|Year : 2018 | Volume
| Issue : 2 | Page : 50-54
Surgery of abdominal wall hernias in Russia with special reference to new technical developments
V Abolmasov Alexey1, V Abolmasov Andrey2, Bashankaev Badma3, AM Tariverdiev4
1 Oryol State University Clinic, Plesheevo Regional Hospital, Oryol, Russia
2 Department of General Surgery, Plesheevo Regional Hospital, Oryol, Russia
3 GMS Clinic and Hospitals, Centrosojuz Hospital, Moscow, Russia
4 Department of General Surgery, Centrosojuz Hospital, Moscow, Russia
|Date of Submission||02-Jul-2018|
|Date of Acceptance||02-Jul-2018|
|Date of Web Publication||16-Aug-2018|
Dr. V Abolmasov Alexey
Beregovaia str-9, 302531 Plesheevo, Oryol
Source of Support: None, Conflict of Interest: None
BACKGROUND: We analyzed historic date to follow up hernia surgery changes in Russia since 2002 till 2018 to find out the technical tendencies and to predict the development in the future.
METHODS: Official annual statistic report data, mailing questionaries' of Russian Surgery Society, Russian Surginet community and internet survey, generated by surveymonkey.com were used to obtain information regarding inguinal and ventral hernia therapy in Russia.
RESULTS: For the first 12 patients operated on in the new eTEP technique we recorded no surgical site infection and recurrence. All patients were satisfied with the procedure. The median operative time was 98 min (range: 82 – 160 min). Good cosmetics were achieved in all patients.
CONCLUSIONS: Unfortunately, the principal method of umbilical and midline hernia repair in Russia is a double layer technique without paying attention to concomitant rectus diastasis. This is one of the main reasons for the high recurrence rate.
Keywords: eTEP, laparoscopic hernia, rectus diastasis
|How to cite this article:|
Alexey V A, Andrey V A, Badma B, Tariverdiev A M. Surgery of abdominal wall hernias in Russia with special reference to new technical developments. Int J Abdom Wall Hernia Surg 2018;1:50-4
|How to cite this URL:|
Alexey V A, Andrey V A, Badma B, Tariverdiev A M. Surgery of abdominal wall hernias in Russia with special reference to new technical developments. Int J Abdom Wall Hernia Surg [serial online] 2018 [cited 2021 Apr 18];1:50-4. Available from: http://www.herniasurgeryjournal.org/text.asp?2018/1/2/50/239130
| Introduction – historical Development|| |
Bobrov A. was the first Russian surgeon who did an inguinal hernia repair in 1892. In 1898, Sapezhko K.M. offered his two-layer anterior wall reconstruction. As a matter of fact, his method is still being used in Russia for ventral hernia defect closure. In 1903, Radkevich V.J. published his paper of 315 inguinal hernia surgeries. According to his data, there was 9.6% of recurrence for small and 26.6% for big hernia. The first scientific book by Krymov A.P. "Learning of hernia" was published in 1903. Martinov A.M. and Kimbarovski presented a new technique of anterior wall reinforcement.In 1960–1970s, many papers described the introduction of such synthetic and biological materials such as nylon, auto derma, dura mater, peritoneum, positron emission tomography, and kapron for ventral hernia repair. In 1976, a polypropylene mesh was used in the surgery of 274 patients.
First laparoscopic transabdominal preperitoneal (TAPP) surgery in Russia, according to the report at the International Moscow Congress "Laparoscopic Surgery," was conducted in 1992, but the real progress followed by Bittner et al.'s live surgery at Moscow Meeting in 1995.
However, being technically demanding, this operation was not widely spread within the country until 2010. Lichtenstein's technique was adopted rather soon and finally became one of the most popular among surgeons. For most of Russian surgeons and anesthesiologists, who have been performing inguinal hernia under local anesthesia for decades, it was not easy to switch to endotracheal. Besides, many hospitals were not equipped with laparoscopic tools. In 2002, there was a survey among "Russian Surginet" (RS) community. The questions were (1) Do you use the mesh in inguinal hernia repair; (2) What is your basic method of inguinal hernia operation. At that time, 95% of surgeons had not used the mesh at all. Only 1% declared TAPP.
In 2003, the guidelines of the first hernia society meeting were published. It recommended Lichtenstein technique as a method of choice, leaving for TAPP recurrence and bilateral hernias.
| Methods|| |
Official annual statistic report data, mailing questionaries' of Russian Surgery Society, RS community, and internet survey, generated by surveymonkey.com, were used to obtain the information regarding inguinal and ventral hernia therapy in Russia.
| Results|| |
Operative procedure in 2007
In 2007, another Internet questionnaire form was sent to colleagues. In 2007, nearly 350 members participated in the forum. 44.8% of inguinal hernias were managed in autoplastic way: 7.7% – shouldice, 17.6% – Bassini, 13% – postempsky, 6.5% – anterior wall reconstruction; 55.2% of inguinal hernias were managed in mesh surgery: 50.2 – Lichtenstein, 5% – laparoscopic (80% TAPP vs. 20% totally extraperitoneal [TEP]).
According to the data, more than 200,000 inguinal hernia surgeries are performed in Russia now. An exact number of ventral or incisional hernias are unknown. It could be explained by the statistic form structure inherited from the former Soviet period. There is only a general notion – gastrointestinal diseases. However, according to the 2017 annual obligatory insurance data, there had been 2.6 all hernia operation (ICD codes K40-K46) per 1000 in one of the central regions of Russia with 760,000 residents. However, these data may differ geographically, varying from a higher number in capital cities to a lower one in province.
Scientific organizations and activities
Today, there are two hernia societies in Russia and International Surgery Practice School (ISPS) working as educational centers. The first one is the Society of Herniologists (SH) founded in 2002, with an assigned status of associative Russia Surgery Society (ROS) membership, with total of 205 members. The second one is a member of ROS – Herniologist Club (HC), and it has 406 members.
So far, there were two big international hernia conferences organized by the ISPS in 2014 and 2015, where both ventral and inguinal hernias topics were developed in real-time surgery educational program mode. Both SH and HC societies are taking an active part in annual hernia meetings under ROS. Every year, the questions of abdominal wall hernias and life surgery turn on to the main surgery conference held by ROS. Other educational sources such as First Medical TV channel and Internet channel (laparoscopy.rf) also translate the hernia tutorial content.
Current situation in inguinal and abdominal wall hernia repair
The latest survey generated by ROS and RS (2018) involves 453 surgeons with 25% response rate. The survey consisted of two parts: inguinal hernia and ventral hernia.
Responding to the question "What method of inguinal hernia repair do you use in your practice": 37.35% indicate open, 7.23% indicate laparoscopic and 55.42% indicate both methods. Using mesh in each case mark - 63,68% of surgeons always used mesh, 1,38 - never used mesh, 34,94% - used mesh selectively. Responding to the question "What laparoscopic methods do you use," surgeons indicate 82.25% – TAPP, 1.64 – TEP, and 13.01% – TAPP + TEP. And to the question "What method do you use most commonly (only one to indicate)" shows that 62.5% of surgeons choose Lichtenstein, 31.2% choose TAPP, 2.5% choose TEP, 2.5% choose shouldice, 2.5% chose Bassini, and 1% choose always autoplastic.
Typically, 28% of surgeons who perform less than 50 surgeries per year choose Lichtenstein method and 12% TAPP. Only 1% of respondents are conducting 300 procedures per year. According to [Table 1], 12% TAPP technique surgeons are not able to reach the learning curve quantities even within 5-year period. There are no TEP surgeons who are doing less than 150 inguinal hernias per year. It means that TEP surgeries conducted mostly in high volume hernia centers or specialists.
As to ventral hernias, responding to the question "What method of ventral hernia repair do you use in your practice," 56.84% indicate open, 2% indicate laparoscopic, and 41.05% indicate both methods. Using mesh in each case mark 61% of surgeons always used mesh, 39%. The question "What laparoscopic methods do you use" shows 43% intraperitoneal onlay mesh (IPOM), 9% TAR, 3% Rives-Stopa, 19% TAPP, 3% Ramires, 24% indicate other technique. And the final question, "What do you use most commonly" (only one to indicate) show that 80% choose open and only 20% choose laparoscopic way. An interesting response was received to the question "Who pays for IPOM mesh and stapler," 53.8% indicated the patient, 15% indicated insurance, 7% indicated private insurance, 4.3% indicated other sources, and 20% do not use IPOM technique. And besides, the insurance costs for ventral hernia repair vary from 500 EUR up to 3000 EUR. The price depends on the region of Russia: the highest in Moscow, the lowest in provinces.
Fifty-seven percent of surgeons who are doing <50 ventral hernias per year choose an open repair. 66% of surgeons are doing less than one incisional hernia per week. Only 1% of surgeons are doing >250 hernias per year and they mostly choose an open repair [Table 2].
|Table 2: Number of surgeries per year and most commonly used ventral hernia repair techniques|
Click here to view
| Discussion and New Technical Developments|| |
As we can judge from above-mentioned data, the state of hernia therapy in Russia has been dramatically changed since 2002: (1) Today, more than 60% of surgeons are always using mesh in inguinal and ventral hernia (5% in 2002); (2) Laparoscopic inguinal surgery is the method of choice for 7% (1% in 2002); (3) Just 1.24% of surgeons are still been conducting no mesh inguinal repair compared to 44.8% in 2007; (4) There is no more anterior inguinal wall reconstruction (6.5% in 2007).
However, it is necessary to solve a lot of issues in the future:
(1) There is still no standard in inguinal and ventral hernia therapy in Russia; (2) No reliable statistical data about quantities and qualities of hernia repair are available, and the real morbidity and mortality rates and the true number of recurrences are unknown; (3) Only 7% inguinal and 2% incisional hernias managed by laparoscopy and the quality of this procedures is unknown; (4) There are a many hospitals where the surgeons perform less than 50 hernias per year; (5) Further educational and technical support is needed to follow International Endohernia Society, or Hernia Surge Group guidelines; (6) An obligatory national hernia register may be a good option to improve the outcomes of surgeries.
Despite the various surgical techniques in abdominal wall hernia treatment existed, the optimal therapy of primary and secondary abdominal wall hernias is still in discussion. The open sublay repair is burdened by a large trauma to the abdominal wall, severe pain, and high risk for wound complications. The disadvantages of the transabdominal IPOM repair are (1) a significant risk for bowel's injuring, (2) expensive mesh and fixation devices, and (3) tackers or suture fixation-induced pain. Moreover, there is a particular problem with the patients suffering from a hernia in the midline which is combined with a rectus diastasis. Due to these issues and to overcome these disadvantages, there have been several new procedures developed recently to improve the outcome for the patients and to save money for the health-care system in general. There have been a lot of new procedures in the field of abdominal wall hernias as well. Works of Bittner et al., Reinpold et al., and Belyansky et al. have opened a new conception in the treatment of diastasis, too. Mini- or less-open sublay operation (MILOS),, endoscopic MILOS (EMILOS), extended totally extraperitoneal (eTEP) approaches are changing the former paradigm. Evidence seems to suggest that extraperitoneal approach has advantages over other procedures regarding morbidity and cosmetics. This alternative strategy has been developed to avoid direct viscera contact to the mesh, which carries the risk for adhesions and ileus formation later on.
Not at least due to an increasing scientific exchange in meetings or by internet with our colleagues in Europe or America during the recent years, we became familiar with the technique of the eTEP approach introduced by Belyansky et al. However, we implied this new revolutionary technique in the management of symptomatic patients with rectus abdominal muscle diastasis.
The data of the first 12 patients who underwent an eTEP procedure were retrospectively analyzed with a minimum follow-up of 2 months. Their data were analyzed for operative details and intraoperative and postoperative complications.
We used 3–4 5 mm and one 12 mm ports for eTEP approach. The first entry point depends on clinical data. We inserted first 5 mm port under the right costal margin in patients with previous upper abdominal surgeries or no surgeries to perform bottom crossover. The right retro rectus space was developed and the second 5 mm port added under direct vision in the right inguinal region. Bogros and Retzius spaces were developed and 12 mm port inserted in suprapubic region followed by 5 mm left inguinal port. The camera moved to 12 mm port; the surgeon moved to the legs. Both arcuata lines and posterior rectus sheath were cut with complete linea alba preservation. The xiphoideus was the upper dissection point. A zero V-lock suture was used to restore anterior rectus sheath and to close diastasis. We used 2/0 V-lock for posterior layer closure if needed. A polypropylene mesh of appropriate size was inserted to cover all retro rectus space. The mesh was not fixed.
We inserted the first 5 mm port under the left costal margin to perform upper crossover technique in patients with previous low abdomen surgeries; the second 5 mm port was inserted in the left flank, followed by 5 mm port in the left inguinal region. An optic moved to inguinal port and the left rectus sheath was opened. The dissection proceeded through falciform ligament and the right rectus sheath was opened. Additional 5 mm port in the right costal margins was added. The camera moved to the left subcostal port. Both retro rectus spaces were developed. Additional 12 mm port was inserted in the right flank for suturing and mesh delivery. Diastasis suturing and mesh placement were done the way written above.
| Results|| |
During the study period, 12 consecutive patients were admitted to our center for surgical treatment of midline hernia with or without diastasis recti. None of the patient had a recurrent or incisional hernia at admission. There were nine patients complaining of hernia (6 umbilical, 3 linea alba) and three women complaining of abdominal wall protrusion without concomitant hernia. All three of them were presented 16, 20, and 24 months after C-section delivery.
Information regarding variables of age, severity of diastasis recti abdominis, and precluded side effects was recorded for analysis.
Patients characteristic are displayed in [Table 3].
For a total of 12 patients, we recorded no surgical site infection and recurrence. All patients were satisfied with the procedure. The median operative time was 98 min (range: 82–160 min). Good cosmetics were achieved in all patients.
| Conclusions|| |
Unfortunately, the principal method of umbilical and midline hernia repair in Russia is a double-layer technique without paying attention to concomitant rectus diastasis. This is one of the main reasons for the high recurrence rate. Moreover, there is no routine computed tomography (CT) for diagnostics of complicated hernia because very few hospitals have this image options. At the same time, preoperative planning with a CT scan can give information about hernia defect configuration. Conventionally, patients with diastasis are treated by plastic surgeons who unaware of modern tendencies in hernia surgery. Very few surgeons are able to perform laparoscopic or video-assisted procedure (MILOS/EMILOS/eTEP) in Russia. Most of them choose IPOM repair because of its simplicity. Meanwhile, the high mesh and stapler's cost are not covered by insurance. This fact makes IPOM an exclusive option, which is not available for everyone. Obviously, the new techniques (MILOS/EMILOS/eTEP) could make these surgeries more effective. Moreover, using cheaper polypropylene mesh and avoiding fixation device make this surgery accessible for low-income groups. For this to happen, new training and instrumentation are required, and the limitations of this technique must be acknowledged.
The teaching program and mentoring are the only way to introduce the new methods in practice.
Judging from our short-term results, we suggest that the eTEP technique can be adapted in centers with advanced laparoscopic skills with the careful patient selection. Further investigations are needed in the evaluation of outcome and feasibility of laparoscopic eTEP technique for diastasis recti correction.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]