Separation plasty in the treatment of large and giant postoperative hernias of the anterior abdominal wall

Abstract

Introduction. Surgical treatment of patients with large and giant ventral hernias presents significant difficulties. The occurrence of an extensive defect of the anterior abdominal wall entails severe disorders of the functioning of internal organs and systems due to the lack of abdominal function. Significant progress in providing care to patients with large and giant postoperative hernias of the anterior abdominal wall occurred after Novitsky.W. et al. proposed in 2012 posterior separation plastic surgery of the abdominal wall (TAR-transversus abdominis release).The aim of the study was to present the operative technology and the results of surgical treatment of large and giant postoperative hernias of the anterior abdominal wall.Materials and methods. 158 TAR (transversus abdominis release) was performed for postoperative hernias of the anterior abdominal wall. Patients with large and giant postoperative hernias of the anterior abdominal wall W3 – 42 (26.8%) and W4 – 113 (71.5%) prevailed according to the classification of J. P. Chevrel and A.M. Rath, 1999. The modified posterior separation plastic surgery was performed by separating all the muscles of the anterior abdominal wall. The medial edges of the internal oblique muscles were fixed to the mesh implant in order to create an attachment point. With an increase in intra-abdominal pressure, the transverse abdominal muscle was partially or completely crossed. The intersected transverse abdominal muscle with the internal oblique muscle was also fixed to a mesh implant. Two groups of patients were compared: those operated by the TAR (transversus abdominis release) method and by the developed modified technology.Results. The main task of the modified plastic surgery of the anterior abdominal wall – the maximum preservation of the anatomical and functional state of the transverse abdominal muscle – was performed by refusing to cross it or creating new fixation points for its crossed parts (patent for invention No. 2715095 of 27.11.2019). There are no statistically significant differences in the degree of complications according to the Clavien – Dindo criteria in group I and II, although there is a degree V complication in the second group. The greatest number of postoperative complications is observed in patients with obesity of 2-3 degrees. The total mortality rate was 0.6%. Discussion. The indisputable advantage of the TAR (transversus abdominis release) technique is the possibility of a significant increase in the volume of the abdominal cavity and, as a result, the prevention of intraabdominal hypertension and abdominal compartment syndrome. It is difficult to assess in detail the shortcomings of the technique in samples from 30 to 42 patients, but it is still established that the stage of hernioplasty in the form of the intersection of the transverse abdominal muscle determines the subsequent dysfunction of the abdominal muscles, with the formation of a barrelshaped abdomen, reduces the quality of life. The operative technology proposed by us is an anatomically and functionally justified direction of modification of the Novitsky Y. W. et al. technique, which allows preserving the physiological attachment of the transverse abdominal muscle, preventing its atrophy and, thereby, reducing the number of relapses and improving the quality of life of the patient.Conclusions. The modified separation plastic surgery of the anterior abdominal wall in large and giant ventral hernias has advantages in terms of the anatomical and functional state of the muscles of the anterior abdominal wall compared to the method of Novitsky. W. et al, and there were no significant differences in complications according to the Clavien – Dindo criteria in the studied groups.