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1 . 2022

Endoscopic extraperitoneal reconstruction in primary midline hernias and diastasis of the rectus abdominis muscles

Abstract

The study describes a prospective comparative analysis of the treatment of patients with primary midline hernias and concomitant diastasis of the rectus abdominis muscles (DRAM) using endoscopy extraperitoneal reconstruction (EER) and open retromuscular reconstruction.

Aim. To determine the effectiveness of treatment in patients with combined primary midline hernia and diastasis of the rectus abdominis muscles using the methods of open and endoscopic extraperitoneal reconstruction with retromuscular placement of the endoprosthesis at an early stage of the postoperative period (up to 8 months).

Material and methods. This prospective study included observations of 93 patients with combined DRAM and primary midline hernia who were admitted to the surgical department of the Central clinical hospital "RZD-Medicine" in the period between 2018 and 2019. The patients were divided into two groups: the first (study group) included 45 patients undergoing EER, whereas, the second (comparison group) consisted of 48 patients undergoing open reconstruction with retromuscular mesh implant placement. The groups were homogeneous in terms of mean age 46±11.8 and 51.3±12 years, respectively) and gender ratio (the number of men and women was 3:2 in both groups). Complications were classified according to the Clavien-Dindo scale. The median follow-up in the study group was 14 months (8-18 months), in the control group - 25 months (20-32 months). 

Results. EER is comparable to open retromuscular reconstruction in terms of efficiency, there are no severe complications and statistically significant differences in complications of mild and moderate severity (χ2=1.63, p=0.653). At the same time, there are significant advantages in the degree of pain syndrome (p≤0.003) and the rate of physical activity recovery (p<0.001) in the immediate postoperative period (the first 5 days after surgery). Besides, the necessity for analgesic therapy in the study group is significantly less (p<0.001).

Conclusion. Thus, the presented data in total suggests that EER is an effective less invasive treatment method for patients with combined primary midline hernia and DRAM, which allows recommending EER for wider study and implementation.

Keywords:diastasis of the rectus abdominis muscles; diastasis recti; umbilical hernia; primary midline hernias; line alba hernias, laparoscopy hernioplasty; endoscopy extraperitoneal reconstruction; eTEP (extended-view Totally ExtraPeritoneal)

Funding. The study had no sponsor support.
Conflict of interest. The authors declare no conflict of interest.
For citation: Yurasov A.V., Rakintsev V.S., Dubrov V.E. Endoscopic extraperitoneal reconstruction in primary midline hernias and diastasis of the rectus abdominis muscles. Clinical and Experimental Surgery. Petrovsky Journal. 2022; 10 (1): 65-71. DOI: https://doi.org/10.33029/2308-1198-2022-10-1-65-71 (in Russian)

References

1. Zhebrovsky V.V., El’bashir T.M. Surgery of abdominal hernias and events. Simferopol’: Biznes-Inform, 2002: 440 p. (in Russian)

2. Köhler G., Luketina R.-R., Emmanuel K. Sutured repair of primary small umbilical and epigastric hernias: concomitant rectus diastasis is a signifi cant risk factor for recurrence. World J Surg. 2014; 39 (1): 121–6. DOI: http://doi.org/10.1007/s00268-014-2765-y

3. Schumpelick V., Fitzgibbons R.J. (eds). Recurrent Hernia. Berlin; Heidelberg: Springer, 2007. DOI: http://doi.org/10.1007/978-3-540-68988-1

4. Blagovestnov D.A., Upyrev A.V., Srukova A.H. The role and place of prosthesis fitting methods of forward belly wall plasticity in primary median hernia surgery. Vestnik novykh meditsinskikh tekhnologiy [Bulletin of New Medical Technologies]. 2011; 18 (1): 153–5. (in Russian)

5. Belyansky I., Reza Zahiri H., Sanford Z., Weltz A.S., Park A. Early operative outcomes of endoscopic (eTEP access) roboticassisted retromuscular abdominal wall hernia repair. Hernia. 2018; 22 (5): 837–47. DOI: http://doi.org/10.1007/s10029-018-1795-z

6. Kudsi O.Y., Gokcal F. Lateral approach totally extraperitoneal (TEP) robotic retromuscular ventral hernia repair. Hernia. 2021; 25 (1): 211–22. DOI: http://doi.org/10.1007/s10029-019-02082-9

7. Belyansky I., Daes J., Radu V.G., Balasubramanian R., Reza Zahiri H., Weltz A.S., et al. A novel approach using the enhanced-view totally extraperitoneal (eTEP) technique for laparoscopic retromuscular hernia repair. Surg Endosc. 2017; 32 (3): 1525–32. DOI: http://doi.org/10.1007/s00464-017-5840-2

8. Burdakov V.A., Matveev N.L., Ukhanov A.I. Evolution of methods of endoscopic ventral hernioplasty // Moscow surgical journal. 2018; 3 (61): 130. (in Russian)

9. Juárez Muas D.M. Preaponeurotic endoscopic repair (REPA) of diastasis recti associated or not to midline hernias. Surg Endosc. 2018; 33 (6): 1777–82. DOI: http://doi.org/10.1007/s00464-018-6450-3

10. Li B., Qin C., Bittner R. Totally endoscopic sublay (TES) repair for midline ventral hernia: surgical technique and preliminary results. Surg Endosc. 2018; 34 (4): 1543–50. DOI: http://doi.org/10.1007/s00464-018-6568-3

11. Burdakov V.A., Zverev A.A., Makarov S.A., Kupriyanova A.S., Matveev N.L. Endoscopic extraperitoneal approach in the treatment of patients with primary and postoperative ventral hernias. Endoskopicheskaya khirurgiya [Endoscopic Surgery]. 2019; 25 (4): 34–40. (in Russian)

12. Köckerling F., Botsinis M.D., Rohde C., Reinpold W. Endoscopic- assisted linea alba reconstruction plus mesh augmentation for treatment of umbilical and/or epigastric hernias and rectus abdominis diastasis – early results. Front Surg. 2016; 3: 27. DOI: http://doi.org/10.3389/fsurg.2016.00027

13. Köckerling F., Botsinis M.D., Rohde C., Reinpold W., Schug-Pass C. Endoscopic-assisted linea alba reconstruction: New technique for treatment of symptomatic umbilical, trocar, and/or epigastric hernias with concomitant rectus abdominis diastasis. Eur Surg. 2017; 49 (2): 71–5. DOI: https://doi.org/10.1007/s10353-017-0473-1

14. Schwarz J., Reinpold W, Bittner R. Endoscopic mini/less open sublay technique (EMILOS) – a new technique for ventral hernia repair. Langenbecks Arch Surg. 2016; 402 (1): 173–80. DOI: http://doi.org/10.1007/s00423-016-1522-0

15. Bellido Luque J., Bellido Luque A., Valdivia J., Suarez Gráu J.M., Gomez Menchero J., García Moreno J., et al. Totally endoscopic surgery on diastasis recti associated with midline hernias. The advantages of a minimally invasive approach. Prospective cohort study. Hernia. 2015; 19 (3): 493–501. DOI: http://doi.org/10.1007/s10029-014-1300-2

16.    Miserez M., Penninckx F Endoscopic totally preperitoneal ventral hernia repair. Surg Endosc Interv Tech. 2002; 16 (8): 1207-13. DOI: http://doi.org/10.1007/s00464-001-9198-z

17.    Yurasov A.V., Rakintsev V.S. Technical features of the development extended-viewtotally extraperitoneal (eTEP) patch plasty. Gospital'naya meditsina: nauka i praktika [Hospital Medicine: Science and Practice]. 2019; 1 (4): 32-7. (in Russian)

18.    Yurasov A.V., Abovyan L.A., Kurashvili D.N., Lysenko M.V., Alekseev A.K. Short-term surgical treatment outcomes of patients with combined umpilical hernia and diastasis recti. Moskovskiy khirurgicheskiy zhurnal [Moscow Surgical Journal]. 2014; 5 (39): 5-9. (in Russian)

19.    Matei O.A., Runkel N. A novel technique of midline mesh repair for umbilical hernia associated with diastasis recti. Surg Technol Int. 2014; 24: 183-7. URL: https://pubmed.ncbi.nlm.nih.gov/24526430/

20.    Carbonell A.M. Rives-Stoppa retromuscular repair. In: Hernia Surgery. Switzerland: Springer, 2016. DOI: https://doi.org/10.1007/978-3-319-27470-6_12

21.    Timmermans L., de Goede B., van Dijk S.M., Kleinrensink G.-J., Jeekel J., Lange J.F Meta-analysis of sublay versus onlay mesh repair in incisional hernia surgery. Am J Surg. 2014; 207 (6): 980-8. DOI: http://doi.org/10.1016/j.amjsurg.2013.08.030

22.    Demetrashvili Z., Pipia I., Loladze D., Metreveli T., Eka-ladze E., Kenchadze G., et al. Open retromuscular mesh repair versus onlay technique of incisional hernia: a randomized controlled trial. Int J Surg. 2017; 37: 65-70. DOI: http://doi.org/10.1016/j.ijsu.2016.12.008

23.    Ermolov A.S., Alekseev A.K., Andreev V.G., Gorchakov V.K., Il'ichev V.A. Method for treating patients with medium ventral hernia (options): pat. 2275172 Russia No. 2004121038/14A; decl. 09.07.2004; publ. 10.01.2006, Bull. No. 01: 2 p. (in Russian)

24.    Scott J., Huskisson E.C. Graphic representation of pain. Pain. 1976; 2 (2): 175-84. DOI: http://doi.org/10.1016/0304-3959(76)90113-5

25.    Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care Res (Hoboken). 2011; 63 (suppl 11): S240-52. DOI: http://doi.org/10.1002/acr.20543

26.    Brock M., Kunkel P., Papavero L. Lumbar microdiscectomy: subperiosteal versus transmuscular approach and influence on the early postoperative analgesic consumption. Eur Spine J. 2008; 17 (4): 518-22. DOI: https://doi.org/10.1007/s00586-008-0604-2

27.    World Health Organization. Cancer Pain Relief: with a Guide to Opioid Availability. 2nd ed. World Health Organization, 1996. DOI: https://apps.who.int/iris/handle/10665/37896

28.    Dougherty S.H., Simmons R.L. The biology and practice of surgical drains. Part 1. Curr Probl Surg. 1992; 29 (8): 559623. DIO: https://doi.org/10.1016/0011-3840(92)90022-u

29.    Golovin R.V., Nikitin NA The assessment of different combination prosthetic repair techniques and prognostic criteria for early wound complications in median incisional ventral hernias. Sovremennye tekhnologii v meditsine [Modern Technologies in Medicine]. 2015; 7 (2): 105-12. DOI: http://doi.org/10.17691/stm2015.7.2.14  (in Russian)

30.    Dindo D., Demartines N., Clavien P.-A. Classification of surgical complications. Ann Surg. 2004; 240 (2): 205-13. DOI: http://doi.org/10.1097/01.sla.0000133083.54934.ae

31.    Morales-Conde S. Erratum to: a new classification for seroma after laparoscopic ventral hernia repair. Hernia. 2012; 17 (1): 153-3. DOI: http://doi.org/10.1007/s10029-012-1010-6

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CHIEF EDITOR
CHIEF EDITOR
Sergey L. Dzemeshkevich
MD, Professor (Moscow, Russia)

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