf of the rectus sheath and aponeurosis of the external oblique abdominal muscle.

EFFECT: method makes it possible to reliably eliminate the defect of the anterior abdominal wall, preserve the full function of the anterior abdominal wall, reduce the frequency of relapses, improve the processes of tissue regeneration in the field of plastic surgery, improve the quality of life of patients in the postoperative period.

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Description

The invention relates to the field of medicine, namely surgery, and can be used in the surgical treatment of postoperative hernias after operations with a Kocher incision.

The increase in the number of laparotomies and the expansion of the volume of surgical interventions on the abdominal organs has led to a large number of postoperative hernias due to violations of the anatomical and physiological integrity of the abdominal wall. It is known that after Kocher's laparotomy on the right, performed for acute calculous cholecystitis and operations in the right half of the abdomen, there is a high risk of postoperative hernia in the area of surgical intervention. Factors such as excessive physical activity on an unformed postoperative scar, advanced age, as well as concomitant diseases (hypoproteinemia, vitamin deficiency, diabetes mellitus, etc.) can change the normal process of wound regeneration. With age, patients develop flabbiness and muscle atrophy, aponeurosis and fascia of the abdomen lose strength. Undoubtedly, all these factors can lead to disruption of normal wound healing and the formation of postoperative hernias.

Known methods of hernioplasty of postoperative hernias of the anterolateral wall of the abdomen.

A method for reconstructing the lateral wall of the abdomen in postoperative hernia, including plasty with local tissues, characterized in that the muscles of the lateral wall of the abdomen are separated, the transverse fascia and muscle, the internal oblique muscle of the abdomen are sutured by gathering, without tension, a polypropylene explant is laid and fixed over the internal oblique muscle of the abdomen from the lower edge of the costal arch to the iliac crest and from the Spigel line to the longitudinal muscles of the back and lumbar muscles, the external oblique muscle of the abdomen is sutured and collected without tension. [A method for reconstructing the lateral wall of the abdomen in postoperative hernia. Authors: Alekseev A.K., Yurasov A.V. RU 2325856 C1, publication date 06.10.2008]

The method of combined tension-free hernioplasty for medium, large and giant postoperative ventral hernias, including the formation of a combined layer by stitching the parietal peritoneum with the edge of the greater omentum, an endoprosthesis is fixed over the formed layer, the edges of which are also fixed under the edge of the aponeurosis on both sides. The flap of the hernial sac is fixed over the mesh with single sutures. The edges of the aponeurosis are not sutured together, but are sutured in two rows of sutures on both sides to a hernial sac flap fixed over a mesh endoprosthesis. [The method of combined tension-free hernioplasty for medium, large and giant postoperative ventral hernias. Authors: Tarasenko S.V., Aftaev V.B., Natalsky A.A., Zaitsev O.V., Peskov O.D., Fedorov O.V., RU 2653816С1, publication date 14.05.2018]

The disadvantages of the methods are:

- lack of consideration of biomechanical and topographic anatomical aspects of the state of the anterior abdominal wall. All this leads to the restriction of the anterior abdominal wall in the performance of the physiological mechanism of the act of breathing.

- violation of the innervation of the muscles, due to their extensive mobilization.

As a prototype, we took the method of plastic surgery of the anterior abdominal wall in primary and recurrent postoperative ventral hernias of lateral and anterolateral localizations [Belokonev V.I., Gulyaev M.G. RU 2571008C2, publication date 12/20/2015]. To strengthen the hernia ring, two synthetic prostheses are used - one is installed in the sublay position and fixed along the large and small perimeters with interrupted and continuous sutures, the second prosthesis, cut with an excess of 3-4 cm relative to the defect, is installed in the onlay position and is also fixed along the large and small perimeters with continuous and nodal seams.

The disadvantages of the prototype are:

- the possibility of prosthesis migration, due to the absence of strong aponeurotic and tendon formations in the lateral sections of the abdominal wall, necessary for fixing the endoprosthesis

- due to the lack of a strong fixation of the endoprosthesis to the anatomical structures, this plasty does not always eliminate the weakness of the lateral wall of the abdomen

- because the area of explants is extensive, the frequency of development of complications in the form of gray increases.

That is why at present the problem of developing new methods of operations, preventing complications after hernia repair remains relevant.

The proposed invention is aimed at improving the results of surgical treatment of incisional hernias after operations using the Kocher approach.

The specified technical result is achieved in the invention by the fact that after excision of the old postoperative scar, dissection of the subcutaneous tissue, isolation of the hernial sac from scar adhesions, immersion of the latter into the abdominal cavity without opening, characterized in that a mesh prosthesis is used, 10 cm long and 5 cm wide, the aponeurosis of the external oblique muscle of the abdomen and the anterior leaf of the sheath of the rectus abdominis muscle are separated from the underlying tissues up to the 9th rib, then the mesh prosthesis is placed under the aponeurosis of the external oblique muscle of the abdomen, and the lower edge of the prosthesis and the sides are fixed with interrupted sutures to the aponeurosis of the internal oblique muscle of the abdomen, and the remaining the upper edge of the prosthesis is fixed with interrupted sutures to the external intercostal muscle, after which interrupted sutures are applied to the anterior leaf of the sheath of the rectus abdominis muscle and the aponeurosis of the external oblique abdominal muscle.

The above features contribute to improving the reliability of plasty and maintaining the full physiological functions of the anterior abdominal wall.

The proposed method of surgical treatment of postoperative hernias, in addition to the reconstruction of the anterior abdominal wall, provides for the preservation of the full function of the anterior abdominal wall and allows it to effectively participate in the breathing process.

The stated essence of the invention is illustrated by drawings, where:

Fig. 1 - separation of the aponeurosis of the external oblique muscle of the abdomen and the anterior leaf of the sheath of the rectus muscle to the 9th rib, where

1. Hernial defect

2. Rib

3. External oblique abdominal muscle

4. Aponeurosis of the internal oblique muscle of the abdomen

5. Aponeurosis of the external oblique muscle of the abdomen

6. External intercostal muscle

7. Posterior leaf of the sheath of the rectus abdominis muscle

8. White line of the abdomen

9. Subcutaneous fat

10. Skin.

- Fig. 2 - cutting out a mesh endoprosthesis of a trapezoidal shape.

- Fig. 3 - fixation of the lower edge of the prosthesis and the sides to the aponeurosis of the internal oblique muscle of the abdomen and the upper edge of the prosthesis to the external intercostal muscle of the 9th rib with interrupted sutures.

- Fig. 4 - suturing the aponeurosis of the external oblique muscle of the abdomen and the anterior leaf of the sheath of the rectus abdominis muscle with interrupted sutures, the final view of the plasty.

Our proposed method has been successfully tested in the surgical department of the National Healthcare Institution Departmental Hospital at Astrakhan-1 Station of Russian Railways, in 12 patients. Below are the test results.

Example #1. Patient D. 47 years old Astrakhan-1 JSC "Russian Railways" with a diagnosis of postoperative ventral hernia. From the anamnesis: Cholecystectomy on July 17, 2019. 4 months after the operation, he noted the presence of a hernial protrusion in the projection of the postoperative scar, which gradually increased in size. Examined, admitted for planned surgical treatment.

06/18/2020 - under endotracheal anesthesia, an old postoperative scar in the right hypochondrium was excised, a hernial sac 7 × 6 × 4 cm was found in the subcutaneous fat and separated from the cicatricial adhesions, the latter was not opened, immersed in the abdominal cavity. The abdominal wall defect was 4 cm, sutured with 4 interrupted sutures. The aponeurosis of the external oblique muscle of the abdomen and the anterior leaf of the sheath of the rectus abdominis muscle are separated from the underlying tissues up to the 9th rib (see Fig. 1). Mesh trapezoidal prosthesis 10 cm long and 5 cm wide, placed under the aponeurosis of the external oblique muscle of the abdomen. The lower edge of the prosthesis and the sides are fixed to the aponeurosis of the internal oblique abdominal muscle with interrupted sutures, and the remaining upper edge of the prosthesis is fixed with interrupted sutures to the external intercostal muscle (see Fig. 3). Interrupted sutures were placed on the aponeurosis of the external oblique muscle of the abdomen and the anterior leaf of the sheath of the rectus muscle, while the mesh prosthesis is located under the aponeurosis (see Fig. 4). Layer-by-layer stitches on the wound. Aseptic bandage.

The patient is allowed to get up on the second day. The patient was discharged on the 10th day. At control examinations after 3, 6, 12 months and 2 years, there is no pain, no signs of recurrence, the function of the anterior abdominal wall is not impaired.

Example #2. Patient V., aged 53, was admitted to the o/o NUZ Departmental hospital at Astrakhan-1 station of Russian Railways with a diagnosis of postoperative ventral hernia. From the anamnesis: Cholecystectomy on February 13, 2019. Three months after the operation, he noted the presence of a hernial protrusion in the projection of the postoperative scar, which gradually increased in size. Examined, admitted for planned surgical treatment.

04/17/2020 - under endotracheal anesthesia, an old postoperative scar in the right hypochondrium was excised, a hernial sac 8 × 7 × 6 cm was found in the subcutaneous fat and separated from cicatricial adhesions, the latter was not opened, immersed in the abdominal cavity. The abdominal wall defect was 4 cm, sutured with 3 interrupted sutures. The aponeurosis of the external oblique muscle of the abdomen and the anterior leaf of the sheath of the rectus abdominis muscle are separated from the underlying tissues up to the 9th rib (see Fig. 1). Mesh trapezoidal prosthesis 10 cm long and 5 cm wide, placed under the aponeurosis of the external oblique muscle of the abdomen. The lower edge of the prosthesis and the sides are fixed to the aponeurosis of the internal oblique abdominal muscle with interrupted sutures, and the remaining upper edge of the prosthesis is fixed with interrupted sutures to the external intercostal muscle (see Fig. 3). Interrupted sutures were placed on the aponeurosis of the external oblique muscle of the abdomen and the anterior leaf of the sheath of the rectus muscle, while the mesh prosthesis is located under the aponeurosis (see Fig. 4). Layer-by-layer stitches on the wound. Aseptic bandage.

The patient is allowed to get up on the second day. The patient was discharged on the 10th day. At control examinations after 3, 6, 12 months and 2 years, there is no pain, no signs of recurrence, the function of the anterior abdominal wall is not impaired.

The proposed method improves the results of surgical treatment of patients with incisional hernias after operations with a Kocher incision, namely:

- reliable elimination of the defect of the anterior abdominal wall;

- preservation of the full function of the anterior abdominal wall;

- reducing the frequency of relapses;

- improving the quality of life of patients in the postoperative period;

These features of the operation are conditions that improve both the processes of tissue regeneration in the field of plastic surgery and the results of the operation as a whole, helping to reduce the risk of postoperative complications and improve the quality of life of patients.

The developed method can be widely used in the practical work of surgical departments.

Claims (1)

A method for the treatment of postoperative ventral hernias after operations using the Kocher approach, which includes excision of the old postoperative scar, dissection of the subcutaneous tissue, isolation of the hernial sac from scar adhesions, immersion of the latter without opening into the abdominal cavity, characterized in that a mesh prosthesis is used, 10 cm long and 5 cm wide, the aponeurosis of the external oblique muscle of the abdomen and the anterior leaf of the sheath of the rectus abdominis muscle are separated from the underlying tissues up to the 9th rib, then the mesh prosthesis is placed under the aponeurosis of the external oblique muscle of the abdomen, and the lower edge of the prosthesis and the sides are fixed with interrupted sutures to the aponeurosis of the internal oblique muscle abdomen, and the remaining upper edge of the prosthesis is fixed with interrupted sutures to the external intercostal muscle, after which interrupted sutures are applied to the anterior leaflet of the vagina of the rectus abdominis muscle and the aponeurosis of the external oblique abdominal muscle.

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