RU2796319C1 - Method of surgical treatment of parastomal hernias - Google Patents

Abstract

FIELD: medicine; coloproctology.

SUBSTANCE: invention is used in the surgical treatment of parastomal hernias. The hernial sac is opened and a segment of the intestine carrying the stoma is mobilized. The aponeurosis of the rectus abdominis muscle and the external oblique abdominal muscle is dissected along the entire circumference of the hernial orifice. In the avascular zone, the transverse abdominal muscle and the internal oblique abdominal muscle are separated. The aponeurosis of the internal oblique abdominal muscle is cut off from the aponeurosis of the transverse abdominal muscle upward to the edge of the costal arch, and downward — to the internal inguinal opening. Then the rectus abdominis muscle is separated from the posterior leaf of its vagina upwards to the previously planned place for the removal of the intestinal stoma. An incision is made in the skin, the anterior leaf of the sheath of the rectus muscle, and the muscle fibers are separated by a clamp in the vertical direction. On the anterior axillary line at the costal arch, the fibers of the transverse abdominal muscle are bred in the horizontal direction, and then the intra-abdominal fascia and peritoneum are dissected over an extent equal to the width of the mobilized intestine with the adjacent mesentery. Through the formed hole, the intestine carrying the stoma is passed. It is passed into the space between the transverse abdominal muscle and the internal oblique muscle of the abdomen, and then through the retromuscular space through the previously created hole in the rectus abdominis muscle to the skin of the anterior abdominal wall. The aponeurosis is sutured, restoring the semilunar line, a mesh implant is placed instead of the hernial ring. The wound is sutured in layers and a new intestinal stoma is formed.

EFFECT: method allows to avoid the formation of adhesions between the implant and intestinal loops, reducing the risk of recurrence by maintaining the integrity of the posterior leaf of the aponeurosis of the rectus and transverse abdominal muscles.

1 cl, 1 ex

Description

The invention relates to medicine, namely to colorectal surgery, and can be used for the treatment of parastomal hernias.

Despite the dynamic development of colorectal surgery and the introduction of sphincter-preserving methods of surgical treatment, in 11% of patients with colorectal cancer (CRC), operations end with the formation of a permanent colostomy. The main late complication of permanent terminal intestinal stoma is parastomal hernia (PSH) with a development rate of about 50%. According to specialized literature, up to about half of PSG occurs within the first 2 years after surgery, while the risk of hernia development remains high for 20 years after surgery.

Indications for surgical treatment of PSG are complications (infringement, necrosis, obstruction), violation of its function, impossibility or significant difficulties in caring for the stoma.

Currently, several options for the treatment of complicated stoma are used in surgical practice, which can be divided into stoma reconstruction with transfer to a new location or leaving it in the same place. To improve the results of the treatment of parastomal hernias, you can use the following methods:

• hernia repair with plasty of the hernial orifice with local tissues.

• hernia repair with the transfer of the intestinal stoma to another location.

• hernia repair with hernia orifice plasty with a mesh endoprosthesis (Shugebaker operation).

• The method of forming an extraperitoneal colostomy.

Operations with hernia orifice plasty with local tissues are accompanied by a high recurrence rate of 45-100%, and are currently recognized as ineffective.

An alternative to hernioplasty with local tissues is the operation of transposition (transfer) of the intestinal stoma. The tissue defect at the site of the previously located stoma with parastomal hernia is sutured in layers, additional reinforcement with a mesh implant is possible. But even in this case, the probability of developing a hernia in a new place without the use of mesh implants is 50-76%. In addition, there is a risk of hernia in the area of the laparotomic wound.

Taking into account the high risks of hernia recurrence, a number of methods of hernia repair with hernia ring plasty with a mesh implant have been proposed, reducing the likelihood of hernia recurrence to 5-15%. One of these options for surgical treatment is the P. Sugarbaker operation and its modifications. They consist in closing a parastomal defect in the anterior abdominal wall by applying a mesh implant from the side of the abdominal cavity in such a way that the course of the intestine carrying the stoma runs parallel to the anterior abdominal wall. However, with large and giant parastomal hernias, the operation cannot be performed due to extensive deformation of the anterior abdominal wall. The P. Sugarbaker method showed the greatest effectiveness as a method of prevention, rather than treatment of PSG.

Taking into account the fact that the above methods have significant drawbacks, the search and development of new methods of surgical treatment is constantly underway.

The prototype of the proposed method of treatment is a combined method for the treatment of PSG, which was proposed by A.A. Ibatullin and co-authors. The method is carried out as follows: a bordering incision around the stoma cuts the skin and subcutaneous fatty tissue to the hernial sac. The hernial sac is opened, the contents are pushed into the abdominal cavity. After that, a channel is formed in the preperitoneal tissue from the border of the middle and lower third of the descending colon to the mouth of the hernial sac, through which the sigmoid colon and the lower third of the descending colon are passed. The hernial orifice, depending on the size, is either sutured to the size of the intestine, or, if large, is reinforced with a polypropylene mesh with a hole in the center through which the intestine is brought to the anterior abdominal wall. The disadvantages of the method include a significant deformation of the left half of the anterior abdominal wall, which causes a shift in the previously planned place for the removal of a new intestinal stoma, leading to difficulties in caring for the stoma and a decrease in the quality of life.

The purpose of the invention:

- improve the results of surgical treatment of PSH by reducing the risk of its recurrence, as well as creating optimal conditions for care.

This goal is achieved by performing a hernia repair with parastomal access, isolating the intestine carrying the stoma, additionally mobilizing it for at least 20 cm, making an incision in the aponeurosis of the rectus and external oblique muscles 1 cm away from the edge of the hernial orifice, entering the space between the internal oblique and transverse abdominal muscle and produce their separation in the avascular zone to the costal arch along the anterior or middle axillary line. Then, the aponeurosis of the transverse abdominal muscle is cut off from the aponeurosis of the internal oblique muscle of the abdomen along the semilunar line and enters the retromuscular space of the rectus abdominis muscle. In this case, the stomal canal is formed in the avascular space between the internal oblique and transverse abdominal muscles, as well as between the posterior leaf of the sheath of the rectus abdominis muscle and the rectus abdominis muscle itself. Through an additional hole in the transverse abdominal muscle along the anterior axillary line at the edge of the costal arch, a mobilized segment of the intestine is passed, which is brought out through the rectus abdominis muscle to the anterior abdominal wall. The aponeurosis of the transverse abdominal muscle is sutured with single sutures to the aponeurosis of the internal oblique muscle, thus isolating the newly created stomal canal with the intestine placed in it, carrying the stoma from the hernioplasty area. Then the integrity of the muscular aponeurotic structures in the area of the parastomal hernia is restored in layers.

Operation technique:

In the preoperative period, the place of removal of the terminal intestinal stoma is marked on the skin, in the place most convenient for fixing the colostomy bag and direct visual control of the stoma by the patient. In the horizontal direction, an elliptical, bordering skin incision around the stoma with a length of at least 10 cm is performed. The hernial sac is opened and a segment of the intestine carrying the stoma with a length of at least 20 cm is additionally mobilized. Departing from the edge of the hernial orifice by 1 cm, a dissection is made around the entire circumference of the hernial orifice aponeurosis of the rectus abdominis and external oblique abdominal muscles. Visualize the transverse abdominal muscle, the place of attachment of the aponeurosis of the internal oblique muscle along the semilunar line and the posterior leaf of the aponeurosis of the rectus abdominis muscle. In the avascular zone, the transverse abdominal muscle and the internal oblique abdominal muscle are sharply separated, the aponeurosis of the internal oblique abdominal muscle is cut off from the aponeurosis of the transverse abdominal muscle upward to the edge of the costal arch, and downward - to the internal inguinal opening. In an acute way, the rectus abdominis muscle is separated from the posterior leaf of its vagina up to the place of the previously planned place for the removal of the intestinal stoma in a new place. An incision is made in the skin, the anterior leaf of the sheath of the rectus muscle, and the muscle fibers are separated by a clamp in the vertical direction without crossing them. Along the anterior axillary line near the costal arch, the fibers of the transverse abdominal muscle are bred with a clamp in the horizontal direction, and then the intra-abdominal fascia and peritoneum are dissected over an extent equal to the width of the mobilized intestine with the adjacent mesentery without compression. The intestine carrying the stoma is passed through the formed hole, it is passed into the space between the transverse abdominal muscle and the internal oblique muscle of the abdomen, and then through the retromuscular space through the previously created hole in the rectus abdominis muscle to the skin of the anterior abdominal wall. With a continuous suture, along the floor of the lunar line, in the direction from top to bottom, the posterior leaf of the vagina of the rectus muscle is fixed throughout its entire length to its anterior leaf to the edge of the hernial ring. In the hernial orifice, the peritoneum and the internal oblique muscle are sutured with a continuous suture, over which a mesh implant is placed. The wound is sutured in layers.

Thus, the proposed method allows to eliminate the existing parastomal hernia, to form a new intestinal stoma with the implementation of additional preventive measures and minimal material costs, to avoid the formation of adhesions between the implant and intestinal loops.

Clinical example:

Patient N was admitted with complaints of a hernia-like protrusion around a single-barrel sigmostoma up to 12 cm in diameter, redness and weeping around the stoma, the impossibility of reliable fixation of the colostomy bag, and the need to replace it at least 3 times a day.

During physical and clinical-instrumental examination, it was found that the stoma is located lateral to the Spigellian line, there are deforming scars around the stoma and signs of severe peristomal dermatitis. The size of the parastomal hernia is 12 cm, the defect of the musculoaponeurotic layer reaches the mid-axillary line, the inner edge of the hernial orifice is the outer edge of the left rectus abdominis muscle.

According to the clinical and instrumental examination, the patient was diagnosed with a single-barrel sigmostoma complicated by parastomal hernia and peristomal dermatitis.

The patient underwent surgery by the proposed method. The postoperative period proceeded without complications. There was no pronounced pain syndrome. Postoperative wounds healed by primary intention. The stoma functions well from the 2nd day after the operation, the colostomy bag is hermetically held on the front wall of the abdomen for at least 2 days. Was discharged on the 12th day.

The observation period was 1 year. There are no data for hernia recurrence, there are no signs of peristomal dermatitis. She does not experience any difficulties in caring for the stoma, notes the possibility of using any model of the colostomy bag. The latter is kept on the front wall of the abdomen for at least 3 days, even with physical exertion.

The proposed method, compared with the known methods of surgical treatment of PSG, makes it possible to:

• liquidate PSG;

• to form a new stoma in a place convenient for care;

• reduce the number of relapses of PSG,

• reduce the risk of complications.

Bibliography:

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Claims (1)

A method for surgical treatment of parastomal hernia, including hernia repair by parastomal access and transposition of the intestinal stoma, characterized in that the hernial sac is opened and a segment of the intestine carrying the stoma is mobilized, then, stepping back from the edge of the hernial orifice, the aponeurosis of the rectus abdominis muscle is dissected around the entire circumference of the hernial orifice and external oblique muscle of the abdomen, the transverse abdominal muscle, the place of attachment of the aponeurosis of the internal oblique muscle along the semilunar line and the posterior leaf of the aponeurosis of the rectus abdominis muscle are visualized, in the avascular zone the transverse abdominal muscle and the internal oblique muscle of the abdomen are separated, the aponeurosis of the internal oblique abdominal muscle is cut off from the aponeurosis of the transverse muscle of the abdomen upward to the edge of the costal arch, and downward - to the internal inguinal opening, then the rectus abdominis muscle is separated from the posterior leaf of its vagina upward to the previously planned place for the removal of the intestinal stoma, a skin incision is made, the anterior leaf of the vagina of the rectus muscle, and the muscle fibers are separated by a clamp in in the vertical direction, along the anterior axillary line at the costal arch, the fibers of the transverse abdominal muscle are bred in the horizontal direction, and then the intra-abdominal fascia and peritoneum are dissected over an extent equal to the width of the mobilized intestine with the adjacent mesentery, the intestine carrying the stoma is passed through the formed hole, it is carried into space between the transverse abdominal muscle and the internal oblique muscle of the abdomen, and then through the retromuscular space through the previously created hole in the rectus abdominis muscle to the skin of the anterior abdominal wall, the aponeurosis is sutured, restoring the semilunar line, a mesh implant is placed in place of the hernia gate, the wound is sutured in layers and a new one is formed intestinal stoma.