Mayo operation for umbilical hernia. Hernioplasty of an umbilical hernia: types, possible contraindications, preparation for surgery, recovery period, reviews. Indications for the operation

Acquired umbilical hernias are rare. For a number of reasons, they mostly affect women over the age of 30. Today, surgeons often use Mayo's hernia repair, and there are many videos of such operations. This is due to the fact that this technique is quite simple to perform and safe for the patient.

Method essence

Mayo repair of small umbilical hernias is most often performed under local anesthesia. If this formation is large enough, then it is advisable to use epidural anesthesia. At the same time, the patient remains conscious, and, if the technician allows, he can watch the video broadcast of his operation.

Umbilical hernia repair using the Mayo technology consists in the fact that 2 crescent-like transverse incisions of the skin are made, bordering the hernial protrusion. The connecting plate, called the aponeurosis, is separated from the subcutaneous tissue. After that, it is dissected in the transverse direction to the inner edges of the rectus abdominis muscles.

The hernial ring is dissected in the transverse direction, the neck of the sac is exposed and it is opened. Then the contents are inspected, after which the ring is set back into the abdominal cavity. The hernial sac is excised and removed, and with it the excess subcutaneous fatty tissue.

On the flaps of the connecting plate, stitches in the shape of the letter "P" are applied. For this, silk threads are used. Sewing is done in such a way that when tying, the flaps of the connecting plate lay on top of each other. After that, the free edge of the upper aponeurosis flap to the lower one is sutured with interrupted sutures. This is important, since when the muscles move, it is the seams imposed in this direction that experience less tension. Longitudinal, however, can stretch and deform.

Due to the fact that hernia repair performed according to this technique is quite reliable, it has become the most common among doctors. This is confirmed by various videos showing a similar hernioplasty.

Such surgical interventions are often recorded on video for educational and educational purposes. In addition, there are animated videos, where for novice surgeons, hernioplasty according to the Mayo technique is shown in more detail.

Navel removal according to the Mayo method

The excision of the navel is rarely performed because it is considered incorrect from an aesthetic point of view. However, sometimes it has to be removed. This is a forced measure that is used if there are pronounced changes in the skin in the navel in patients with large hernias. In this case, the hernial sac is closely soldered to the navel and to the highly thinned skin.

If the navel is not excised along with the thinned skin, then a cavity will form in this place in which easily infectious serous fluid will accumulate, and the skin deprived of nutrition will undergo necrosis.

For clarity, such operations are also often recorded on video.

However, such an outcome of the operation does not happen often, and it is always negotiated in advance with the patient.

Advantages and disadvantages

Navel hernia repair according to the Mayo technique is used mainly for small formations in the abdominal cavity. In these cases, it is used by surgeons, as it has several advantages:

• this plastic is most often performed under local anesthesia;
• simplicity of surgical technique, which is confirmed by numerous videos;
• relative safety for patients, even when it comes to pregnant women.

Nevertheless, Mayo's umbilical hernia repair has a number of disadvantages:

• pain syndrome after such an operation lasts up to 1 year;
• the rehabilitation period can take up to 4 months;
• when large hernial sacs are excised, there are often cases of relapse.

The most common methods of surgical treatment of umbilical (umbilical) hernias in adults and children are the methods of Sapezhko, Mayo and Lexer.

K.M. Sapezhko proposed his own scheme of operation in 1900. It consists in the following. The skin over the hernial protrusion is dissected in the vertical direction, then the hernial sac is carefully separated from the subcutaneous tissue and exfoliated from the aponeurosis in all directions by ten to fifteen centimeters. The umbilical ring along the white line of the abdomen is cut up and down, the hernial sac is processed according to the generally accepted technique and, by means of a series of interrupted silk sutures, the edge of the dissected aponeurotic plate of one side is fixed to the posterior wall of the tendon sheath of the rectus abdominis muscle of the contralateral side. The free edge of the aponeurosis remaining after this is placed on the anterior wall of the vagina of the rectus muscle of the opposite side and is hemmed in the same way. As a result, the sheaths of both rectus abdominis muscles are layered one on top of the other along the white line, like the floors of a coat.

Guided by the Mayo technique, to eliminate the umbilical hernia around it in the transverse direction, two semilunar skin incisions are made. The flap formed in this way is grasped with Kocher clamps and carefully peeled around the hernial orifice from the underlying aponeurosis for five to seven centimeters. The umbilical ring is dissected along a special probe in the transverse direction. Highlighting the neck of the hernial sac, the latter is opened, the contents are carefully revised and set back into the abdominal cavity. In cases where there are adhesions between the hernial contents and the walls of the hernial sac, these adhesions are dissected. The hernial sac is resected along the edge of the hernial orifice and removed together with a skin flap. Then the peritoneum is sutured with a continuous suture with catgut thread. If the serous membrane is fused with the edge of the umbilical ring, it is sutured together with the aponeurosis. On the aponeurotic flaps, on Mayo's advice, several U-shaped sutures with silk are applied so that after tying them, one aponeurosis flap is layered onto another. At the end, the free edge of the upper flap is fixed to the lower one with a row of interrupted sutures.

According to the Lexer method, the skin is dissected with a lunate, bordering the hernial protrusion from below with an incision (less often it is made circular). During the operation, the navel, depending on the specific situation, is either removed or retained, especially if the hernia is small. The skin with subcutaneous adipose tissue is exfoliated upward and the hernial sac is isolated. If its bottom is tightly welded to the navel, they work on the neck: they open it, examine the hernial contents and set it back into the abdominal cavity. Then the neck of the bag is stitched using a silk thread, the entire bag is tied and cut off, its stump is immersed in the umbilical ring, the bottom is separated from the navel in a sharp way. Having completed the processing of the hernial sac, they proceed to the plastic of the hernial orifice. For this, under the control of the index finger inserted into the umbilical ring, a silk purse-string suture is applied to the aponeurosis around it, which is subsequently tightened and tied. On top of the front walls of the sheaths of the rectus abdominis muscles, three or four more sutures are carried out with the same thread, but already knotted. At the end, a skin flap is placed and fixed with a number of interrupted sutures.

Today, any hernia is completely cured only by surgical intervention. Conservative therapy, despite its effectiveness, is not the leading method in the treatment of hernias: pharmacological drugs are simply unable to eliminate the cause of such a disease.

This rule applies, among other things, to an umbilical hernia. The latter, according to statistical data, is diagnosed and recorded mainly in women whose age crosses the 30-year line.

At the root of this ailment are pathologies and structural defects of the umbilical structures, which, due to increased pressure, form a hernial canal, and then the hernia itself. It is becoming clear that an organic anomaly cannot be cured with tablets and pills. So, the main indication is surgery.

The essence of the approach

Mayo umbilical hernia repair is one of the most common treatment options. This method of treatment belongs to a number of tension-free hernioplasty, which means that the patient's own tissues are needed for the operation. The main task is to eliminate the hernia, its remnants, and further strengthen the anterior abdominal wall to prevent recurrence. For this, surgeons create a double layer of tissue. This is an important point, as abdominal hernias are notorious for recurring occurrences.

Preoperative period

Before any operation, the patient must undergo a series of studies, which will allow the surgeon to draw up a plan for the operation, have a number of medications in case of complications and, in general, navigate the general condition of the patient.

Such studies include:

• general blood analysis;
• blood chemistry;
• general urine analysis;
• electrocardiogram;
• tests showing the ability of blood to clot;
• analysis for the determination of viral diseases easily transmitted through the blood: HIV infection, hepatitis, syphilis;
• allergic tests.

Preparing for the intervention

Mayo plastic surgery for umbilical hernia is performed against the background of local anesthesia in adults. During the operation, he is in a state of consciousness. In children, the operation can be performed under general anesthesia (full anesthesia). An anesthetic is injected into the cerebrospinal fluid, where it will block pain and other sensations. It is important for the doctor to know what allergic reactions the patient has.

So, if the patient is allergic to lidocaine preparations, he is shown inhalation anesthesia. In this case, the patient will be unconscious.

Operation

Surgical intervention begins with two incisions made in the area of \u200b\u200blarge accumulation of fatty tissue in the transverse direction. The surgeon borders the hernial formation. Having gained access to the internal environment of the body, the specialist separates the layer of connective tissue from the subcutaneous tissue with a cross section. Thus, the doctor gets a hernia in a "naked" form, while manipulating the protrusion becomes easier.

After that, the hernia ring is dissected, and then the hernial sac itself is in the hands of the doctor. Its contents are opened. Specialists examine the filling, evaluate, study the condition of the organs located there, which are then set back to their anatomical location. In the presence of adhesive processes with the inner side of the hernial sac, the adhesions are dissected and removed.

After these manipulations, the incision in the peritoneum is sutured with a continuous catgut suture. If the peritoneal section is welded with a part of the hernial ring, it is sutured together with the aponeurosis. After that, a number of silk seams are applied in the shape of the letter "P" This method allows you to layer parts of the seams on top of each other. At this stage, the operational period ends.

Often there are situations when patients want to remove the navel, or the condition of the patient himself requires it.

There are also several indications for this:

• large hernia;
• weakening of muscle fibers in the area of \u200b\u200bthe protrusion and navel;
• the presence of adhesive processes.

In this case, the removal of the hernia is associated with the removal of the navel.

Disadvantages and advantages of the method

Disadvantages:

• relatively long recovery period;
• the presence of pain after surgery;
• the presence of the likelihood of cases of relapse with large hernias.

The rehabilitation period is time-consuming (on average it lasts up to 4 months). Pain also persists after the intervention, but it is relieved by a number of pain relievers. The size of the hernia is also taken into account.

With a fairly large hernia, there is a small chance of its recurrence.

Benefits:

• the operation is safe for the patient, rarely gives any complications;
• the technique of performing the operation is simple, which means that the process is not laborious and the likelihood of unforeseen operational complications is minimal;
• the intervention can be performed under local anesthesia, which is always better than under general anesthesia.

Rehabilitation

After the surgery, the patient is advised to wear a medical fixation bandage. Such a tool allows you to reduce the stress on the seams, as well as to accelerate the process of regeneration of the formed wound. In the first few days, bed rest is shown, thus excluding any physical activity. You can get up and be physically active after the third or fourth day.

To prevent intense pain, doctors prescribe pain relievers. There is also a risk of inflammatory processes, so the treating specialist prescribes anti-inflammatory drugs.

In addition, the patient is shown further development of the abdominal muscles. For this, doctors prescribe physiotherapy exercises, physiotherapy activities, classes in the pool and massage sessions. In addition, for a quality recovery after surgery, it is recommended to follow a balanced diet containing most of the minerals and vitamin supplements.

You should know that it is necessary to exclude any product containing a large amount of simple carbohydrates, since they are prone to fermentation, which causes an increase in intra-abdominal pressure. It is recommended to eat cereals, stewed vegetables.

Rehabilitation for children is much easier. The child's body is prone to rapid regeneration of damaged tissues. Particular attention should be paid to the baby's nutrition, constipation, or gas.

Complications

In medicine, complications are distinguished in the early and late periods. The first group includes the attachment of local bacterial flora, which causes suppuration, deterioration of the work of some parts of the intestinal tract, intestinal obstruction and some consequences after the use of general anesthesia.

Such conditions are recorded even at the stage of hospital treatment, so the patient can count on professional help from medical personnel.

Complications in the late period occur after the patient is discharged from the hospital. Most often, complications such as recurrent hernia and intestinal obstruction are observed.

Today, surgeons often use Mayo's hernia repair, and there are many videos of such operations. This is due to the fact that this technique is quite simple to perform and safe for the patient.

Method essence

Mayo repair of small umbilical hernias is most often performed under local anesthesia. If this formation is large enough, then it is advisable to use epidural anesthesia. At the same time, the patient remains conscious, and, if the technician allows, he can watch the video broadcast of his operation.

Umbilical hernia repair using the Mayo technology consists in the fact that 2 crescent-like transverse incisions of the skin are made, bordering the hernial protrusion. The connecting plate, called the aponeurosis, is separated from the subcutaneous tissue. After that, it is dissected in the transverse direction to the inner edges of the rectus abdominis muscles.

The hernial ring is dissected in the transverse direction, the neck of the sac is exposed and it is opened. Then the contents are inspected, after which the ring is set back into the abdominal cavity. The hernial sac is excised and removed, and with it the excess subcutaneous fatty tissue.

On the flaps of the connecting plate, stitches in the shape of the letter "P" are applied. For this, silk threads are used. Sewing is carried out in such a way that when tying the flaps of the connecting plate layered on top of each other. After that, the free edge of the upper aponeurosis flap to the lower one is sutured with interrupted sutures. This is important, since when the muscles move, it is the seams imposed in this direction that experience less tension. Longitudinal, however, can stretch and deform.

Due to the fact that hernia repair performed according to this technique is quite reliable, it has become the most common among doctors. This is confirmed by various videos showing a similar hernioplasty.

Such surgical interventions are often recorded on video for educational and educational purposes. In addition, there are animated videos, where for novice surgeons, hernioplasty according to the Mayo technique is shown in more detail.

Navel removal according to the Mayo method

The excision of the navel is rarely performed because it is considered incorrect from an aesthetic point of view. However, sometimes it has to be removed. This is a forced measure that is used if there are pronounced changes in the skin in the navel in patients with large hernias. In this case, the hernial sac is closely soldered to the navel and to the highly thinned skin.

If the navel is not excised along with the thinned skin, then a cavity will form in this place in which easily infectious serous fluid will accumulate, and the skin deprived of nutrition will undergo necrosis.

For clarity, such operations are also often recorded on video.

However, such an outcome of the operation does not happen often, and it is always negotiated in advance with the patient.

Advantages and disadvantages

Navel hernia repair according to the Mayo technique is used mainly for small formations in the abdominal cavity. In these cases, it is used by surgeons, as it has several advantages:

• this plastic is most often performed under local anesthesia;
• simplicity of surgical technique, which is confirmed by numerous videos;
• relative safety for patients, even when it comes to pregnant women.

Nevertheless, Mayo's umbilical hernia repair has a number of disadvantages:

• pain syndrome after such an operation lasts up to 1 year;
• the rehabilitation period can take up to 4 months;
• when large hernial sacs are excised, there are often cases of relapse.

Mayo umbilical hernia repair

An umbilical hernia in an adult can be cured only with the help of surgery. Today, medicine offers various methods of performing operations, one of them is Mayo plastic. This method of getting rid of a hernia is used quite often, it is easy to perform and completely safe for the patient.

Features of the technique

Hernia repairs performed according to the Mayo method are referred to as tension-free hernioplasty, since they use only the patient's own tissues. To strengthen the anterior abdominal wall and prevent recurrence, a double tissue structure is created. This method of removing an umbilical hernia is successful when the size of the hernial orifice is small, up to 3 cm. With a larger size, such measures may not be enough, so the risk of recurrence remains.

Indications for Mayo plastic

• The need to operate on a hernia
• The size of the hernia gate is not more than 3 cm,
• The patient is not obese or is mild.

Preparing for surgery

Before the operation, it is necessary to conduct an examination to avoid complications and unpleasant consequences. If necessary, treatment can be carried out before surgery begins.

• Clinical and biochemical blood test,
• Analysis of urine,
• Blood clotting test,
• Tests to detect infections such as HIV, syphilis or hepatitis.

The essence of the operation

Hernia repair with Mayo repair is performed most often under local anesthesia. It is relevant in cases where the hernial formation is small or medium in size. If it is large, then it is better to choose an epidural for pain relief. In both cases, the patient remains conscious. Although some patients are nervous about this, the side effects and harm from epidural or local anesthesia are far fewer than those from general anesthesia.

Operation stages

• Skin incisions,
• Department of the aponeurosis,
• Muscle dissection,
• Opening the hernial sac and inspection of the contents,
• Reduction of protrusion,
• Suturing the aponeurosis and the edges of the surgical wound.

Mayo umbilical hernia repair begins with providing access to the hernial protrusion. For this, two skin incisions are made. They are performed transversely in the form of a crescent and border the hernial protrusion.

Its contents are examined, if necessary, the necessary manipulations are performed, and the prolapsed internal organs are set into the abdominal cavity. Excess fat deposits are removed before suturing.

Mayo surgery involves a certain method of suturing that allows you to reliably strengthen the site of hernia formation. First, stitches in the shape of the letter "P" are applied to the aponeurosis flaps. This is done in such a way as to ensure layering of the flaps when joining and suturing. Then the edge of one of the flaps of the aponeurosis (upper) is sutured to the other (lower). This method of suturing provides the least tension during muscle contraction. This moment ensures the reliability of the results of the operation performed by the Mayo method.

Removing the navel

If possible, during the hernia repair, the navel is left in order to preserve the natural state of the skin. However, in some cases, you have to delete it. This step is used in certain situations.

Indications for navel removal

• Large hernia
• Thinning of the skin in the hernia area,
• Tight adhesion of the navel with a hernial sac.

With a combination of all these features of a hernia in a particular patient, a decision is usually made to remove the navel. The patient is informed about the consequences of the operation. Of course, the doctor must explain why this decision was dictated. If the navel is not excised along with the thinned skin, a cavity will remain after the operation. This place will fill with serous fluid, become infected and become inflamed. The skin in this area will be deprived of nutrition and after a while it will undergo necrosis.

Pros and cons of the Mayo method

Like any other method of treatment, this type of surgery has certain advantages and disadvantages. They are necessarily taken into account by the surgeon when choosing the method of hernia repair. Each case is considered individually, taking into account the characteristics of the patient and his disease.

Benefits

• Possibility of performing under local anesthesia,
• Simplicity of execution technique,
• Patient safety.

Based on the advantages of Mayo surgery, it can even be shown to pregnant women in the case when there is no way to wait for delivery.

disadvantages

• Long period of rehabilitation,
• Duration of pain syndrome
• Recurrence in large hernia repair.

Mayo's hernia repair requires a rather long period of postoperative rehabilitation. It can last up to 4 months. Pain in the navel can persist for a whole year. This must be taken into account when deciding on an operation.

This method is most successful for small hernias, then the recurrence rate is very low. If the hernial formation is large, cases of relapse are quite frequent, since the technique of performing the operation does not allow to reliably strengthen a large area of \u200b\u200btissue.

Hernia repair (hernioplasty)

Hernioplasty is a surgical way to eliminate hernias (literal translation from Latin - hernia repair). Earlier in medicine, the terms were used: hernia repair or hernia removal.

Types of hernioplasty

There are the following types of hernioplasty:

• tension, in the process of surgical intervention only the body's own tissues are involved, they seem to be pulled over the site of the hernial protrusion, creating a duplication;
• tension-free, mesh implants are used to close the pathological space of the hernia;
• for separate types of operations, both of these types can be combined.

In modern medicine, a greater percentage of hernioplasty is carried out by the tension-free method, since no pathological stretching of tissues is created, the mesh implant immediately takes on all the mechanical load without any consequences, the frequency of relapses is minimized. The implant, "overgrown" with connective fibrous tissue, creates an even better barrier.

Photo: laparoscopic hernioplasty

The operation is carried out in several ways:

1. Tissue incision and organization of hernia access.
2. The bag with hernial contents is removed (excised) or set, depending on the indication.
3. Suturing the hernial orifice.

There are many techniques available for specific hernias or for several types.

Hernioplasty according to Liechtenstein (hernia repair)

The most famous method of tension-free hernia repair. It is used for hernia repair of the white line of the abdomen, as well as umbilical, inguinal, femoral hernias.

The method is quite simple and does not require special training before the intervention.

The mesh graft is sutured under the aponeurosis, no muscles and fascia are affected, that is, the injury to the body tissues is minimal. The mesh is attached with a "margin", since the edges of the hernial orifice are directly affected by pathological changes and do not have sufficient strength. Hernioplasty according to Liechtenstein is performed by open method or laparoscopically.

Photo: hernioplasty using mesh according to the Liechtenstein method

Hernia repair according to Bassini

The method of tension hernioplasty, has a good result for small, first-formed hernias, it is possible to perform plastic surgery under local anesthesia. It is used for inguinal hernias, both straight and oblique.

1. An incision is made over the hernial protrusion.
2. Lead education.
3. Hernia repair or resection is performed, depending on the indications.
4. Then the edges of the transverse and internal oblique muscles of the abdomen with the transverse fascia are sutured to the inguinal ligament, due to this, the wall of the inguinal canal is strengthened.

Mayo hernia repair

The method of stretching surgery, used mainly for the plasty of umbilical hernias and hernias of the white line of the abdomen. The flap of skin from the aponeurosis exfoliates after the hernial sac is opened. The protrusion is set into the cavity, while, if necessary, the adhesions are dissected, the hernial sac is excised along the edge of the hernial ring and removed with a skin graft.

When the peritoneum is fused with the edge of the hernial ring, it is sutured with the aponeurosis with several sutures (resembling the letter P) in such a way that when tying them, the aponeurosis flaps are layered on top of each other.

Hernia repair according to Postemsky

This is a stretch plastic. Local anesthesia during the operation. In this case, the inguinal canal is completely removed, a duplicate canal is created with the spermatic cord placed in it in the physiological direction. The muscles under the canal are sutured so that they do not squeeze it.

Hernia repair according to Sapezhko

It is used for umbilical hernia repair.

1. The deformed flabby umbilical skin is excised together with the navel (it can be preserved only with small hernias).
2. The bag with a hernia after excision is sutured, before that its contents are adjusted inward.
3. The hernia orifice is dissected vertically up and down to the point where the white line of the abdomen is not changed.
4. The peritoneum is carefully peeled off a few centimeters from the posterior surface of the vagina of one of the rectus muscles and the edge with the aponeurosis is sutured on one side, and the posteromedial part of the rectus sheath on the other, to create duplication.

Photo: preparation of the operating field for hernioplasty

Hernia repair according to Lexer

Applied in the case of a welded navel with the bottom of the hernial sac.

1. The neck of the hernial sac is isolated from the surrounding tissues.
2. After opening it, the contents are set into the cavity and the bag is cut off.
3. A suture is applied to the aponeurosis under the umbilical ring, which is tightened and tied.
4. The skin flap is placed in its original place and sutured with interrupted sutures.

Hernia according to Duhamel

It is widely used in pediatric hernia repair. The intervention is carried out without opening the inguinal canal, the neck of the hernial sac (process of the peritoneum) is isolated through the external inguinal ring, then it is sutured and cut off.

Hernia repair according to Martynov

The stretching method of hernioplasty, used mainly in the elimination of an oblique inguinal hernia. The upper flap of the aponeurosis of the external oblique muscle of the abdomen is sutured to the inguinal ligament, while the muscles are left intact, and they are sutured over the existing suture to the lower flap of the aponeurosis.

Hernia repair according to Krasnobaev

It is used for hernia repair in children from 6 months of age.

An interesting technique of conducting surgery is that the aponeurosis is not affected.

The subcutaneous layer is mechanically shifted, after a skin incision, a bag with hernial contents is isolated and cut off, applying a silk suture. After that, another 2-4 sutures are applied to the formed fold of the aponeurosis, they strengthen the wall of the inguinal canal.

Video: hernioplasty of an umbilical hernia

Obstructive hernioplasty

The tension-free method, a mesh graft is used. The technique is similar to the Liechtenstein method, but has some advantages. First, the incision in the skin is half as large. Secondly, the hernial sac is set into the cavity without opening it. Then a mesh is applied and the wound is sutured in layers.

Endoscopic hernioplasty

This is an operation performed inside the abdominal cavity through small incisions of 2-3 cm using a special video device and manipulators. The operation technique is similar to the Liechtenstein method, it is performed under general anesthesia. Traumatism with this type of surgery is minimal, the recovery period is much shorter, and there is a good cosmetic effect.

Possible complications

Photo: polypropylene mesh for hernioplasty

As with any other type of surgical intervention, complications are possible. These include:

• inflammation and suppuration of postoperative sutures;
• hematoma;
• relapse of pathology;
• damage to organs accompanying the operation (spermatic cord, esophagus, intestines, etc.);
• excessive tension of sewn fabrics;
• displacement of the implant, as a result of improper fixation;
• complications after anesthesia.

Rehabilitation and recovery

Modern technologies and advanced developments in medicine, supervision by a specialist and the correct behavior of the patient after surgery will help speed up recovery and avoid possible complications. The wearing of bandages is not necessary, but can be used if indicated, at the discretion of the doctor.

Hernia repair takes place without severe pain in the early rehabilitation period, but sometimes they are still present, then pain relievers are prescribed.

It is necessary to limit physical activity, lifting weights is strictly prohibited, both in the early recovery period and in the late. After permission from the doctor, you can start strengthening the abdominal muscles with the help of exercise therapy, physiotherapy, massage. It is necessary to give up bad habits that contribute to the decrepitude of all body tissues, and normalize the patient's weight.

Hernioplasty prices

With hernia repair, the cost is determined by several factors:

• type of surgical intervention;
• the type of anesthesia performed during the operation (general or local anesthesia);
• the cost of the mesh for hernioplasty;
• patient management during the rehabilitation period (the use of drugs, procedures in the later recovery period).

Abdominal hernia surgery

Operations according to K.M. Sapezhko, Mayo and Lekser

The most common methods of surgical treatment of umbilical (umbilical) hernias in adults and children are the methods of Sapezhko, Mayo and Lexer.

K.M. Sapezhko proposed his own scheme of operation in 1900. It consists in the following. The skin over the hernial protrusion is dissected in the vertical direction, then the hernial sac is carefully separated from the subcutaneous tissue and exfoliated from the aponeurosis in all directions by ten to fifteen centimeters. The umbilical ring along the white line of the abdomen is cut up and down, the hernial sac is processed according to the generally accepted technique and, by means of a series of interrupted silk sutures, the edge of the dissected aponeurotic plate of one side is fixed to the posterior wall of the tendon sheath of the rectus abdominis muscle of the contralateral side. The free edge of the aponeurosis remaining after this is placed on the anterior wall of the vagina of the rectus muscle of the opposite side and is hemmed in the same way. As a result, the sheaths of both rectus abdominis muscles are layered one on top of the other along the white line, like the floors of a coat.

Guided by the Mayo technique, to eliminate the umbilical hernia around it in the transverse direction, two semilunar skin incisions are made. The flap formed in this way is grasped with Kocher clamps and carefully peeled around the hernial orifice from the underlying aponeurosis for five to seven centimeters. The umbilical ring is dissected along a special probe in the transverse direction. Highlighting the neck of the hernial sac, the latter is opened, the contents are carefully revised and set back into the abdominal cavity. In cases where there are adhesions between the hernial contents and the walls of the hernial sac, these adhesions are dissected. The hernial sac is resected along the edge of the hernial orifice and removed together with a skin flap. Then the peritoneum is sutured with a continuous suture with catgut thread. If the serous membrane is fused with the edge of the umbilical ring, it is sutured together with the aponeurosis. On the aponeurotic flaps, on Mayo's advice, several U-shaped sutures with silk are applied so that after tying them, one aponeurosis flap is layered onto another. At the end, the free edge of the upper flap is fixed to the lower one with a row of interrupted sutures.

According to the Lexer method, the skin is dissected with a lunate, bordering the hernial protrusion from below with an incision (less often it is made circular). During the operation, the navel, depending on the specific situation, is either removed or retained, especially if the hernia is small. The skin with subcutaneous adipose tissue is exfoliated upward and the hernial sac is isolated. If its bottom is tightly welded to the navel, they work on the neck: they open it, examine the hernial contents and set it back into the abdominal cavity. Then the neck of the bag is stitched using a silk thread, the entire bag is tied and cut off, its stump is immersed in the umbilical ring, the bottom is separated from the navel in a sharp way. Having completed the processing of the hernial sac, they proceed to the plastic of the hernial orifice. For this, under the control of the index finger inserted into the umbilical ring, a silk purse-string suture is applied to the aponeurosis around it, which is subsequently tightened and tied. On top of the front walls of the sheaths of the rectus abdominis muscles, three or four more sutures are carried out with the same thread, but already knotted. At the end, a skin flap is placed and fixed with a number of interrupted sutures.

Hernia treatment in Moscow

Laparotomy and laparoscopic treatment of abdominal hernias at the Federal State Institution Treatment and Rehabilitation Center - KTSMRRA Moscow.

Hernioplasty: essence, types, indications, options for surgery, rehabilitation

Hernia of the anterior wall of the abdomen and groin area is perhaps the most common pathology in general surgery, the only radical treatment for which is surgery - hernioplasty.

A hernia is a protrusion of the abdominal organs, covered by the peritoneum, through natural channels or those places that are not sufficiently strengthened by soft tissues. The study of the features of this pathological process formed the basis of a whole area of \u200b\u200bmedical science - herniology.

Hernial protrusion is by no means a new pathology, known to man for several millennia. Shortly before the beginning of our era, attempts were made to surgically treat hernias; in the Middle Ages, barbers and even executioners did this, piercing and cutting off sections of the contents of the hernial sac or introducing various solutions there.

The lack of basic knowledge in the field of the anatomical structure of hernias, non-observance of the rules of asepsis, the impossibility of adequate anesthesia made hernia repair operations practically useless, and more than half of the patients were doomed to death after such treatment.

The turning point in the surgical treatment of hernias was the end of the 19th century, when it became possible to carry out operations under anesthesia and the principles of preventing infectious complications were developed. An invaluable contribution to the development of hernioplasty was made by the Italian surgeon Bassini, who made a real breakthrough - after his operations, relapses occurred in no more than 3% of cases, while in other surgeons this figure reached 70%.

The main disadvantage of all known methods of hernioplasty until the second half of the last century was the fact of tissue tension in the area of \u200b\u200bhernial orifice suturing, which contributed to complications and relapses. By the end of the twentieth century, this problem was also solved - Liechtenstein proposed using a composite mesh to strengthen the abdominal wall.

Today, there are more than 300 modifications of hernioplasty, operations are performed by open access and laparoscopic, and the Liechtenstein method is considered one of the most effective and modern in this century.

Varieties of hernia surgery

All interventions carried out to eliminate hernial protrusions are conventionally divided into 2 types:

The stretching method of treating a hernia is carried out only at the expense of the patient's own tissues, which are matched in the area of \u200b\u200bthe hernial orifice and sutured. The main disadvantage is tension, at which there is a high probability of inconsistency of the suture, improper scarring, which causes a long rehabilitation period, pain after surgery and a relatively high percentage of recurrence.

Tension-free hernioplasty is a more modern and highly effective method of surgical treatment of hernias, when the absence of tension is achieved using meshes made of polymer inert materials. Such plastic hernia orifice reduces the likelihood of organ re-emergence to 3% or less, healing occurs quickly and painlessly. The tension-free method is the most commonly used today.

Depending on the access, hernioplasty can be:

Whenever possible, laparoscopic hernioplasty is preferred as the least traumatic treatment option with a lower risk of complications. In addition, these operations are possible in patients with severe concomitant diseases.

Hernioplasty is performed both under general anesthesia and under local anesthesia, which is preferable in patients with respiratory and cardiovascular pathologies. Endoscopic hernioplasty (laparoscopy) requires endotracheal anesthesia and muscle relaxation.

Not looking at the great variety of methods of hernia orifice repair, all these operations have similar stages:

• First, the surgeon cuts the soft tissue and looks for the bulge.
• The contents of the hernia are either "sent" back into the abdominal cavity, or removed (if indicated).
• The final stage is hernia repair, which occurs in many known ways, depending on the variant, structure and location of the hernia.

When is hernioplasty performed and to whom is it contraindicated?

Any hernia can be radically eliminated only by surgery, conservative treatment can only slow down the progression and alleviate the unpleasant symptoms of the disease, therefore, the very presence of a hernial protrusion can be considered a reason for an operation, with which, however, surgeons are not always in a hurry.

When planning a hernioplasty, the doctor assesses the benefits of the proposed intervention and the possible risks. This is especially true for elderly patients and those with severe comorbidities. In most cases, elective surgery is well tolerated, but sometimes it happens that it is safer to live with a hernia than to perform an operation, especially if this requires general anesthesia.

A relative indication for surgical treatment of a hernia of the abdomen is the presence of a reducible protrusion of a small size, when the risk of infringement is minimal, and the general condition of the patient is not disturbed. The method is selected individually, taking into account the localization of the hernia.

If the hernia is not repaired, then the likelihood of dangerous complications, including infringement, increases significantly, therefore surgeons insistently advise such patients to be operated on without much delaying treatment.

Absolute indications for hernioplasty are:

1. Infringement of a hernia - treatment will be urgent;
2. Relapse after a previous hernia repair;
3. Bulging in the area of \u200b\u200bpostoperative scars;
4. The likelihood of a hernia rupture if the skin above it is thinned or inflamed;
5. Adhesions of the abdominal cavity with impaired intestinal patency;
6. Obstructive intestinal obstruction.

There are also obstacles to surgical excision of hernial protrusions. So, for patients over 70 years of age with heart or lung diseases in the stage of decompensation, surgery is contraindicated even with gigantic hernias (this does not apply to cases of infringement requiring urgent treatment).

For pregnant women with abdominal hernias, the surgeon will almost certainly advise to postpone the operation, which will be safer after childbirth, laparoscopy is completely prohibited.

Acute infectious diseases, sepsis, shock, terminal conditions are a contraindication to all types of hernioplasty, and a pronounced degree of obesity makes laparoscopy impossible.

Patients with cirrhosis of the liver, who have high portal hypertension with ascites and varicose veins of the esophagus, with diabetes mellitus, uncontrolled insulin, severe renal failure, serious blood coagulation pathology, as well as patients with postoperative hernias that appeared after palliative cancer treatment, in surgery will be denied due to the high risk to life.

The modern level of surgical technique, the possibility of local anesthesia and laparoscopic treatment make hernioplasty more accessible for seriously ill patients, and the list of contraindications is gradually narrowing, therefore, in each case, the degree of risk is assessed individually and, perhaps, the doctor will agree to the operation after careful preparation of the patient.

Preoperative preparation

Preoperative preparation for planned hernioplasty is not much different from that for any other intervention. With a planned operation, the surgeon appoints the optimal date until which the patient undergoes the necessary studies in his clinic:

• General and biochemical blood tests;
• Urine examination;
• Fluorography;
• Testing for HIV, hepatitis, syphilis;
• Determination of blood group and Rh-affiliation;
• Coagulation analysis;
• Ultrasound of the abdominal organs.

Other procedures can be carried out according to indications.

If the patient takes any medications, then it is imperative to inform the doctor about it. Anticoagulants and blood thinners based on aspirin, which can cause severe bleeding, can be of great danger when planning an operation. They should not be canceled in a day or two, so it is better to discuss this issue in advance, when the date of the operation is just being chosen.

At the latest - a day before the operation, the patient comes to the clinic with ready-made test results, some studies can be repeated. The surgeon once again examines the hernial protrusion, the anesthesiologist will necessarily talk about the nature of the anesthesia and find out possible contraindications to a particular method.

On the eve of the intervention, the patient takes a shower and changes clothes, after dinner he does not eat anything, drinking is allowed only by agreement with the doctor. With strong excitement, light sedatives may be prescribed, in some cases of ventral hernias, a cleansing enema is required.

In the morning, the patient is sent to the operating room, where general anesthesia is performed or a local anesthetic is administered. The duration of the intervention depends on the type of treatment of the hernia orifice and the structure of the hernia itself.

A feature of a very large ventral hernia is considered to be an increase in intra-abdominal pressure during the immersion of the intestine back into the abdomen. At this stage, an increase in the height of the diaphragm is possible, due to which the lungs will expand in a smaller volume, the heart can change its electrical axis, and from the side of the intestine itself, the risk of paresis and even obstruction increases.

Preparation for huge ventral hernias necessarily includes the maximum emptying of the intestine through an enema or the use of special solutions to prevent the above complications.

Variants of hernia repair and methods of hernia repair

After processing the operating field and incision of the soft tissues, the surgeon reaches the contents of the hernia, examines it and determines the viability. In case of necrosis or an inflammatory process, the hernial contents are removed, and if the tissues (usually intestinal loops) are healthy, then they are set back spontaneously or by the hand of the surgeon.

In order to solve the problem once and for all, it is very important to choose the best way to handle the bulge gate - plastics. The vast majority of operations at this stage are performed in a tension-free way.

Liechtenstein method

Hernioplasty according to Liechtenstein is the most common and most popular option for closing the hernial orifice, which does not require lengthy patient preparation, is relatively simple to perform and gives a minimum of complications and relapses. Its only drawback can be considered the need to implant a polymer mesh, the price of which can be quite high.

liechtenstein operation

This type of surgery is possible for most types of hernias - umbilical, inguinal, femoral. The organ exit site is reinforced with a mesh made of synthetic material, which is inert to the patient's tissues. The mesh implant is installed under the muscular aponeurosis, while there are no incisions of the muscles and fascia - the operation is less traumatic, and this is one of its main advantages.

Liechtenstein hernioplasty is performed under general anesthesia or local anesthesia, open access or endoscopic intervention. With laparoscopy, through one incision, it is possible to install meshes on both inguinal or femoral canals at once if the pathology is bilateral.

Obstructive hernioplasty is considered less traumatic, which is very similar to the Liechtenstein technique, but does not require opening the hernia and is accompanied by a significantly smaller skin incision.

Video: Liechtenstein hernioplasty

Bassini Tension Hernioplasty

The classic operation developed by Bassini is still in use today. It is indicated as a plasty of inguinal hernias and gives the best result with a small amount of protrusion, especially if it has arisen for the first time.

An incision up to 8 cm in length is made slightly away from the inguinal ligament, while the peritoneum is not dissected. The surgeon finds the spermatic cord, opens it and determines the hernial sac, the contents of which are returned to the abdomen, and some of the membranes are cut off. After the elimination of the hernia, the posterior wall of the inguinal canal is plasticized according to Bassini - the rectus abdominis muscle is sutured to the ligament, the spermatic cord is placed on top, after which the aponeurosis of the external oblique muscle and integumentary tissues are sutured.

plastic surgery of the posterior wall of the inguinal canal according to Bassini

Mayo way

Mayo hernia repair is indicated for umbilical protrusions. It is referred to as tensioning methods. The skin is cut longitudinally, bypassing the navel on the left, then the skin with fiber is separated from the wall of the hernial sac and the umbilical ring is dissected.

With the Mayo method, the umbilical ring is cut across, with another type of umbilical hernia repair - according to Sapezhko - the incision goes along the navel.

mayo plastic

When the hernial sac is completely isolated, its inner part is returned back into the abdomen, and the hernia membrane is excised, suturing the serous cover tightly. In the Mayo method, the upper aponeurotic edge of the rectus muscle is first sutured, then the lower one, while the latter is placed under the upper and fixed, and at the completion of the plasty, the free upper edge of the aponeurosis is fixed to the lower independent suture. Such a complex sequence of suturing provides multilayer and strength of the abdominal wall at the site of the former hernial protrusion.

Laparoscopic hernioplasty

Laparoscopic surgical treatment is the most gentle method for any surgical pathology. Endoscopic hernioplasty has been successfully used for many years and shows not only high efficiency, but also safety even for those patients who may be refused open surgery.

The advantages of laparoscopic hernioplasty are, first of all, quick recovery with minimal painful sensations and a good aesthetic result, and the main disadvantages are the need for general anesthesia with the use of muscle relaxants and the long duration of the intervention.

In endoscopic hernia repair, the surgeon makes three small incisions in the abdominal wall through which the instruments are inserted. Gas is injected into the abdominal cavity to improve visibility, then the surgeon carefully examines the organs, looks for a hernia, determines its exact volume, location, and anatomical features. The option of plastic surgery is selected individually - both suturing and implantation of a polymer mesh are possible.

In case of large hernias, when laparoscopy can be traumatic as a way to isolate the bag, as well as in the absence of technical capabilities to isolate the contents through laparoscopy, it is possible to combine open access with a skin incision at the first stage of the operation and endoscopic mesh placement at the final stage.

Postoperative period and complications

With a favorable course of the postoperative period, the stitches on the skin are removed by the end of the first week, after which the patient is discharged home. Over the next few weeks, the operated patients gradually return to their usual way of life, observing the doctor's recommendations and following some restrictions. Full recovery can take from three months to six months.

In the early postoperative period, analgesics are prescribed if necessary. It is important to follow a diet that prevents constipation, as any tension in the abdominal wall can provoke a relapse or dehiscence.

The first few weeks are prohibited active physical exercises, lifting weights - for a long time, it is useful to wear special bandages. After the stitches have healed, your doctor will recommend starting exercises to strengthen your abdominal muscles to prevent recurrent herniation.

Hernioplasty operations are almost always well tolerated and relatively rarely give complications, but they are still possible:

1. Inflammatory and purulent process in the area of \u200b\u200bthe postoperative wound;
2. Recurrence;
3. Damage to surrounding organs, nerves or blood vessels during the operation;
4. Strong tissue tension, suture cutting;
5. Displacement of the mesh implant relative to the place of its initial installation;
6. Adhesive disease;
7. Rejection of the implant.

Hernia repair operations are most often carried out free of charge in conventional surgical departments, but those who wish to increase the comfort of treatment and the quality of the materials used, as well as choose a specific specialist, can be operated for a fee. The price for hernioplasty starts from thousand rubles for hernias up to 5 cm, larger protrusions will also require large investments - up to 30 thousand. Installation of a mesh implant will cost an average of thousands of rubles.

Treatment of an umbilical hernia in adult patients is possible only by surgical intervention. Doctors are familiar with many methods of performing operations, but most often, Mayo's umbilical hernia repair is used. This technique is easy to perform and safe for the patient.

An umbilical hernia is a protrusion of internal organs beyond the anterior wall of the peritoneum through the umbilical ring.

Symptoms of the disease

An umbilical hernia is a protrusion of internal organs beyond the anterior wall of the peritoneum through the umbilical ring. It decreases in volume or disappears completely when the person is in the supine position.

The development of this pathology is characterized by the appearance of abdominal pain when coughing or physical exertion, nausea and an expansion of the umbilical ring.

The severity of the symptoms of the disease depends on the size of the hernia, the presence of adhesions in the abdominal cavity or infringement of the hernial sac, as well as on the general condition of the patient.

Indications for the operation

Mayo plastic surgery for an umbilical hernia should be performed without fail in the presence of a hernial protrusion, regardless of whether the disease is painless or causes pain and discomfort.

The appearance of sharp pain indicates the infringement of the contents of the hernia, which leads to necrosis and peritonitis. This condition requires immediate medical attention.

The essence of the approach

Mayo plastic is a tension-free surgery that requires the patient's own tissue. The main task of the procedure is to eliminate the hernia and its remnants with further strengthening of the anterior peritoneal wall in order to prevent recurrence. This is important because abdominal hernias tend to recur.

If the hernial lesion is small to medium in size, the operation is performed under local anesthesia. If the mass has a large volume, epidural anesthesia is used, which involves the introduction of drugs into the epidural space of the spine through a catheter. The patient remains conscious in both cases. Compared to general anesthesia, these methods of pain relief have fewer side effects.

Disadvantages and advantages of the method

Like any other treatment, this method has advantages and disadvantages. They are taken into account in a situation where the surgeon has an alternative method of treating a hernia. The choice of the method of surgical intervention is carried out individually, based on the patient's condition and the severity of the pathology.

Among the main advantages of the hernioplasty method, first of all, the safety for the patient and the possibility of performing the operation under local anesthesia are noted. In addition, the simplicity of the operation technique is taken into account. Based on this, it can even be prescribed to pregnant women in a situation where there is no way to wait for childbirth.

Among the disadvantages of the method, the presence of prolonged pain syndrome was noted, as well as the likelihood of recurrence after removal of a large hernia. Pain in the navel can persist for a long time. In addition, postoperative rehabilitation can take 4 months. These circumstances must be taken into account when choosing a treatment method.

The Mayo technique is most suitable for removing small hernias. This minimizes the risk of recurrence.

Preparing for surgery

Before the Mayo umbilical hernia repair, the patient is assigned a number of studies. Their results will allow you to more thoroughly prepare for the operation and prevent the development of complications.

Before the operation, appoint:

1. Analysis of urine.
2. Clinical and biochemical blood tests.
3. Tests to determine blood clotting.
4. Electrocardiogram.
5. Tests to identify infectious diseases that are transmitted through the blood: HIV infection, hepatitis, syphilis.
6. Allergy tests.

Operation progress

At the first stage of the operation, access to the hernial protrusion is provided. For this, the surgeon makes 2 cross-sections in the place of the greatest accumulation of adipose tissue. After that, using a transverse incision, the aponeurosis is separated from the subcutaneous tissue. Then the hernial ring is dissected and the doctor gains access to the "body" of the formation.

The walls of the hernial sac are dissected. This allows you to examine its contents, assess and study the state of the organs that are there. After examination, the organs are set to their anatomical places. If there are adhesions on the inner side of the hernial sac, then they are dissected and removed.

After that, they begin to suture the abdominal muscles. The Mayo technique involves the use of a special method of applying surgical sutures, the purpose of which is to reliably strengthen the protrusion site. The seams are made in the form of the letter "P". First, they are applied to the aponeurosis flaps so that they are layered on top of each other. The edge of the upper flap is sutured to the lower one. This method of suturing provides the least tension during contraction of the abdominal muscles.

Most often, during hernia surgery, the navel remains in place. However, a situation may arise that its removal becomes mandatory. The indications for this step are:

• the presence of a hernia of too large a size;
• thinning of the skin around the hernial protrusion;
• the presence of a tight adhesion of the hernial sac with the navel.

The Mayo technique involves the use of a special method of applying surgical sutures, the purpose of which is to reliably strengthen the protrusion site.

If the navel is not removed along with the thinned area of \u200b\u200bthe skin, after the operation, a cavity will remain, which will be filled with serous fluid, which will lead to infection and the development of inflammation. Skin deprived of the necessary nutrition will undergo necrosis.

Restrictions in the postoperative period

A quick recovery after surgery depends on how well the patient follows the doctor's recommendations. After the operation, bed rest must be observed for several days. After discharge, the patient is advised to wear a bandage to support the muscles. This avoids recurrence and maintains the immobility of the sutures.

It is allowed to take food the very next day. Meals should be fractional, divided into 4-5 meals. The menu should include low-fat, light meals. This will avoid strong pressure on the abdominal area. It is necessary to adhere to the diet for at least 2 weeks.

If an urgent operation was performed to remove a strangulated hernia, then the patient needs to wear a denser bandage, inspect postoperative wounds and dressings daily. To prevent purulent inflammation, a course of antibiotics may be prescribed.

Regardless of the complexity of the operation, patients are advised to limit physical activity for 4 months. If the professional activity is associated with hard physical labor, then a profession change will be required.

Prevention of the disease

To prevent the development of an umbilical hernia, it is necessary to constantly train the rectus abdominis muscles and swing the press. You can work out at home or in the gym.

When engaging in heavy physical labor or lifting weights, the load on the abdomen increases and the risk of pinching of internal organs increases. In this situation, doctors recommend using a special bandage or belt. Wearing it can be recommended for the elderly, since their muscular frame is no longer so strong and even a minimal load can cause a hernia. The use of a bandage is also prescribed for pregnant women.