Efficiency of Paraumbilical Trocar Hernias Alloplasty Methods, Combined with Diastasis Recti, Taking Into Account the Risk Factors of Their Relapse (First Notice)

摘要

Introduction. Frequency of occurrence of trocar hernias after laparoscopic cholecystectomy is 3.4-6.7 %. Among the local risk factors for the occurrence of trocar hernias: size and type of trocar, its location, expansion of the trocar wounds and mistakes during their sewing, infection of the trocar wound, among the general ones – old age of a patient, obesity, diabetes mellitus, anemia, immunosuppressive state, etc. The use of large diameter trocars (10.0­12.0 mm) often promotes to the appearance of a trocar hernia. Clinical trials have also shown that dull trokars form smaller wound compared to the oblique and accordingly reduce the risk of trocar hernias developing. The use of acute trokars is accompanied by the appearance of herniasin 1.83 % of the patients, while dull (conical) – in 0.17 %. The paraumbilical area is the most often (75.7 %) place for the formation of trocar hernia, inparticular after the laparoscopic cholecystectomy.In most cases this is due not only to the expansion of the trocar wound to extract the gall bladder from the abdominal cavity, but also due to the features of the anatomical structure of this area. In the paraumbilical area, above and below the navel, there are the extension of the white line and the diastasis of the straight abdominal muscles, that make this are a mechanically weak and can create the preconditions for the appearance of a trocar hernia. Besides this, aponeurosis and muscles of the paraumbilical are are more thin compared to the other are as of the white line of the abdomen. Alloplasty of trocar hernias, combined with the diastasis recti, is accompanied with the high frequency (10.0-25.0 %) relapse. This is due to the fact that in case of the strengthening of the trocar defect with implant, the diastasis recti is not often liquidated, and white line becomes more weak. This results in a relapse of the hernia along the edge of the implant fixation.Aim. To determine the effective method of alloplasty of paraumbilical trocar hernias, combined with the diastasis recti, taking into account the risk factors of their relapse.Materials and methods. The results of alloplasty of trocar hernias combined with the diastasis recti in 56 patients aged 30 to 75 years were analyzed. There were 38 (67.9 %) females and 18 (32.1 %) males included into the study. Depending on the method of alloplasty, the patients were divided into 2 groups. The groups were comparable in size of the trocar hernia, the width of the diastasis recti, age and gender. In the first (comparison) group (29 patients), preperitoneal alloplasty was performed without the elimination of the diastasis recti. In the second (main) group (27 patients), the hernioplasty was carried out using technique “sublay” with the elimination of the diastasis recti and strengthen the white line of the abdomen from the processus xiphoideus and 3.0-4.0 cm below the navel.Results and discussion. It was found that postoperative complications were observed only in three patients (10.3 %) from the comparison group, in the main group there was no relapse of the disease (c2 = 2.95, p = 0.0858), as well as the fact that in the comparison group they were more often observed in the patients over the age of 60 years andwith the high body mass index (>45.0 kg/m2), aponeurosis incision length during primary laparoscopy >45.0 mm, significant disorders of the external respiration function and cardiovascular system. But the significant risk factor of the trocar paraumbilical hernias relapse was only the hemodynamics disorders in patients of the comparison group.Conclusions.The performed study suggests that the best results of surgical treatment of the trocar paraumbilical hernias, combined with the diastasis recti, using alloplastic materials are in case of the “sublay” method with the elimination of diastase use.However, due to the small number of the patients included into this study, it is expedient to continue the further accumulation of the actual material, the processing of which would allow to obtain the substantially probable results of the revealed patterns.