Myofascial Defects of the Lateral Abdominal Wall: Features of Diagnosis and Surgical Correction

The dissertation is devoted to the study of postoperative myofascial defects of the lateral abdominal wall and the lumbar-lateral region, most often formed after lumbar and other transverse surgical approaches widely used in urology, abdominal surgery, oncology and related disciplines. The author analyzes the prevalence and causes of such defects, including neuropathic hernias, and points to the absence of unified classification approaches and standardized methods of surgical correction, as well as to a significant number of recurrences when using local tissue repair, autoplasty and even mesh endoprostheses.

The work clarifies the frequency and factors of formation of myofascial defects in patients operated on the organs of the urinary system via lumbar approach, proposes a comprehensive diagnostic algorithm using ultrasound, computed tomography and morphological analysis, as well as an original method of reconstruction of the lateral abdominal wall, protected by an RF patent. The course of the early postoperative period and the long-term results of treatment are evaluated, which allows the work to be considered as a contribution to the development of reconstructive-restorative surgery of the anterior and lateral abdominal wall.

Relevance of the Problem.

The treatment of patients with postoperative abdominal hernias (PAH) is one of the urgent problems of modern surgery due to the fact that the total number of patients with this pathology remains rather large, since the frequency of occurrence of patients with PAH is 3-7% of the entire population [38,53,54,55,90,92,107], and from 20 to 26% of the total number of external abdominal hernias [16,42,147,198,205], and from 3 to 15%, and according to some sources up to 58.7% of the total number of patients operated on for various surgical diseases [67,105,106,157,164,179,194,199,201,202,235]. At the same time, the frequency of PAH formation is higher in patients operated on for emergency indications. It should be noted that the number of these patients continues to increase [9,10,24,38,39,43,52,68,72,116,239].

The frequency of formation and the probability of occurrence of various postoperative myofascial defects depend on many factors. First of all, on the method and surgical technique of suturing the postoperative wound [176]. No lesser role is played by concomitant diseases, the age and weight of the patient. The course of the postoperative period is of particular importance, for example, complications in the postoperative wound, including suppuration; the adequacy of physical activity of patients in the postoperative period. It should be noted that the percentage of PAH formation is higher after surgical interventions performed for urgent and emergency indications. No less important is the localization of the surgical approach, as well as its length [48,92,270,241].

Postoperative hernias of lateral and lumbar-lateral localization account for more than 33% of postoperative hernias [190]. When performing lateral and lumbar-lateral approaches, there is a high probability of transection of nerves and vessels of the lateral abdominal wall and the lumbar-lateral region, which leads to atrophy of muscle fibers and the formation of various postoperative myofascial defects [42,75,77,81,82,92,104,112], including neuropathic hernias [12,13,29,36,76,169,173,189,215,223,236]. These approaches are widely used not only in abdominal surgery, but also in other fields of surgery — endocrinology, vascular surgery, oncology, gynecology, etc. Incisions through the lateral and lumbar-lateral regions are most often used in urology. Lumbar incision remains the most frequently used surgical approach in operations on the kidneys and ureters and is the most traumatic of the approaches through the lateral abdominal wall and the lumbar-lateral region. The literature data confirm the above: after appendectomy, hernias form in 0.7% of cases [153], after the subcostal approach in liver and biliary tract surgery — in 4.8-31.3% of cases [48,163,167,183,232,248], in reconstructive operations on the aorta — in 13.4-56% of cases [185,207,215], after adrenalectomy — in 18.2% of cases [188]. However, at present there is no exhaustive information on the true number and frequency of formation of various myofascial defects in patients who have undergone operations on the organs of the urinary system via lumbar approaches. This is due to a significant separation of spheres of interest and diverse approaches to the treatment and prevention of hernia formation in modern surgery and urology, since the problems for which lumbar approaches are used are mainly dealt with by urologists, while the treatment of such complications as myofascial defects is dealt with by surgeons. In the literature available to us, we did not find exhaustive information on the true number and frequency of formation of myofascial defects in patients who underwent operations via lumbar approach for various diseases of the kidneys and ureters. It should be noted a rather large scatter of the data given by the authors: from 7 to 49% for both true and neuropathic hernias [151,160,172,173,174,223].

Also in the literature available to us, a number of authors provide data on the number of operated patients for hernias of lumbar-lateral localization: from 3.1% to 35.5% [13,29,71,88,189,190,218,219,220].

The problem of treatment of patients with PAH also remains relevant in connection with a large number of recurrences — according to various authors, hernia recurrences are noted quite often — 30%-50% and more [66,85,86,98,99,115,118,135,136,198,225], apparently therefore today more than 300 methods of PAH treatment have been proposed, which undoubtedly indicates the lack of a unified approach to the treatment of PAH and the unresolved nature of this problem.

More than 20 years of world experience in the use of synthetic mesh endoprostheses for inguinal canal repair according to the Liechtenstein method has proved good engraftment of the polypropylene explant in the deep layers of the abdominal wall, a minimal number of complications in postoperative wound healing, and a minimal number of hernia recurrences [158,206]. In this regard, the use of polypropylene explants has become the "gold standard" in the treatment of inguinal hernias, and subsequently in the treatment of postoperative hernias.

With the use of endoprostheses in the reconstruction and correction of the anterior abdominal wall for existing myofascial defects in it, it was possible to achieve good results, primarily due to a significant reduction in the number of recurrences [40,41]. However, with regard to the elimination of postoperative myofascial defects of lateral and lumbar-lateral localization, a number of unresolved issues remain at present. First of all, this is due to a large number of recurrences [205,244]. In tissue repair with local tissues, it is necessary to use unsuitable atrophic, thinned, flabby muscles of the lateral abdominal wall. In the case of mesh endoprostheses, hernioplasty is usually performed in an inadequate volume with respect to the entire lateral wall, which cannot contribute to a reduction in the number of recurrences and an adequate solution to the question of the functional and cosmetic effect of the performed operations [13,14,15,91,230]. With the use of autodermoplastic methods of hernioplasty, the number of recurrences is also very high: up to 37.5% [238]. Therefore, autoplastic and autodermoplastic methods are currently practically not used.

Even with the use of mesh endoprostheses, hernia recurrences can reach 2.5-34% [12,13,14,88,162,171,189,190,198,201,202,203,250] and more [165]. Despite the advantages of using explants in the treatment of postoperative myofascial defects in comparison with the methods of local tissue hernioplasty, a number of authors indicate unsatisfactory results due to a large number of wound complications — 11-21% [152,195,203,241,246].

Considering the above, it should be recognized that there is very little information on special studies, as well as the studies themselves concerning the surgical treatment of patients with postoperative myofascial defects of the lateral abdominal wall and the lumbar-lateral region. There is also no consensus on the classification of postoperative myofascial defects of the lateral abdominal wall and the lumbar-lateral region [4,33,40,71,88,105,127,215,230,236], in connection with which the authors classify them as postoperative hernias.

Thus, based on the above, the problem of diagnosis and surgical treatment of postoperative myofascial defects of the lateral abdominal wall and the lumbar-lateral region remains not fully studied and therefore requires continued research.

Objective of the Study: to clarify the mechanisms of occurrence, as well as to develop diagnostic approaches that allow an objective assessment of the nature of myofascial defects of the lateral abdominal wall and the lumbar-lateral region. Based on the data obtained, to develop the principles of surgical correction of these myofascial defects, thereby improving the results of treatment of this group of patients.

Tasks of the Study.

1. To clarify the frequency and causes of formation of myofascial defects after surgical treatment of patients with diseases of the urinary system organs, depending on the approach.

2. To develop diagnostic algorithms and a technique for performing reconstructive-restorative operations for myofascial defects of the lateral abdominal wall and the lumbar-lateral region.

3. To evaluate the course of the early postoperative period in patients who underwent surgical treatment by the developed method for postoperative myofascial defects of the lateral abdominal wall.

4. To evaluate the long-term results of surgical treatment of patients with postoperative myofascial defects of the lateral abdominal wall by the proposed method.

Scientific Novelty.

The frequency and causes of formation of myofascial defects after surgical treatment of patients with diseases of the urinary system organs have been clarified depending on the approach.

A method of reconstruction of the lateral abdominal wall in postoperative hernia has been developed and introduced into clinical practice (RF patent No. 2325856), which can be used in the treatment of patients with myofascial defects of the lateral abdominal wall and the lumbar-lateral region.

The use has been substantiated and diagnostic criteria for dynamic monitoring of the state of the abdominal wall using CT and ultrasound methods have been developed for patients operated on by the proposed method in the long-term period.

Practical Significance.

The proposed diagnostic methods, as well as the method of reconstruction of the lateral abdominal wall used in the treatment of patients with myofascial defects of the lateral abdominal wall and the lumbar-lateral region, make it possible to improve the results of treatment of this group of patients.

Main Provisions Defended.

The transverse approaches through the lateral abdominal wall and the lumbar-lateral region used in various fields of surgery are quite traumatic and dangerous. They often lead to the formation of myofascial defects in the postoperative period. The most traumatic approach is lumbar incision due to the inevitability of transection of muscles and neurovascular formations over a large extent.

In the examination of patients with postoperative myofascial defects of the lateral abdominal wall and the lumbar-lateral region, it is necessary to apply a comprehensive diagnostic approach, which includes, in addition to questioning, inspection, physical examination, ultrasound diagnostics and computed tomography methods, morphological examination of the musculo-aponeurotic structures of the abdominal wall. These examination methods, complementing each other, make it possible to clarify the localization of the myofascial defect, its size, type, the presence of hernial gates and the degree of atrophic changes in the musculo-aponeurotic structures of the lateral and lumbar-lateral region.

The proposed method of reconstruction of the lateral abdominal wall contributes to the elimination of postoperative myofascial defects of the lateral abdominal wall and lumbar-lateral localization, to the improvement of the shape of the abdomen from a cosmetic point of view, and allows ensuring the restoration of the function of the abdominal press as a whole over time.

Implementation into Practice.

The developed method of reconstruction of the lateral abdominal wall has been introduced and applied since 2002 in the work of the surgical departments of: the Non-State Healthcare Institution "Central Clinical Hospital No. 1 of the Open Joint Stock Company "Russian Railways" and the State Healthcare Institution "City Clinical Hospital No. 51" of the Moscow Department of Healthcare.

The materials of the dissertation are used in the educational process and scientific research of the Department of Surgery of the Federal State Institution "Educational and Scientific Medical Center" of the Administration of the President of the Russian Federation.

Approbation of the Work.

The materials of the dissertation were reported: at the scientific and practical conference of Russian doctors "Uspenskiye Readings", dedicated to the 70th anniversary of the Tver State Medical Academy (Tver, December 2006), and at the I International Conference "Modern Technologies and Possibilities of Reconstructive-Restorative and Aesthetic Surgery" (Moscow, April 2008).

Publications.

According to the results of the study, 9 printed works have been published. The RF patent for invention No. 2325856 has been obtained.