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Factors influencing the choice of hernia repair method in patients with incisional hernias
DOI: http://dx.doi.org/10.20534/ESR-17-1.2-153-155
Shamsiyev Azamat, Samarkand State Medical Institute, doctor degree in medicine, department of pediatric surgery E-mail: azamat.shamsiev@mail.ru Davlatov Salim, Samarkand State Medical Institute Master degree in medicine, Department of surgical diseases № 1 E-mail: sammi-xirurgiya@yandex.ru
Factors influencing the choice of hernia repair method in patients with incisional hernias
Abstract: The research work is based on analysis of hernia repair results in 228 patients with incisional, recurrent and primary ventral hernias. All operations were performed in the surgical department of the 1st and 2nd SamMI Clinics in period from 2008 to 2016. Patients were divided into two groups: the control group and the main one. Long-term results of surgical treatment of incisional and recurrent hernias were observed in 196 patients in period from 1 to 10 years. From 196 studied patients with long-term observation of outcomes 112 were in the main group, who were assessed by the mark score, and 84 were in the control group. From 84 examined patients of the control group tension hernia repair using autotissues was performed in 36 patients, hernia repair using polypropylene mesh implants in 41 and tension-free mesh repair in 7 patients. The mark score of assessment the perioperative risk criteria in patients with incisional hernias allows you to choose the best way of hernia repair based on individual characteristics of the organism and improve treatment outcomes.
Keywords: incisional and recurrent hernias, tension free mesh hernia repair, mark score, program.
Relevance. Despite the dynamic development of medical science, the problem of treatment of ventral hernias remains relevant. The increased incidence of ventral hernias is maintained mainly due to incisional hernias, after the laparotomy it is from 10 to 15% according to various data [1; 4; 7]. Results of surgical treatment of incisional hernias are largely dependent on complex issues such as the rational preoperative preparation aimed at the patient's adaptation to increased intraabdominal pressure, the choice of an adequate method of hernia repair and prevention of postoperative complications [3; 6; 7; 9]. In this case the surgeon has a difficult task in determining the indications for use of a particular method of hernia repair taking into account the different risk factors. As a rule, surgeon takes into account the possibility ofpostoperative complications and the risk of post-operative recurrence ofhernia choosing the particular method of hernia repair. To solve the problems every surgeon is guided by its own criteria [2; 5; 8]. Some authors are guided by
Table 1. - Distribution of the main
clinical data, others — by the data of various instrumental methods of research, others use different algorithms to decide how repair the hernia. Analysis of scientific medical and patent documentation shows that in available literature three is no exact indications for use of a particular method of hernia repair taking into account the different risk factors. The decision of the above-mentioned problems is an urgent and priority issue in modern today herniology.
Purpose of the research: To develop a program for quantifying recurrence risk factors in patients with ventral hernias.
Materials and methods. The work is based on an analysis of hernia repair results in 228 patients with incisional, recurrent and primary ventral hernias. All the operations were performed in the surgical department of the 1st and 2nd SamMI Clinics date from 2008 to 2016. The patients were divided into two groups: the control group (96-42.1%) and the main group (132-57.9%). Patients in the main group were divided into 3 subgroups (table 1). group of patients into subgroups
Gender Group Total
1st 2nd 3d
Male 13 15 29 57
Female 22 26 27 75
Total 35 41 56 132
№ Risk factors Quantitative characteristics Marks
1 2 3 4
1 Condition of the abdominal wall by ultrasound, CT. Normal Mild weakness Severe weakness 0 1 2
Up to 5 cm 0
2 Width of the hernial ring 6-15 cm More than 15 cm 1 2
Table 2. - Scoring system of indications to the use of different methods of hernis repair
Section 8. Medical science
3 Weight (body mass index) Normal Obesity I-II degree Obesity III-IV degree 0 1 2
4 Age Up to 40 years old 40-60 years old Older than 60 years old 0 1 2
5 History of hernia Up to 1 year long From 1 to 3 years Longer than 3 years 0 1 2
6 Physical exertion Absent Moderate Severe 0 1 2
7 Functional condition of the respiratory system No disorders Periodic breathing difficulties Chronic respiratory failure 0 1 2
8 Functional condition of the digestive system No disorders Periodic constipation Persistent constipation 0 1 2
9 Functional condition of the urinary system No disorders Periodic urination difficulties Constant urination difficulties 0 1 2
10 Severity of adhesive process No adhesions Adhesions in the hernial sac Abdominal adhesions 0 1 2
In patients of the 1st subgroup with the total number of marks up to 5 (certificate of official registration — the program for electronic computers № DGU 03724) (Table. 2) tension hernia repair using local tissues was performed (Table. 3). This group consisted of patients who, as a rule, had minor defects and observed significant changes in the tissues of the anterior abdominal wall and no comorbidities. In such patients hernia repair by standard methods with th formation of dublicature was performed. In the 2nd subgroup with a score of 6 to 10, taking into account the risk of tissue tension, the various constitutional features that affect the postoperative period, we performed a combined method which is defect of aponeurosis was sutured edge to edge with additional cover of the seams by polypropylene mesh, thereby eliminating the need to overlay the double row stitches. This has allowed to avoid increase of intraabdominal pressure in the early postoperative period and to create optimal conditions for the formation of a strong postoperative scar. In the 3rd subgroup patients with the dialed number of marks from 11 to 20 had a higher risk of tissue tension and increased intraabdominal pressure, in this case it would be advisable to apply only tension free sublay, inlay and onlay techniques, however, we believe that these techniques almost do not reduce the risk of recurrence and do not eliminate the hernia defect. Obviously, the radicalism can be achieved only by eliminating the defect, rather than by its replacement by mesh implants, and therefore the combination of tension and tension free techniques can be considered the best way of hernia repair. A significant factor holding surgeon from radical surgery, is excessive tension during the suture of tissues and a high probability of eruption of stitches in the postoperative period. In such cases, we use combined hernia repair with mobilization of rectus abdominis muscles sheaths by Ramirez. The advantages of the proposed method is that the hernia repair is performed by single-row stitching (which less reduces abdominal cavity), mobilization of rectus abdominis muscles sheaths allows to distribute uniformly
and significantly reduce the pressure on the tissue during the suture. To compare our results 164 patients of the control group who were operated on for incisional and recurrent abdominal wall hernias routinely were taken exclude scoring. We used the same technique as in the main group, at the same time we took into account the width and duration of herniation, patients' age and comorbidities, all other factors, besides the data of CT and MRI, histology and spirometric study (Table 4).
Results and Discussion. Long-term results of surgical treatment of incisional and recurrent hernias of the anterior abdominal wall we had been observing in 196 patients in period from 1 to 10 years. From 196 observed patients with investigated long-term outcomes 112 were from the main group in which we used the score, and 84 from the control group. From 84 observed patients of the control group autoplastic hernia repair was performed in 36, mesh hernia repair in 41 and tension free mesh hernia repair in 7 patients. From the 112 investigated patients, in which hernia repair based on scoring was performed, autoplastic hernia repair was made in 19, combined mesh hernia repair — in 28, tension free mesh hernia repair — in 34 and tension free mesh hernia repair with mobilization of the rectus abdominis muscles sheaths by Ramirez — in 31. Recurrent disease we identified in 8 patients, which accounted for 4.1% of the total number (209) investigated patients. In the group, we performed hernia repair without scoring, disease recurrence was detected in 7 (8.3%) patients. Where autoplastic hernia repair was performed in 6 (7.1%), combined hernia repair stitching edge to edge with the additional strengthening of the seam line by polypropylene mesh in 1 (1.2%) patient. In group, where we used scoring, disease recurrence was detected in 1 (0.9%) patient. Reccurence occured in a patient after hernia repair using autotissues. In patients who had undergone tension free mesh hernia repair relapses have not been observed.
Accompanying defects of development in children with congenital cleft of lip and palate
Table 3.- Distribution of patients in the main group depending on gender, age and method of hernia repair
Method of hernia repair Gender A ge
m. w. Up to 40 40 to 60 Older than 60 Total
Autoplastic hernia repair 8 17 1 18 6 25
Mesh hernia repair 12 19 1 21 9 31
Tension free mesh hernia repair 23 13 2 32 2 36
Tension free mesh hernia repair with mobilization of rectus muscles sheaths by Ramirez 14 26 9 19 12 40
Total 57 75 13 90 29 132
Table 4. - Distribution of patients in the control group depending on gender, age and method of hernia repair
Method of hernia repair Gender A ge
m. w. Up to 40 40 to 60 Older than 60 Total
Autoplastic hernia repair 12 28 5 27 8 40
Mesh hernia repair 18 30 7 26 15 48
Tension free mesh hernia repair 3 5 1 5 2 8
Total 33 63 13 58 25 96
Conclusions. Thus, the Mark score criteria of perioperative the optimal method of hernia repair based on individual character-risk in patients with incisional ventral hernias allows you to choose istics of the organism and to improve treatment outcomes.
References:
1. Аббасзаде Т. Н., Анисимов А. Ю. Диагностика и профилактика ранних послеоперационных раневых осложнений у больных с большими вентральными грыжами//Медицинский вестник Башкортостана. - 2013. - Т. 8. - №. 3.
2. Кукош М. В., Власов А. В., Гомозов Г. И. Профилактика ранних послеоперационных осложнений при эндопротезировании вентральных грыж.//Новости хирургии - 2012.- Том 20. - № 5. - С. 32-37.
3. Лаврешин П. М., Гобеджишвили В. К. Дифференцированный подход к лечению послеоперационных вентральных грыж//Вестник экспериментальной и клинической медицины. - 2014. - №. 3. - С. 246-251.
4. Shamsiyev Azamat, Kurbaniyazov Zafarjon and Davlatov Salim. "Criteria's of choice method in surgical treatment of patients ventral hernia with concomitant obesity". European science review No. 3-4. - 2016.
5. Breuing K. et al. Incisional ventral hernias: review of the literature and recommendations regarding the grading and technique of repaid/Surgery. - 2010. - Т. 148. - No.. 3. - С. 544-558.
6. Dietz U. A. et al. Importance of recurrence rating, morphology, hernial gap size, and risk factors in ventral and incisional hernia classification/Hernia. - 2014. - Т. 18. - No. 1. - С. 19-30.
7. Fink C. et al. Incisional hernia rate 3 years after midline laparotomy//British Journal of Surgery. - 2014. - Т. 101. - №. 2. - С. 51-54.
8. Shamsiev A. M., Davlatov S. S. Хирургическое лечение больных вентральными грыжами с сопутствующим ожирением//Шпитальна хiрургiя. Журнал iменi ЛЯ Ковальчука. - 2016. - No. 1.
9. Slater N. J. et al. Criteria for definition of a complex abdominal wall hernia//Hernia. - 2014. - Т. 18. - No. 1. - С. 7-17.
DOI: http://dx.doi.org/10.20534/ESR-17-1.2-155-157
Shamsiyev Jamshid, Samarkand State Medical Institute, doctor degree in medicine, department of pediatric surgery
E-mail: shamsievja@mail.ru Shamsiev Ravshan, Samarkand state medical institute, resident graduate 2st year students, specializing in maxillofacial surgery
E-mail: ravuz@yahoo.com
Accompanying defects of development in children with congenital cleft of lip and palate
Abstract: For the examination and correction 122 patients with congenital cleft of lip and palate were in the clinic № 2 of SamMI during 2004-2014. In combination of pathology the child was examined by particular specialists. Detected in children with cleft of upper lip and palate external stigma of disembryogenesis — congenital defects of development of extremities, kidneys and other changes of organs have systemic character, progress which is conditioned with dysplasia of connective tissue. For extension of complex aid and provision complete rehabilitation of patients with congenital cleft of lip and palate is necessary synchronic work of specialists.
