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27MODERN STATE OF PROBLEM OF POSTOPERATIVE VENTRAL HERNIAS SURGICAL TREATMENT (LITERATURE REVIEW) Shamsiev A.M.1, Davlatov S.S.2, Kan S.A.3
1Shamsiev Azamat Mukhitdinovich - Professor, DEPARTMENT OF PEDIATRIC SURGERY;
2Davlatov Salim Sulaymonovich - Senior Lecturer, DEPARTMENT OF SURGICAL DISEASES № 1;
3Kan Svetlana Afanasyevna - Surgeon, SURGERY DEPARTMENT AT THE CLINIC, SAMARKAND STATE MEDICAL INSTITUTE, SAMARKAND, REPUBLIC OF UZBEKISTAN
Abstract: the urgent issues of surgical treatment of postoperative ventral hernias are considered. The existing classifications of postoperative hernia, advantages and disadvantages of various materials used for hernioplasty are disassembled, the effectiveness of dermatolipidectomy with abdominoplasty is shown. Modern methods and methods of fixing implants are analyzed. A large space is devoted to local complications arising after hernia repair, and ways of their prevention.
Keywords: postoperative ventral hernia, hernioplasty, dermatolipidectomy, abdominoplasty, complication, prevention.
Despite the rapid development of minimally invasive endovideosurgical technologies in abdominal surgery, the number of surgical procedures using conventional laparotomy remains high, after which in 4-18% of the cases develop incisional hernias (IH), and in the general statistical structure of ventral hernias IH makes up 20-26% [17]. In the structure of the abdominal hernias large incisional hernias (LIH) occupy a special place, and they account for between 3 and 14% [20]. About 60% of patients with IH - aged from 21 years to 60 years, i.e., they are a significant part of the working population [14]. Results of IH treatment characterized by a fairly high number of recurrences (from 4.3 to 46%), while in LIH recurrences reach 60% of the cases [4]. The causes of IH in 31,4-63,4% are infectious processes in the wound [7, 16], in 35.1% - drainage and tamponade of abdominal cavity through the major wound, and in 40.7% of cases - eventration [8]. Only in 18% of cases, development of hernias occurs in a favorable postoperative period. But even with a favorable current of wounds IH develop in patients with imbalance of collagen type III, which results to progressive tissue morphofunctional deficiency that is most characteristic of patients with recurrent hernias, with the subsequent development of their «hernia disease» [14].
The increasing incidence of IH associated with the increase in the number of elderly patients with their characteristic severe concomitant somatic diseases - chronic diseases of the respiratory, circulatory, urinary system, as well as chronic constipation and metabolic diseases (diabetes mellitus, obesity, hypothyroidism) [11]. In the pathogenesis and recurrences of IH an important role belongs to obesity. In cases of morbid obesity risk of ventral hernias after uncomplicated laparotomy increased 2-fold, reaching 28-30%. Among all patients with LIH overweight or obesity is found in 70-90% of cases [15]. According to the literature, most of IH occur after gynecological surgery (26 to 50% of cases), operations in the bile ducts (20 to 30%), over the stomach and duodenum (approximately 12%), appendectomies (6 to 14%), abdominal wounds and injuries (about 9%). The mortality after surgical interventions on the LIH reaches 10% [2, 12]. The mechanism of hernia formation is complicated and varied. The main etiological point is a violation of the dynamic balance between the intra-abdominal pressure (IAP) and the ability of the abdominal wall to counteract. Significant factors for the formation of hernias are patient's weight and fat metabolism disorders [4, 9], the patient's age, pregnancy and childbirth in women [5, 15]. Investigations of biomechanical properties of the anterior abdominal wall showed that in patients with hernia of linea alba mechanical strength of tissues within the linea alba in the
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longitudinal direction is 40.8% and in the transverse direction is less than 38.7% compare to those, who have a healthy abdominal wall. «Risk zone» for the formation of a hernia is located in the projection of the linea alba of the abdomen in the umbilical area [5]. At the present stage of herniology development it's believed that ventral hernia is a disease, not only local, but also systemic one. In patients with hernias disorder of the synthesis of collagen and reduction the ratio of collagen types I and III were detected. In addition, the specific enzymes are important -metalloproteinase, which regulate the balance and synthesis of collagen [12]. A separate and actual problem of modern surgery is IH with large and giant sizes accompanied by dysfunction of the respiratory, cardiovascular and digestive systems, changes in the abdominal wall muscles [3]. The entire history of abdominal surgery strongly supports the position according to which the IH is an inevitable consequence of surgery.
It does not change the statement and application of modern videolaparoscopic operations on the abdominal organs. It was assumed that with their use, if not disappear; it will sharply decrease the problems relevance. However, the percentage of IH, for example, after videolaparoscopic cholecystectomies, according to various authors [14], is proved to be not less than after laparotomic operations (2.5% - 7.6%). Surgical treatment of those hernias is by not a simple matter [11].
Etiological factors leading to IH, are divided into general and local.
General: 1) predisposing factors - linked to depression of reparative processes and the reduction of general non-specific reactivity (glucocorticoids, antibiotics, diabetes, etc.); 2) producing factors - linked to the weakening of the abdominal wall, and the morphological and functional impairment of tissues (age-related changes in the tissues, the crossing of the nerve trunks, etc.).
Local: 1) factors related to the operation (traumatic access, violation of art suturing the wound, holding through a wound drainage and tampons, relaparotomy etc.); 2) factors associated with wound complications (abscess, incomplete hemostasis, eventration etc.) [12].
Currently, a single and universal classification of ventral hernias does not exist [14]. Classification of IH by J.P. Chevrel, A.M. Rath, (2000) takes into account three parameters - the site, width and recurrence rate after primary surgery.
A large number of hernia repair methods and modifications, the appearance of publications on all new elaborations are on the one hand, the undeniable fact of dissatisfaction with the results incisional hernia repair, the other - evidence of an ongoing search for solutions to this problem [9]. The frequency of recurrences after laparotomy is 313%, while in morbid obesity it is 28% [4].
Mesh implants made from PP and PTFE are now widely used [21]. There are four variants of the implant location: supraaponeurotic fixation of the implant - «onlay»; subaponeurotic fixation of the implant (preperitoneal and retromuscular) - «sublay»; plastic of the abdominal wall defect partially or completely - «inlay»; intraabdominal fixation of the implant - «intraabdominal» [11]. The advantages of the method include the technical simplicity of implementation [7]. Intra-abdominal location of the endoprosthesis assumes contact with the bowel loops and the risk of intestinal fistulas formation [9]. The literature describes cases of intestinal fistula 14 years after implantation of PP mesh [11]. Above described variants of prosthetic hernia repair methods in an isolated form do not fully satisfy modern herniology. In this regard, some authors offer combined techniques. V.I. Belokonev et al. (2000) on the basis of the biomechanical pathogenesis of IH concept developed a combined «inlay-sublay»-method; two versions for the abdominal wall plastic repair over the large and giant ventral hernias [13].
In 1990 O.M. Ramirez et al. proposed a method of hernia repair with a gradual separation of the components of the anterior abdominal wall («components separation») [13]. Despite the trauma, the technology allows us to reduce the edges of large hernia defects without increasing IAP. Therefore, a number of herniologists combine the technology of «components separation» with the prosthetic techniques. V.N. Egiev et al. (2011) combine with intraperitoneal hernia repair [9], A. Kingsnorth et al. (2008) combine
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with the «onlay»-method [11], T. Satterwhite et al. (2012) in the treatment of combined and recurrent IH recommend to combine the «sandwich»-type hernia repair with the dual endoprosthesis placement [5].
In addition to the open methods ventral hernia repair, laparoscopic techniques are actively used. For this purpose implants with a release coating are implanted. The advantages of laparoscopic abdominal prosthetic mesh-repair are mild postoperative course, early rehabilitation of patients, and reduction of the incidence of postoperative complications. Negative sides: the maximum size of a defect in the muscle-aponeurotic layer, according to the recommendations of the majority of authors, should not exceed 10 cm; the high risk of intestinal damage in the separation of adhesions by electrocoagulation; and there is the problem of fixing the endoprosthesis. Thus, the guidance in the literature on many techniques and methods of abdominal wall prosthetic surgery on ventral hernias with a variety of immediate and long-term results say about the absence of a single, universal method [7, 9].
Abdominoplasty (dermolipectomy of the anterior abdominal wall) in all cases allows to reduce the effect of ongoing efforts needed to match the edges of the defect in the muscular-aponeurotic layer of the anterior abdominal wall. This reduction in the maximum (15-70%) in a range of areas generated by defects in the abdominal wall from 32 to 150 cm2 and the thickness of the subcutaneous fat layer of the anterior abdominal wall more than 3 cm [10]. Thus, abdominoplasty, performed by indications and complementing with herniotomy about ventral hernia of the anterior abdominal wall may be an additional factor that reduces the strain of tissue of the anterior abdominal wall and the degree of increased intra-abdominal pressure, which occurs during the closing of hernial orifice, and as a result of this method recurrences of ventral hernias are prevented [3]. An important problem of ventral hernia repair is early postoperative complications, because it is a major cause of prolonged postoperative period, more moral and physical suffering of patients and possible deaths [3]. One of the significant problems of large and giant ventral hernias repair, besides the technical aspects, is increased IAP, which leads to the development of intra-abdominal hypertension syndrome, respiratory and cardiac failure. An easily accessible way to monitor IAP is to measure the pressure in the bladder [16].
A number of authors for the prevention of intra-abdominal hypertension offer original methods. S.G. Izmailov et al. (2003) developed a special apparatus for the metered edges to close hernia defect controlled by IAP. Researchers note that wound complications are observed both at using different types of implants (PP, PTFE), and methods for various locations in the tissue [12]. The most frequent complications are seroma, infiltrate, long exudation from the wound, more rarely - festering, necrosis of the skin edge, infarction of subcutaneous tissue, fistula, meshoma and granuloma. The frequency of wound complications after prosthetic mesh repair according to Y.R. Mirzabekyan, S.R. Dobrowolskiy (2008) is 67%; T. White et al. (1998) - 44%; J. McGreevy et al. (2003) -21%; A. Bazaeva, I.A. Tsverova (2011) - 12% [6]. Local complications of early postoperative period include: disruption of the wound, the formation of infiltrates, hematomas, seromas, ligature fistulas, long chylorrhea, festering wounds, etc. The frequency of inflammatory wound complications, according to different authors, reaches impressive numbers - 20.9 - 49.2% [19, 21]. For LIH, when dissection of tissues of anterior abdominal wall and extensive surgical trauma combined with the presence of a foreign body (alloplasty), frequency of seromas at preperitoneal and subaponeurotical location of implant reaches 6.9 - 17%, and at supraaponeurotical version from 21.3 to 31.8% [21].
Currently, there are numerous ways to prevent and treat seromas. These include intraoperative prevention measures (closure of «free spaces» over the aponeurosis) [7], various types of drainage, early bandaging, puncturing, probing, antibiotic therapy [6], physiotherapy. These multiple forms of treatment have their own characteristics and weaknesses and indicate an absence of a single effective method for the prevention and treatment of this complications.
According to A.B. Laricheva et al. (2012), the appearance of infiltration in the wound area caused by a local inflammatory response of the body to the prosthesis as a foreign body, which usually has the character of an aseptic and self-treated, so the infiltration should be removed from the category of complications [13, 18].
According to A.V. Podergin, V.L. Halzova (2007), the problem of ligature fistulas with prosthesis of abdominal wall in ventral hernias is associated only with the use as suture polyester (lavsan, nylon) and is solved by using a PP suture material for fixing the same prosthesis [2]. S.Y. Pushkin and others (2011) examined the nature of the morphological and functional changes in tissues during the formation of liquid effusions in the surgical wound in patients after prosthetic plastics. Results of morphological studies have shown that the reason for the formation of residual cavities in the subcutaneous adipose tissue and the appearance in these fluid buildup - exudates is a disorder of the blood supply in the deep layers (below the superficial fascia), due to its considerable detachment from the fascia and the absence of its closing after the operation [8]. Other authors to eliminate voids in the subcutaneous fat propose imposing U-shaped sewing perpendicularly the axis of the wound through the skin and subcutaneous tissue with a space from the skin edge of the wound by 57 cm and tying threads on gauze balls [11].
Thus, the presence of many ways to prevent wound complications for prosthesis of the abdominal wall in the ventral hernia repair and relevance of the problem dictates the need to develop techniques and tactics of patients care after prosthesis to reduce the frequency of wound complications.
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