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ABSTRACT
The study is based on a clinical examination of 105 patients with postoperative ventral hernias who were operated on
in the surgical department of the multidisciplinary clinic of Samarkand State Medical University for the period from
2019 to 2023. Depending on the choice of operation, patients were divided into two groups:The first group (main
group) consisted of 50 patients operated on laparoscopically, the second group, the comparison group included 55
patients who underwent open (traditional) prosthetic hernioplasty. The use of the laparoscopic "ipom" technique can
significantly reduce the number of early postoperative and general complications (by 3.6 times), the duration of
hospitalization (from10.2 ± 1.8days before6.2 ± 0.8days), periods of temporary disability (from40.9 ± 5.6days
before15.1 ± 1.8days), and also reduce the number of relapses (from 10.9% to 2.0%).
KEYWORDS
Postoperative ventral hernias, alloplasty, endovideosurgery.
Research Article
RESULTS OF LAPAROSCOPIC AND LAPAROTOMIC INTERVENTIONS FOR
POSTOPERATIVE VENTRAL HERNIA
Submission Date:
January 08, 2024,
Accepted Date:
January 13, 2024,
Published Date:
January 18, 2024
Crossref doi:
https://doi.org/10.37547/ajbspi/Volume04Issue01-08
Kurbaniyazov Z.B.
Samarkand State Medical University, Samarkand, Uzbekistan
Sayinaev F.K.
Samarkand State Medical University, Samarkand, Uzbekistan
Yuldashev P.A.
Samarkand State Medical University, Samarkand, Uzbekistan
Abdurakhmanov D.Sh.
Samarkand State Medical University, Samarkand, Uzbekistan
Journal
Website:
https://theusajournals.
com/index.php/ajbspi
Copyright:
Original
content from this work
may be used under the
terms of the creative
commons
attributes
4.0 licence.
Volume 04 Issue 01-2024
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American Journal Of Biomedical Science & Pharmaceutical Innovation
(ISSN
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INTRODUCTION
An increase in surgical activity associated with the
improvement of surgical techniques and anesthesia
methods has led to an increase in the number of
patients with postoperative ventral hernias (POVH) by
9-10 times over the past 25 years [7]. Every year, about
20 million hernioplasties are performed in the world, of
which approximately 700 thousand are performed in
the USA, about 1 million in Europe, and up to 2
thousand in Uzbekistan [4, 7, 10].
In this regard, the problem of surgical treatment of
POVH remains an urgent task in abdominal surgery.
These hernias take second place after inguinal hernias,
and account for 20-22% of the total number of
abdominal wall hernias. In approximately 50% of cases,
POVH develops within the first two years after surgery,
and 75% after three years [2, 5, 6].
The problem of effective treatment of POVH has not
been fully resolved. Despite the large number (more
than 200) of proposed methods for their surgical
treatment, the rate of disease relapse remains high,
amounting to 15-50%, and repeated operations are
accompanied by its increase to 20-65% [1, 3, 8]. The
inconsistency of assessments of the proposed
methods of surgical treatment of POVH, the variety of
traditional methods of hernia repair used and the
emergence of new methods using various mesh
implants make it difficult to choose the most rational
method of plastic closure of the hernia defect. In
modern conditions, various methods of tension-free
hernioplasty using a variety of synthetic mesh implants
are considered the operation of choice for POIG.
Tension methods of hernioplasty using local tissues
have practically ceased to be used due to the high
frequency of relapses and remain in the arsenal of
surgeons only for small POIGs [1, 9].
Since the late 1990s, the development of laparoscopic
technology and the introduction of new synthetic
materials have pushed surgeons to develop and
introduce into practice laparoscopic methods for the
treatment of POVH.
However, to this day, the following issues of
laparoscopic hernioplasty remain unresolved: the
rational choice of a mesh implant according to the
quality/price criterion, the method of its placement and
method of fixation, the problem of delimiting the mesh
implant from the abdominal organs, determining the
indications and contraindications for this type of
plastic surgery [2] .
The purpose of the
study
improving the results of
laparoscopic hernioplasty for postoperative ventral
hernias.
METHOD
The study is based on a clinical examination of 105
patients with postoperative ventral hernias who were
operated on in the surgical department of the
multidisciplinary clinic of Samarkand State Medical
Volume 04 Issue 01-2024
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American Journal Of Biomedical Science & Pharmaceutical Innovation
(ISSN
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VOLUME
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46-55
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5.
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(2023:
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OCLC
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1121105677
Publisher:
Oscar Publishing Services
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University for the period from 2019 to 2023. Depending
on the choice of operation, patients were divided into
two groups:The first group (main group) consisted of
50 patients operated on laparoscopically, the second
group, the comparison group included 55 patients who
underwent open (traditional) prosthetic hernioplasty.
Among the patients there were 58 men, 47 women.
The location and size of the PIH were determined using
the classification proposed by the European Society of
Herniology (modified and based on the classification of
J. Chevrel and A. Rath) and adopted by international
consensus (Belgium, October 2-4, 2008) [10].
According to this classification, the following types of
POVG are distinguished:
I) By localization:
M - medial hernia (borders of the midline of the region:
cranially - the xiphoid process, caudally - the pubic
bone, from the side - the lateral edges of the rectus
abdominis muscle):
M1 - subxiphoid hernia (from the xiphoid process to 3
cm caudally);
M2 - epigastric hernia (from 3 cm below the xiphoid
process to 3 cm above the umbilical ring);
M3 - umbilical hernia (from 3 cm above to 3 cm below
the umbilical ring);
M4 - infraumbilical hernia (from 3 cm below the
umbilical ring to 3 cm above the pubis);
M5 - suprapubic hernia (from the pubic bone to 3 cm
cranially).
L - lateral hernia (limits of the lateral surface area:
cranially - the edges of the costal arches; caudally - the
inguinal areas, medially - the lateral edges of the rectus
abdominis muscle, laterally - the lumbar region):
L1 - hypochondrium (from the anterior edge and
horizontal line 3 cm above the umbilical ring);
L2 - flank (on the side of the rectus muscle 3 cm above
and below the umbilical ring):
L3 - iliac region (between the horizontal line 3 cm below
the umbilical ring and the groin area);
L4 - lumbar region (latero-dorsal part from the anterior
axillary line).
Various defects in the anterior abdominal wall caused
by one incision are considered as one hernia, two or
more different surgical incisions are considered as two
or more hernias.
II). According to the size of the hernial orifice:
W1 <4 cm; W2 ≥ 4
-
10 cm; W3 ≥ 10 cm. The width of the
hernia defect is defined as the greatest horizontal
distance in cm between the lateral edges
hernia defect on both sides. In the case of multiple
defects, the width of the hernia is measured between
the most transversely located edges of the most
laterally located defects on the same side. The length
of the hernia defect is defined as the greatest vertical
distance in cm between the most cranial and most
caudal edges of the hernia defect. In the case of
multiple hernia defects from one incision, the length is
measured between the most cephalad defect and the
most caudal defect.
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III). By adjustability:
1. Reducible, with or without obstruction; 2.
Irreversible, with or without obstruction.
IV). Based on the presence of symptoms:
1. Asymptomatic; 2. Symptomatic.
In terms of age composition, div mass index,
presence of concomitant pathology, location, size and
area of the hernia defect, both groups of patients did
not differ significantly from each other (Table 1).
Table 1.
Distribution of patients between study groups
Sign
Laparoscopic
hernioplasty (n=50)
Open hernioplasty
(n=55)
floor
husband
26
32
wives
24
23
Average age (years)
52.7±3.2
56.1±5.3
Average period of occurrence of POVG (years)
0.7±0.1
0.9±0.2
Body mass index (kg/m2)
32.1 ± 1.2
30.2 ± 2.3
Presence of
concomitant
pathology (abs., %)
Diseases of the heart
and blood vessels
8
9
Lung diseases
5
6
Kidney diseases
2
2
Gastrointestinal
diseases
4
6
Diabetes
3
4
Distribution of POVG
according to the EOG
classification of 2008
(abs., %)
M – medial hernia
M (45): M1-1; M2-17;
M3-19; M4-7; M5-1
M (47): M1-2; M2-20;
M3-18; M4-5; M5-2
L – lateral hernia
L(5): L1-2; L2-1; L3-
1; L4-1
L(8): L1-3; L2-2; L3-
2; L4-1
W – size of the
hernial orifice
W1 - 4; W2 - 35; W3
- 11
W1 - 4; W2 - 39; W3
- 12
POIG in patients of both groups arose after the
following previous operations: after cholecystectomy,
suturing of a perforated gastric or duodenal ulcer,
gastric resection for complications of gastric or
duodenal ulcer (perforated ulcer, gastrointestinal
bleeding, gastric outlet stenosis) from the traditional
upper midline laparotomy access - in 40 patients, after
midline surgical approaches for acute surgical
pathology and injuries of the abdominal organs - in 21,
lower midline incisions for gynecological diseases - in
15, lumbotomy approaches for urolithiasis - in 13,
cesarean section for obstetrics
–
in 13, appendectomy
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from a typical approach
–
in 3 patients. The occurrence
of POVH in patients was observed within a period of 2
months to 4 years after the last previous operation.
In the main group of patients who underwent
laparoscopic hernioplasty using the “ipom” method
(Laparoscopic
Intra
Peritoneal
Onlay
Mesh),
composite mesh implants “Physiomesh” or “Prosid”
(Ethicon) were used. All laparoscopic operations were
performed under general anesthesia using a Karl Shorz
video complex. The main working instruments for
laparoscopic prosthetic hernioplasty were: ultrasonic
scalpel “Harmonic” (Ethicon) a
nd 5 mm endoscopic
herniostapler “ProTack™” (Covidien).
Surgical intervention was performed according to
standard techniques.
Stage I
–
insertion of the first trocar in conditions of
POVH, as far as possible from the hernia, in an area free
from adhesions. Typically, entry into the free
abdominal cavity was carried out in the left
hypochondrium or in the left iliac region using a special
optical trocar “Visiport™” (Covidien) or under visual
control using the Hasson technique.
Stage II of the operation - after the introduction of the
first trocar with optics and revision of the abdominal
cavity, 2 or 3 working trocars were introduced. The
sites for trocar insertion in patients with POIG are not
standardized and were chosen where it was more
convenient and safe. At the same time, we tried to
observe the principle of interaction of two
laparoscopic instruments at an angle to each other of
at least 45° (Fig. 1).
Rice. 1. Places for installing 10 mm and 5 mm trocars for the laparoscope and working instrument
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Stage III was adhesiolysis. Separation of adhesions
between the hernial sac, anterior abdominal wall and
nearby organs was performed using endoscissors or an
ultrasonic scalpel “Harmonic”
(Ethicon) (Fig. 2).
Rice. 2. Stage separation of adhesions between the anterior abdominal wall and liver using an ultrasonic
scalpel “Harmonic” (Ethicon)
Stage IV
–
identification of the aponeurosis defect,
determination of the true size of the hernial orifice,
selection of a mesh implant of the appropriate size
(Fig. 3).
Rice. 3. General view of the defect of the aponeurosis of the anterior abdominal wall after separation of
the adhesions
Stage V
–
cutting out and modeling the mesh implant
(if necessary), marking the hernial orifice and points of
fixation of additional ligatures, stitching the edges of
the mesh implant with 2 or 4 ligatures for its intra-
abdominal straightening and pressing to the anterior
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abdominal wall before final fixation with an
endoherniostapler.
Rice. 4. Final fixation of the mesh implant to the anterior abdominal wall using an endoherniostapler
Stage VI
–
insertion of a mesh implant into the
abdominal cavity, straightening and pressing it to the
anterior abdominal wall using ligatures tied along the
edges of the implant, final fixation using an
endoherniostapler (Fig. 4). The number of fixation
staples depended on the size of the hernia defect, the
volume of the hernia sac and the size of the mesh
implant (usually after 3-4 cm).
Stage VII - control of hemostasis, desufflation of gas,
removal of trocars and suturing of 10 mm punctures of
the anterior abdominal wall, application of intradermal
absorbable sutures to the skin incisions and aseptic
dressings.
Open prosthetic hernioplasty (comparison group) was
performed under general anesthesia or epidural
anesthesia, which depended on the location and size of
the PIH. When performing prosthetic hernioplasty
using a laparotomic approach (comparison group), a
Prolene mesh implant (Ethicon) of the appropriate size
was used in all patients. In this case, the mesh implant
was fixed with a polypropylene thread to the
aponeurosis using the “onlay” method (supra
-neurotic
location) in 16 patients, and the “inlay” method
(subaponeurotic, preperitoneal location) in 39
patients. All patients underwent active aspiration of
wound exudate for 1-3 days.
Patients in both groups, in addition to analgesics
(Ketorolac 50 mg/ml, intramuscularly 2 ml 2 times a
day, or Ketoprofen 30 mg/ml, intramuscularly 1 ml 2
times a day) and infusion therapy, received standard
anticoagulant and antibacterial drugs. The active
regimen was prescribed by the end of the first day of
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the postoperative period with mandatory banding. In
addition to limiting physical activity, wearing a
bandage was recommended for patients in the main
group for 1 month, and for patients in the comparison
group for 3-4 months after surgery.
The results of surgical treatment were assessed based
on the clinical picture, local status and ultrasound
examination in the postoperative period for up to 2
years. The immediate results of operations in patients
with POIG were assessed according to the following
criteria: postoperative local complications; general
complications; duration of taking analgesics; duration
of inpatient treatment; periods of temporary disability.
Long-term results of operations and quality of life were
assessed using a questionnaire - the SF-36
questionnaire, filled out by patients 2 years after
surgery. The 36 questionnaire items were grouped into
eight groups, characterizing: physical functioning, i.e.
ability to withstand physical activity; role physical
functioning, which reflects the impact of physical
condition on daily activities; pain intensity and impact
of pain on daily activities; general health; general
activity, energy; social functioning; role-emotional
functioning, which characterizes the influence of the
emotional state on everyday activities; mental health.
The first 4 groups of questions of this scale
characterized the patients’ assessment of their
physical health, and the 5-8 groups of questions reflect
the main parameters of mental health.
RESULTS AND DISCUSSION
The general results of surgical treatment of patients
with POVH are presented in Table 2.
Table 2.
Results of surgical treatment of patients with POVH
Sign
Laparoscopic
hernioplasty (n=50)
Open hernioplasty
(n=55)
Operation duration (min.)
85.4 ± 8.4*
102.4 ± 9.7
Activation time for patients after surgery
(hours)
10.2 ± 1.2*
27.4 ± 1.8
Duration of taking analgesic drugs (days)
3.6 ± 1.5*
5.4 ± 1.8
Postoperative local
complications
(abs.,%)
- seroma
4 (8.0%)
*
14 (25.4%)
- hematoma
1 (2.0%)
*
6 (10.9%)
- infiltrate
1 (2.0%)
*
3 (5.4%)
- suppuration
-
1 (1.8%)
General complications (abs., %)
1 (2.0%)
*
6 (10.9%)
Duration of inpatient treatment (days)
6.2 ± 0.8*
10.2 ± 1.8
Duration of temporary disability (days)
15.1 ± 1.8*
40.9 ± 5.6
Recurrence of hernia abs., %
1 (2.0%)
6 (10.9%)
Note: * - differences between groups are statistically significant (P < 0.05).
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The average duration of laparoscopic hernioplasty was85.4 ± 8.4min., which turned out to be less than with open
hernioplasty -102.4 ± 9.7min. (p
˂
0.05). We associate the reduction in operation time with laparoscopic access with
the absence of the following stages, standard for open hernioplasty: 1) incision of the skin and subcutaneous tissue,
2) wide detachment of subcutaneous tissue from the aponeurosis along the entire perimeter of the hernial orifice, 3)
thorough hemostasis along the course of the hernial sac and hernial orifice, 4) manual fixation of the mesh using
interrupted or continuous sutures, 5) layer-by-layer suturing of the skin wound.
Postoperative local wound complications were detected in 6 patients (12.0%) of the main group, while in the
comparison group they were recorded in 24 (43.6%), which is 3.6 times more than in the main group. All wound
complications were eliminated by conservative measures and puncture methods under ultrasound guidance. The
results obtained confirm the minimal trauma of the endovideosurgical approach to performing hernioplasty and
demonstrate a reduction in the incidence of postoperative local complications by 31.6% compared to similar results in
patients operated on by laparotomy. In our opinion, this is directly related to minimizing the size of the surgical
approach and reducing the area of the wound surface, the absence of lymphorrhea and tissue exudation, the absence
of a postoperative cavity between the skin and the aponeurosis, as well as the location (intraperitoneal) of the mesh
implant during laparoscopic hernioplasty.
CONCLUSIONS
•
The supraponeurotic placement of the mesh
implant using the “onlay” method is associated
with a large number of wound complications
(grays,
hematomas,
infiltrates,
purulent
complications) and a high risk of relapse of POIG.
•
With the “inlay” technology, the risk of developing
wound complications and the likelihood of relapse
of POIG is significantly lower, but this method is
more technically complex and is not always
possible.
•
The use of the laparoscopic “ipom” technique can
significantly reduce the number of early
postoperative and general complications (by 3.6
times), the duration of hospitalization (from10.2 ±
1.8days before6.2 ± 0.8days), periods of temporary
disability (from40.9 ± 5.6days before15.1 ± 1.8days),
and also reduce the number of relapses (from 10.9%
to 2.0%).
•
In modern conditions, the method of laparoscopic
hernioplasty can be recommended as the
operation of choice in patients with PVH.
REFERENCES
1.
Yu.H. Abdurakhmanov, V.K. Popovich, S.R.
Dobrovolsky. Quality of life of patients with
postoperative ventral hernia in the long-term
period // Surgery. Journal named after N.I. Pirogov.
- 2010.- No. 7. P. 3236.
2.
Belokonev V.I., Fedorina T.A., Kovaleva Z.V.,
Pushkin S.Yu., Nagapetyan S.V., Supilnikov A.A.
Volume 04 Issue 01-2024
55
American Journal Of Biomedical Science & Pharmaceutical Innovation
(ISSN
–
2771-2753)
VOLUME
04
ISSUE
01
P
AGES
:
46-55
SJIF
I
MPACT
FACTOR
(2021:
5.
705
)
(2022:
5.
705
)
(2023:
6.534
)
OCLC
–
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Pathogenesis
and
surgical
treatment
of
postoperative ventral hernias. // Samara. - 2005.
3.
Biryaltsev V.N., Shaimardanov R.Sh., Filippov V.A.,
Khalilov Kh.M. Hernioabdominoplasty: A guide for
doctors. - Kazan: Idel-press, 2008. - 102 p.
4.
Dudelzon V.A., Parshikov V.V., Rotkov A.I.
Intraperitoneal plasty with mesh endoprostheses
(IPOM) as a method of choice in modern
herniology. Mat. scientific-practical conf. with
international participation "New technologies in
surgery and intensive care", Saransk, 2010: 75-76
5.
A.Z. Zamaleev, A.V. Kochnev, D.A. Slavin //
Evaluation of different methods of endoprosthesis
placement during repair of postoperative ventral
hernias. // Practical medicine, 2006, No. 3 (17), p. 37-
38
6.
Nelyubin P.S., Galota E.A., Timoshin A.D. Surgical
treatment of patients with postoperative and
recurrent ventral hernias // Surgery. - 2007. - 7. - P.
71
7.
V.V. Parshikov, V.V. Petrov, R.V., Romanov, A.A.
Samsonov, A.V. Samsonov, V.P. Gradusov, A.B.
Baburin // Quality of life of patients after
hernioplasty / No. 1 (6) March, 2009. Medical
almanac
8.
K.V. Puchkova Author's method of treating ventral
hernias
using
the
laparoscopic
method,
http://www.puchkovk.ru/obschayahirurgiya/posle
operatsionnye-gryzhi/avtorskaya-metodika-
lecheniya/
9.
Slavin L.E., Fedorov I.V., Seagal E.I. “Complications
of abdominal hernia surgery”, M., publishing house
“Profile”, 2005, p. 176
10.
Chistyakov D.B. Evolution of technology for using
synthetic implants in herniology / Chistyakov D.B.,
Borisov A.E., Yashchenko A.S. // Bulletin of surgery
named after I.I. Grekova. - 2011. - No. 2. - pp. 88-90
