Volume 03 Issue 05-2023
5
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
ISSUE
05
P
AGES
:
05-15
SJIF
I
MPACT
FACTOR
(2021:
5.
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(2022:
5.
893
)
(2023:
6.
184
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
ABSTRACT
The article presents the data of a clinical examination of 105 patients with ventral hernias, who were operated on in
the surgical department of the multidisciplinary clinic of Samarkand State Medical University for the period from 2018
to 2022. Depending on the choice of treatment tactics, the patients were divided into two groups. The first group, the
comparison group, consisted of 65 (61.9%) patients who underwent open hernia repair. The second group, the main
group, consisted of 40 (38.1%) patients who were initially planned for laparoscopic prosthetic hernioplasty.
KEYWORDS
Ventral hernia, alloplasty, endovideosurgery.
INTRODUCTION
The relevance of research. Postoperative ventral
hernia (ventral hernia, cicatricial hernia) is a protrusion
Research Article
ENDOVIDEOSURGICAL PREAPERITONEAL PROSTHETIC HERNIOPLASTY
IN VENTAL HERNIAS
Submission Date:
May 03, 2023,
Accepted Date:
May 07, 2023,
Published Date:
May 12, 2023
Crossref doi:
https://doi.org/10.37547/ijmscr/Volume03Issue05-02
Sayinaev F.K.
Samarkand State Medical University, Samarkand, Uzbekistan
Kurbaniyazov Z.B.
Samarkand State Medical University, Samarkand, Uzbekistan
Yuldashovp.A.
Samarkand State Medical University, Samarkand, Uzbekistan
Davlatov S.S.
Bukhara State Medical Institute, Bukhara, Uzbekistan
Journal
Website:
https://theusajournals.
com/index.php/ijmscr
Copyright:
Original
content from this work
may be used under the
terms of the creative
commons
attributes
4.0 licence.
Volume 03 Issue 05-2023
6
International Journal of Medical Sciences And Clinical Research
(ISSN
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2771-2265)
VOLUME
03
ISSUE
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P
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05-15
SJIF
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FACTOR
(2021:
5.
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(2022:
5.
893
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(2023:
6.
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OCLC
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1121105677
Publisher:
Oscar Publishing Services
Servi
of organs (greater omentum, intestinal loops) that
extends beyond the abdominal cavity through defects
in the scar formed after surgical treatment.
Postoperative hernias appear in those anatomical
areas where typical surgical incisions were made,
providing access to the abdominal organs: in the area
of the white line of the abdomen, right iliac region,
navel, lateral lumbar region, suprapubic region. The
number of postoperative ventral hernias in the
structure of all abdominal hernias is 20-30.5% [3]. The
frequency of their occurrence, despite the widespread
use of modern technologies and tactics, ranges from
7.5 to 30.7% [1], while the number of complications in
the postoperative period when repairing ventral
hernias reaches 30.5% [2].
One of the important factors that determines the
results of surgical treatment of postoperative ventral
hernias using mesh implants is the frequency of hernia
recurrence, reaching 15-20% according to the literature
[5]. Often, the cause of recurrence is not only
complications after surgery, but also the method of
fixing mesh implants when performing prosthetic
corrective plasty. This is due, first of all, to the adhesive
properties of most mesh prostheses, which ensure the
quality of hernioplasty. Attempts to use non-adhesive
meshes, for example, from polyteterofluoroethylene,
are safe in relation to the development of adhesions
and subsequent complications, but are ineffective in
relation to the formation of a reliable scar in the area
of the hernia ring.
The most promising for the development of
laparoscopic hernioplasty technology was the
appearance of composite mesh prostheses, consisting
of an adhesive component on one surface, providing
the effect of reliable hernioplasty, and a non-adhesive
surface facing the internal organs of the abdominal
cavity,
allowing
the
rapid
development
of
neomesothelium adjacent to the intestine, preventing
the formation of adhesions [ 3, 6].
In the literature and patent sources, there are a
number of methods for laparoscopic hernioplasty for
ventral hernias. At present, a number of randomized
trials have already passed, proving the safety, efficacy,
rapid rehabilitation and improvement in the quality of
life of patients after laparoscopic ventral hernia repair,
compared with traditional open hernioplasty with
anterior abdominal wall prosthesis [6].
However, the methods of laparoscopic hernia
alloplasty proposed in the sources have a number of
shortcomings, which prompted us to look for solutions
to these problems.
The aim of the study was to simplify the method of
laparoscopic
hernioplasty,
to
prevent
the
development of adhesions and recurrence of ventral
hernia.
Volume 03 Issue 05-2023
7
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
ISSUE
05
P
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05-15
SJIF
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FACTOR
(2021:
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5.
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(2023:
6.
184
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
Materials and research methods. The study is based on
a clinical examination of 105 patients with ventral
hernias who were operated on in the surgical
department of the multidisciplinary clinic of
Samarkand State Medical University for the period
from 2018 to 2022. All patients were operated on in a
planned manner. Depending on the choice of
treatment tactics, the patients were divided into two
groups. The first group, the comparison group,
consisted of 65 (61.9%) patients who underwent open
hernia repair. The second group, the main group,
consisted of 40 (38.1%) patients who were scheduled
for laparoscopic prosthetic hernioplasty.
In the main group, 37 (92.5%) laparoscopic prosthetic
hernioplasties were performed. They used standard
polypropylene mesh implants.
In the main group of patients, several stages of
standard endovideosurgical hernioplasty have been
improved: the places for conducting working trocars
have been standardized; the size of the implant along
the perimeter is 5 cm larger than the size of the hernial
defect;
improved
method
of
laparoscopic
hernioplasty.
Surgery was performed according to the standard
technique.
Stage I - the introduction of the first trocar. Depending
on the primary or postoperative hernia, the
introduction of the first trocar was carried out in two
ways:
1. Patients with primary ventral hernia used the
standard method with the introduction of a Veresh
needle (Fig. 1), pneumoperitoneum was applied to a
pressure of 12-14 mm Hg. st., after removing the
needle, a trocar was inserted into the abdominal cavity.
Usually, entry into the free abdominal cavity was
carried out using a special optical trocar "Visiport
™
"
(Covidien), followed by a revision of the abdominal
cavity;
Volume 03 Issue 05-2023
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(ISSN
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Publisher:
Oscar Publishing Services
Servi
Fig. 1. Insertion of the Veresh needle and application of the pneumoperitoneum
2. If adhesions were likely, patients with postoperative
ventral hernias were treated with the Hassen
technique, i.e. the abdominal wall was opened in layers
with a 2-4 cm long incision, adhesions around the
wound were separated under visual control, and a
trocar with an obturator was inserted through the
incision, the wound was sealed.
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 inserted. Places of
introduction of trocars were 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. 2).
Hernia of the white line of the abdomen
above the umbilicus (M1)
Hernia of the white line of the abdomen
below the umbilicus (M3)
3
1
2
3
1
2
I
III
II
IV
V
VI
VIII
IX
I
II
III
IV
V
VI
VII
VIII
IX
VII
Volume 03 Issue 05-2023
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(ISSN
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Publisher:
Oscar Publishing Services
Servi
Postoperative hernia of the abdomen of the
right iliac region (L3)
Postoperative abdominal hernia in the right
hypochondrium (L1)
Fig. 2. Scheme of trocar insertion points for the most typical localizations of ventral hernias
Stage III was adhesiolysis. Separation of adhesions
between the hernial sac, anterior abdominal wall and
nearby
organs
was
performed
using
electrocoagulation.
Stage IV - identification of the aponeurosis defect,
determination of the true size of the hernia ring,
selection of a mesh implant of the appropriate size.
Stage V - cutting out the implant, the dimensions
of which along the perimeter are 5 cm larger than the
dimensions of the hernial defect and modeling the
mesh implant (if necessary), marking the hernia orifice
and fixation points of the ligatures, stitching the edges
of the mesh implant with ligatures for its intra-
abdominal expansion and pressing against the anterior
abdominal wall in front of final fixation (Fig. 3).
1
2
1
2
3
VII
I
3
I
II
II
III
III
IV
V
VI
VI
V
IV
VIII
VIII
VII
IX
IX
Volume 03 Issue 05-2023
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(ISSN
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VOLUME
03
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(2021:
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5.
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(2023:
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OCLC
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1121105677
Publisher:
Oscar Publishing Services
Servi
Fig. 3. View of a mesh polypropylene implant, the dimensions of which along the perimeter are 5 cm larger than
the dimensions of the hernial defect
VI stage. At this stage, before the introduction of the
implant into the abdominal cavity, the peritoneum was
open
ed, the hernial sac was isolated and a “pocket”
was created in the preperitoneal space, the
indentation along the perimeter from the hernial
orifice was 5-6 cm. In the lower part of the anterior
abdominal wall, the “pocket” was created from the
hernial defect to the bottom of a full bladder. The
bladder during the operation was filled with a solution
of furacilin through a urethral catheter. Then, a mesh
implant rolled into a tube was introduced into the
abdominal cavity through the trocar, unfolded and
pla
ced in the created preperitoneal “pocket” (Fig. 4).
It was pressed against the anterior abdominal wall
using ligatures tied around the edges of the implant.
Fig. 4. Unfolding into a tubed mesh implant
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6.
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OCLC
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1121105677
Publisher:
Oscar Publishing Services
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The implant was sutured to the anterior abdominal wall using an Endo Close needle (Fig. 5).
Fig. 5. Puncture of the needle from the side of the abdominal cavity visually under the control of the
endovideolaparoscope
Thus, the caudal part of the endoprosthesis does not
reach the bottom of the full bladder, and visual fixation
of the endoprosthesis to the anterior abdominal wall
does not injure the bladder wall. Desufflation is
performed under visual control. The trocars are
removed, the wounds are sutured in layers. A
schematic
representation
of
the
improved
endovideosurgical
preperitoneal
prosthetic
hernioplasty for ventral hernias is shown in Figure 6.
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1121105677
Publisher:
Oscar Publishing Services
Servi
Fig. 6. The method of laparoscopic ventral hernia repair proposed by us: 1-hernial defect; 2-full bladder; 3 - non-
composite (conventional) mesh implant; 4-peritoneum; 5-pre-imposed U-shaped seams; 6-pocket between the
peritoneum and the muscular-aponeurotic layer extending from the hernial defect to the bottom of the full
bladder
The implant was fixed by suturing with an Endo Close needle using a non-absorbable suture material. The threads
were tied extracorporeally after they were completely removed (Fig. 7).
Fig. 7. View of the removed sutures from the side of the abdominal wall
VII stage. Next, in order to prevent adhesions in the abdominal cavity, peritonization of the implant is performed (Fig.
8).
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Servi
Fig. 8. Peritonization of a Standard Mesh Implant with an Endo Close Needle
At the end of the operation, hemostasis control, gas
desufflation, removal of trocars and suturing of 10 mm
punctures of the anterior abdominal wall, intradermal
absorbable sutures on skin incisions and aseptic
dressings were performed.
Research results. Improving the choice of tactics for
surgical treatment of ventral hernias, the technique of
performing laparoscopic prosthetic hernioplasty, and
other innovations developed and implemented within
the framework of this study could not but affect the
immediate results of managing this category of
patients.
In the first years, i.e. during the period of mastering the
laparoscopic technology, performing prosthetic
hernioplasty took a rather long time (up to 71.6 ± 0.7
minutes), however, with the growth of the experience
of surgeons and the development of technology, the
course of the operation significantly decreased to 51.4
± 0.6 minutes (T-criterion = 6.74, P<0.001) (Fig. 9).
In addition, it should be noted that during the period of mastering the technique, 3 (5.8%) patients underwent
conversion, i.e. hernioplasty was completed by the open method.
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The reason for the conversion was associated with a pronounced adhesive process in the abdominal cavity,
concomitant diseases of the cardiovascular and respiratory systems, which responded to prolonged
pneumoperitoneum. The reasons for the conversion are shown in Table 1.
Table 1 Reason for conversion of laparoscopic prosthetic hernia repair
Reason for conversion
Number of patients(n=3)
abs.
%
Pronounced adhesive process and lengthening of the stage of
separation of adhesions for more than 50 minutes:
3
100,0
- Intraoperative increase in arterial blood pleasure
2
66,7
- Intraoperative reduction of saturation
1
33,3
As can be seen from the table, in all cases (5.8% of the
total number of patients in the main group), the cause
of conversion was a pronounced adhesive process of
the abdominal cavity in patients with postoperative
ventral hernias.
Long-term separation of adhesions for more than 50
minutes,
i.e.
prolonged
pneumoperitoneum
manifested itself as an increase in blood pressure
intraoperatively up to 200/100 mm Hg. Art. in 2 patients
and in 1 patient with a concomitant chronic respiratory
disease, it led to a decrease in blood oxygen saturation.
In all of the above 3 cases, operations were completed
with open allohernioplasty using the “on lay” method.
Spasmodic changes in the parameters of the
cardiovascular and respiratory system during surgery
can be explained by the long course of
pneumoperitoneum, which is a rather stressful factor
associated with stretching of the peritoneum, rich in
nerve endings. It should also be noted that the return
to the initial level of indicators of the cardiovascular
and respiratory system occurred after the conversion,
i.e. elimination of pneumoperitoneum.
CONCLUSION
Improvement of technical aspects allowed: due to the
differentiated introduction of the first trocar, to
eliminate such complications as perforation of the wall
of a hollow organ; by standardizing the management
of working trocars, the technique of the operation was
simplified; by fixing the implant with a 5-6 cm offset
from the hernia orifice, hernia recurrence was
minimized in the late postoperative period; due to the
use of a modified needle, it was possible to level out
technical difficulties in fixing the prosthesis and during
prisonization of standard non-composite mesh
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implants with a reduction in this stage of the operation
from 27.4 ± 0.5 to 12.6 ± 0.7 minutes (P<0.001).
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