Profilaktik tibbiyot va salomatlik
–
Профилактическая
медицина
и
здоровье
–
Preventive Medicine
and Health
Journal home page:
https://inscience.uz/index.php/preventive-medicine
Enhancing postoperative care to reduce complications in
ventral hernia surgery
Karim GAZIYEV
Bukhara State Medical Institute
ARTICLE INFO
ABSTRACT
Article history:
Received April 2024
Received in revised form
10 May 2024
Accepted 25 May 2024
Available online
15 August 2024
The use of synthetic materials for hernioplasty in patients
with postoperative ventral hernias (PVH) helps reduce the
incidence of wound complications. However, the success of PVH
surgical treatment depends on thorough preoperative
preparation, selecting the optimal alloplasty method, and
effective postoperative patient management.
An analysis of the surgical treatment outcomes for 143 PVH
patients operated on between 2018 and 2022 at the Bukhara
Regional Multidisciplinary Medical Center was conducted.
Polypropylene mesh implants produced by "Paha" (Turkey)
were used for hernioplasty. Of these patients, 65 (45.4%)
underwent onlay plasty, while 78 (54.5%) received sublay
plasty. In the early postoperative period, general complications
were noted in 7 patients (4.8%), wound complications in
15 patients (10.5%), and the mortality rate was 0.69%.
To improve surgical outcomes for PVH patients, specific
recommendations should be followed. A comprehensive
preoperative examination, combined with an individualized
program to prevent wound, thromboembolic, and pulmonary
complications, can be beneficial.
2181-3663
/©
2024 in Science LLC.
https://doi.org/10.47689/2181-3663-vol3-iss4-pp27-32
This is an open-access article under the Attribution 4.0 International
(CC BY 4.0) license (
https://creativecommons.org/licenses/by/4.0/deed.ru
Keywords:
postoperative ventral
hernia,
polypropylene mesh
implant,
prophylaxis of
complications,
recurrence of hernia.
1
PhD, Associate Professor, Bukhara State Medical Institute. Bukhara, Uzbekistan. E-mail: gazievku1970@gmail.com
Profilaktik tibbiyot va salomlatlik
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Ventral chirishlarni davolashda asorlarni kamaytirish
uchun operatsiyadan keyingi davolashni optimallashtirish
ANNOTATSIYA
Kalit so‘zlar
:
operatsiyadan keyingi
ventral chirishlar,
polipropilen torli implantat,
asorlanishlarning oldini
olish,
chirishning qaytalanishi.
Operatsiyadan keyingi ventral chirishlari (PVG) bo‘lgan
bemorlarda gernioplastika uchun sintetik materiallardan
foydalanish jarohat asorlari jadalligini kamaytirish imkonini
beradi. Biroq, xirurgik davolashning muvaffaqiyati operatsiyaga
to‘g‘ri tayyorlanishga, alloplastikaning optimal usulini tanlashga
va bemorni operatsiyadan keyingi davrda samarali yuritishga
bog‘liq bo‘lmaydi.
2018
–
2022-
yillar davrida Buxoro viloyati ko‘p tarmoqli
tibbiyot markazida amalga oshirilgan 143 nafar bemorni
xirurgik davolash natijalari tahlil qilindi. Gernioplastika uchun
«Paha» (Turkiya) ishlab chiqarilgan polipropilen torli
implantlardan foydalanilgan. Bemorlarda 65 (45,4%) onlay
plastikasi, 78 (54,5%) bemorlarda sublay plastikasi bajarildi.
Erta operatsiyadan keyingi davrda 7 (4,8%) bemorda umumiy
asorlar, jarohat asorlari 15 (10,5%) da ko‘rsatilgan, o‘lim hajmi
0,69% ni tashkil etgan.
Bemorlarni xirurgik davolash natijalarini yaxshilash uchun
ayrim tavsiyalarga mos bo‘lishi kerak. Operatsion oldingi
davrda jarohat, tromboembolik va engil asorlarning oldini olish
bo‘yicha yakka tartibdagi dasturni tuzgan holda bemorlarni
kompleks tekshiruvdan o‘tkazish foydali bo‘lishi mumkin.
Оптимизация
послеоперационного лечения
для
минимизации осложнений при лечении вентральных
грыж
АННОТАЦИЯ
Ключевые слова:
послеоперационные
вентральные грыжи,
полипропиленовый
сетчатый имплантат,
профилактика
осложнений,
рецидив грыжи
.
Использование
синтетических
материалов
для
герниопластики
у пациентов с послеоперационными
вентральными грыжами (ПВГ) позволяет снизить частоту
раневых осложнений. Однако успех хирургического лечения
ПВГ зависит от правильной подготовки к операции, выбора
оптимального метода аллопластики и эффективного ведения
пациента в послеоперационном периоде.
Проанализированы результаты хирургического лечения
143 пациентов с ПВГ, прооперированных в период
2018
–2022 гг. в Бухарском областном многопрофильном
медицинском центре. Для герниопластики использовались
полипропиленовые сетчатые имплантаты производства
"Paha" (Турция). У 65 (45,4%) пациентов была выполнена
пластика onlay, у 78 (54,5%) пациентов
–
пластика sublay.
В раннем послеоперационном периоде общие осложнения
отмечены у 7 (4,8%) пациентов, раневые осложнения
–
у 15 (10,5%), летальность составила 0,
69%.
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Для улучшения результатов хирургического лечения
больных с ПВГ необходимо придерживаться некоторых
рекомендаций. В предоперационном периоде полезным
может быть комплексное обследование пациентов с
составлением индивидуальной программы профилактики
раневых, тромбоэмболических и легочных осложнений.
INTRODUCTION
Currently, there is no doubt about the expediency of using additional materials in
the surgical treatment of patients with postoperative ventral hernias (POVH). Over the
last 30 years, the methods of prosthetic plasty of hernia gates using synthetic mesh
prostheses have become the most widespread. The use of these techniques allowed for a
relatively low incidence of wound complications (3.5-3.9%) [6].
At the same time, it has been established that incorrect selection of patients,
inadequate preoperative preparation, technical errors during surgery and errors of
patient management in the postoperative period can lead to the development of
complications in the early postoperative period in patients with POVH.
The aim of the work: is to determine the main methods of complications
prevention in the early postoperative period after prosthetic plasty with polypropylene
mesh implant. The work was performed in the clinic of faculty and hospital surgery of
Bukhara State Medical Institute (BukhMI) on the basis of the regional multidisciplinary
medical center of Bukhara in the period 2018-2022.
MATERIAL AND METHODS
During this time period, prosthetic surgeries for POVH were performed on
143 patients (mean age of patients
–
55.05 ± 1.36 years). Among the patients, there were
102 (71.3%) women and 41 (28.6%) men. According to the hernia protrusion size
according to the classification proposed by the European Society of Herniology (EHS),
adopted at the XXI International Congress of Herniologists in Madrid (1999), patients
with small (W1) and medium (W2) POVGs prevailed (Table 1).
The polypropylene mesh implant of the "Paha" company (Turkey) was used for
hernia gate plasty. In 65 (45,4%) patients onlay plastic surgery was performed, and in
78 (54,5%) patients the mesh implant was placed in the sublay position. In the early
postoperative period wound complications were noted in 15 (10,5%) patients (Table 2).
General postoperative complications occurred in 7 (4.8%) patients with POVH.
3 patients developed early adhesive intestinal obstruction, which was resolved
conservatively. 2 patients had acute tracheobronchitis and in 2 cases phlebothrombosis
of deep veins of the lower limbs occurred.
Table 1
Distribution of patients with postoperative ventral hernias by size of hernial
protrusion
(
п
=
143)
Hernia size
Number of patients
а
bs.
%
W1 (small)
–
< 4 cm
62
43,3
W2 (medium)
–
≥4
-10 cm
57
39,9
W3 (large)
–
≥10 cm
24
16,8
Total
143
100
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Table 2
Structure of local (wound) complications in patients with postoperative ventral
hernias after alloplasty
Complication
Number of patients, abs.
Frequency of complications, %
Wound seroma
7
4,89
Wound hematoma
2
1,39
Lymphorrhea
1
0,69
Wound margin necrosis
1
0,69
Wound infiltrate
3
2,09
Wound suppuration
1
0,69
Total
15
10,5
Fatal outcome in the early postoperative period was observed in 1 (0.69%) patient
whose cause of death was pulmonary embolism (PTE).
RESULTS AND DISCUSSION
When analyzing the results of POVH treatment it was established that the
prevention of alloprosthetic complications should start at the preoperative stage.
Complex preoperative preparation is aimed at creating favorable conditions for
performing operations, preventing a significant increase in intra-abdominal pressure and
related complications in the early postoperative period. Assessment of external
respiratory function allows predicting the risk of developing high intra-abdominal
pressure during surgery. In the case of a decompensated state (GIEL less than 60%),
special preparation is necessary. It includes the use of a bandage in combination with
active breathing exercises and complex therapeutic exercises.
According to literature data, there is a reliable increase in the incidence of wound
complications of ventral hernias with a higher div weight of the patient [8]. According
to the results of our study, the average div mass index in patients with POVH was
32 ± 0.62 kg/m2. Overweight was observed in 82.6% of patients with POVH. One of the
tasks of the preoperative period is to reduce the patient's div weight. For this purpose,
the patients were trained in outpatient conditions together with a nutritionist.
The development of wound complications after alloprosthesis in patients with
POVH was started in the preoperative period. In the presence of pathologic changes
(diaper rash, skin excoriation) the preparation was carried out from 5 days to 2 weeks.
The anterior abdominal wall was treated daily with an antiseptic solution, physical
therapy was prescribed. According to many authors, antibiotic prophylaxis significantly
reduces the incidence of suppuration after alloplasty [13, 14, 17]. In our clinic it is carried
out according to the following scheme: 30-40 min before the operation amoxiclav 1.2 g
intravenously (intravenous) is administered.
The greatest danger for patients' life is pulmonary embolism and abdominal
compartment syndrome, lethality in this case can be up to 10% [3]. Prevention of
thromboembolic complications begins immediately before surgery. It includes elastic
compression of the lower extremities and anticoagulant therapy. Elastic compression
should be performed in all patients with POVH before transportation to the operating
room until full activation of the patient in the postoperative period. Low molecular weight
heparin (fraxiparin) was used for specific prophylaxis. The dosage depended on div
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weight: up to 50 kg
–
0.2 ml subcutaneously, 50
–
69 kg
–
0.3 ml, more than 70 kg
–
0.4 ml
once. In the group of patients we studied there was one fatal outcome as a result of TELA.
This patient had a high risk of thromboembolic complications due to the presence of
obesity of III
–
IV degree, large size POVH, varicose veins of the lower extremities.
Prophylactic measures were carried out in the usual manner. In spite of this, a lethal
outcome occurred. Probably, in such category of patients it is necessary to be more
cautious in favor of surgery and in some cases conservative methods of treatment should
be limited. To predict the development of increased intra-abdominal pressure syndrome, it
is currently recommended to perform X-ray computerized hernio-abdominometry [2]. The
technique allows to assess the state of the abdominal wall, determine the volume of the
abdominal cavity and hernial protrusion, and plan the technique of the forthcoming plasty.
Intraoperative stage of prevention of early postoperative complications is the most
important and determines the success of surgery, as well as the quality of life of the
patient. Often POVH is combined with other pathologies of the anterior abdominal wall
requiring surgical correction. Thus, in 8 (5.6%) patients POVH was combined with
diastasis of rectus abdominis muscles, and in 23 (16%)
–
with sagging abdomen.
Diastasis elimination was performed by applying invaginating sutures to the vaginas of
the rectus abdominis by the Championeer method with simultaneous implantation of the
mesh prosthesis under the aponeurosis. In the presence of saggy abdomen,
abdominoplasty was performed.
The question of the necessity of draining the surgical wound is debatable. Some
surgeons question the necessity of wound drainage after alloplasty and consider it as one
of the factors that contributes to its suppuration [16]. We approach wound drainage in a
differentiated manner. In onlay plasty we necessarily drain the wound for no more than
4-5 days. In sublay plasty in patients with small and medium-sized hernias we refrain
from placing drains, we install them only in patients with obesity and with extensive
hernias.
Management of the early postoperative period also influences the results of
treatment. After alloprosthesis in patients with large and giant hernias we use prolonged
peridural analgesia, which is an effective method of prevention of intestinal paresis. In
this case, the pain syndrome is successfully controlled, which contributes to earlier
activation of the patient.
An important role in the diagnosis and prevention of wound complications is
played by ultrasound of the postoperative wound. In case of fluid accumulation of more
than 20 mm, seroma puncture under ultrasound navigation is performed.
The closed method of wound management avoided a high incidence of purulent
complications, which amounted to 0.69%.
CONCLUSION
Thus, to improve the results of surgical treatment of POVH using plasty with mesh
prostheses it is necessary to fulfill a number of recommendations.
1. In patients with POVH a comprehensive examination should be carried out in
the preoperative period to identify concomitant diseases and to correct disorders of the
functions of organs, systems and homeostasis indicators.
2. In patients with high surgical risk due to the probability of dysfunction of vital
organs and systems, thromboembolic complications and development of compartment
syndrome, it is advisable to limit conservative treatment (wearing a bandage).
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3. All patients with POVH should be prophylactically treated for thromboembolic
complications both before surgery and in the early postoperative period.
4. In the presence of abdominal diseases requiring surgical correction, it is
advisable to perform simultaneous surgery with the choice of optimal access.
5. The issue of drainage of the operation area should be approached in a
differentiated manner. It is advisable to install vacuum-aspiration systems for drainage in
case of significant detachment of subcutaneous tissue. The terms of drainage should be
short (within 4-5 days).
6. In the presence of fluid formations, the best is a closed method of treatment
–
puncture under ultrasound navigation.
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