Efficacy evaluation of case-specific approach for
surgical treatment of incisional ventral hernia
Ocena skuteczności zindywidualizowanego podejścia do leczenia
nacięciowej przepukliny brzusznej
Svetlana Sokolova
1, Andrey Sherbatykh
1, Konstantin Tolkachev
1, Vladimir Beloborodov
2, Vadim Dulskiy
3,
Natalia Kozlova
4, Vladimir Vorobev
21Department of Faculty Surgery, Irkutsk State Medical University, Irkutsk, Russian Federation
2Department of General Surgery and Anesthesiology, Irkutsk State Medical University, Irkutsk, Russian Federation
3Department of Outpatient therapy and general practice, Irkutsk State Medical University, Irkutsk, Russian Federation
4Department of Faculty Therapy, Irkutsk State Medical University, Irkutsk, Russian Federation
Article history: Received: 28.05.2020 Accepted: 23.06.2021 Published: 25.06.2021
ABSTRACT: Aim: The aim of this research is to improve the results of surgical treatment of incisional ventral hernia by applying a case-specific approach and a new method of plastic repair of the anterior abdominal wall.
Methods: The prospective controlled dynamic study is based on incisional ventral hernia treatment results with the use of meshed endoprostheses among 219 patients. On-lay alloplasty was used in patients younger than 60 years of age, without severe concomitant pathology, with small and medium hernias and anterior abdominal wall defect of up to 10 cm (W1–W2).
Results: The article shows a selection algorithm for anterior abdominal wall plastic repair method. It goes through advantages of the author’s proprietary technique. The article displays frequency and patterns of complications, with life quality of the patients after various prosthetic plastic repairs. In the main group, positive treatment results were observed in 65.0%, long- term results of the operation were observed in 88.4%, complications occurred in 13.6%, relapse in 4.5%. «Onlay» treatment tactics showed positive results in 59.4%, long-term results of the operation were observed in 74.7%, complications occurred in 40%, relapse in 3.1%. After «sublay» intervention, excellent results were observed in 40.0% of patients, long-term results of the operation were observed in 81.9%, complications occurred in 12%, and relapse in 1.4%.
KEYWORDS: abdominal wall, endoprostheses, life quality, surgery, ventral hernia
STRESZCZENIE: Cel: Celem niniejszej pracy jest poprawa wyników leczenia chirurgicznego nacięciowej przepukliny brzusznej poprzez zastosowanie zindywidualizowanego podejścia do każdego przypadku, łącznie z nowym sposobem wykonywania plastyki przedniej ściany jamy brzusznej.
Metody: Prospektywne, kontrolowane badanie dynamiczne oparto na wynikach leczenia nacięciowej przepukliny brzusznej z wykorzystaniem endoprotez siatkowych u 219 pacjentów. Alloplastykę typu onlay stosowano u osób w wieku poniżej 60 lat, bez ciężkich chorób współistniejących, z małymi lub średnimi przepuklinami i defektem przedniej ściany jamy brzusznej o wymiarach do 10 cm (W1–W2).
Wyniki: W artykule przedstawiono algorytm wyboru sposobu wykonania plastyki przedniej ściany jamy brzusznej. Omówiono również zalety autorskiej techniki naprawczej i zaprezentowano dane na temat częstości i charakteru powikłań oraz jakości życia pacjentów po różnych zabiegach plastyki z użyciem protez siatkowych. W grupie głównej korzystne wyniki leczenia obserwowano w 65,0% przypadków, długoterminowe korzyści pooperacyjne w 88,4% przypadków, powikłania w 13,6% przypadków, zaś nawroty przepukliny w 4,5% przypadków. Taktyka leczenia sposobem onlay prowadziła do korzystnych wyników leczenia w 59,4%
przypadków, długoterminowych korzyści pooperacyjnych w 74,7% przypadków, powikłań w 40% przypadków, zaś nawrotów w 3,1% przypadków. Po interwencji sublay korzystne wyniki leczenia obserwowano w 40,0% przypadków, długoterminowe korzyści pooperacyjne w 81,9% przypadków, powikłania w 12% przypadków, zaś nawroty w 1,4%.
SŁOWA KLUCZOWE: chirurgia, endoprotezy, jakość życia, przepuklina brzuszna, ściana jamy brzusznej
ABBREVIATIONS
CCG I – clinical comparison MG – main group
PPM – polypropylene mesh VH – ventral hernia
INTRODUCTION
The incisional ventral hernia (VH) treatment currently continues to be a quite complex and, unfortunately, not completely solved surgical problem. On the one hand, this follows from an increas- ing number of abdominal operations, and as a result, an increasing number of VHs. On the other hand, this is due to a high number
(according to different authors) of incisional ventral hernias de- veloping in 2–20% cases after all laparotomies, complications and abdominal hernias recurrences after operations [1, 2]. Most of- ten (26–50%) VH develops after gynecological operations, while 20–30% after biliary tract interventions [1, 2]. The analysis showed that the first 3 years after laparotomy are the high-risk period for hernia development (92–97%) [3]. The frequency of recurrent her- nias after anterior abdominal wall plastic repair can reach 50% [4–6].
The application of synthetic prostheses in herniology has reduced the frequency of relapses to 6–10% [7–9], while most authors pre- fer combined prosthetic methods of anterior abdominal wall plas- tic repair, considering them the best option for surgical treatment of VH [7–9]. At the same time, the widespread use of prosthetic methods led to an increase in the number of wound complications and a decrease in the quality of life in 30–40% of operated patients [3]. In general, the wound complications’ frequency after anterior abdominal wall surgery for VH ranges from 20.9 to 67% [12–14].
The structure of wound complications includes: suppuration, di- vergence of wound edges, seroma, inflammatory infiltrate, long- term lymphorrhea, ligature fistulas, and necrosis of wound edges [14–17]. The “new” complications caused exclusively by the use of synthetic mesh prostheses are: prosthesis migration into the lu- men of the hollow organ; formation of intestinal fistula caused by trauma to the intestinal wall; formation of prosthetic cysts; adhe- sive intestinal obstruction in case of the intestine adhering to the prosthesis; mesh rupture with formation of recurrent hernia or infringement of the hollow organs [14, 18, 19]. However, the data on complications is contradictory.
The choice of the surgery method for VH, especially for recurrent hernias, also presents certain difficulties. The traditional “sublay”
method is quite complex, long-term, and traumatic (damage of a.a.
epigastric superior et inferior with atrophy and rectus muscles’ scar- ring, hematomas and fluid formation, prolonged pain syndrome after surgery) and difficult to perform, with a pronounced scar- adhesive process of the anterior abdominal wall tissues.
Dissatisfaction with the results of well-known anterior abdomi- nal wall plastic surgery methods makes surgeons look for ways to improve them, not only by developing and implementing new methods but also by a differentiated approach to the choice of the plastic surgery method. At the same time, the VH surgical treat- ment should be minimally invasive and not only provide recon- struction of the anterior abdominal wall with maximum recovery of its function, but also reduce the rate of wound complication and hernia recurrences, maintaining a high level of the quality of life of the operated patients [20–22].
The research aims to analyze the effectiveness of the differentiated approach in the surgical treatment of VH based on the study of immediate and long-term results of various anterior abdominal wall plastic methods.
MATERIALS AND METHODS
Patients
The study presents the surgical treatment results of 219 patients who underwent prosthetic operations with polypropylene mesh (PPM)
for incisional median ventral hernias in the Surgical Department of Irkutsk State Medical University Hospital from 2010 to 2014.
Depending on the synthetic prosthesis location in relation to the aponeurosis, there were three groups of patients distinguished.
The main group (MG) included 52 patients (23.7 ± 2.6%) who un- derwent anterior abdominal wall plastic surgery with the method developed by the author, the first group of clinical comparison (CCG I) included 95 patients (43.4 ± 3.8%) operated on with the
“onlay” method, the second CCG II included 72 patients (32.9
± 3.5%) operated on with the “sublay” method. All surgical inter- ventions were performed with a mesh polypropylene endopros- thesis “Lintex-Esfil” (Saint Petersburg). The groups did not differ significantly regarding gender, age, concomitant pathology nature, size, hernia location or disease duration (P > 0.05). The distribu- tion of patients by gender in all groups revealed a predominance of women. The mean age of patients in MG, CCG I and II was 54.0
± 6.1, 59.0 ± 9.3 and 56.0 ± 10.2 years, respectively. According to the J.P. Chevrel and A.M. Rath classification (SWR-classification, 1999) [23] in all groups, patients with hernia gate size of 5–10 cm (W2) (155 [70.7 ± 3.7%] cases) and 10–15 cm (57 [26.0 ± 3.0%]
cases) predominated.
The treatment technique
In the preoperative period, patients with VH underwent a com- prehensive examination, including clinical, laboratory and instru- mental methods. All patients underwent preoperative antibiotic prophylaxis, prevention of thromboembolic complicationswhich continued after the operation, along with adequate pain relief ther- apy and concomitant pathology correction. All surgical interven- tions included intubation (endotracheal) anesthesia.
Since 2010, the surgical department of Irkutsk State Medical Uni- versity Hospital has been using an original method of anterior ab- dominal wall plastic surgery. The operation technique is as follows:
after excision of the old postoperative scar and mobilization of the aponeurosis from the subcutaneous tissue at a distance of 4 cm from the hernia gate edge, we carefully select and open the hernia sac, trying to preserve its flap as much as possible. Next, the her- nia gate edges are sewn together with separate nodal seams under the flap of the hernia sac. We cover the seam line with a mesh im- plant, fixing it along the perimeter to the aponeurosis of the ante- rior abdominal wall muscles with a continuous seam. The size of the implant should be big enough to keep its outer edges at least 4 cm away from the aponeurosis suture line. From the flap side in the mesh prosthesis at a distance of 2 cm from the aponeurosis suture, we make a longitudinal incision, the so-called “window”
to output the hernia sac flap. Along the incision line, we fix the hernia sac to the mesh with separate U-shaped seams to eliminate the “window”. We sew the peritoneum flap on one side along the seam line of the nearest edge of the mesh with additional nodal seams and we cover the entire mesh implant with the free part of the flap, fixing it with separate nodal seams along the perimeter and throughout the entire area of the endoprosthesis. Thus, the implant is located between the hernia sac and the aponeurosis.
To prevent peritoneal fluid exudation and its accumulation in the subcutaneous tissue, we perform peritoneal mesothelium desqua- mation with a gauze and hernia sac peritoneodesis. It was proved that the peritoneum, devoid of mesothelial cover, loses its abil- ity to produce fluid. Peritoneodesis of the hernia sac, due to the
and sub-umbilical observation areas (M3) (16 [30.8 ± 9.9%] and 25 [34.7 ± 6.7%]), respectively. Recurrent hernias (R 1–2) were observed in 41 (18.7 ± 3.0%) of all operated patients. The highest number of patients in all groups had a 1- to 3-year history of the disease– 106 (48.4 ± 3.8%) patients. The leading position in the group of concomitant diseases held the cardiovascular system pa- thology: hypertension – 161 (73.5 ± 3.4%), and coronary heart dis- ease – 67 (30.6 ± 3.5%) patients. As many as 96 patients had II–III degree obesity (43.8 ± 3.8%), while 25 (11.4 ± 2.4%) had diabetes.
When choosing the method of anterior abdominal wall plastic sur- gery, we use a differentiated approach, considering, in each case, the age of the patient, the presence of concomitant pathology, the size of the hernia and the duration of its existence.
For patients younger than 60 years, without severe concomitant pathology, with small and medium hernias and an anterior ab- dominal wall defect of up to 10 cm (W1–W2) we chose the “on- lay” phalloplasty.
Patients with small and medium-sized hernias (W1–W2) of elderly and senile age (older than 60 years) and/or concomitant diseases, increasing the risk of complications and relapse, as well as large and giant hernias from 10 to 20 cm (W3–W4) underwent “sublay”
method or the author's method.
If the size of the hernia gate is more than 20 cm (W4) with expressed tension of the anterior abdominal wall tissues, it is necessary to use non-tensioned “inlay” phalloplasty to prevent the development of intraabdominal hypertension syndrome.
In case of inability to differentiate anatomically scar-modified tis- sues of the anterior abdominal wall, phalloplasty in the proposed modification is the operation of choice. It is also justified for pa- tients with the most favorable conditions to use a hernia sac: i.e.
in patients under 60 years old with an average size of hernia (W2), present for up to 3 years [25].
Clinical studies have shown that the duration of postoperative wound drainage, the nature and frequency of wound complica- tions, and the quality of life after surgery depend on the method of anterior abdominal wall plastic surgery, namely, the location of the implant. Thus, the duration of subcutaneous tissue drain- age in MG (4.09 ± 0.79 days) and CCG II (3.72 ± 1.26 days) was significantly shorter in comparison with CCG I (4.8 ± 1.64 days) (P 0.05). At the same time, from the 3rd postoperative day, MG patients had a significant decrease in the discharge liquid rate to 20 (16.5–30) mL/day and to 10 (6.25–13.75) mL/day – by the 5th day after the operation. In comparison with the “onlay” group (CCG I) – 30 (20–40) ml/day (P < 0.05) and 20 (15–30) ml/day (P < 0.01), respectively. After 3 days, MG and CCG II became com- parable in the discharge liquid rate (P > 0.05).
The use of anterior abdominal wall plastic methods with the iso- lation of the endoprosthesis from subcutaneous tissue allowed for reducing the number of wound complications in the early postoperative period. Thus, in the MG group, 3 patients suffered from wound complications (13.6%), while in CCG II – 6 (12%), which is significantly less than in CCG I – 38 (40.0%) (χ2 = 4.6583, P < 0.05; χ2 = 10.1484, P < 0.01; P 0.01). The most common compli- cation was fluid accumulation in the subcutaneous tissue, caused tight fit of the deepithelized peritoneum to the implant surface,
prevents the “dead spaces” formation and exudate accumulation in the wound [24]. The operation ends with layer-by-layer sutur- ing of the wound, with drainage of subcutaneous tissue by Redon.
In the postoperative period, starting from the second day, we in- troduce early activation of patients; they begin to wear an elastic bandage, which is recommended even after discharge from hos- pital. We remove Redon drains when the amount of liquid is 10.0 mL/day. To monitor the course of the wound healing process, we use the ultrasound examination on day 5–7 of the postoperative period. In the absence of active complaints and wound complica- tions, and with normal laboratory control parameters, patients are discharged home under the supervision of a doctor.
Methods of evaluation for immediate and long-term results
of anterior abdominal wall plastic prosthetics
The effectiveness of the applied methods included the analysis of immediate and long-term results of anterior abdominal wall plastic prosthetics. In the early postoperative period, it was the postoperative wound drainage duration and the number and na- ture of wound complications. In the long-term period, it was the quality of life and the number of disease relapses in the period from 6 months to 3 years after surgery. A questionnaire based on the MOS SF-36 questionnaire (Russian version developed and recommended by the International Center for Quality of Life Re- search, Saint Petersburg) helped to evaluate the quality of life.
Each point ranges from 1 to 5 and allows to assess the patient's physical abilities and identify a recurrence of the hernia. In our study, physical well-being was the main indicator of the quality of life. The following criteria were used to evaluate it: health status before and after surgery; limited or complete exercise at home and recovery of professional activity; discomfort and pain after surgery; violation of bowel functions (constipation) and breath- ing (shortness of breath) associated with the operation; wearing a bandage; recurrent hernia. The higher the score, the higher the patient's quality of life. According to the results of the examina- tion and survey, the quality of life was assessed as excellent (more than 43 points), good (34–43 points), satisfactory (24–33 points) or unsatisfactory – in case of a recurrent hernia or the sum of points from 13 to 23.
Statistics
The Student's t-test and the Mann-Whitney (U) test helped to evaluate the significance of the difference in quantitative charac- teristics. For qualitative indicators, we used the Chi-square crite- rion (χ2) and two-sided Fischer's method (φ) for four-field tables.
The differences were considered significant at P < 0.05. Statisti- cal processing of the obtained data was performed on a person- al computer using the Statistica 6.0 (StatSoft, USA) and the MS Excel 2010 application software.
RESULTS
For CCG I, the hernia defect was more often localized in the su- prapubic (M1) – 25 (26.3 ± 4.5%) and peripheral (M2) observa- tion areas – 42 (44.2 ± 5.1%), while for the MG and CCG II group in the peripheral (M2) (21 [40.4 ± 10.5%] and 27 [37.7 ± 6.8%]),
professional work, observed in 38 cases (40%) of CCG I. It was significantly higher in comparison to other groups (RF < 0.05).
DISCUSSION
The authors’ method of VH surgical treatment has shown good results in comparison to two other generally accepted approaches, i.e. “onlay” and “sublay” plastic surgery. In [1, 5], the authors point out that the surgical intervention is performed by separating the components by posterior opening or using an endoscopic approach, which shows good results and eliminates the risk of relapses and blood loss, but this tactic involves massive surgical intervention and has contraindications for some categories of patients, for ex- ample, the elderly. The retro rectus method with polypropylene mesh, proposed in [5, 18, 19] for restoring the midline of the an- terior abdominal wall with VH, according to the results presented by the authors, is safe and characterized by minimal complications and relapses for medium-sized hernias (6–13%). For the recovery of large-sized hernias, the method is recognized as the procedure of choice. In large hernias, there is a possibility of using the pa- tient's tissues with tensor fascia lata and vastus lateralis to close the abdominal wall [17]. The quality of the patient's life after sur- gery and the risk of complications and relapses are also affected by the quality of the mesh material, but the presented reviews do not indicate the brands of materials and their impact on the final result [17]. The quality of the mesh and its composition directly affect the interaction of the mesh with the tissue, the encapsula- tion of the mesh, as well as the risk of infection, which was 1% in our studies. We used sutures for fixing tissues with mesh, but the results of using special fixing devices during the operation were presented as well. For example, [2] indicates postoperative pain syndrome and the need to use painkillers up to 12 weeks after surgery, since the fixing nails are made of polydioxanone, hydro- lysis of which is completed within 12–18 months after implanta- tion. Special materials used for fixing meshes, for example Pro- GripTM according to the authors of [11] showed a satisfactory (average) fixing strength of 1.3 N/cm (± STE 0.2). The strength of mesh fixation with the TisseelTM solution was 2.6 N/cm (± STE 0.5). According to the authors, [7, 11] LifeMeshTM adhesive had an average fixing strength of 8.0 N/cm (± STE 2.1). Undoubtedly, the immediate strength of fixing the mesh with adhesive solutions significantly increases the effectiveness of the surgical interven- tion, but it has remote negative consequences and can cause early relapse and mesh reduction. However, this fixing method is one of the non-traumatic methods and demonstrates clear advantages of LifeMeshTM technology [6, 7, 11]. The authors’ method tested on the main group had clear advantages over the method presented in [11], since it excluded mesh reduction and subsequent complica- tions. The research results also showed the possibility of preventing exudate accumulation in the subcutaneous tissue. Desquamation of the mesothelium and peritonitis hernia sac also prevents fluid formation and accumulation in the wound. Our research corre- lates with the results presented in [24].
In the study [3], which included 64 patients aged from 25 to 98 years who underwent abdominal surgery, the risk of complica- tions ranged from 31.2% to 40.6% (26/64), while hernia recur- rence and mortality were at 7.8%. In our research, there were no patient deaths in the three groups, and the complication rate did not exceed 40%. The developed method of VH surgical treatment by the contact of subcutaneous tissue with the endoprosthesis,
and the development of ischemia of the skin and deep layers of subcutaneous tissue after their wide mobilization and in the ab- sence of dense contact with aponeurosis. Therefore, postoperative wound seromas were more common after “onlay” plastic surgery in CCG I (32 [33.7%] cases) than in MG (2 [9.1%] cases) (χ2 = 4.1163, P = 0.04; P 0.01) and CCG II (4 [8%] cases) (χ2 = 10.1484, P < 0.01;
P 0.01). We considered all liquid formations detected during post- operative wound ultrasound in the subcutaneous tissue. There were no significant differences in the frequency of other compli- cations (P > 0.05).
To monitor the course of the wound healing process, all patients in the early postoperative period on the 5th–7th day underwent an ultrasound examination of the postoperative wound. Patients with a large volume of liquid and clinical manifestations thereof underwent dotted exudate under ultrasound control. The num- ber of punctures depended on the dynamics of the process and was 1–3 punctures on average. The amount of extravasate less than 10.0 mL, the disappearance or reduction of the size of the liquid formation were the criteria for completion of punctures.
In CCG I, the number of patients who required a puncture reached four (4.2%), in CCG II – 2 (4.0%). In MG, 1 (4.5%) patient needed punctual management of fluid formation. In all cases, there was a positive result. One patient In CCG I (1.05%) as well as one pa- tient in CCG II (2%) had spontaneous opening of seroma dehis- cence. Subcutaneous tissue hematoma developed in two (2.1%) cases among CCG I patients, in one case (2%) in CCG II, and one (4.5%) case among MG patients. The cause of hematomas was in- adequate hemostasis during surgery.
After “onlay” plastic surgery, postoperative wound suppuration occurred in one case (1.05%) in CCG I, wound infiltration in one case (1.05%), and ligature fistula of the anterior abdominal wall in one case (1.05%). The fistula needed excision with removal of an anterior abdominal wall section.
We studied the results of the long-term operation, including qual- ity of life assessment and detection of hernia recurrence, for 176 patients: in CCG I – 71 (74.7%), in CCG II – 59 (81.9%) and in MG – 46 (88.4%) patients.
In the CCG I group after “onlay” plastic surgery, relapse occurred in three (3.1%) cases. Two of them refused to be re-operated. The third patient underwent the operation in another medical facility a few months after the initial operation. The reason for the relapse was the inadequate size of the mesh implant and insufficient fixa- tion of the upper edge of the mesh. In CCG II, relapse occurred in one case (1.4%), as in MG (4.5%). There were no significant differ- ences in the frequency of the relapses between the groups (P > 0.05).
The Quality of Life survey showed excellent results being more common in MG (65.0%) and CCG II (59.4%) than in CCG I (40.0%) (RF < 0.01). The average score in the quality of life assessment in MG and CCG II was 44.7 ± 7.6 (79.8%) and 45.4 ± 6.8 (80.9%), respectively, which was higher than in CCG I and was evaluat- ed as an excellent indicator of the quality of life (P < 0.01). At the same time, in CCG I, the average score according to the results of the survey was 40.6 ± 6.3 (72.4%) points, which corresponded to a good level of the quality of life. The main factors that harmed the quality of life were the restriction and reduction of the daily and
diagnosis was very cost-effective compared to other interventions commonly used in healthcare in other countries. The average cost of the operation in the US was USD 27,700$ to 50,000. Patients with a high risk of perioperative mortality, complications, and re- lapses need conservative monitoring [9, 12]. Due to economic is- sues, patients who experience no reduction in the quality of life caused by ventral hernia also need monitoring [12, 15]. Besides, the issue of performing open or laparoscopic operations to elim- inate ventral hernias is based on the optimal ratio of the cost of surgery and the quality of life [12, 23, 24].
CONCLUSION
The application of a differentiated approach to the choice of the anterior abdominal wall plastic surgery method and the use of the authors’ method of plastic surgery allowed us to improve treat- ment results. The wound complications’ frequency decreased to 13.6%, while the incidence of fluid accumulation in the subcutane- ous tissue – to 9.1%, and the quality of life after surgery increased to 7.4%. Excellent quality of life was found in 65.0% of patients of the main group, 59.4% of CCG I and 40,0% of CCG II. Long-term results of the operation were observed in 88.4% of the MG group, 74.7% of CCG I, and 81.9% of CCG II. The relapse rate was 4.5%
for the main group, 3.1% for the first clinical comparison group, and 1.4% for the second group.
caused complications in 13.6% of cases, while the “sublay” method applied in the second clinical comparison group caused compli- cations in 12% of cases. Intraoperative fluorescent angiography with indocyanine green can help to prevent relapses and com- plications during ventral hernia surgery [15]. One of the factors that cause relapses, complications, and ventral hernias is obesity.
The authors of the studies [1, 6–8] presented the treatment re- sults of patients with obesity, which is not only a risk factor for complications during abdominal surgery. The research focused in particular on the complications in the treatment of ventral abdominal wall hernias, postoperative hernias, and complica- tions after ventral hernia repair. Obesity also increases the risk of hernia injury and relapse after treatment. The authors believe that the laparoscopic approach to VH treatment minimizes the risk of complications caused by obesity during abdominal wall surgery. The study [9] demonstrates analogous results in patients with grade III obesity compared to patients with a BMI of ≤ 39.9 kg/m2. It should be noted that the bulk of patients with compli- cations and relapses (74.5%) who took part in our research were patients with some degree of obesity.
As regards predicted clinical and economic results of the VH treat- ment throughout life, the developed method is not only compa- rable in terms of the quality and reproducibility of results to other studies but also has some advantages. In a typical group of pa- tients with ventral hernia, laparoscopic recovery [9] at the time of
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Word count: 4047 Page count: 6 Table: – Figures: – References: 25 10.5604/01.3001.0014.9756 Table of content: https://ppch.pl/issue/13885
Some right reserved: Fundacja Polski Przegląd Chirurgiczny. Published by Index Copernicus Sp. z o. o.
The authors declare that they have no competing interests.
The content of the journal „Polish Journal of Surgery” is circulated on the basis of the Open Access which means free and limitless access to scientific data.
This material is available under the Creative Commons – Attribution-NonCommercial 4.0 International (CC BY-NC 4.0).
The full terms of this license are available on: https://creativecommons.org/licenses/by-nc/4.0/legalcode Dr Svetlana Sokolova; Department of Faculty Surgery, Irkutsk State Medical University, Irkutsk, Russian Federation;
Phone: +7 9086608770; E-mail: sokolova.svetlana05@rambler.ru
Sokolova S., Sherbatykh A., Tolkachev K., Beloborodov V., Dulskiy V., Kozlova N., Vorobev V.: Efficacy evaluation of case-specific approach for surgical treatment of incisional ventral hernia; Pol Przegl Chir 2021; 93(5): 1-6
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