Method of combined plasty of giant post-operational ventral hernias

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery and can be applied for treatment of giant post-operational ventral hernias. After dissection of aponeurosis of rectus muscles of abdomen, indenting 4-5 cm from hernial ring edge, hernial sac is opened. Intraabdominal stage of operation is performed. By means of two pararectal cuts from both sides dissected are skin, subcutaneous fat to aponeurosis of external oblique and transverse abdominal muscles. Tendon part of external oblique, internal oblique and transverse abdominal muscles is excised. Implants in form of mesh endoprostheses are sewn to external oblique, internal oblique and transverse abdominal muscles and rectus abdominal muscle from both sides. Aponeurosis is sutuired together without tension on medium line with continuous suture "joint-to-joint". Above sutured aponeurosis of rectus abdominal muscles third mesh endoprosthesis is implanted.

EFFECT: improvement of results of giant post-operational ventral hernia treatment and reduction of number of recurrences and complications.

1 ex, 1 dwg

 

The invention relates to medicine, namely to surgery, and may be applicable for the treatment of giant postoperative ventral hernias.

Surgical treatment of hernias of the anterior abdominal wall and remains one of the most urgent problems of abdominal surgery, the incidence is 3-4%. According to Russian statistics, the share of hernias account for up to 20% of all operations performed in a surgical hospitals [2]. Despite the large number (over 200) the proposed methods of surgical treatment of postoperative ventral hernias remains high frequency of relapses, component 14-50%and re-operation accompanied by rising to 20-64% [4, 6]. The main reasons for the failure of autoplasty are marked degenerative and cicatricial changes in the field of hernia gate and nearby musculoaponeurotic frame, progressive rigidity of the abdominal wall, which significantly affects the formation of connective tissue in the area of surgical intervention and reduces its strength [1]. Thus, from the point of view of surgical tactics, the key issue is the location and method of fixation of the implant [3].

The known method combined hernioplasty without opening the abdominal cavity, the proposed Devlin in 1993, the Essence of this method consists of placing the Explant is ahead of musculoaponeurotic layer with minimal tension on the edges of the hernial defect. Palpation determine the size of the hernial defect, excised the scar and the subcutaneous fat over grievin bag, departing at 4-5 cm from the edge of the hernia gate, cut through the front wall of the vagina of recti on both sides, the hernia SAC without opening immersed in the abdominal cavity, then sew the medial edge of the cut sheets of the vagina of recti, to the lateral edges of the cut sheets is stitched to the graft [7].

The advantage of this method plastics is no need to cut all layers of the anterior abdominal wall and the entry into the abdominal cavity, and therefore decreases the likelihood of complications from abdominal cavity.

However, the method has the following disadvantages: a) the risk of complications specific to the subcutaneous location of the implant (seroma, hematoma, infiltrates); b) impossibility of the use of this plastic with postoperative ventral hernias with a defect in the aponeurosis of more than 10 cm in diameter.

Closest to the present invention is a method Ramirez, proposed in 1990, the idea of the method is in the intersection of the tendinous part of the external oblique muscle of the abdomen on both sides, which reduces the width of the hernial defect. Originally mobilize the hernia SAC and the front leaf sheaths of recti to Segalovich is ini on both sides. Then on the edge of the muscular part of m. obliquus abdominis externus its tendinous part of the cross throughout from the costal arch to the iliac bone. The zone plate, it is advisable to limit or using flaps hernial SAC, or by the greater omentum. Gryzenia gate reduces seams, avoiding large tension. This is followed by implantation [5].

The advantages of this plastics: helps to strengthen the anterior abdominal wall with large and giant postoperative ventral hernias.

The disadvantages of this method are: 1) frequent formation of accumulations of serous fluid due to the intersection of many lymph and blood capillaries in the detachment of subcutaneous fat basis; 2) the broad contact of fatty tissue from the Explant, which may lead to rejection of the implant and further to hernia recurrence.

The objective of the invention is to improve the results of treatment of giant postoperative ventral hernias and to reduce the number of relapses and complications.

The task carried out due to the fact that after the dissection of the aponeurosis of recti, departing at 4-5 cm from the edge of the hernia gate, open hernia SAC, perform intra-abdominal phase of the operation, two adrectal slits on both sides cut through the skin, subcutaneous fat to aponet the oz the external oblique and transverse abdominal muscles, perform clipping of the tendinous part of the external oblique, internal oblique and transverse abdominal muscles; the implants in the form of mesh implants are attached to the tendinous part of the external oblique, internal oblique, transverse abdominal muscles and the rectus abdominis muscle on both sides, the wound is sutured in layers, the aponeurosis is sutured between the tension in the midline continuous seam "at the junction interface on top, then sutured over the aponeurosis of recti implanted third mesh implant, skin wound is sutured closed.

The proposed method is shown schematically in figure 1, where:

A - longitudinal dissection postoperative wound on the white line of the abdomen, abdominal phase of the operation;

B - run adrectal incisions on both sides and trim the tendinous part of the external oblique, internal oblique and transverse abdominal muscles on both sides;

- Sew mesh implants to the tendinous part of the external oblique, internal oblique, transverse abdominal muscles and the rectus abdominis muscle on both sides;

Mr. sewing placed over the sutured aponeurosis of recti implant in the form of a mesh implant.

The invention consists in the following. Two semi-oval sections excised the scar and the excess skin and subcutaneous fat over grievin bag, departing at 4-5 cm from the edge of the hernia gate, RA is scout the aponeurosis of recti. Open hernia SAC, perform intra-abdominal phase of the operation (Fig.1a). Two adrectal slits on both sides cut through the skin, the subcutaneous fat to the aponeurosis of the external oblique and transverse abdominal muscles. Perform clipping of the tendinous part of the external oblique, internal oblique and transverse abdominal muscles (Fig.1b). Implants in the form of mesh implants are attached to the tendinous part of the external oblique, internal oblique, transverse abdominal muscles and the rectus abdominis muscle on both sides (Resv). Install the vacuum drainage Redon in nationalrates space on both sides. Layers are sutured the wound. The aponeurosis is sutured between the tension in the midline continuous seam "at the junction interface". Above sutured aponeurosis of recti implanted third mesh implant (risg). Install the vacuum drainage Redon in nationalrates space. The skin wound is sutured closed.

According to the method of Ramirez (the comparison group) and the proposed method (study group) were operated on 9 patients. In the comparison group 3 patients (33%) patients had seroma formed with a long exudation from the wound within 14 days. When ultrasonography in the subcutaneous tissue was determined by the accumulation of serous fluid in volume from 50 to 90 ml, which required a multiple (3-5 times) punctures. Drain the LM was removed on a 7-9 day. Infiltration into the surgical wound was observed in one (11%) patients. One (11%) patient was noted superficial suppuration of postoperative wounds, mesh implant was not removed. In the study group seroma formed in two (22%) patients with exudation from the wound within 5-6 days. The drainage was removed on a 5-6 day. The suppuration of wounds and infiltration into the surgical wound in this group of patients was not observed.

An example implementation of the method

Patient C., 48 years old, medical history, No. 1345, hospitalized, 03.03.2008 routinely for surgical treatment of giant postoperative ventral hernia. Complaints on admission to the presence of a hernial protrusion of the old postoperative scar, intermittent pain in the hernial protrusion. From the anamnesis it is known that ten years ago the patient underwent median laparotomy for acute calculous cholecystitis. Two years after surgery, noted the emergence of a hernial protrusion of the postoperative scar. About 1.5 years ago there was an episode of infringement hernia, which the patient own right. To doctors did not address. A bulge is noticeable gradually increased in size, episodes infringement was repeated. Comorbidities: hypertension of II degree. The condition ol the receipt of satisfactory. Skin and visible mucous membranes pale pink. The vesicular breathing, is all lung fields, no wheezing. AD - 135/90 mm Hg Pulse - 76 minutes Language clean, damp. The abdomen is soft, not swollen, not tense, asymmetric due to the hernial protrusion, participates in the act of breathing, painless on palpation in all departments. Symptoms of peritoneal irritation no. Intestinal noises normal sonority. Stool and urination are normal. Locally: on the anterior abdominal wall from the xiphoid process to the umbilicus there is an old, postoperative scar. In the upper third of the scar is determined by the bulge is noticeable, size 22 x 15 cm, painless, soft-elastic consistency, pravima into the abdominal cavity. The symptom "cough push" positive. 06.03.2008, Made elective: gryzhesechenie of the proposed method. Operations: by palpation determined the size of the hernial defect 2215 cm, two semi-oval sections excised the scar, the excess skin and subcutaneous fat over grievin bag, departing at 4-5 cm from the edge of the hernia gate, cut through the aponeurosis of recti. Open hernia SAC, perform intra-abdominal phase of the operation (Fig.1a). Two adrectal slits on both sides cut through the skin, the subcutaneous fat to the aponeurosis of the external oblique and transverse muscles is Iwata. Perform clipping of the tendinous part of the external oblique, internal oblique and transverse abdominal muscles (Fig.1b). Implants in the form of mesh implants are attached to the tendinous part of the external oblique, internal oblique, transverse abdominal muscles and the rectus abdominis muscle on both sides (Resv). Install the vacuum drainage Redon in nationalrates space on both sides. Layers are sutured the wound. The aponeurosis is sutured between the tension in the midline continuous seam "at the junction interface". Above sutured aponeurosis of recti implanted mesh implant, size 3030 cm (risg). Install the vacuum drainage Redon in nationalrates space. The skin wound is sutured tightly, treated with iodine solution, apply a sterile dressing.

The postoperative period was uneventful. The wound healed by first intention, the sutures were removed on the 8th day. The patient was examined by one month, signs of inflammation of postoperative scar and no recurrence of the hernia is not marked.

The proposed method allows to:

to reduce the number of complications in the early postoperative period (gray, suppurations, infiltrates), due to the limited area of contact between the mesh endoprosthesis with fat;

- run plicatio of recti, to restore and strengthen the white line of the abdomen due to dissection of the tendon part of the external oblique, the internal oblique and transverse abdominal muscles;

- allows to approximate the rectus muscles of the abdomen without tension and more extensive mobilization of subcutaneous fat flap.

Sources of information

1. IVAN Borodin, Scarabei E.V., Akulich VP Surgery incisional hernias of the abdomen. - Mn.: Belarus, 1986. - 159 S.

2. Eview NR. Stretch hernioplasty. - M.: Malpractice-M, 2002. - P.146.

3. Ermolov A.S., Epirev AV and other Features of the postoperative period when the various technologies of plastics hernias of the abdominal wall // New technologies in surgery of hernias: proc. Dokl. scientific and practical use. conference. - Saratov, 2006. - P.6-9.

4. Toskin CD, Zebrowski CENTURIES Hernia of the abdominal wall. - M.: Medicine, 1990. - 272 S.

5. Devlin H.B. Managament of abdominal hernias. - London: Butterworths, 2000. - 430 R.

6. Langer, S., Kley, S., Neufang T. et al. Problem of recurrent incisional hernia after mesh repair of the abdominal wall // Chirurg. - 2001. - Vol.72, No. 8. - P.927-933.

7. Ramirez O.M., Ruas e, Dellon L. 'Components separation' method for closure of abdominal wall defects: an anatomic and clinical study // Plastic and Reconstructive Surgery. - 1990. - Vol.86. No. 3. - H.519-526.

The method of combined plastics giant postoperative ventral hernias, including the intersection of the tendinous part of the external oblique muscle of the abdomen on both sides, characterized in that after the dissection of the aponeurosis of recti, departing at 4-5 cm from the edge of the hernia gate, open hernia SAC, perform intra-abdominal phase of the operation, two parar stalnye slits on both sides cut through the skin, the subcutaneous fat to the aponeurosis of the external oblique and transverse abdominal muscles, perform clipping of the tendinous part of the external oblique, internal oblique and transverse abdominal muscles, the implants in the form of mesh implants are attached to the tendinous part of the external oblique, internal oblique, transverse abdominal muscles and the rectus abdominis muscle on both sides, the wound is sutured in layers, the aponeurosis is sutured between the tension in the midline continuous seam "at the junction interface on top, then sutured over the aponeurosis of recti implanted third mesh implant, dermal wound tightly sutured.



 

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2 dwg, 1 ex

FIELD: medicine; traumatic surgery; orthopedic devices.

SUBSTANCE: device for applying lengthening or stretching force to patient's body has aid for fastening first and second components to bones or to adjacent bones. Mentioned components are connected by increasing-length connecting aid. Device also has magnet connected with connecting aid and drive unit disposed outside patient's body for generating moving or changing electromagnetic field which results in rotation of magnet and elongation of connecting aid. Connecting aid has screw and nut. Magnet is connected with screw and nut by means of transmission box to generate relative rotation for elongating the device. Endoprosthesis replacement device to be elongated has first and second components that are connected by increasing-length unit. The first component has fraction of extremity joint. The second component has aid for fastening to resected long bone, magnet connected with connecting unit, and aid adjusted for disposition outside patient's body for generation of moving electromagnetic field which results in rotation of magnet and elongation of connecting unit. Magnet is connected with connecting unit by means of reduction gear. Device for correcting curvature of the spine has first and second shafts for elongation. Any shaft has its end to be connected with aid for fastening to corresponding vertebra. Connecting unit is adjusted in such a way that ends provided with fastening means were relatively movable. Mentioned connecting unit is connected with drive mechanism, which has rotated magnet, reduction gear, and drive aid for disposition outside patient's body. Generated moving or changing electric/magnetic field induces rotation of magnet and motion of fastening aid, disposed onto one shaft, relatively fastening aid, disposed at the other shaft.

EFFECT: elongation of bones or implants without surgical operation.

15 cl, 5 dwg

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