V. Dadayan

Shupyk National Medical Academy, Kyiv

Introduction. The frequency of occurrence of trocar hernias after laparoscopic cholecystectomy is 3.4-6.7 % [1, 3, 5, 10]. Local risk factors for the occurrence of trocar hernias are the following: size and type of trocar, its location, expansion of the trocar wounds, as well as mistakes during their sewing, infection of the trocar wound [2, 4, 8, 10, 11]. General risk factors include old age of patient, obesity, diabetes mellitus, anaemia, immunosuppressive state, etc. The use of large diameter trocars (10.0- 12.0 mm) often promotes the appearance of trocar hernia [6, 9, 12, 13]. Clinical trials have also shown that dull trocars form smaller wound compared to the oblique and accordingly reduce the risk of trocar hernias development. The use of acute trocars is accompanied by the appearance of hernias in 1.83 % of patients, while dull (conical) – in 0.17 % [4, 14, 15].

The paraumbilical area is the most frequent (75.7 %) place for the formation of trocar hernia, in particular after the laparoscopic cholecystectomy [16, 17]. 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 is an extension of the white line and the diastasis of the straight abdominal muscles that make this area mechanically weak and can create preconditions for trocar hernia. Moreover, aponeurosis and muscles of the paraumbilical area are thinner compared to the other areas of the white line of the abdomen. Alloplasty of trocar hernias combined with rectus abdominis diastasis is accompanied by high frequency (10.0-25.0 %) of recurrence. This is due to the fact that in case of strengthening of trocar defect with implant, rectus abdominis diastasis is not often eliminated, and white line becomes weaker. This results in recurrence of hernia along the edge of implant fixation.

Aim. To determine an effective method of alloplasty of paraumbilical trocar hernias combined with rectus abdominis diastasis taking into account risk factors of their recurrence.

Materials and methods. Fifty-six patients with paraumbilical trocar hernias underwent surgical treatment. Among them there were 38 (67.9 %) women and 18 (32.1 %) men. The age of patients ranged from 30 to 75 years. All the patients were divided into 2 groups. The first (comparison) group included 29 patients who underwent preperitoneal alloplasty without elimination of rectus abdominis diastasis. The second (main) group consisted of 27 patients who underwent hernioplasty using sublay technique with elimination of rectus abdominis diastasis.

The surgery in the first group involved cicatrectomy, mobilization of the abdominal peritoneum from muscle-aponeurotic tissues along the perimeter of 5.0-6.0 cm from the edges of the wound. After that, the abdominal peritoneum defect was sutured and polypropylene mesh implant with a size of 10.0 x 10.0 ± 2.1 cm was preperitoneally placed and fixed along the perimeter with interrupted sutures through the muscles and aponeurosis. Drainage tube was placed in the mesh implant and the aponeurotic edges of the trocar wound were sutured over the implant. Thus, the strengthening of muscle-aponeurotic tissues around the trocar wound was carried out at a width of 5.0 cm along the perimeter.

In the main group, there was used sublay technique with elimination of rectus abdominis diastasis and strengthening its white line from the xiphosternum and 3.0-4.0 cm below the navel. The wound was expanded to the level of rectus abdominis diastasis. The section of the aponeurotic sheaths of the rectus abdominis muscles on the right and left was made at the edges of the abdominal wall defect along the white line. Mobilization of the back walls of aponeurotic sheaths from the direct muscles was performed at their width; interrupted or continuous sutures (proline 0) were used for stitching the walls. The mesh implant was placed and fixed over the stitched back walls of the aponeurotic sheaths of the rectus abdominis muscles under the muscles. Drainage of the retromuscular space was carried out with one or two vacuum drainages. Muscular aponeurotic edges of the abdominal wall defect above the mesh implant were stitched with continuous or interrupted sutures (proline 1.0 or 0). The hypodermic space was drained by one or two vacuum drains. The subcutaneous tissue and the skin were closed in layers.

Postoperative treatment in both groups of patients was carried out according to generally accepted principles.

The results of treatment of trocar hernias were evaluated taking into account risk factors (age, body mass index, aponeurosis incision length during laparoscopy, external respiration function disorder, cardiovascular disease with severe hemodynamic disorders) and postoperative complications according to Clavien-Dindo classification [7].

The protocol of the study was approved by the University Commission on Bioethics, in accordance with the norms of the Declaration of Helsinki. The patients provided written informed consent before the study.

Statistical computing of the indicators was carried out by non-parametric methods using standard computer programs (StatisticaVersion 6, StatSoft, Inc.) with χ2 K. Pearson criterion. The difference was considered significant when p <0.05.

Results and discussion. The results of determining the efficiency of alloplasty methods of paraumbilical trocar hernias combined with rectus abdominis diastasis taking into account risk factors of their recurrence are presented in the table.

Postoperative complications were observed only in three patients (10.3 %) from the comparison group; in the main group there was no recurrence of the disease (χ² = 2.95, p = 0.0858). In the comparison group they were more often observed in patients over the age of 60 years and with 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 for trocar paraumbilical hernia recurrence was only hemodynamic disorders in patients of the comparison group.

Conclusions. The performed study suggests that the best results of surgical treatment of trocar paraumbilical hernias combined with rectus abdominis diastasis, using alloplastic materials are in case of sublay technique with elimination of diastasis.

However, due to a small number of patients included into this study, it is expedient to continue further accumulation of factual information, the processing of which will provide substantially probable results of the revealed patterns. 

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