Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_888_Библиотеки_им_академика_М_И_Перельмана
.pdf
23 Mesh Sutured Repairs oftheAbdominal Wall
Fig. 23.8 CT scan
demonstrates 15.9cm
separation between
abdominal wall edges
327
Fig. 23.9 Upper mesh
sutures in place between
left semilunar line and
right rectus muscle
328
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Fig. 23.10 Continued
primary closure with mesh
sutured technique
G. A. Dumanian and S. T. Lanier
Fig. 23.11 Six-month
outcome with intact
closure and without wound
issues
23 Mesh Sutured Repairs oftheAbdominal Wall
329
Discussion
The key to all high-tension tissue repairs (including the linea alba, rotator cuffs,
Achilles, nger tendons, etc.) is for the strength of the repair to remain high. At the
time of surgery, the strength of the repair is a complex mixture of the strength of the
sutures, the number of sutures applied, knot integrity, and the resistance of the tissues to tear at the suture/tissue interface (STI). Soon after suture repair of tissues,
and over the next several days, there is loosening of the suture tension by up to 50%
[17], perhaps due to a “softening” STI from local ischemia, inammation, or collagenases. The postoperative weakening of the physical construct of tendon repairs
was rst shown in 1941 and was determined to last approximately 5days before
biologic healing becomes additive to the total repair strength [18]. Early tearing of
sutures through tendons is referred to as “gap formation” in the orthopedics literature and is due to the forces applied at the STI being greater than tissue tolerance. In
hand surgery, early gap formation of a repaired nger exor tendon of 1–3mm is
associated with either rupture or scar formation [19]. Analogously, early separation
of the midline abdominal closure at 30days of 15mm or more as shown by migration of metal clips placed at the time of laparotomy or by CT scan demonstrates that
early failure of the abdominal wall closure construct is predictive of incisional hernia formation [20–22].
Sutures concentrate forces at the STI, and for high-tension closures a zone of
ischemia of variable size and dimensions is created. This zone of ischemia causes
an internal pressure sore, though its size is small enough to permit remodeling over
time through the creation of scar. Humans scar more than other animals and regenerate less [23]. Scar is not normal tissue, and it lacks pulsatile blood ow that
accompanies normal wound healing [24]. It does not respond to tensile forces with
hypertrophy as described by Wolff’s law. Instead, scar deforms in response to normal tensile stresses, elongates, and weakens over time. If the strength of the scar
falls below the outward forces applied to the abdominal wall by the viscera, an
incisional hernia will develop. Scar is also not as strong as the native tissue it
replaces, gaining only 70% of the strength of the native linea alba [25]. It is the
replacement of the linea alba with scar that could be the cause of “late” incisional
hernias over time [26].
It has been shown in preclinical animal models that mesh sutured repairs have a
greater early tensile strength than suture closures, but the tissue tolerance of the
mesh strips, especially in a contaminated eld, then becomes important for clinical
usage. Classic teaching is to limit permanent materials to a minimum and possibly
to only use absorbable sutures and absorbable meshes (synthetic or bioprosthetic).
In our reported series [16], several patients had their midline skin incisions left open
with exposure of 0-polypropylene sutures (diameter 0.4mm) and mesh strips (lament diameter 0.15mm for Soft Prolene). Over time, the sutures required removal
to permit healing, whereas we observed the deposition of granulation tissue over
and around mesh strips during the course of secondary wound healing. Several other
patients with seromas and exposed mesh strip knots had their skin opened in the
ofce, and the wounds were allowed to close with local wound care. This clinical
330
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
G. A. Dumanian and S. T. Lanier
experience is consistent with animal data that the foreign body reaction quantitatively differs depending on the lament diameter [27]. We propose that a high surface area/low lament size closure with mesh strips is more biocompatible than a
low surface area/high lament diameter device such as a large monolament suture.
In addition, the high surface area conditions of a permanent suture will result in a
magnied foreign body reaction that persists and is located immediately at the
repair site. This compares well conceptually to large planar meshes that create scar
burden far from the abdominal wall closure.
Mesh sutured repairs have simplied our abdominal wall paradigm. Clean midline cases that require either a long repair or associated treatment of rectus diastasis
receive a narrow well-xed retrorectus mesh. Almost every other clinical situation
(other than parastomal hernias) have been treated successfully and simply with
mesh sutures.
Conict of Interest Statement Dr. Dumanian has nancial interest in the Advanced Suture Co
and the Mesh Suture Co. He could potentially benet from the outcomes of this research. There are
no additional conicts to report for Drs. Dumanian or Lanier.
References
1. Wallace S, Mioton L, Ko J.Biomechanical properties of a novel mesh suture in a cadaveric
exor tendon repair model. J Hand Surg; submitted for publication.
2. Zhang T, Hatta T, Thoreson AR, Lu CC, Steinmann SP, Moran SL, Zhao C.Rotator cuff repair
with a novel mesh suture: an ex-vivo assessment of mechanical properties. J Orthop Res.
2018;36(3):987–92. https://doi.org/10.1002/jor.23668.
3. Souza JM, Dumanian Z, Gurjala D, Dumanian GA.In vivo evaluation of a novel mesh suture
design for abdominal wall closure. Plast Reconstr Surg. 2015;135:322e–30e.
4. Dumanian GA, Tulaimat A, Dumanian Z.Experimental study of the characteristics of a novel
mesh suture. Br J Surg. 2015;102:1285–92.
5. Lanier ST, Dumanian GA, Jordan SW, Miller KR, Ali NA, Stock SR.Mesh sutured repairs of
abdominal wall defects. PRS GO. 2016;28:e1060. PMID 27757361.
6. Ko JH, Salvay DM, Paul BC, Wang EC, Dumanian GA. “Components separation” technique
for the treatment of complex abdominal wall defects: an 11-year experience in 200 patients.
Arch Surg. 2009;144:1047–55.
7. Lanier ST, Fligor JE, Miller KR, Dumanian GA. Reliable complex abdominal wall hernia
repairs with a narrow well-xed retrorectus polypropylene mesh: a review of over 100 consecutive cases. Surgery. 2016;160:1508–16. PMID 27545993.
8. Carbonell AM, Criss CN, Cobb WS, etal. Outcomes of synthetic mesh in contaminated ventral
hernia repairs. J Am Coll Surg. 2013;217:991–8.
9. Slater NJ, Knaapen L, Bokkerink WJV, etal. Large contaminated ventral hernia repair using
component separation technique with synthetic mesh. Plast Reconstr Surg. 2015;796e:136.
10. Shankar DA, Itani KMF, O’Brien WJ, Sanchez VM.Factors associated with long-term out-
comes of umbilical hernia repair. JAMA Surg. 2017;152:461–6.
11. Berger RL, Li LT, Hicks SC, Liang MK.Suture versus preperitoneal prolypropylene mesh for
elective umbilical hernia repairs. J Surg Res. 2014;192:426–31.
12. Abbott DE, Dumanian GA, Halverson AL.Management of laparotomy wound dehiscence.
Am J Surg. 2007;73:1224–7.
13. Baumann DP, Butler CE. Lateral abdominal wall reconstruction. Semin Plast Surg.
2012;16:1548–53.
23 Mesh Sutured Repairs oftheAbdominal Wall
14. Purnell CA, Park E, Turin SY, Dumanian GA.Postoperative ank defects, hernias, and bulges:
a reliable method of repair. Plast Reconstr Surg. 2016;137:994–1001. PMID 26910684.
15. Itani KM, Rosen M, Vargo D, etal. Prospective study of single-stage repair of contaminated
hernias using a biologic porcine tissue matrix: the RICH study. Surgery. 2012;152:498–505.
16. Dumanian GA, Lanier ST, Souza JM, Wu-Young M, Mlodinow AS, Boller AM, Mueller KH,
Halverson AL, McgeeMF, Stulberg JS. Mesh sutured repairs of contaminated incisional hernias. Am J Surg. 2017; https://doi.org/10.1016/j.amjsurg.2017.10.025.
17. Klink CD, Binnebosel M, Alizai PH, Lambertz A, von Trotha KT, Junker E, etal. Tension
of knotted surgical sutures shows tissue specic rapid loss in a rodent model. BMC Surg.
2011;11:36–45.
18. Mason ML, Allen HS. The rate of healing of tendons. An experimental study of tensile
strength. Ann Surg. 1941;113:424–59.
19. Seradge H.Elongation of the repair conguration following exor tendon repair. J Hand Surg.
1983;8:182–5.
20. Playforth MJ, Sauven PD, Evans M, Pollock AV.The prediction of incisional hernias by radio-
opaque markers. Ann Royal Col Surg Eng. 1986;68:82–4.
21. Pollock AV, Evans M.Early prediction of late incisional hernias. Br J Surg. 1989;76:953–4.
22. Burger JW, Lange JF, Halm JA, Kleinrensink G-J, Jeekel H.Incisional hernia: early complica-
tion of abdominal surgery. World J Surg. 2005;29:1608–13.
23. Sauvage LR, Berger KE, Wood SJ, Yates SG 2nd, Smith JC, Manseld PB.Interspecies heal-
ing of porous arterial prostheses: observations, 1960 to 1974. Arch Surg. 1974;109:698–705.
24. Gibbons GW, Wheelock FC, Hoar CC, al e. Predicting success of forefoot amputations in
diabetics by noninvasive testing. Arch Surg. 1979;114:1034.
25. Hollinsky C, Sandberg S.Measurement of the tensile strength of the ventral abdominal wall in
comparison with scar tissue. J Clin Biomech. 2007;22:88–92.
26. Ellis H, Gajraj H, George CD.Incisional hernias: when do they occur? Br J Surg. 1983;70:290–1.
27. Klink CD, Binnebosel M, Kaemmer D, etal. Comet-tail-like inammatory inltrate to poly-
mer laments develops in tension-free conditions. Eur Surg Res. 2011;46:73–81.
331
Treatment ofParastomal Hernias
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
24
ZacharySanford, AdamS.Weltz, andIgorBelyansky
Introduction
Parastomal hernias are a dreaded yet common complication following the creation
of a surgical stoma. Their repair represents a signicant surgical challenge as the
presence of functional bowel passing through the abdominal wall by means of an
iatrogenic defect makes fascial continuity impossible to restore. Although surgical
intervention was once associated with high rates of recurrence and signicant postoperative complications, modern techniques for parastomal hernia repair through
incorporation of mesh reinforcement and minimally invasive procedures have
brought about improvements in the perioperative and postoperative course.
Risk Factors andIncidence
Parastomal hernia formation following stoma creation remains extremely common
in the extant literature necessitating thoughtful planning and patient education [1–
3]. While the greatest risk for formation presents in the rst 3–5years following the
creation of the diverting ostomy, parastomal hernias may form before and after this
period as well [4, 5]. There are several associated risk factors that may predispose
patients to greater likelihoods of parastomal hernia formation. Pathologies associated with increased intra-abdominal pressure or weakening of the abdominal wall
increase a patient’s risk of parastomal hernia formation [6, 7]. Chief among these
are advanced age resulting in age-related thinning of abdominal wall musculature
with concomitant loss of counter-tension to externally directed pressures [4].
Obesity represents an increasingly common modiable risk factor in Western societies and has been directly correlated to increases in risk for parastomal hernia
Z. Sanford · A. S. Weltz · I. Belyansky (*)
Department of Surgery, Anne Arundel Medical Center, Annapolis, MD, USA
e-mail: zsanford1@aahs.org; aweltz@aahs.org; ibelyansky@aahs.org
© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2019
S. S. Davis Jr. et al. (eds.), The SAGES Manual of Hernia Surgery,
https://doi.org/10.1007/978-3-319-78411-3_24
333
334
formation as measured by increases in BMI and abdominal circumference [8, 9].
Additional diseases implicated in higher-risk patients are chronic pulmonary disease or chronic cough syndromes, malnutrition, chronic steroid use, sepsis, or past
history of previous abdominal wall hernia [5, 7, 10].
Z. Sanford et al.
Diagnosis
Correct diagnosis of a clinically signicant parastomal hernia can be made with
adequate physical exam by means of having the patient perform a Valsalva maneuver, during which the clinician will be able to appreciate a bulging of hernia contents either on visual inspection or palpation of the ostomy site [11]. Equivocal
ndings on physical exam can be claried with computed topography (CT) of the
abdomen, although increasing reliance on imaging has resulted in a dramatic
increase in the identication of incidental subclinical hernias that have no harmful
impacts on patient quality of life [11, 12]. Some estimates place the rate of incidental parastomal hernia discovery by CT scan as high as 70%, raising concerns about
the utility of conventional usage of diagnostic imaging in place of adequate physical
exam [13]. These incidental ndings are a source of potential iatrogenic exacerbation as many hernias do not require surgical correction but may still postoperatively
present with high rates of recurrence or postoperative complications. If the patient
lacks clearly dened complaints relating to the presence of a parastomal hernia and
presents with no risk for strangulation, conservative management and routine follow-up exam should be strongly considered [10].
Repair ofParastomal Hernias
Operative repair of parastomal hernias is appropriate in acceptable surgical candidates who present with symptomatic hernias as discussed earlier. Symptomatic hernias are dened as those presenting with herniated abdominal contents at risk for
strangulation or bowel obstruction although bleeding and ill-tting stomal devices
may benet from surgical consideration [10]. Other less troubling considerations
include local pain or irritation and insufcient cosmesis due to telescoping of bowel
or retraction of the ostomy. The following represents a systemic review on the topic
of surgical repair of parastomal hernias while offering discussions of tips and pitfalls where appropriate.
Stoma Relocation
Ideal stoma placement should be below the level of the umbilicus and often within
the left or right lumbar region of the abdomen along surfaces without bony protuberances or redundant tissue or skin folds. An encircling disc of smooth skin should
surround the stoma, making it easy for direct patient visualization and stomal care.
24 Treatment ofParastomal Hernias
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
335
In the event where a stoma has been improperly constructed, placed in an emergency setting, or if the abdomen has undergone distortion as a consequence of the
disease process additional surgery to relocate the stoma may be necessary [14, 15].
Although laparotomy was formerly the surgical approach of choice in relocating
a previously established stoma, in experienced hands laparoscopy is now a commonly used modality. Compared to the substantially more invasive midline dissections required of laparotomy, laparoscopic techniques have been associated with
reductions in postoperative patient pain scores, complication rates, intra-abdominal
adhesion formation, and midline incisional hernia formation as the midline abdominal wall remains intact [16–20].
Relocation is not without its challenges, as the introduction of a new stoma site
disrupts local abdominal architecture. The presence of a new defect in addition to
the closure of a potentially large preexisting defect may make adequate restoration
of abdominal wall integrity a challenge. The use of prosthetic devices to restore
abdominal wall continuity has become increasingly common. The authors encourage the judicious selection and use of synthetic nonabsorbable materials. At present
there is insufcient data to support claims as to long-term efcacy of biologic materials in abdominal wall repair that may offset their increased material costs.
The high rate of hernia recurrence associated with the creation of a stoma is
comparable to the creation of a new stoma site during relocation and increases with
each additional abdominal surgery. Some reports indicate parastomal hernia formation following relocation may approach 50%, although selection of a contralateral
stoma site may reduce this risk [15, 21, 22]. As such, relocation is appropriate when
necessary but should be discussed with the patient to manage postoperative
expectations.
Primary Repair
Primary repair of parastomal fascial defects present often unacceptably high failure
rates but may be considered as a means of last resort when other options are deemed
unavailable or unsafe.
If attempted, the surgeon begins by making an incision approximately 5cm from
the mucocutaneous junction of the hernia defect and proceeds with dissection until
the hernia sac is identied. The sac is then mobilized and the hernia reduced, taking
care to avoid injury to the adjacent stoma. Cases where fascial edges are brought
into approximation under tension are at risk of hernia recurrence when compared to
techniques utilizing mesh [19, 21–24].
Parastomal Hernia Mesh Repair
Appropriate selection of mesh material is crucial in planning parastomal hernia
repair. Traditionally, most parastomal hernia repairs utilize synthetic expanded
polytetrauoroethylene (ePTFE) mesh due in large part to its resilience against
336
Z. Sanford et al.
forming intra-abdominal adhesions to exposed bowel and against erosion into adjacent structures [25–27]. These benets must be weighed against the risk for ePTFE
mesh to acquire postoperative mesh infection and raise concerns specically in
instances of contaminated or dirty surgical elds, such as in open bowel resection
[26, 28].
Biologic mesh materials have been promoted by some experts to be use in contaminated elds [29]. Allograft and xenograft materials are derived human, porcine,
or bovine donors and decellularized to form collagen matrices that serve as a stabile
lattice suitable for mesh creation [30–34]. Collagen matrix materials were developed with the intention of implementation in clean-contaminated or contaminated
surgical elds, suggesting they may be ideal materials in the repair of parastomal
hernias [29]. Early reports suggest that limitations to the use of biologic meshes
arise in heavily contaminated elds where bacterial loads can compromise tensile
strength of the mesh and in their use with bridging techniques which result in unacceptable degrees of stretch and mechanical failure of biologics [35].
Newer composite meshes are now available on the market, and a variety of them
may be used for parastomal hernia repair in IPOM (intraperitoneal onlay mesh)
fashion. In addition, more recently several modications to parastomal hernia repair
techniques have been reported where natural abdominal wall spaces are utilized to
hide the mesh from intra-abdominal contents [36, 37]. In such cases, the use of
uncoated macroporous polypropylene medium-weight mesh (MPMW) is becoming
quite common. Recent data suggests that the use of MPMW mesh in contaminated
eld may be a safe viable option, although much needed randomized prospective
studies are lacking to make a strong recommendation for their use [38, 39].
Onlay Mesh
The onlay repair technique is a supercial reinforcement of the anterior abdominal fascia surrounding the stoma site, positioning mesh within the subcutaneous
space [40, 41]. The technique has been widely adapted and reinterpreted by a
number of hernia repair surgeons, all taking a subtle variation on the general principle [42–44]. One such approach as described by Rosin and colleagues presents
a stomal reconstruction whereby the existing stoma is stapled to a close and
retracted through a circumferential incision to then be reintroduced through a
polypropylene mesh that is afxed to the anterior fascia [45]. By contrast, Leslie
maintains the stomal mucocutaneous junction, instead opting for the utilization of
a preexisting laparotomy scar to create an L-shaped incision from scar to ostomy
which enables repair of coexisting parastomal and incisional hernias with mesh
reinforcement [46, 47]. Tekkis has described a window exposure technique
whereby a semicircular incision along the lateral edge of the stoma can allow for
mesh reinforcement of three-quarters of the surrounding abdominal wall [48, 49].
When performing these types of repair, it is important to consider that supercial
placement of mesh in the subcutaneous layer poses a risk for mesh infection secondary to wound morbidity.
24 Treatment ofParastomal Hernias
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
337
Underlay Mesh Placement
The underlay technique derives its name from the tunneling of lateralized bowel
supercial to a deeper mesh layer rather than penetrating the mesh material. First
pioneered by Sugarbaker in 1985, the technique has since undergone numerous
revisions and technical adjustments; however, all variations universally afford wide
exposure of the fascial defect from within the intra-abdominal cavity [50, 51]. This
allows for substantial mesh overlap and confers stability to the abdominal wall
defect while attempting to mimic the physiologic functions of the abdominal wall.
With the development of laparoscopic techniques, the underlay technique is performed via a minimally invasive approach while avoiding the wound morbidity
associated with laparotomy. Current studies show the incidence of parastomal hernia recurrence up to 10%, although consensus seems to suggest that the laparoscopic Sugarbaker technique is superior to the keyhole technique resulting in fewer
recurrences [13, 42].
Underlay keyhole technique is so named for its resemblance to an actual keyhole, with the securing mesh having a slit placed from a lateral edge to the middle
to accommodate the presenting segment of bowel and leaving the stoma undisturbed. This technique can be performed laparoscopically. The hernia sac and its
contents are reduced. Minimum of 5cm overlap is desirable between the mesh and
fascia to ensure proper integration and stability. The aperture site around the stoma
should be tightened with sutures without obstructing the conduit passing through it.
Once the mesh is inserted and the intact stoma is threaded through the keyhole slit,
the keyhole is sutured together and afxed to the anterior abdominal wall, either
with sutures, tacks, or a combination thereof. This technique is associated with high
rates of parastomal hernia recurrence [52–54].
Laparoscopic approach to the Sugarbaker technique leaves the mucocutaneous
junction intact. Adhesiolysis is again completed and the colon is lateralized. After
reduction of the hernia, the fascial defect is closed primarily and covered with a
mesh prosthetic. Mesh is centered over the stoma site then fastened with several
transfascial sutures, providing broad coverage for the lateralized colon. Care should
be taken to prevent stenosis or angulation of the colon during mesh placement.
When adequate coverage of the lateralized colon is obtained, tacks alone or a combination of tacks and sutures may be used to achieve sufcient stabilization of the
prosthesis. The resulting ap created by the implanted mesh prevents parastomal
hernia formation around the colon and has demonstrated acceptable rates of hernia
recurrence [
55].
Transversus Abdominis Release andModified Retrorectus
Sugarbaker
Posterior components separation via the transversus abdominis release (TAR) technique facilitates enlargement of the retrorectus space, allowing for wide mesh overlap of abdominal wall defects and facilitating closure of larger abdominal wall
Соседние файлы в папке Библиотека им академика М.И. Перельмана