RU2186532C2 - Method for combined lower-median and ilioinguinal access - Google Patents

Abstract

FIELD: medicine, surgery. SUBSTANCE: it is separated an inguinal ligament and tendon of rectus muscle of abdomen together with periosteum and an osseous fragment at the site of their fixation to a pubic bone. Then periosteum is fixed with an osseous fragment by interrupted sutures to its own bed and tightened with the same sutures to a pectineal muscle and rectus muscle of abdomen. The method enables to increase reliability of suturing and healing the anterior abdominal wall due to keeping the safety of inguinal ligament and rectus muscle of abdomen and collateral net, as well. EFFECT: higher efficiency. 2 ex, 1 dwg

Description

 The invention relates to medicine, namely to surgery.

 A known method of laparotomic-iliac-inguinal access, in which a lower middle laparotomy is performed, a tendon of the rectus abdominis muscle and an inguinal ligament is medially crossed at the site of attachment, then with a single block the rectus abdominis muscle and muscles of the anterior abdominal wall are pulled up and laterally, the lower epigastric artery is ligated and (Caracusis K.P. Trans-peritoneal-inguinal access for pelvic tumors // In the book: Sarcomas of bones and soft tissues. M., p. 188 -197).

 The disadvantages of this known method include the intersection of the rectus abdominis muscle, as well as the inguinal ligament and the resulting unreliability of their connection again. In addition, trauma to the rectus abdominis muscle, leading to impaired collateral circulation, especially against the background of ligation of the lower epigastric artery, can lead to the appearance of a necrosis zone at the junction of the transverse and midline incisions.

 The objective of the present invention is to increase the reliability of suturing and healing of the anterior abdominal wall by maintaining the integrity of the inguinal ligament and rectus abdominis muscle and ensuring the existing collateral blood flow in this area.

 This problem is solved by the fact that the patient has a lower midline incision and the ileo-inguinal retroperitoneal access, the inguinal ligament and tendon of the rectus abdominis muscle with periosteum and bone fragment are separated at the point of attachment to the pubic tubercle and pubic symphysis, and then the periosteum is fixed with separate bone fragment interrupted sutures to his bed and reinforced by fixation on the same sutures to the comb and rectus muscles.

 Comparison of the proposed method with the prototype shows that in the proposed method there is a new action - the separation of the inguinal ligament and tendon of the rectus abdominis muscle with the periosteum and bone fragment at the place of their attachment to the pubic tubercle and pubic symphysis, with the fixation of the periosteum with the bone fragment by separate interrupted sutures to its bed and reinforcement by fixing on the same seams to the comb and rectus muscles. This improves the reliability of suturing of the postoperative wound while maintaining collateral blood flow.

 In practice, the method is carried out as follows: in the patient’s position on the back, a skin incision is made corresponding to the lower middle laparotomy to the fold, then laterally at an angle of 90 degrees until it intersects the line of the corresponding projection of the inguinal ligament, the intersection point should correspond to the projection of the femoral vessels (the inguinal ligament is conditionally divided in half, the point is one transverse finger medial to the middle of the inguinal ligament). Then the skin incision is continued vertically down to the hip at a distance of about 5-6 cm.

 The subcutaneous fat is dissected, the blood vessels of the tissue are ligated and cut, the fiber of the “skin corners” (see drawing) is sharply separated, the latter are sutured laterally to the skin of the lateral abdominal wall, and to the skin of the opposite thigh medially. Thus, the inguinal ligament, the aponeurosis of the external oblique muscle, the white line of the abdomen, the place of attachment of the inguinal ligament and rectus to the pubic bone are exposed. Fiber of the femoral triangle is prepared until v. saphena magna, tracing the path of the latter until it flows into the femoral vein. The superficial leaf of the femoral fascia is dissected downward by 1-2 cm. The femoral vessels are isolated with a blunt and sharp path. You should beware of injuring a.et v. pudenda ext., which extend 1-1.5 cm below the inguinal ligament. Remove the lymph nodes located at the entrance to the femoral canal; finger inserted into the last, protect the femoral vein from injury, cross the lacunar ligament with scissors.

 The next step is the dissection of the anterior wall of the inguinal canal. The inguinal cord (in men) is separated from the surrounding adhesions, taken to the holder, and laterally removed. For a more complete abduction, the intersection of the ilio-inguinal nerve is possible. In women, the round ligament of the uterus is bandaged and crossed. The next step is the dissection of the white line of the abdomen to the point of attachment of the rectus abdominis muscle to the pubic bone. Free the place of attachment from fatty tissue.

 The rectus abdominis muscles are bluntly pushed apart, the peritoneal sac is bluntly pulled up. In a blunt and sharp way, the surface of the pubic bone is prepared, while removing fatty tissue as much as possible, the periosteum is cut around the place of attachment of the inguinal ligament and rectus muscle by about 0.7 -1 cm.

 The scalloped fascia is dissected, the same muscle is stupidly taken down. The periosteum with a raspator is taken to the place of attachment of the muscles and ligaments.

 A phalangeal saw produces a cut of the periosteum of the pubic bone 3 cm wide, 4 cm long, 3 mm high. Complex: inguinal ligament, rectus abdominis muscle attached to the cut of the pubic bone, laterally, while in the peritoneal tissue lies a. et v. epigastrica inferior, the latter are bandaged and crossed at the site of discharge from the femoral vessels.

 After taking the peritoneal sac upward and medially, adequate conditions are created for manipulating the tumor located in the iliac fossa, the pelvic vessels, the ureter, and retroperitoneal lymph nodes, which greatly expands the surgeon's capabilities.

 The opening of the peritoneal sac is carried out based on the operating situation, i.e. at the beginning or at the last stage of surgery.

The postoperative wound is sutured in several stages:
Stage 1: 6-7 lavsan sutures on a round needle, the periosteum of the bone fragment is sutured in its place to the periosteum of the pubic bone. It should be noted that on the inside, the periosteum is very thin and easily penetrates. Ligatures are not cut, because they also hem in front the scallop muscle with the fascia of the same name and laterally and behind the rectus muscle of the same name with the fascia.

 Stage 2: plastic surgery of the femoral canal according to Bassini.

 Stage 3: plastic surgery of the posterior wall of the inguinal canal according to Bassini or Postempsky.

 Stage 4: suture soft tissue and skin.

 The practical application of the method in an anatomical experiment is illustrated by the following examples.

 Example 1. Laparotomic ileo-inguinal access was performed on the corpse of a 54-year-old patient (post-mortem diagnosis: acute cerebrovascular accident).

 In the position of the patient on the back, a skin incision was made corresponding to the lower middle laparotomy to the fold, then at a 90-degree angle laterally to the intersection with the line corresponding to the projection of the inguinal ligament (medial 2/5 border), the skin incision was continued vertically down to the hip at a distance of 6.0 cm.

 The subcutaneous fat is dissected, the blood vessels of the fiber are tied up and crossed, the “corners of the skin” are hemmed to the skin of the lateral abdominal wall laterally, to the skin of the opposite thigh medially. The inguinal ligament, the aponeurosis of the external oblique muscle, the white line of the abdomen, the place of attachment of the inguinal ligament and rectus to the pubic bone are exposed. Fiber of the femoral triangle is prepared until v.saphena magna is isolated. The superficial leaf of the femoral fascia is dissected down by 2.5 cm. The femoral vessels are bluntly distinguished. The lymph nodes located at the entrance to the femoral canal were removed, the lacunar ligament was crossed.

 The spermatic cord is separated from the surrounding adhesions, taken to the holder, retracted laterally. The white line of the abdomen was dissected to the point of attachment of the rectus abdominis muscle to the pubic bone. The place of its attachment is freed from fatty tissue.

 The rectus abdominis muscles are stupidly apart, the peritoneal sac is stupidly retracted upward. The periosteum is cut around the place of attachment of the inguinal ligament and rectus muscle, in a circle (1.1 cm). The scalloped fascia is dissected, the same muscle is stupidly laid down. The periosteum with a raspator is assigned to the place of attachment of the muscle and ligament.

 A phalangeal saw produced a cut of the periosteum of the pubic bone 3.2 cm wide, 3.9 cm long, 4 mm high. Complex: inguinal ligament, rectus abdominis muscle attached to the cut of the pubic bone, laterally allotted, while the lower hypogastric vessels are ligated and crossed.

 The peritoneal sac was not opened. The postoperative wound is sutured as follows: with seven dacron sutures on a round needle, the periosteum of the bone fragment is sutured in its place to the periosteum of the pubic bone. With the same ligatures, the scallop muscle with the fascia of the same name is sewn in front and the rectus abdominis muscle with the fascia of the same name is laterally and posteriorly. Plastic surgery of the femoral canal according to Bassini and plastic of the posterior wall of the inguinal canal according to Postempsky. Sutures on soft tissue and skin.

 This method was simulated in an experiment on corpses in another 26 studies. There are 3 clinical applications of the above access method (VONTS RAMS), one of which is given below.

 Example 2. Laparotomic ilio-inguinal access was performed in patient M., 72 years old (diagnosis: tumor of the ileal fossa).

 In the position of the patient on the back, a skin incision was made corresponding to the lower middle laparotomy, to the bosom, then laterally at an angle of 90 degrees to the intersection with the line corresponding to the projection of the inguinal ligament (border of the medial 2/5), the skin incision was continued vertically down to the hip at a distance of 5, 5 cm

 The subcutaneous fat is dissected, the blood vessels of the fiber are tied up and crossed, the “corners of the skin” are hemmed to the skin of the lateral abdominal wall laterally, to the skin of the opposite thigh medially. The inguinal ligament, the aponeurosis of the external oblique muscle, the white line of the abdomen, the place of attachment of the inguinal ligament and rectus to the pubic bone are exposed. Fiber of the femoral triangle is prepared until v.saphena magna is isolated. The superficial leaf of the femoral fascia is dissected down by 3.0 cm. The femoral vessels are bluntly distinguished. The lymph nodes located at the entrance to the femoral canal were removed, the lacunar ligament was crossed.

 The round ligament of the uterus is separated from the surrounding adhesions, taken to the holder, retracted laterally. The white line of the abdomen was dissected to the point of attachment of the rectus abdominis muscle to the pubic bone. The place of its attachment is freed from fatty tissue.

 The rectus abdominis muscles are stupidly apart, the peritoneal sac is stupidly retracted upward. The periosteum is cut around the place of attachment of the inguinal ligament and rectus muscle, in a circle (1.0 cm). The scalloped fascia is dissected, the same muscle is stupidly laid down. The periosteum with a raspator is assigned to the place of attachment of the muscle and ligament.

 A phalangeal saw cuts the periosteum of the pubic bone 3.0 cm wide, 4.5 cm long, 3 mm high. Complex: inguinal ligament, rectus abdominis muscle attached to the cut of the pubic bone, laterally allotted, while the lower hypogastric vessels are ligated and crossed.

 The isolation and removal of the tumor filling the entire right iliac fossa was performed.

 The abdominal sac is opened at the end of surgery. The postoperative wound is sutured as follows: with six dacron sutures on a round needle, the periosteum of the bone fragment is sutured in its place to the periosteum of the pubic bone. With the same ligatures, the scallop muscle with the fascia of the same name is sewn in front and the rectus abdominis muscle with the fascia of the same name is laterally and posteriorly.

 Bassini femoral canal grafting and Bassini grafting of the posterior inguinal canal produced. Sutures on soft tissue and skin. The wound healed by first intention, the patient was discharged home on the 12th day after surgery in a satisfactory condition.

 The task of the method was also achieved in 2 other clinical cases. In none of the cases, postoperative hernias were observed, the wounds healed by first intention, which reduces the incidence of early and late postoperative complications associated with the divergence of sutures, the formation of postoperative combined hernias.

Using the presented method of combined lower middle and ilio-inguinal access, it is proposed:
1. In contrast to the prototype, to increase the reliability of suturing the wounds of the anterior abdominal wall by maintaining the integrity of the inguinal ligament and rectus abdominis muscle.

 2. In contrast to the prototype, to maintain the viability of the rectus abdominis muscle and soft tissues in the access area by maintaining the collateral network.

Claims (1)

 A method of combined lower middle and ilio-inguinal access, including performing a lower middle laparotomy and iliac-inguinal retroperitoneal access with a connected incision, characterized in that the inguinal ligament and tendon of the rectus muscle with periosteum and bone fragment are fixed at the site of attachment to the pubic bone, and then the periosteum with a fragment of bone with separate interrupted sutures to its bed and reinforced by fixation on the same sutures to the comb muscle and rectus abdominis muscle.