RU2254063C2 - Method for surgical treatment of postoperative ventral hernias - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: one should open hernial defect to carry out its plasty with a reticular synthetic implant, perform arch-shaped incisions from both sides of anterior wall of the sheath of rectus muscles of abdomen at the distance of 0.5-1 cm against the edges of hernial defect at its whole length and further for 3-4 cm upwards and downwards against it to form the pouches due to exfoliating sheath's wall against rectus muscles. Implant should be placed above hernial defect in the pouches. Aponeurosis incisions should be sutured with interrupted sutures at simultaneous suturing the implant, as well. In peculiar case, one should cut the implant at cross-sectional size being correspondent to the distance between lateral edges of rectus muscles of abdomen, and longitudinal size being correspondent to the length of aponeurosis incision. In peculiar case, implant should be sutured to aponeurosis both from the top and from the bottom against hernial defect with two rows of interrupted sutures. The innovation enables to decrease the chance for inflammation and suppuration of operational wound and provide reliable fixation of the implant.

EFFECT: decreased traumaticity level.

2 cl, 2 dwg

Description

The invention relates to medicine, namely to surgery, and can be used for plastic surgery of median postoperative ventral hernias, in which the resulting defect of the abdominal wall is localized at the section of the last midline of the abdomen during previous operations.

Postoperative ventral hernias of the anterior abdominal wall occupy a significant place in surgical practice, however, the outcomes of surgical treatment of these diseases cannot satisfy the increased requirements of modern surgery due to a significant number of relapses and other complications (25-49%).

The autoplastic method of aponeurotic plasty is known, which is used for extensive defects that cannot be eliminated by simply mobilizing and suturing the edges of the aponeurosis and abdominal muscles (V.I. Orokhovsky. Main herniasection. - Muntsekh, KITIS. Hanover-Donetsk-Cottbus, 2000, p.196 -197).

A known method for the surgical treatment of ventral hernias includes a longitudinal incision and mobilization of the skin and subcutaneous tissue over an aponeurosis defect, two longitudinal incisions of the anterior vaginal wall of the rectus abdominis muscles, mobilization of cut out aponeurosis sheets towards the center, suturing of the aponeurosis sheets between each other over the defect and layered suturing of the wound .

The disadvantage of this method is that when you try to limit your own tissues with plastic hernia gate due to their deficiency, the intra-abdominal volume decreases, the intra-abdominal pressure increases and the tension of the tissues of the abdominal wall increases. Reducing the contents of the hernial sac into the abdominal cavity also increases intra-abdominal pressure, which causes a violation of the cardiovascular and respiratory systems. Tension of tissues in the area of surgical intervention leads to ischemic disorders, a decrease in the mechanical strength of the tissues of the abdominal wall and the development of relapse of the disease.

In recent years, hernioplasty methods using various synthetic implants have become widespread. The allomaterial closing the hernia gate causes the rapid formation of mature connective tissue, with a strength equal to or greater than the strength of the aponeurosis. Variants of plastic, in which their own fabrics are not stitched, and the stitched seams do not experience tension, are classified as "non-tensioned".

A known method of plastic surgery of postoperative ventral hernias with the use of allomaterials, called "Inlay" technology (Tension hernioplasty. Edited by V.N. Egiev. - M .: Medpraktika, 2002. - S.112-113). The essence of the known method lies in the fact that an incision is made in the skin and subcutaneous tissue, a hernial sac is secreted, followed by excision or reduction into the abdominal cavity, a pocket is created under the aponeurosis in the preperitoneal space around the hernial collar, then the hernial sac is excised, the peritoneum is sutured, and the peritoneal peritoneum is sutured. a synthetic implant is placed in the space, for example, a mesh of polytetrafluoroethylene (PTFE) with a pore diameter of less than 10 microns. U-shaped seams mesh back to the rectus abdominis muscle. After all the threads have been applied, but not tied, the aponeurosis defect is sutured with a continuous suture without duplicating with polypropylene suture, and then the previously applied U-shaped sutures are sutured and the surgical wound is sutured.

The location of the implant in the preperitoneal space requires a wide detachment of the peritoneum from the edges of the hernial defect, which significantly complicates and lengthens the operation and, in addition, fixation of the implant with U-shaped through sutures determines the need for a sufficiently large exposure of the anterior surface of the aponeurosis from the subcutaneous tissue, which also increases the risk of complications.

With intraperitoneal localization of the implant, slowly forming reactions of rejection of a foreign body are observed with the development of corresponding complications - hematomas, seromas, adhesions. In addition, when the allograft comes into contact with the surface of the intestines, there is a high risk of intestinal fistulas against the background of the rapid integration of the involved tissues into a single conglomerate, which complicates surgical intervention in the future.

A method is proposed for surgical treatment of postoperative ventral hernias, including dissection of the skin and subcutaneous tissue, isolation of the hernial sac and its reduction into the abdominal cavity, plastic defect with a synthetic implant and subsequent suturing of the surgical wound.

The invention consists in the fact that at a distance of 0.5-1 cm from the edges of the hernial defect along its entire length and further 3-4 cm down and up from it, arcuate sections of the anterior vaginal wall of the rectus abdominis are made on both sides and pockets are formed by peeling one of the walls of the vagina from the rectus muscles, and the implant is placed on top of the hernial defect and in the pockets and the aponeurosis incisions are sutured with interrupted sutures while the implant is sutured.

The implant is cut out with a transverse dimension corresponding to the distance between the lateral edges of the rectus abdominis muscles and a longitudinal dimension corresponding to the length of the aponeurosis incision.

The difference is also that the implant is sutured to the aponeurosis from below and from the hernia defect in two rows of nodal joints.

The main advantage of the proposed method for surgical treatment of postoperative ventral hernias from the known ones is a significant reduction in the area of contact of the mesh implant with subcutaneous fat, which significantly reduces the likelihood of seromas, hematomas, inflammatory infiltrates and suppuration of the surgical wound.

In addition, there is a more reliable fixation of the implant due to a single seam of the dissected aponeurosis and mesh, while the implant is clamped by interrupted sutures between the edges of the dissected aponeurosis. The operation involves minimal detachment of subcutaneous fat, which significantly reduces its invasiveness.

The invention is illustrated by an example of execution and drawings, in which Fig. 1 shows an operational wound (plan view), and Fig. 2 is the same, section I-I.

The procedure for performing surgery on the proposed method is given below.

After dissection and mobilization of the skin 1 and subcutaneous tissue 2 and exposure of the hernial defect 3 with a hernial sac exiting through it (not shown), the anterior wall of the aponeurosis, the anterior wall 4 of the vagina of the rectus 5 of the abdomen, is dissected.

The incisions are made in the form of two arcs 6 located on both sides of the hernial defect 3 at a distance of 0.5-1 cm from its edges, and to increase the reliability of the plastic they are performed throughout the hernial defect and further down and up 3-4 cm Then pockets are formed by detachment of the anterior 4 or posterior 7 wall of the vagina of the rectus muscles from the muscles themselves to their outer edge. The hernial sac is not removed, but inserted into the abdominal cavity 8. The mesh synthetic implant 9 should have the following parameters: the longitudinal dimension (l) should correspond to the length of the incision of the anterior wall of the aponeurosis (vagina of the rectus abdominis muscles), and the transverse dimension (b) to the distance between the lateral the edges of the rectus muscles. The implant cut out in these sizes is placed over the hernial defect 3, while its lateral edges are placed in the formed pockets of the rectus sheaths so that the mesh lies flat, without wrinkles. Suturing of the arcuate incisions 6 of the aponeurosis is done with interrupted sutures 10 with simultaneous flashing of the implant 9. Above and below the hernial defect, the implant is sutured to the front surface of the aponeurosis with two rows of interrupted sutures 11.

The final stage of the operation involves the layered closure of the surgical wound.

The proposed method for the treatment of postoperative ventral hernias is less traumatic compared to the known ones and significantly reduces the likelihood of postoperative complications.

Claims (3)

1. A method of surgical treatment of postoperative ventral hernias, including dissection of the skin and subcutaneous tissue, isolation of the hernial sac and its reduction into the abdominal cavity, exposure of the hernial defect and plastic with its mesh synthetic implant, followed by suturing of the surgical wound, characterized in that at a distance of 0.5 -1 cm from the edges of the hernial defect along its entire length and further 3-4 cm up and down from it, arcuate sections of the anterior vaginal wall of the rectus abdominis muscles are made on both sides and form karma They are performed by exfoliating the vaginal wall from the rectus muscles, and the implant is placed over the hernial defect and in the pockets and the aponeurosis incisions are sutured with interrupted sutures while the implant is sutured. 2. The method according to claim 1, characterized in that the implant is cut out with a transverse dimension corresponding to the distance between the lateral edges of the rectus abdominis muscles and a longitudinal size corresponding to the length of the aponeurosis incision. 3. The method according to claim 1, characterized in that the implant is hemmed to the aponeurosis from below and from the hernia defect in two rows of interrupted sutures.

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