Method for surgical treatment of hernias of anterior abdominal wall with intraperitoneal placement of mesh implant in combination with liposuction and liposculpture

Abstract

FIELD: herniology and plastic surgery.SUBSTANCE: Laparocentesis with a Veress needle and CO2 insufflation with automatically maintained intra-abdominal pressure are performed. A trocar is inserted for a 5 mm camera, optics 30°. Under optical control, two more punctures are made in the right and left iliac regions for instruments. The size of the hernial defect and diastasis of the rectus abdominis muscles are determined. The LigaSure device is used to mobilize the round ligament of the liver over a length of 6 cm. A non-absorbable V-loc 1-0 suture is inserted, and a locking suture is used to close the posterior plate of the rectus sheath along the white line and aponeurosis, eliminating the median hernia. A Parietex Composit mesh implant of the required size is inserted, covering the defect by 4 cm. It is straightened and positioned with the hydrophilic film facing the abdominal cavity. The edges of the implant are fixed with Prolen 0 thread and a Protack hernia stapler around the entire perimeter. Through the existing skin punctures: one in the umbilical region, two in the right and left iliac regions and two additional punctures in the right and left inguinal regions, hydropreparation of the subcutaneous fat tissue is performed with a physiological solution with adrenaline 1:100000. Using a Standard 4.0 mm cannula and a negative pressure of 600 mmHg, vacuum aspiration of subcutaneous fat from the anterior abdominal wall and lateral abdomen is performed with elements of liposculpture.EFFECT: method allows to increase the effectiveness of surgical treatment of hernias of the anterior abdominal wall with combined deformation of the anterior abdominal wall, to reduce the risk of hernia recurrence and diastasis of the rectus abdominis muscles, and to improve the cosmetic result.1 cl, 2 ex

Description

[0001] The method of surgical treatment of hernias of the anterior abdominal wall by intraperitoneal placement of a mesh implant in combination with liposuction and liposculpture relates to the field of medicine, in particular to herniology and plastic surgery, and can be used for the surgical treatment of hernias of the anterior abdominal wall in combination with aesthetic and functional deformation of the anterior abdominal wall.

[0002] Simultaneous surgical interventions are known from the prior art, for example, a method of abdominoplasty with suturing of diastasis of the rectus abdominis muscles (Patent of the Russian Federation No. 2805819C1 IPC A61B 17 / 00 A61F 2 / 02 10.24.2023 Bulletin No. 30), which consists of making a cutaneous-subcutaneous incision between the anterior-superior spines of the iliac bones along a previously marked line, suturing the medial edges of the rectus abdominis muscles from the xiphoid process to the lower third of the hypogastric region with immersion of the endoprosthesis into the interaponeurotic space under the medial edges of the rectus abdominis muscles, formation of the navel, dermolipectomy and layer-by-layer suturing of the wound.

[0003] This method has the following disadvantages:

[0004] - a significant skin incision is made, which reduces the cosmetic result of the operation;

[0005] - significant separation of subcutaneous fat tissue increases the risk of seroma formation, postoperative wound infections and the recovery period;

[0006] - placement of the mesh implant in the interaponeurotic space does not result in the necessary overlap of the formed scar, which increases the risk of recurrence due to the biomechanically unfavorable location of the implant.

[0007] The closest to the proposed method is the surgical treatment of hernias in combination with abdominoplasty (RU Patent No. 2658161, A61B 17 / 00, Bulletin No. 17, June 19, 2018), which includes suturing the medial edges of the rectus abdominis muscles from the xiphoid process to the lower third of the hypogastric region. The hernial protrusion is isolated with subsequent immersion of the hernial contents into the abdominal cavity. A mesh implant, forming a window for the umbilical pedicle, is placed on the aponeurosis in the umbilical ring area and fixed to the aponeurosis with U-shaped sutures made of nickel-titanium thread. A dermolipectomy is performed up to the level of excision of the umbilicus. The umbilicus is transposed.

[0008] However, this method has a number of disadvantages:

[0009] - a significant skin incision and removal of the skin flap is performed, which reduces the cosmetic result of the operation;

[0010] - significant separation of subcutaneous fat tissue increases the risk of seroma formation, postoperative wound infections and the recovery period;

[0011] - the location of the mesh implant on the aponeurosis leads to a higher number of seromas and a high risk of hernia recurrence due to the functionally unfavorable location of the implant;

[0012] - in case of long-standing hernias and formation of adhesions in the hernial sac, it is impossible to perform adhesiolysis without entering the abdominal cavity.

[0013] A method combining surgical treatment of hernias of the anterior abdominal wall, diastasis of the rectus abdominis muscles with liposuction and liposculpture has not been found.

[0014] The technical result of the proposed method for surgical treatment of hernias of the anterior abdominal wall by intraperitoneal placement of a mesh implant in combination with liposuction and liposculpture consists in increasing the effectiveness of surgical treatment of hernias of the anterior abdominal wall and combined deformation of the anterior abdominal wall, reducing the risk of recurrence of hernia and diastasis of the rectus abdominis muscles, the number of seromas and improving the cosmetic result.

[0015] The technical result is achieved due to the fact that the method of surgical treatment of hernias of the anterior abdominal wall by intraperitoneal placement of a mesh implant in combination with liposuction and liposculpture includes laparoscopic access, adhesiolysis according to indications, suturing of diastasis of the rectus abdominis and a hernial defect, intra-abdominal installation of a two-component anti-adhesive mesh implant on the peritoneum (IPOM), partial vacuum aspiration of subcutaneous fat from the area of ​​the anterior abdominal wall and lateral parts of the abdomen with elements of liposculpture.

[0016] The proposed method of surgical treatment of hernias of the anterior abdominal wall by intraperitoneal placement of a mesh implant in combination with liposuction and liposculpture is performed as follows.

[0017] At the first stage, after preparing the surgical field, a laparoscopic lift is performed using two laparoscopic needles. A laparocentesis with a Veress needle is performed under the navel, confirmed by a drip test, a syringe test, and a hardware test. CO2 insufflation is performed with an automatically maintained intra-abdominal pressure of 12 mmHg. A 5 mm camera trocar is inserted with a 30-degree telescope. Under optical guidance, two more punctures are made in the right and left iliac fossae for instruments. The abdominal organs are inspected. Adhesions are visualized. The size of the hernia defect and diastasis of the rectus abdominis muscles are determined. Next, additional trocars are inserted for instruments. The LigaSure device is used to mobilize the round ligament of the liver over a distance of 6 cm to improve implant adaptation. A non-absorbable V-loc 1-0 thread is inserted and the posterior plate of the rectus sheath is sutured using a wrapping suture along the white line and aponeurosis, eliminating the median hernia.A Parietex Composite mesh implant of the required size is inserted into the abdominal cavity, covering a 4 cm defect. It is straightened, and the hydrophilic film is positioned toward the abdominal cavity. The edges of the implant are secured with Prolen 0 suture and a Protack hernia stapler around the entire perimeter. Hemostasis is achieved, and the instruments and trocars are removed from the abdominal cavity. Carboxyperitoneum is desufflated.

[0018] At the second stage, after additional preparation of the surgical field, hydropreparation of the subcutaneous fat is performed through the existing skin punctures in the anterior abdominal wall area: one in the periumbilical region, two in the right and left iliac regions, and two additional punctures in the right and left inguinal areas with 1200.0 ml of saline solution with adrenaline 1:100000. Next, using a Standard 4.0 mm cannula and a negative pressure of 600 mmHg, partial vacuum aspiration of the subcutaneous fat from the anterior abdominal wall and lateral abdomen with elements of liposculpture is performed. Immersed sutures on the skin Monocryl No. 5-0. Toilet of the suture lines. Aseptic stickers with modeling of the correct anatomical relief of the anterior abdominal wall.

[0019] The effectiveness of the proposed method of surgical treatment of hernias of the anterior abdominal wall by intraperitoneal placement of a mesh implant in combination with liposuction and liposculpture is confirmed by clinical examples.

[0020] Example 1. Patient G., 43 years old, was admitted to the hospital for planned surgical treatment with the diagnosis: 1. Grade II diastasis of the rectus abdominis muscles. 2. Reducible umbilical hernia. 3. Combined deformation of the anterior abdominal wall (aesthetic and functional), hyperlipodystrophy in the anterior abdominal wall and lateral abdomen. Adhesions of the abdominal organs. Superficial gastritis, remission. Multiple small uterine fibroids. The patient complained of a hernial protrusion in the umbilical area, weakness of the anterior abdominal wall, an increase in abdominal volume after eating, excess subcutaneous fat in the anterior abdominal wall, lateral abdomen and lumbar region. From the medical history: the above complaints appeared after the second birth in 2008. I went to a Swiss university hospital. I consulted a surgeon, and upon examination, I was diagnosed with diastasis recti.A soft tissue ultrasound was performed. A midline divergence of the rectus abdominis muscles from the xiphoid process to the umbilical ring was detected, with a width of 14 mm at the xiphoid process, 21 mm in the middle third, and 28 mm above the umbilical ring (diastasis). In the umbilical region, functional tests revealed an expansion of the umbilical ring to 8 mm, and a hernial sac measuring 10 x 6 mm containing a preperitoneal lipoma. A plastic surgeon was consulted, and a combined deformity of the anterior abdominal wall (aesthetic and functional) and hyperlipodystrophy in the anterior abdominal wall and lateral abdomen were diagnosed. Simultaneous surgical treatment was recommended. The patient was examined and prepared for surgery on an outpatient basis.

[0021] Surgery: Laparoscopy. Adhesiolysis. Elimination of diastasis recti. Elimination of umbilical hernia. Plastic surgery of the anterior abdominal wall using a mesh implant. Vacuum-assisted PAL liposuction with elements of liposculpture.

[0022] Procedure of the operation: Stage 1: A 5 mm skin incision was made intraumbilically. Next, a laparoscopic lift was performed using two pins, a laparocentesis with a Veress needle was performed, which was confirmed by a drip test, a syringe test, a hardware test, and CO2 insufflation with an automatically maintained intra-abdominal pressure of 12 mmHg. A trocar for a 5 mm camera with a 30 degree optics was inserted. A trocar for a 5 mm camera is inserted with a 30 degree optics, and two more punctures are made under optical control in the right and left iliac fossa for instruments. The subdiaphragmatic space, liver, gallbladder, stomach, and small intestine are unchanged. A diastasis recti of 4 cm in width and 10 cm in length is determined. The umbilical ring is dilated to 2 cm. Adhesions are visible in the right iliac fossa—the anterior surface of the cecum is adherent to the parietal peritoneum of the anterior abdominal wall. Additional trocars for instruments are then inserted.

[0023] Completed: the above-described adhesive adhesions were separated using the LigaSure device. To improve the adaptation of the sutured tissue surfaces and fixation of the mesh implant, the LigaSure device was used to mobilize the round ligament of the liver over a length of 6 cm. Using non-absorbable 2-0 V-loc sutures, the posterior plate of the rectus sheath was sutured along the white line and aponeurosis, eliminating the umbilical hernia. A 15x10 cm Parietex Composit mesh implant was inserted into the abdominal cavity, straightened, and positioned with the hydrophilic film facing the abdominal cavity. The edges of the implant were fixed with Prolen 0 suture and a Protack hernia stapler along the entire perimeter. Hemostasis control - dry. Instruments and trocars were removed from the abdominal cavity. Desufflation was performed.

[0024] Stage 2: After additional processing of the surgical field, hydropreparation with 1200.0 ml of saline solution with adrenaline 1:100,000 was performed through the existing skin punctures in the anterior abdominal wall, one in the periumbilical region, two in the right and left iliac regions and two additional punctures in the right and left inguinal regions. Using a Standard 4.0 mm cannula and under a negative pressure of 600 mm Hg, partial vacuum aspiration of subcutaneous fat from the anterior abdominal wall and lateral abdomen with liposculpture elements is performed. The volume of removed fat detritus was 1000.0 ml.

[0025] Atraumatic Monocryl #5-0 immersed skin sutures. Suture lines are cleaned. Aseptic adhesive tape is applied to create the correct anatomical contour of the anterior abdominal wall. Compression garments are used. Treatment included a TAP block, infusion, antibacterial, and symptomatic therapy. Clexane, intraoperative variable pneumatic vasocompression of the lower extremity veins using the Kendall system, and compression stockings were used to prevent thrombosis.

[0026] The patient was discharged from the hospital in a satisfactory condition under the supervision of a surgeon, gastroenterologist, and plastic surgeon at the clinic with recommendations.

[0027] No complications were observed in the postoperative period; the hospital stay was 6 days. An ultrasound of the abdominal cavity and soft tissues of the anterior abdominal wall on the 7th postoperative day revealed no pathological changes. No fluid accumulations were noted. At follow-up examinations 3 and 6 months after surgery, the patient rated the cosmetic and functional outcome as "excellent." No deformities of the anterior abdominal wall were observed. Physical activity was fully restored. No recurrence has occurred during a 2-year follow-up.

[0028] Example 2. Patient Zh., 39 years old, was hospitalized for planned surgical treatment with the main diagnosis: 1. Reducible hernia of the linea alba 2. Diastasis recti grade I-II. 3. Combined deformation of the anterior abdominal wall (aesthetic and functional), hyperlipodystrophy in the area of ​​the anterior abdominal wall and lateral abdomen. Concomitant diseases: Adenomyosis, diffuse form. Cyst of the right ovary. Varicose veins of the lower extremities C2 according to CEAP in the GSV basin on the right, reticular (net) varicose veins, chronic venous insufficiency grade 1. Chronic gastritis, not exacerbated.

[0029] The patient presented complaints of weakness and deformation of the anterior abdominal wall, protrusion in the epigastric region, excess subcutaneous fat in the anterior abdominal wall and lateral abdomen.

[0030] Medical history: History of two pregnancies and two births, after which she noted the above-mentioned complaints. She denies episodes of strangulated hernia. She visited a Swiss university hospital and was consulted by a surgeon. An examination revealed diastasis of the rectus abdominis muscles and a hernia of the linea alba. Ultrasound of soft tissues revealed diastasis of the rectus abdominis muscles. Hernia of the linea alba. She was consulted by a plastic surgeon. An examination revealed hyperlipodystrophy in the anterior abdominal wall and lateral abdomen. Simultaneous surgical treatment was recommended. She was examined and prepared for surgery on an outpatient basis.

[0031] Surgery: Laparoscopy. Elimination of diastasis recti. Elimination of linea alba hernia. Plastic surgery of the anterior abdominal wall using a mesh implant, vacuum-assisted PAL liposuction of the anterior abdominal wall and lateral abdomen.

[0032] Procedure of the operation: Under aseptic conditions, a 5 mm skin incision was made intraumbilically under ETN, laparolifting was performed with two pincers, laparocentesis was performed with a Veress needle, which was confirmed by a drip test, syringe test, and hardware test, CO2 insufflation with an automatically maintained intra-abdominal pressure of 12 mmHg. A trocar for a 5 mm camera with a 30 g optics was inserted, and two more punctures were made under optical control in the right and left iliac regions for instruments. The subdiaphragmatic space, liver, gallbladder, stomach, and small intestine are unchanged. A hernial protrusion up to 3 cm in diameter is detected 4 cm above the umbilicus. Diastasis recti of the abdominis muscles is 4 cm wide and 12 cm long. Then, additional trocars for instruments are inserted.

[0033] Completed:

[0034] Stage 1: To improve tissue adaptation and mesh implant fixation, the LigaSure device was used to mobilize the round ligament of the liver over a length of 6 cm. Non-absorbable V-loc 1-0 sutures were used to close the hernia defect and close the posterior plate of the rectus sheath along the white line and aponeurosis using a locking suture. An umbilical lift was performed. A Parietex Composit 15x10 cm mesh implant was inserted into the abdominal cavity, straightened, and positioned with the hydrophilic film facing the abdominal cavity. The edges of the implant were secured with Prolen 0 suture and a Protack hernia stapler along the entire perimeter. Hemostasis was monitored and a dry surface was observed. Instruments and trocars were removed from the abdominal cavity. Desufflation was performed.

[0035] Stage 2: After additional processing of the surgical field, with the patient in the supine position, hydropreparation of the subcutaneous fat of the anterior abdominal wall and lateral abdomen was performed through the existing skin punctures in the anterior abdominal wall with 1,200.0 ml of saline solution with 1:100,000 adrenaline. After exposure for 15 minutes, using a Standard 4.0 mm cannula and under negative pressure of 600 mmHg, partial vacuum aspiration of the subcutaneous fat from the anterior abdominal wall and lateral abdomen with elements of liposculpture of the lateral abdomen with elements of liposculpture is performed. The volume of removed fat detritus was about 850.0 ml. Toilet of the anterior abdominal wall, immersed sutures Monocryl 5-0. Steri-strip on the suture line. Modeling stickers on the anterior abdominal wall. Aseptic dressings. Compression garments.

[0036] Treatment: TAP block, infusion, antibacterial, and symptomatic therapy. Clexane, intraoperative variable pneumatic vasocompression of the lower extremity veins using the Kendall system, and compression stockings were used to prevent thrombosis. No complications were observed postoperatively; the hospital stay was 4 days.

[0037] Ultrasound of the abdominal cavity and soft tissues of the anterior abdominal wall on the 7th postoperative day revealed no pathological changes. At follow-up examinations 3 and 6 months after surgery, the patient rated the cosmetic and functional outcome as "excellent." No deformities of the anterior abdominal wall were noted. Physical activity was fully restored. No recurrence has occurred during a 2.5-year follow-up.

[0038] The proposed method of surgical treatment of hernias of the anterior abdominal wall by intraperitoneal placement of a mesh implant in combination with liposuction and liposculpture has the following advantages:

[0039] 1. The mesh implant is positioned in the most advantageous functional intra-abdominal position (IPOM), minimizing the risk of hernia recurrence, and also eliminates the reaction of subcutaneous fat to the mesh implant in the form of seromas, which shortens the rehabilitation period for patients;

[0040] 2. Simultaneous hernia repair, suturing of diastasis of the rectus abdominis muscles and liposuction with elements of liposculpture allows for a single and comprehensive solution to aesthetic and functional disorders of the anterior abdominal wall;

[0041] 3. Simultaneous performance of laparoscopic hernia repair and liposuction through the same skin incisions from the bikini area with a total length of up to 2 cm allows for an “excellent” cosmetic result;

[0042] 4. The use of V-loc anchor thread and ergonomic placement of trocars helps reduce surgical time.