EFFECT OF CONNECTIVE INSUFFICIENCY AND SIZES OF MEDIAN HERNIAS ON BEFORE AND POSTOPERATIVE FUNCTION OF THE ABDOMINAL MUSCLE

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Abstract


The article analyzes the results of electromyography of the abdominal muscles in 189 patients with median postoperative hernia of the anterior abdominal wall of different sizes before and after the combined methods of hernioplasty, including considering the level of connective tissue failure. In the preoperative period, electromyography was performed in 69 (36,6%), after combined hernioplasty, 120 (63,4%) patients. The patients were divided into a group of 161 (85,1%) patients with clinically significant or histologically confirmed connective tissue insufficiency and into a group of 28 (14,9%) patients without it. The distribution of patients in the examination groups was carried out using an original method of assessing the degree of deviation of collagen fibers from the projection of the Langer lines in microscopic specimens of the skin areas excised during the operation and based on the results of a retrospective analysis of case histories with determination of the intraoperative adhesions of the adhesions in the abdominal cavity or hernial sac. In the formed groups, we studied the amplitude, frequency, front and area of electromyograms obtained from the direct and lateral muscles of the anterior abdominal wall. It was found that in patients with median postoperative hernias, mesenchymal dysplasia was the main reason for the decrease in functional activity and the imbalance of forces between the direct and lateral abdominal muscles. Optimal restoration of electroactivity of the abdominal muscles after combined hernioplasty occurred among patients without clinically significant connective tissue insufficiency. When reaching a giant postoperative hernia of gigantic size in patients with a clinically significant level of connective tissue dysplasia, the functioning of the abdominal muscles decreased by 26%, and in patients without it only by 15%. The pathology of collagen in skin grafts excised during surgery was detected in 91,5% of patients with mid-incisional hernias.


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Introduction. There is no doubt that connective tissue insufficiency is involved in the recurrence of the disease after hernioplasty of median postoperative hernias [1-5]. The mechanisms of influence of genetically determined collagenopathy on the number of unsatisfactory results of surgical treatment of hernial defects are still being discussed [6-8]. One of the most important aspects of postoperative herniogenesis in the midline of the abdomen is the “weakness” of the muscular aponeurotic framework of the anterior abdominal wall, which is manifested in the violation of contractile ability and in the reduction of the adaptive abilities of the abdominal muscles in relation to intra-abdominal pressure and leading to tissue overstretching and eruption of the hernia repair [9-14]. Purpose of the study. Electromyography compares the function of the abdominal muscles of patients with mid-postoperative hernias of different sizes before and after surgery, considering the level of connective tissue failure. Materials and methods. During the period from 2014 to 2018 on the basis of department of surgical diseases of medical faculty of PGU T.G. Shevchenko Public Educational Institution, Tiraspol 189 patients with median postoperative hernias are examined. Men made of them 63 (33,4%), women - 126 (66,6%) the person. The research is approved by the commission on questions of ethics of medical faculty of the of T.G. Shevchenko. Average age of surveyed - 61,5 ± 0,64 years. In the preoperative period the electromyography is executed 69 (36,6%), after the combined hernioplasty - 120 (63,4%) to patients. At survey before operation all greenseal at different quantity had external symptoms of a connective tissue dysplasia [15]. They were divided into group of 161 (85,1%) the patient with clinically significant or histologically confirmed and into group of 28 (14,9%) patients without clinically significant or histologically the confirmed level of connective tissue insufficiency. Among 35 (18,5%) greenseal to whom during operation the fence of sites of skin in the longitudinal direction concerning lines of a tension was carried out the expressiveness of connective tissue insufficiency was estimated on degree of a deviation of collagenic fibers in microdrugs from a projection of lines of Langer. Distribution of the others 154 (81.5%) patients with median postoperative hernias in groups of examination was conducted by results of the retrospective analysis of stories of diseases with definition of existence during operation of the expressed commissural process in an abdominal cavity. In the created groups the analysis to and a postoperative electromyography of belly muscles is made. The Statistica 10 program calculated value arithmetic averages with an error of average size of such electrophysiologic parameters as amplitude, the frequency, the front and the area of the summatsionny electromyograms recorded over direct and side muscles of a stomach on both sides. At all patients the informed consent to processing of personal data and participation in a research according to the Helsinki declaration of the World Medical Association was received (2013). RESULTS Variance analysis of collagenic fibers in skin microdrugs concerning lines of a tension of Langer allowed three (8,5%) patients who have a collagen relation with a direction corner to Langer’s lines in the range of 0-20° to number of collagenic fibers with more considerable angle of orientation to lines of a tension of skin (21-40°, 41-60° and above) corresponded 3:1, to carry in group without histologically the confirmed level of a connective tissue dysplasia (Fig. 1). At the others 32 (91,5%) patients with median postoperative hernias in microdrugs of the skin excised during operation the ratio of collagen changed aside or reduction of number of fibers with a direction corner to reference points of lines of Langer in the range of 0-20°, or increases in number of fibrous structures with other angles of orientation to lines of a tension that allowed to carry them in group of patients with histologically the confirmed level of a connective tissue dysplasia (Fig. 2). Fig. 1. The structure of the collagen matrix in the skin of a patient with a median postoperative hernia from the group without a histologically confirmed level of connective tissue dysplasia: a - the decolored skin specimen with multidirectional collagen fibers of relatively longitudinally oriented Langer lines (´400); b - surface diagram of the interposition of collagen fibers with different direction angle relative to the Langer tension lines Fig. 2. The structure of the collagen matrix in the skin of a patient with a median postoperative hernia from the group with a histologically confirmed level of connective tissue dysplasia: a - the decolored skin specimen with multidirectional collagen fibers of relatively longitudinally oriented Langer lines (´400); b - surface diagram of the interposition of collagen fibers with different direction angle relative to the Langer tension lines Thus, practically at all patients with median postoperative hernias disturbance of structure of a collagenic matrix in microdrugs in the form of change of normal orientation of collagen is revealed that confirmed value of a factor of a connective tissue dysplasia in the micropathological organization of an abdominal wall around median postoperative hernial defect. For entering of risk factor of connective tissue insufficiency into assessment of results of an electromyography of belly muscles at 154 (81,5%) patients with median postoperative hernias the analysis of electrophysiologic parameters of muscles of a stomach according to retrospective studying of protocols of operations in case histories is made. In 129 (83,7%) clinical cases at a herniolaparotomy the expressed commissural process in an abdominal cavity which brought was found that allowed to carry these patients in group with clinically significant level of a connective tissue dysplasia. This approach is based on the idea of a pathogeny of an adhesive disease existing now, as about one of manifestations of ischemia of intra belly bodies in the postoperative period arising against the background of anomaly of a vascular bed of dysplastic genesis [16-19]. At 25 (16,3%) patients of commissure in a stomach were slightly expressed or in general were absent therefore they were carried in group without clinically significant level of a connective tissue dysplasia. Among 58 (84%) patients with median postoperative hernias and clinically significant or histologically the connecting fabric confirmed with a dysplasia at which the electromyography is carried out before operation indicators of electromyograms of muscles of a stomach had the following value (tab. 1). Reduction of side muscles led to generation of electromyograms with an amplitude at 12% below that at direct muscles of a stomach. The front of side muscles appeared above the similar parameter of direct muscles by 1,7 times. Thus, function of direct muscles in group with clinically significant or histologically the confirmed connective tissue failure slightly exceeded side stomach muscles. And at 48 (82.7%) patients with hernias of averages and the big sizes amplitude of electromyograms of direct muscles practically did not differ from each other, and only at achievement hernia of the huge sizes noted it to decrease by 26%. Amplitude of direct muscles at 11 (16%) patients with median postoperative hernias without clinically significant or histologically the confirmed connective tissue failure at which the electromyography is carried out before operation exceeded amplitude of preoperative electromyograms of the same muscles at patients from clinically significant or histologically the confirmed dysplasia for 18,2% (tab. 2). Frequency, the front and the area of electromyograms of direct muscles in the same group of patients exceeded indicators of direct muscles of patients before operation from clinically significant or histologically the confirmed connective tissue failure in 1,6; 1,75 and 1,5 times respectively. Amplitude of presurgical electromyograms of direct muscles of patients with median postoperative hernias without clinically significant or histologically the confirmed connective tissue failure was above this parameter of group of side muscles of a stomach for 29.2%. Decrease in amplitude of electromyograms of direct muscles at 3 (27.3%) the patients with huge median postoperative hernias who do not have clinically significant or histologically the confirmed level of connective tissue failure reached 15% (Fig. 3). Table 1 Parameters of the abdominal muscles in patients with median postoperative hernias before surgery with clinically significant or histologically confirmed levels of connective tissue dysplasia Parameter MPHAS MPHBS MPHGS RM LM RM LM RM LM А (МкВ) 549,7 ± 12,4 482,9 ± 14,5 553,1 ± 16,8 476,9 ± 32,4 401,9 ± 66,7 398,7 ± 75,4 F (oscillations/second) 70,4 ± 2,1 63,2 ± 7,3 69,9 ± 10,8 62,5 ± 3,6 51,8 ± 4,3 60,1 ± 26,1 Fr (мс) 342,5 ± 16,7 580,6 ± 47,3 380,1 ± 35,7 577,2 ± 19,9 253,7 ± 15,8 306,4 ± 17,6 Ar (мВ*мс) 148,3 ± 2,4 109,6 ± 15,2 147,3 ± 5,2 103,1 ± 5,7 109,6 ± 19 105,8 ± 7,4 Note: A - amplitude; F - frequency; Fr - front; Ar - area electromyograms; MPHAS - median postoperative hernias of the average sizes; MPHBS - median postoperative hernias of the big sizes; MPHGS - median postoperative hernias of the giant sizes; RM - rectus muscles; LM - lateral muscles. Table 2 Parameters of the abdominal muscles in patients with median postoperative hernias before surgery without clinically significant or histologically confirmed levels of connective tissue dysplasia Parameter MPHAS MPHBS MPHGS RM LM RM LM RM LM A (МкВ) 673,4 ± 45,2 476,8 ± 28,3 674,1 ± 35,3 408,2 ± 14,5 573,2 ± 64,8 478,3 ± 22,9 F (oscillations/second) 112,6 ± 14,2 48,3 ± 6,8 100,3 ± 8,7 56,1 ± 1,1 93,7 ± 4,2 58,4 ± 1,5 Fr (мс) 599,3 ± 37,9 274,5 ± 17,3 600,2 ± 53,4 275,7 ± 20,8 509,5 ± 54,9 199,9 ± 18,5 Ar (мВ*мс) 222,4 ± 19,6 116,8 ± 3,2 198,8 ± 17,9 130 ± 9,9 189,1 ± 16,8 170 ± 8,8 Note: A - amplitude; F - frequency; Fr - front; Ar - area electromyograms; MPHAS - median postoperative hernias of the average sizes; MPHBS - median postoperative hernias of the big sizes; MPHGS - median postoperative hernias of the giant sizes; RM - rectus muscles; LM - lateral muscles Fig. 3. Electromyograms of the abdominal muscles of patients with median postoperative hernias before surgery with clinically significant and without clinically significant levels of connective dysplasia: RM - rectus muscles; LM - lateral muscles; A - amplitude; F - frequency; With CSCD - with clinically significant connective dysplasia; Without CSCD - without clinically significant connective dysplasia Table 3 Parameters of abdominal muscles in patients with median postoperative hernias after surgery with clinically significant and without clinically significant levels of connective tissue dysplasia Parameter WithCSCD WithoutCSCD RM LM RM LM A (МкВ) 667,02 ± 19,4 597,08 ± 22,1 847,44 ± 32,29 647,67 ± 37,7 F (oscillations/second) 88 ± 4,3 64,02 ± 5,6 62,04 ± 4,6 41,64 ± 4,4 Fr (мс) 415,6 ± 52,7 399,3 ± 20,9 472,91 ± 66,12 410,84 ± 53,34 Ar (мВ*мс) 178,73 ± 3,6 125,1 ± 10,7 341,34 ± 19,09 253,88 ± 26,1 Note: A - amplitude; F - frequency; Fr - front; Ar - area electromyograms; WithCSCD - with clinically significant connective dysplasia; WithoutCSCD - without clinically significant connective dysplasia In the postoperative period had clinically significant level of connective tissue insufficiency 103 (85,8%) the patient which had median hernial defects it is liquidated by the ways of a hernioplasty combining an autoplastic with autodermoplasty [20]. Among them the electric activity of direct muscles of a stomach appeared below the corresponding parameters of direct muscles at patients with median postoperative hernias before operation without clinically significant and histologically the confirmed level of a connective tissue dysplasia as much as possible on the front and the square at 30,8% and 20,4% respectively (tab. 3). Amplitude and the area of electromyograms of side muscles of a stomach among the operated patients with clinically significant connective tissue Fig. 4. Electromyograms of abdominal muscles of patients with median postoperative hernia after autoplasty in combination with autodermoplasty with a clinically significant and without a clinically significant level of connective dysplasia: RM - rectus muscles; LM - lateral muscles; A - amplitude; F - frequency; With CSCD - with clinically significant connective dysplasia; Without CSCD - without clinically significant connective dysplasia insufficiency appeared for 20,2% and 26,5% above similar indicators of side muscles at patients with postoperative median hernias before operation without clinically significant or histologically the confirmed level of a connective tissue dysplasia. The difference in electric activity between direct and side muscles among the operated patients with clinically significant level of a connective tissue dysplasia reached on amplitude of 10,5%, on frequency - 27,3%, on the front - 4%, on the area - 30,1%. Thus, the ratio of forces in an anterior abdominal wall in this group of patients after a hernioplasty practically did not change and corresponded to that at the patients with hernias before operation having clinically significant or histologically the confirmed dysplasia level. Amplitude of direct and side muscles of a stomach at 17 (14,2%) operated concerning median postoperative hernias without clinically significant connective tissue insufficiency was more considerable than amplitude as among the others 103 (85,8%) patients after an autoplasty in combination with autodermoplastiky for 21,3%, and among patients with hernias before operation without clinically significant or histologically confirmed with the level of dysplasia at 20,5%. Difference in amplitude of direct muscles among patients after operation without clinically significant level of a dysplasia and patients to surgical intervention with clinically significant or histologically the proved dysplasia made 34,8% (Fig. 4). The ratio of multidirectional forces in an anterior abdominal wall at the patients who transferred a hernioplasty and not having clinically significant level of a connective tissue dysplasia was displaced to a prevalence of function of direct muscles over group of side muscles for 23,6%. CONCLUSIONS 1. At patients with median postoperative hernias connective tissue insufficiency was a basic reason of reduction of functional activity and disturbance of balance of forces between direct and side muscles of an anterior abdominal wall. 2. At achievement by median postoperative hernia of the huge sizes at patients with clinically significant level of a connective tissue dysplasia functioning of belly muscles decreased by 26%, and at patients without it - only for 15%. 3. Optimum restoration of electroactivity of belly muscles after the combined hernioplasty occurred among patients without clinically significant or histologically the confirmed level of connective tissue insufficiency. 4. Pathology of a collagenic matrix in connecting fabric the skin rags excised during operation from an anterior abdominal wall is authentically revealed among 91,5% of patients with median postoperative hernial defects.

About the authors

R. I. Railianu

Shevchenko State University of Pridnestrovie

Author for correspondence.
Email: railianu.radu@yandex.com
SPIN-code: 2736-4592
Moldova, Tiraspol

G. I. Podoliniy

Shevchenko State University of Pridnestrovie

Email: railianu.radu@yandex.com
Moldova, Tiraspol

A. V. Marshaluk

Shevchenko State University of Pridnestrovie

Email: railianu.radu@yandex.com
Moldova, Tiraspol

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