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Bauchdeckenverschluss bei Narbenhernien und Herniationen nach Laparostoma

Abdominal wall closure by incisional hernia and herniation after laparostoma

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Zusammenfassung

Verschiedene Ätiologien der Hernien und Bauchwanddefekte, deren Komplikationen und Komorbiditäten ergeben unterschiedlichste Konstellationen, für deren effiziente Behandlung ein patientenorientiertes Management benötigt wird. Gerade die komplizierten Hernien erfordern ein individualisiertes Vorgehen sowie eine interdisziplinäre Abstimmung. Eine standardisierte Therapieempfehlung gibt es nicht.

Die Bauchwandverstärkung bei Hernienrezidiven beansprucht den direkten Faszienverschluss unter Verwendung der eher leichtgewichtigen Netze in der Sublay-Technik. Bei persistierenden Entzündungen, Mesh-Dislokationen, Fistelungen oder anderen Langzeitkomplikationen ist nach wie vor ungeklärt, ob gewisse Materialen oder die operative Technik dafür verantwortlich zeichnen. Im Fall einer Mesh-Infektion hat es sich jedoch als vorteilhaft erwiesen, Polytetrafluorethylen-Netze zu explantieren, während für Polypropylen oder Polyester die Kombination einer systemischen und lokalen Therapie ausreichend erscheint.

Für den Bauchwandersatz bei Riesenhernien, Mehrfachrezidiven und großen Bauchdeckendefekten sind schwergewichtige Netze in der Sublay-Position oder körpereigenes Gewebe in Form plastischer Rekonstruktionsverfahren indiziert.

Das Laparostoma, dessen Anlage im Rahmen intraabdomineller septischer Prozesse immer häufiger zur Therapie der Wahl wird, ist zu einem wesentlichen Teil für komplizierte Hernien verantwortlich. Ist die Annäherung der Bauchdecken primär unmöglich, erfolgt die Abdeckung mittels resorbierbarer Materialien oder Spalthaut unter den Auspizien einer programmierten Narbenhernie.

Abstract

As hernias and abdominal wall defects have a variety of etiologies each with its own complications and comorbidities in various constellations, efficient treatment requires patient-oriented management. There is no recommended standard treatment and the very different clinical pictures demand an individualized interdisciplinary approach.

Particularly in the case of complicated hernias, the planning of the operation should focus on the problems posed by the individual patient. Treatment mainly depends on the etiology of the hernia, immediate or long-term complications and the efficiency of individual repair techniques.

Abdominal wall repair for recurrent herniation requires direct closure of the fascia generally using the sublay technique with a lightweight mesh. It is still unclear whether persistent inflammation, mesh dislocation, fistula formation or other long-term complications are due to certain materials or to the surgical technique. With mesh infections it has been shown to be advantageous to remove a polytetrafluoroethylene (PTFE) mesh, while the combination of systemic and local treatment appears to suffice for a polypropylene or polyester mesh.

Heavier meshes in the sublay position or plastic reconstruction with autologous tissue are indicated as substitutes for the abdominal wall for giant hernias, repeated recurrences and large abdominal wall defects. A laparostoma is increasingly more often created to treat septic intra-abdominal processes but is very often responsible for a complicated hernia. If primary repair of the abdominal wall is not an option, resorbable material or split skin is used for coverage under the auspices of a planned hernia repair.

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Authors and Affiliations

  1. Klinische Abteilung für Allgemeinchirurgie, Universitätsklinik für Chirurgie, Medizinische Universität Graz, Auenbruggerplatz 29, 8036, Graz, Österreich

    H.-J. Mischinger, P. Kornprat, G. Werkgartner & A. El Shabrawi

  2. Klinische Abteilung für Plastische, Ästhetische und Rekonstruktive Chirurgie, Universitätsklinik für Chirurgie, Medizinische Universität Graz, Graz, Österreich

    S. Spendel

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  1. H.-J. Mischinger
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  2. P. Kornprat
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Mischinger, HJ., Kornprat, P., Werkgartner, G. et al. Bauchdeckenverschluss bei Narbenhernien und Herniationen nach Laparostoma. Chirurg 81, 201–210 (2010). https://doi.org/10.1007/s00104-009-1818-5

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