RU2135094C1 - Method of treatment of inguinal hernias - Google Patents

Abstract

FIELD: medicine, particularly, surgery; methods of plasty of inguinal canal in cases of oblique, direct and congenital hernias. SUBSTANCE: used as plastic material for closing of hernia fissures in autoplast from aponeurosis of musculus obliquus externus abdominis by cutting out U-shaped pedicle graft with preservation of base facing proximally with which spermatic cord is wrapped. Edge of autoplast is connected behind spermatic cord, its medial side is sutured with musculus obliquus internus abdominis, and opposite-lateral side with inguinal ligament over the entire length of inguinal canal. Graft base at internal opening of inguinal canal is fixed by separate sutures to transverse fascia from sides and behind cord, and internal ring of inguinal canal is formed. Opposite distal external ring of sutured graft is sutured by edges to periosteum of symphysis and pubic tubercle and formed defect of aponeurosis of musculus obliquus externus abdominis is sutured above formed canal to prevent antigenic reaction. EFFECT: higher efficiency of treatment. 3 dwg

Description

 The invention relates to medicine, surgery, and relates to methods for treating oblique, direct and congenital inguinal hernias.

 There is a method of plasty of the inguinal canal according to Girard-Spasokukotsky with a Kimbarovsky suture, when the upper flap of the aponeurosis of the external oblique muscle of the abdomen is punctured with a silk thread by 1.5-2 cm from the free edge, while capturing the internal oblique and transverse abdominal muscles . The needle is punctured, freely circling below the indicated muscles at the edge of the same upper flap of the aponeurosis of the external oblique muscle of the abdomen in the direction from the inside out. After the injection with the same ligature, the inguinal ligament is stitched tightly. There are several such seams. When ligatures are tightened, the edge of the aponeurosis is tucked to the inguinal ligament and the edges of the muscles covered by the aponeurosis are pulled. The lower flap of the aponeurosis is sutured to the overlying site of the aponeurosis, covering these sutures, resulting in the formation of a duplicate aponeurosis [1]. The disadvantage of this method is trauma, since the muscles in the groove are strongly compressed and doom to inactivity and atrophy [5, p. 155].

 There is a method of plasty of the inguinal canal according to Bassini, when deep sutures are placed under the spermatic cord between the edge of the rectus muscle and its vagina and periosteum of the pubic tubercle, as well as between the internal oblique, transverse muscles and transverse fascia on the one hand and the inguinal ligament on the other, which eliminate the inguinal the gap. Then the spermatic cord is laid on the newly formed posterior wall and the edges of the aponeurosis of the external oblique muscle of the abdomen are sewn on top of it [2]. The main disadvantage of the Bassini method and its modifications is sewing the edge of the lateral abdominal muscles all the way to the intractable inguinal ligament, which completely disrupts the valve mechanism of the inguinal canal, and the connective tissue muscles degenerate, turning into a scar [5, p. 163-164]. Therefore, this method is also very traumatic.

 There is also known a method of plastic surgery of the inguinal canal according to Postempsky, in which the inguinal canal as such is eliminated and a new bed for the spermatic cord is created. In this case, the spermatic cord is dissected as far as possible in the lateral direction and the inner ring of the inguinal canal is sutured from the medial side. Further, from the medial side, the connected tendon of the internal oblique, transverse and the edge of the vagina of the rectus abdominis is sutured to the pubic tubercle and upper pubic ligament. The transverse fascia, the internal oblique and transverse muscles of the abdomen, as well as the upper leaf of the aponeurosis of the external oblique muscle are sutured to the pubic-iliac cord and inguinal ligament, and these sutures push the spermatic cord to the lateral side to the limit. The lateral aponeurosis flap of the external oblique muscle of the abdomen is fixed with sutures on top of the medial flap, and the spermatic cord is laid on the aponeurosis and the superficial fascia and skin are sutured above it in layers [3, p. 119]. However, this method is also traumatic, since the spermatic cord, this tender organ, should not be subjected to completely unnecessary and harmful movement from one place to another. The onset of pain in the testicle in some cases with atrophy of it with methods with moving spermatic cord was noted by many authors from 6 to 25% [5, p. 220].

 As a prototype taken the method of treatment of extensive and recurrent inguinal hernias [4].

This method consists of the following moments of the operation:
- opening of the inguinal canal;
- removal of the hernial sac;
- allocation of spermatic cord to the inner inguinal ring;
- exposure of the transverse fascia;
- the use of an implant made of synthetic polymer tissue (allogeneic canned dura mater);
- wrapping the spermatic cord with an implant up to a diameter of 0.8-1 cm;
- the formation of the tube by stitching the edges of the implant: between themselves and the front surface of the internal oblique muscle of the abdomen throughout the inguinal canal;
- stitching of the lateral edge of the implant with the inguinal ligament;
- the formation of the inner ring of the inguinal canal by suturing the lateral end of the implant to the transverse fascia around the entire circumference;
- hemming the distal end of the implant to the periosteum of the symphysis;
- stitching of the aponeurosis of the external oblique muscle of the abdomen over the formed implant, creating the front wall of the inguinal canal.

 Clinical experience from 1977 to 1990 set out in the book [3, p. 130]. The method of creating an artificial inguinal canal was used in 54 patients with extensive and recurrent hernias. Studied long-term results in the period from six months to 8 years. No relapse was detected.

 However, this method has disadvantages. Any implant, being a foreign body, has antigenic properties and can lead to aseptic inflammation; cases of resorption of implants with scarring of surrounding tissues were observed [5, p. 133], as well as their destruction [3, p. 55].

 The aim of the invention is to eliminate the antigenic response to the implant.

 The method is as follows.

 After a standard dissection of the skin, the front wall of the inguinal canal is opened above the hernial protrusion, for which the aponeurosis of the external oblique muscle of the abdomen is dissected with a scalpel along the fibers along the entire length of the inguinal canal so that they retreat 0.5-1 cm from the inner semicircle of the outer ring of the inguinal canal . A hernial sac is found that is highly secreted and removed. Using a ligature, which is brought under the cord, measure the circumference. Then parallel and lateral to the main section of the aponeurosis, they retreat by the circumference of the cord plus 1/6 of the diameter of the cord for contractility, a second section of the aponeurosis is made, the length corresponding to the first. Thus, a U-shaped flap is cut out from the aponeurosis of the external oblique muscle of the abdomen on the feeding leg with the base facing proximal. The flap width (L) should correspond to the circumference of the spermatic cord or three diameters plus 1/6 of the diameter of the created tube for contractility and be from 2.6 to 3.8 cm (Fig. 1).

 The next moment of the operation, the spermatic cord 1 is isolated along the entire length of the inguinal canal and the transverse fascia 2 is exposed at its internal opening. The spermatic cord is wrapped with a cut flap along the entire length of the inguinal canal and the edges of this flap are sutured together behind the cord. The medial side of the autograft is also sutured with the internal oblique muscle of the abdomen 3, and the opposite side, the lateral side, with the inguinal ligament 4 along the entire length of the inguinal canal. At the inner opening of the inguinal canal, the base of the flap is fixed with three separate sutures to the transverse fascia 2 from the sides and behind the spermatic cord and an inner ring of the inguinal canal is formed, which should have a diameter of not more than 0.8 - 1 cm. The opposite distal, outer, ring of the stapled flap at the edges hemmed to the periosteum of the symphysis and pubic tubercle 5 (Fig. 2) and create an inguinal canal in the plastic zone, exactly corresponding to the spermatic cord along its entire length.

 Finally, the resulting aponeurosis defect of the external oblique muscle of the abdomen over the formed canal is stitched, nullifying the formed fold at the base of the cut flap (Fig. 3). The most medial suture is tied in such a way that the created hole misses the tip of the index finger. End the operation by applying individual sutures to the skin and subcutaneous fat.

 Example 1. Patient B., born in 1947, machine operator, N case history 1851, was admitted to the hospital 02.07.90, with a diagnosis of right-sided oblique inguinal-scrotal hernia. The duration of the disease at the time of treatment was 2 years. On examination, in the right iliac-inguinal region there is a hernial protrusion of 5x3 cm in size, descending into the right half of the scrotum, which, when the patient is horizontal, sets into the abdominal cavity. The external inguinal ring is expanded to 2 cm in diameter. 04/04/90, under local infiltration anesthesia with a 0.5% solution of novocaine in an amount of 300.0 ml, a right-sided inguinal herniotomy was performed by dissecting the aponeurosis of the external oblique muscle of the abdomen along the fibers along the entire length of the inguinal canal, retreating 0.5 cm inwards from the inner semicircle of the outer ring of the inguinal canal. The hernial sac is selected throughout, opened. Its contents are examined and then inserted into the abdominal cavity. The selected bag is sewn at the neck, tied up and cut off. Using the ligature, the circumference of the spermatic cord was measured, which was 2.5 cm, and, retreating 2.6 cm taking into account contractility, a second incision of the aponeurosis of the external oblique muscle of the abdomen was made parallel and lateral to the main incision, also along its fibers and such In this way, a U-shaped flap was cut on the supply leg with the base turned proximally. Then, the spermatic cord is selected along the entire length of the inguinal canal, and the transverse fascia is exposed at its internal opening. The cord itself is shrouded in a cut flap of aponeurosis throughout the inguinal canal, and the edges of the flap are sewn together by interrupted silk sutures behind it in the form of a tube. The medial side of the newly created tube is sewn with the internal oblique muscle of the abdomen, and the lateral side with the inguinal ligament throughout the inguinal canal. At the inner opening of the inguinal canal, the base of the flap is fixed with three sutures to the transverse fascia on the sides and behind the suture in such a way that the diameter of this hole is 1 cm.The distal ring of the stitched flap is sewn along the edges to the periosteum of the symphysis and pubic tubercle with three separate sutures. The resulting aponeurosis defect of the external oblique muscle of the abdomen above the formed tube is sewn end to end with separate interrupted sutures. The most medial suture is tied in such a way that the hole created corresponds to a diameter of 1 cm. The postoperative period was uneventful. There was no temperature reaction. The wound was bandaged in 1-2 days. Sutures were removed on the 7th day. Healing by first intention.

 12.02.90, the patient in satisfactory condition was discharged from the hospital with recommendations. The average bed day was 10 days. At the time of discharge, there was a suture line with well-adapted edges in the area of surgical intervention. After 3 months, the patient was examined. There is no data on the recurrence of the disease. In the right iliac-inguinal region - a fragile postoperative scar up to 10 cm long. The function of the genital organs is not impaired, the cremaster reflex is preserved. Next, the patient was examined after a year. No recurrence of the disease. At the next examinations after 2 years and 5 years, there is no data for relapse. The last time was examined 8 years after the operation - the patient is healthy, no complaints, no recurrence of the disease. The postoperative scar in the field of surgical intervention has become stronger.

 Example 2. Patient P., born in 1940, employee, N case history 138, was admitted to the hospital on 01.16.91 with a diagnosis of left-sided direct inguinal hernia. The duration of the disease is 2 years. At the time of examination, in the left iliac-inguinal region there is a hernial protrusion of 3.5 x 1.5 cm with an expanded outer ring of the inguinal canal up to 1.5 cm. 01/18/91 under local infiltration anesthesia with a 0.5% solution of novocaine in the amount of 250.0 ml left-sided inguinal herniotomy was performed, the hernial sac was isolated and opened. Its contents are examined and set into the abdominal cavity. The hernial sac itself is stitched, bandaged and cut off. Hernioplasty was performed according to the method described above. The postoperative period was uneventful. Sutures were removed on the 7th day. 01/25/91 was discharged from the hospital. The average bed day was 9 days. At discharge, the seam area is clean. At the time of the first follow-up examination, after 3 months, there were no complaints, the postoperative scar in the field of surgical intervention is fragile, clean. There is no data for relapse. The second follow-up examination after 1 year, no data for relapse. It was subsequently examined after 2 years and 5 years. No complaints, no relapse detected. Last examination 7 years after surgery. The scar in the area of intervention is stronger, no complaints, no relapse.

 Example 3. Patient P., born in 1949, driver, N case history 195, was admitted to hospital 22.01.91 with a diagnosis of right-sided oblique inguinal hernia. The duration of the disease is 1 year. When viewed in the right ileo-inguinal region, a hernial protrusion of 4 x 2.5 cm in size with a hernia size in the area of the external opening of the inguinal canal up to 2 cm. 01/24/91 under local infiltration anesthesia with a 0.5% novocaine solution 250.0 ml produced right-sided inguinal herniotomy followed by hernioplasty according to the described procedure. The postoperative period was uneventful. Sutures were removed on the 7th day. Healing by first intention. 01/31/91 was discharged from the hospital. It was examined after 3 months and 1 year. There is no data for relapse. During follow-up examinations after 2 and 5 years, there were no complaints, no recurrence of the disease was detected. Last inspection 7 years after the operation. There is no data for relapse; the postoperative scar in the right ileo-inguinal region has become stronger.

 This method was tested in 1990 at the Department of Operative Surgery and Topographic Anatomy of the Chita State Medical Institute, was reported at the cathedral meeting of the department staff, as well as at the conference of surgeons in 321 District Military Hospital. Experiments on this topic were carried out on 5 corpses and 17 outbred dogs, which made it possible to substantiate its safety, simplicity and suitability for further performance in the clinic.

Patients were treated in the period from 1990 to 1998. on the basis of the surgical departments of the Chita district, the 1st city hospital, as well as 321 District military hospital. In total, 30 patients were treated with this method: 27 men and 3 women aged 29 to 49 years, with an average age of 39.5 ± 9.5 years. The duration of the disease until reaching the hospital ranged from 6 months. up to 4.5 years. Among this group of patients, oblique and 3 - direct inguinal hernia were diagnosed in 27 patients, and one patient had a bilateral direct inguinal hernia. Prior to the operation, all patients undergoing treatment underwent clinical and biochemical analysis of blood and urine, as well as determination of blood group, therapist’s consultation, and an electrocardiogram with daily thermometry. The surgical intervention itself was mainly carried out under local infiltration anesthesia with 0.25 - 0.5% solution of novocaine in an amount of 200.0 to 400.0 ml. The removed surgical material was subjected to mandatory histological examination. In the early postoperative period (first 2-3 days), all patients received parenteral analgesics. Dressings were carried out after 1 to 3 days. Sutures were removed, as a rule, on the 7th day. Bed rest was prescribed for the first 2-3 days, and then patients were allowed to get out of bed. Active mode was prescribed after removing the stitches. Before discharge from the hospital, a control study of blood and urine was carried out, as well as recommendations for observing the correct mode of work, rest and nutrition. No complications after the operation were noted in any case, except for an increase in body temperature in the evening on the day of surgery to 37-37.8 ^o C. All patients who underwent surgery were monitored and examined after 3 months. after treatment, and subsequently after 1, 2 and 5 years, respectively. The longest follow-up was 8 years.

 The proposed method allows to improve the quality of the operation using autotissue on the feeding leg and can be used for various forms of inguinal hernias - oblique and straight, since it maintains topographic and anatomical relationships in the area of the inguinal canal. In addition, it is simple and less traumatic and can be used in the surgical departments of hospitals.

 Literature.

 1. Operative surgery and topographic anatomy / Ed. Kovanova V.V. - M .: Medicine, 1978, p. 334.

 2. Surgical Surgery / Edited by I. Littmann. - 2nd edition in Russian. - Budapest: publishing house Hungary, 1982, p. 362 and 363.

 3. Toskin K. D., Zhebrovsky V.V. Hernia of the abdominal wall. - M.: Medicine, 1990, 272 p.

 4. Copyright certificate of the USSR N 628897, A 61 B 17/00.

 5. Kukujanov N.I. Inguinal hernia. - M.: Medicine, 1969, 439 p.

Claims (1)

 A method of treating inguinal hernias, including the isolation of the spermatic cord and inguinal canal plasty, characterized in that the plasty is performed using an autograft from the aponeurosis of the external oblique abdominal muscle by cutting a U-shaped flap on the feeding leg with the base proximal to which the spermatic cord is wrapped by suturing the edges behind him.

Images