Dubchenko V. S. Substantiation and improvement of laparoscopic preperitoneal hernioplasty in surgical treatment of ventral hernias of lower and middle localization.
The thesis presents the outcome of a prospective analysis of clinical results of surgical treatment of 440 patients with ventral hernias of lower and middle localization, including postoperative ventral hernias, where the classic "Sublay", "TAPP" and our modified "TAPP" methods were used.
The research work was performed on the basis of the Department of General Surgery of the Dnipro State Medical University and the surgical department of the State Institution "Specialized Multidisciplinary Hospital №1 of the Ministry of Health of Ukraine". During the period from 2013 to 2020, 440 patients were operated on and divided into 3 groups by the method of surgical intervention. During the scientific work, surgical interventions were performed in three main ways - open with preaneurotic retromuscular implant placement ("Sublay"), laparoscopic transabdominal with the preperitoneal placement of the mesh prosthesis ("TAPP") and our improved method "TAPP". 139 patients underwent the "Sublay" method (104 (74.8%) women, 35 (25.2%) men), TAPP operated on 231 patients (148 (64.1%) women, 83 (35.9 %) men), 70 patients (50 (71.4%) women, 20 (28.6%) men) were operated with the modified "TAPP" method at P=0.26. The average age of the operated was 58.0 [45.8; 67.0] years at P=0.15.
Accumulated clinical experience has demonstrated that the technique of "Sublay" as a result allows achieving a certain functional activity of the anterior abdominal wall and takes its place in the surgical treatment of ventral hernias. A significant advantage of the "Sublay" method is the possibility of surgical intervention under spinal anesthesia, which, if necessary, allows using the necessary surgical techniques for plastic reconstruction of the anterior abdominal wall and securely fixing the mesh prosthesis. However, the disadvantage of this method is the significant trauma of surgery. Fixation of the prosthesis along the contour with anchor sutures to the external leaf of the aponeurosis deforms the muscle layer, in the presence of sutures erupting and with appropriate muscle contraction, this leads to shrinkage and displacement of the prosthesis and as a result of recurrence of the hernia. In addition, greater tension when suturing the internal leaf than the external can cause rupture of the internal leaf with the subsequent formation of an internal hernia in the anterior abdominal wall in the postoperative period.
The defining advantage of the "TAPP" method is the slight traumatic injuries of surgical intervention, a full revision of the abdominal organs, better visualization of the anatomical structures of the anterior abdominal wall. We should notice that the activation of the patient after surgery occurs as soon as possible, along with the resumption of intestinal function, as well as less inflammatory reactions in the patient, reduces the length of stay in the hospital and the best aesthetic outcome of surgery. Complications that occur in the postoperative period are minor and easily corrected. The disadvantages of this method are the technical complexity, and sometimes the inability to perform surgery for large and giant ventral hernias. Moreover, one of the specific risks of "TAPP" is the possible intestinal damage in patients who have a large number of joints with the parietal peritoneum or hernia sac, especially in postoperative ventral hernias.
When comparing the classical and laparoscopic methods "TAPP", we did not find a significant difference in such indicators as the length of staying in hospital (P=0.18), VAS (P=0.82), temperature reaction (P=0.15), recovery of intestinal function (P=0.44), the width of the layer of peritoneum-prosthesis-aponeurosis (P=0.86), blood flow velocity (P=0.89), scar stiffness (P=0.13), SF-36 (P=0.54), pain in the long term P=0.55). However, we consider the developed method "TAPP" more promising in the surgical treatment of ventral hernias of lower and middle localization, especially postoperative ventral hernias, given the greater technical and technological capabilities of reliable preperitoneal hernioplasty and better overall early and long postoperative rates taking into account indicators of clinical and instrumental methods of research of patients.
Key words: ventral hernia, preperitoneal plastic, laparoscopic hernioplasty, TAPP, sublay
