Evaluation of the effectiveness of negative pressure wound therapy in the complex treatment of patients with infected mesh endoprostheses of the anterior abdominal wall

Introduction. Wound complications after the placing of various implants of the abdominal wall after hernia repair account for up to 15 % of all hospitalizations with purulent diseases. Their treatment is often accompanied by a high frequency of explantation of a mesh endoprosthesis with a risk of recurrent hernias in this category of patients.The objective of the study was to improve the results of surgical treatment of patients with infected implants of the abdominal wall after herniaplasty based on the assessment of the effectiveness of the negative pressure wound therapy (NPWT).Methods and materials. A retrospective analysis of the treatment results of patients with infected mesh endoprostheses of the anterior abdominal wall (n=68) was carried out. We formed for comparison two homogeneous representative groups of patients, who underwent adequate debridement of a purulent wound with empirical antibiotic therapy. Patients from the study group (n=38) received local therapy using NPWT, patients from the control group (n=30) received traditional local therapy. The evaluation of the treatment results was carried out according to a number of criteria: the course of the systemic inflammatory reaction, the dynamics of reparative processes in the wound of the anterior abdominal wall, evaluation of the clinical outcomes of treatment of patients.Results. The use of vacuum therapy was accompanied by a positive effect on the course of the systemic inflammatory reaction, stimulation of reparative processes in the wound due to the rapid elimination of bacterial agents from the wound cavity (p= 0.003), as well as significant retraction of the wound cavity (p=0.004) compared to traditional methods of wound treatment. Patients from the study group had more favorable treatment outcomes such as a reduction in the duration of hospitalization (p=0.005) and the number of surgical interventions (p=0.003). Due to the NPWT, it was possible to save implants in 30 patients out of 38 (78.9%) with infected mesh endoprostheses of the anterior abdominal wall, which prevented the formation of recurrent hernias and helped to avoid reoperations in this category of patients.Conclusion. The use NPWT is a safe and effective method for treating wounds of the anterior abdominal wall with infected mesh endoprostheses after hernioplasty.

LITERATURE REVIEW METHODS FOR PROSTHETIC MESH FIXATION IN SURGICAL REPAIR OF INGUINAL HERNIAS

The article is devoted to the evolution of fixation methods for synthetic mesh endoprostheses in surgery of inguinal hernias. We have analyzed the data on failures and complications of synthetic implants. We paid a special attention to available techniques, such as endoprostheses fixation without sutures as well as to the fixation using various types of glue. Our review is based on its own experimental and clinical data as well as the data from world's best hospitals. We found that the use of fibrin glue frequently leads to formation of seromas and hematomas, whereas albumin-glutaraldehyde glue may result in abscesses and pyogenic inflammatory infections of surgical sites. The authors pointed out the importance of further research for the optimal fixation of the prosthetic mesh in hernia repair.

Immunological Reactivity of the Body to Implanted Retic Endoprosthesis Used for Hernias of the Anterior Abdominal Wall

The article analyzes the review of the literature of foreign authors and authors of the CIS countries on the immunological response to the used mesh endoprostheses in patients after alloplastic methods of hernioplasty with hernias of the anterior abdominal wall. Currently, it is possible to monitor the course of the wound process in patients operated on for hernia using the immunological method. The correlation dependence of the nature of complications in the wound with indicators of additional research methods has not been sufficiently studied, which requires further study of this issue.

THE USE OF MESH ENDOPROSTHESIS IN SURGICAL TREATMENT OF VENTRAL HERNIA

Surgical treatment of patients with ventral hernias remains an urgent problem in abdominal surgery. More than 20 million operations are performed annually in the world for hernias. The urgency and complexity of the problem is based on the fact that inadequately performed surgery leads to a recurrence of the disease in 14-54% of cases. The aim of the work is to study the results of surgical treatment of patients with ventral hernias using mesh endoprostheses. The results of a retrospective analysis of 437 hernioplasty performed with hernias of various localizations for the period from 2010 to 2014 were used. Patients were classified by hernia localization and divided into groups depending on the methods of alloplasty. The duration of observation of patients operated by using polypropylene mesh ranged from 6 month to 3 years. An analysis of the complications that developed after alloplasty of the inguinal, postoperative, umbilical hernias and hernias of the linea alba was carried out. Our clinical experience confirms that the operation of Liechtenstein is rightly considered to be the “gold standart” for the treatment of inguinal hernias. However, the use of polypropylene mesh in the treatment of inguinal hernias leads to the development of postsurgical wound complications. Placed next to the polypropylene mesh peritoneum flap plays the role of internal drainage, prevents the development of seromas in the wound. The use of a new inguinal alloplasty technique reduced the number of postoperative complications. Also, the best immediate and long-term results are obtained by alloplasty using a sublay method. In patients with postoperative hernias operated by sublay method, no recurrences were observed and they showed the best quality of life.

Modified Polypropylene Endoprosthesis for Hernia Repair: Experimental Assessment of the Efficiency of its Application

Objective: to assess the biological properties of a modified polypropylene endoprosthesis for hernia repair. Material and methods. The object of the study was polycaprolactone-modified mesh endoprostheses for hernia repair implanted in experimental animals. Results. During the study it was determined that the implanted modified endoprostheses caused more pronounced proliferation of fibroblasts and formation of connective tissue in comparison with the control group of implants. It should be also noted that there were more inert general biological reactions from the surrounding tissues.

Morphology of multinucleated giant cells in different types of stimulation to reparative regeneration in hernioplasty

Изучением морфологических особенностей, функциональной роли и механизмов образования гигантских клеток инородных тел занимались многие российские и зарубежные ученые. Однако данных о возможной причастности этих клеток, вероятно опосредованно, к процессам регенерации тканей, окружающих эндопротезы, используемые в герниологии при пластике брюшной стенки не было выявлено. Такое состояние проблемы и определило цель данного исследования: изучить морфологические особенности многоядерных клеток при имплантации сетчатых эндопротезов в ткани передней брюшной стенки. Материалы и методы. Экспериментальное исследование было выполнено на кроликах-самцах породы «Шиншила», массой 2500 г, в возрасте от 1 до 1,5 лет, которым под внутривенным наркозом препаратом «Золетил 50» в дозе 5 мг/кг массы, в асептических условиях надапоневротически имплантировали сетчатые эндопротезы: «Плазмофильтр», «Эсфил», «Унифлекс+Ag», «Гинефлекс» и «Гинефлекс + АПоТр». Полученные гистологические срезы толщиной 5-7 мкм, окрашивали гематоксилином и эозином, по методу Ван Гизон, по Маллори и проводили иммуногистохимическое исследование к маркеру клеточной пролиферации Ki-67. Результаты. Первое появление многоядерных клеток было отмечено на 7-е сутки эксперимента, далее происходило увеличение их количества на стандартной площади среза, размеров, числа ядер и площади занимаемой этими клетками. Через три недели после оперативного вмешательства отмечалось снижение данных показателей, что, по всей видимости, связано с окончанием перестройки соединительной ткани и приживлением импланта. Было замечено, что на ранних сроках многоядерные клетки локализуются чаще на нитях эндопротеза, затем между ними и позднее во внутреннем слое сформированной перипротезной капсуле. Необходимо так же отметить, что нанесение на эндопротез биологического материала в качестве внешнего слоя (антимикробное или антибактериальное покрытие) служащего неким «амортизатором», а также, одновременное введение аутоплазмы, обогащенной тромбоцитами под эндопротез приводит к появлению в перипротезных тканях морфологически разных видов многоядерных клеток. Заключение. Выявленные морфофункциональные особенности гигантских многоядерных клеток зависят от физико-химических характеристик эндопротезов, а кажущаяся неравномерность и беспорядочность в локализации многоядерных клеток, отражает определенную закономерность в реакции клеточного компонента перипротезной соединительной ткани на разных сроках эксперимента. Many Russian and international scientists have studied morphological features and the functional role and mechanisms for formation of foreign-body giant cells. However, possible and probably indirect involvement of these cells in regeneration of tissues surrounding the endoprosthesis used in hernioplasty of the abdominal wall is unknown. This status of the issue has determined the aim of this study: to examine morphological features of multinucleated cells during implantation of mesh endoprostheses into the anterior abdominal wall. Material and methods. This experimental study was performed on 1-1.5-year old Chinchilla male rabbits weighing 2500 g. The rabbits were anesthetized with Zoletil 50 (5 mg/kg, i.v.), and Plasmofilter, Esfil, Uniflex + Ag, Gineflex or Gineflex + ApoTr mesh endoprostheses were implanted unser aseptic conditions. Histological sections (5-7 μm) were stained with hematoxylin and eosin, according to Van Gieson staining procedure, and Mallory staining procedure. and immunohistochemical staining for the cell proliferation marker, Ki-67. Results. Multinucleated cells first emerged on day 7 of the experiment; then their number per standard sectional area, nucleus size, and the area occupied by these cells increased. At three weeks after the surgery, these indexes decreased, which was apparently associated with the end of connective tissue remodeling and engraftment. It was noted that in the early stages, multinucleated cells were localized primarily on the endoprosthesis threads, then between them, and later in the inner layer of the formed periprosthetic capsule. Covering the endoprosthesis with a biological material serving as a “shock absorbing” outer layer (with an antimicrobial or antibacterial coating) and simultaneous administration of platelet-enriched autoplasma under the endoprosthesis resulted in emergence of morphologically different types of multinucleated cells in periprosthetic tissues. Conclusion. The identified morphofunctional features of multinucleated giant cells depend on physicochemical characteristics of the endoprosthesis. The ostensible irregular and chaotic localization of multinucleated cells reflects a certain pattern in the reaction of the periprosthetic connective tissue cellular component at different periods of the experiment.

Polypropylene endoprostheses in the surgical treatment of strangulated postoperative ventral hernias

Aim. To determine and implement the best ways to position mesh endoprostheses in the anterior abdominal wall during strangulated postoperative ventral hernias; to introduce methods of non-stretch hernioplasty into emergency surgery of giant hernias. Methods. 115 patients (27 males and 88 females) with strangulated postoperative ventral hernias aged 30-73 years were under observation. Depending on the size of the hernia and on the intraoperative findings different methods of implantation of the mesh endoprostheses were used, which prevented the mesh contact with subcutaneous fat and abdominal organs. For small and medium-sized hernias the mesh was placed under or over the abdominal membrane, it was fixed to the abdominal wall, the aponeurosis was sewn together in an «edge to edge» fashion. In cases with giant hernias non-stretch hernioplasty was performed. During the operation of non-stretch hernioplasty, dissection and excision of the hernial sac was performed in such a way that made it possible to use it to cover the abdominal wall defect. Results. In the early postoperative period in 17 (14.8%) patients seromas had formed in the wound, which were treated by needle puncture under ultrasound guidance. Postoperative mortality was 5.2% (6 people). In 5 cases the deaths were due to myocardial infarction and pulmonary embolism. One patient developed peritonitis due to suture insufficiency of the enteric anastomosis. Of all patients with lethal outcomes five patients were admitted after more than 6 hours from the start of the strangulation, one patient was admitted after 3 hours. Conclusion. The usage of techniques that delimit the mesh prosthesis from the abdominal cavity and subcutaneous tissue, and the introduction of non-stretch methods for giant hernias in the surgical treatment of strangulated postoperative ventral hernia contribute to improved outcomes of treatment in this group of patients.