Intraperitoneal alloplasty combined with the anterior separation technique in giant incisional hernias.

The use of the anterior technique for abdominal wall components separation combined with "onlay" alloplasty (ACST + onlay) in giant incisional hernias (IH) may pose a surgical challenge as it does not exclude increased intra-abdominal pressure (IAP) and the occurrence of abdominal compartment syndrome (ACS). There remains a high incidence of surgical site complications. In our view, the use of intra-abdominal alloplasty combined with anterior separation of the anterior abdominal wall components (ACST + IPOM) will contribute to the improvement of surgical outcomes in giant IH. PURPOSE: to improve the results of surgical treatment of giant IH using ACST + IPOM. MATERIALS AND METHODS: Analysis of surgical treatment of 164 patients with giant IH aged 30 to 75 (mean age 54.7 ± 3.3). Depending on the surgery, the patients were divided into two groups. Group I (82 patients) consisted of patients who underwent our modified technique, including ACST + IPOM. The surgery in group II (82 patients) involved ACST + onlay. RESULTS AND DISCUSSION: As compared with ACST + onlay, ACST + IPOM surgery contributes to a significantly reduced incidence of ACS [6.1% (group II) versus 0 (group I), (p <0.05)], seroma [25.6% versus 7.3%, p <0.05], surgical site infection (SSI) [4.9% versus 2.4%, p> 0.05], meshoma [3.7% versus 0] and hernia recurrences [6.5% versus 1.6%, p> 0.05]. CONCLUSIONS: IAP value equal or exceeding 9.1 mmHg (1.2 kPa) during surgery in approximated rectus muscles is prognostic for ACS occurrence and requires intraoperative preventive measures. Utilization of ACST + IPOM in giant IH ensures an optimal abdominal cavity volume without a substantial increase in IAP and reduces the probability of ACS, whereas the use of ACST + onlay results in ACN in 6.1% (p <0.05) patients. Reduced contact of the mesh with the subcutaneous tissue in ACST + IPOM contributes to a significantly lower incidence of seroma [7.3% vs 25.6% (p <0.05)], surgical site infection (SSI) [2.4% vs 4.9% (p> 0.05)], postoperative wound infiltrate [2 (2.4%) vs. 11 (13.4%) (p <0.05)], chronic postsurgical pain [1 (1.6%) vs. 5 (8.1%) (p> 0.05)] and recurrent IH [1 (1.6%) vs. 4 (6.5%) (p> 0.05)] as compared with ACST + onlay technique.

Features of respiratory support during laparoscopic correction of inguinal hernias in children.

INTRODUCTION: The objectives were to study the changes in the mechanics of respiration in children undergoing surgery depending on the value of intra-abdominal pressure (IAP) during laparoscopic procedures, and to compare the effects of different mechanical ventilation modes - pressure controlled (PCV) and volume controlled (VCV) ventilation - on the mechanics of respiration considering carboxyperitoneum conditions (CP). AIM: To study the changes in the mechanics of respiration in operated children depending on the value of intra-abdominal pressure during laparoscopic procedures. MATERIAL AND METHODS: Fifty-two children aged 1-12 years undergoing laparoscopic surgery on inguinal hernias were randomly allocated to receive mechanical ventilation using either VCV (n = 24) or PCV (n = 28) mode. Respiratory mechanics were measured before application of carboxyperitoneum (initial data) and after the gas had been pumped into the abdominal cavity, at the following intra-abdominal pressure values: 6 mm Hg, 8 mm Hg, 10 mm Hg, 12 mm Hg, 14 mm Hg. RESULTS: Elevation of intra-abdominal pressure due to carboxyperitoneum conditions had a negative effect on the mechanics of respiration. Changes in the respiratory mechanics were restrictive in nature in both groups. The patients who were receiving pressure controlled ventilation showed a decrease in tidal volume, exhaled minute volume, and dynamic lung compliance, which affected the gas exchange at intra-abdominal pressure values ≥ 12 mm Hg. Patients who were receiving volume controlled ventilation showed an increase in peak inspiratory pressure and mean airway pressure and a decrease in dynamic lung compliance in response to higher intra-abdominal pressure. A significant increase of concentration of exhaled carbon dioxide (etCO2) was registered at IAP ≥ 12 mm Hg. CONCLUSIONS: Application of carboxyperitoneum causes increased intra-abdominal pressure and restrictive disorders in respiratory mechanics. Intra-abdominal pressure readings within 8-12 mm Hg allow laparoscopic procedures to be performed without significant gas exchange disorders in children older than 1 year.