Background. Postoperative ventral hernias (PVH) account for 20.4-22 % of all abdominal hernias. The recurrence rate after alloplastic surgery of large and giant PVH is 10-25 %. Adequate selection of alloplastic surgery method in PVH may help to improve treatment outcomes and reduce the frequency of relapses.
Objective. To describe the features of laparoscopic and open alloplastic surgery of PVH.
Materials and methods. Analysis of literature sources on this topic.
Results and discussion. According to the classification, PVH are divided into medial (subxiphoid, epigastric, umbilical, subumbilical, suprapubic) and lateral (subcostal, flank, iliac, lumbar). Autoplastic surgery (according to Sapezhko, Mayo) is used only for small-sized PVH in young and middle-aged people in the absence of diastasis recti and obesity (up to 3.5 %). In 96.5 % of cases alloplastic surgery is used (open – 81.1 %; laparoscopic – 15.4 %). There are about a dozen types of alloplastic interventions. When choosing the optimal intervention, it is necessary to take into account the width of the defect, the width of diastasis or contracture of the rectus abdominis muscles, the level of intra-abdominal pressure. When performing laparoscopic alloplastic intervention, prevention of trocar wound infection is performed using Dekasan solution (“Yuria-Pharm”) by rinsing before suturing. Alloplastic surgeries of giant PVH should be performed in combination with techniques for separating the anatomical components of the anterior abdominal wall and mandatory monitoring of intra-abdominal pressure, as intra-abdominal hypertension is a frequent complication of such procedures. Preoperative preparation and examination of patients before PVH surgery includes laboratory tests (general and biochemical blood tests, coagulation analysis), electro- and echocardiography, ultrasound or computed tomography of the required areas, spirography, consultations with related specialists, slag-free nutrition and 10-12 days of laxatives (in the outpatient settings), correction of comorbidities, maximum bowel cleansing before surgery, control of intra-abdominal pressure, prevention of infectious complications of the wound and prevention of thromboembolic complications. Contraindications to elective surgery include ineffective preoperative preparation, impaired cardiopulmonary activity, increased intra-abdominal pressure >12 mm H2O using bandage compression, reduction of breathing function <60 % of normal. To prevent postoperative wound infection during surgery at the stages of separation of the anatomical components of the anterior abdominal wall, fixation of the mesh and before drainage and suturing the wound, Decasan washing is used (400-800 ml depending on the wound surface area). Postoperative treatment includes analgesia (paracetamol – Infulgan, “Yuria-Pharm”), oxygen therapy, abdominal bandaging, monitoring of intra-abdominal pressure, stimulation of intestinal function (metoclopramide – Reosorbilact, “Yuria-Pharm”), antibacterial treatment, correction of electrolyte balance, nonsteroidal anti-inflammatory drugs. Removal of drainages from the mesh implant is performed in 3-4 days, from the subcutaneous wound – in 5-6 days.
Conclusions. 1. The choice of PVH alloplastic surgery type should be made taking into account the size of the defects, the width of the diastasis recti and intra-abdominal pressure. 2. Optimization of the choice of treatment procedure for giant PVH can be achieved by determining the intra-abdominal pressure during surgery during contact of the rectus abdominis muscles. 3. Decasan lavage is used to prevent infection of trocar and surgical wounds.
Reconstruction of the anterior abdominal wall with postoperative ventral hernias by a modeled implant