RU2187971C1 - Method for setting implant in performing preperitoneal hernioplasty - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves separating parietal peritoneum by means of retroperitoneoscope device. Hernial sack is selected. Polypropylene net is rolled by using two clamping devices rotated towards each other until their meeting takes place. The set is introduced into the prepared preperitoneal space. The zone of hernia formation with net is covered by rotating the clamping devices in opposite directions relative to each other. EFFECT: accelerated net installation. 4 dwg

Description

 The invention relates to medicine, in particular surgery.

 Currently, in the treatment of inguinal hernias, endoscopic and endovascular surgical techniques with closing hernial gates with a special implant (polypropylene mesh) are becoming more widespread.

 With all types of these operations, the most time-consuming step is the installation of an implant. Depending on the type of implant, this stage takes from 15 to 40 minutes: with a rigid structure ("Prolen", etc.) - an average of 17 minutes, with a soft structure ("Cor-tex", "Plastopolymer") - on average 28 minutes Of course, the speed of this stage of the operation depends on the manual abilities of the surgeon and the degree of training. Foreign and domestic researchers are trying to solve this problem by introducing self-healing implants and using special tools.

 A known method of installing a prosthesis from elastic tissue in an endoscopic manner, which consists in the fact that using a tubular case in which a prosthesis (implant) is placed in a rolled state, the latter is introduced through a trocar to the surgical site (French patent N 2705225 A1, from 05.21.93, published on 11.25.94, m.cl.A 61 V 17/00). From the slots in the case, the prosthesis unfolds with a fork-like part by rotation.

 The disadvantage of this method is the difficulty of manipulation due to the small volume of the working space, multiple punctures of the anterior abdominal wall, the need for general anesthesia and expensive equipment, due to this high cost.

 A known method of implant placement in transabdominal extraperitoneal laparoscopic hernioplasty, which consists in the formation of a cavity in the preperitoneal space from the pubic joint to the navel, through an incision under the navel (Ferzli GS, Massad A., Albert R. // J. Laparoendosc. Surg. - 1992. - Vol. 2, N6. - P. 281-286). The implant is introduced in a folded state through a 12 mm trocar, deployed and placed in the surgical area using endoscopic instruments.

 However, this method is difficult due to the small amount of work space. The number of local complications increases on average by 2 times. Pneumoperitoneum, which occurs when the peritoneum is damaged, makes it difficult to visualize and cover defects. Other disadvantages include high cost, the need for general anesthesia, multiple punctures of the anterior abdominal wall, and mesh migration.

 Closest to the claimed method is the method of preperitoneal hernioplasty using a retroperitoneoscope and the method of installing the mesh with a Billroth clip or forceps (materials of the conference "New directions in clinical medicine" All-Russian conference June 15-16, 2000, Leninsk-Kuznetsk, pp. 121-122 , Tarasov A.L., Krylov Yu.M., Zakharov A.V., Agalaryan A. X. "Possibilities of direct non-optical endoscopy in the treatment of hernias of inguinal localization"). The technique includes preperitoneal isolation using an anteromical anteromical structure that forms the inguinal canal, a hernial sac with a spermatic cord, and pubic articulation through a minimum (up to 3.0-3.5 cm) incision in the iliac-inguinal region. The installation of a grid folded in half is carried out with a Billroth clamp or forceps through the same incision. The operation is performed under epidural anesthesia.

 The disadvantage of this method is the difficulty of expanding the mesh due to the small volume of the working space, as a result of which the lengthening of the operation time.

 The objective of the invention is to increase the efficiency of hernioplasty operations, reducing time at the stage of installation of the mesh.

 The task is achieved by the fact that previously, with two clamping devices, by turning them towards each other, the mesh is rolled up to close and inserted into the prepared preperitoneal space in this form, and the hernia formation zone is closed by turning the clamping devices in opposite directions to each other.

The novelty of the method:
1. Preliminary folding into two mesh tubes by a clamping device provides ease of mesh installation and significantly reduces the operation time.

 2. The installation of the mesh by unrolling during rotation of two clamping devices in opposite directions ensures the accuracy of implant placement.

 The invention is illustrated in the drawing, where figure 1 shows a diagram of the operation; figure 2 - the front wall of the abdomen and pelvis from the inside (1/2) with a folded mesh in clamping devices; figure 3 - position of the grid in the side projection; in FIG. 4 - the front wall of the abdomen and pelvis from the inside with an implanted mesh.

 The essence of the method is as follows: for patients diagnosed with inguinal or femoral hernia, the following operation is performed.

 Position on the back. Epidural anesthesia. The skin incision is up to 3.0-3.5 cm (1) in the ileo-inguinal region in the oblique direction (appendicular), departing from the upper anterior spine by 3-4 cm. The aponeurosis is cut over 3.0-3.5 cm Stupidly, the hooks of Farabef spread the muscles to the peritoneum. The parietal peritoneum exfoliates with a tuffer in a limited area for the introduction of a retroperitoneoscope. The patient is transferred to the Trendelenburg position and on the side opposite to the operation, after which a retroperitoneoscope is inserted towards the external inguinal ring and the parietal peritoneum is exfoliated with a retroperitoneoscope blade and a tupfer. The inner opening of the inguinal canal (2), the spermatic cord with a hernial sac, stands out. The hernial sac bluntly and sharply stands out from the spermatic cord to the neck. Further, the parietal peritoneum continues to exfoliate with a retroperitoneoscope and tupfer. As you progress, the blades of the retroperitoneoscope change from smaller to larger, usually two blades are enough.

 The external opening of the inguinal canal (3), the pubic joint, are distinguished, after which the retroperitoneoscope blade rotates perpendicular to the rectus abdominis muscle and the peritoneum exfoliates from the anterior abdominal wall for 4-5 cm from the pubic joint. The detachment is carried out until a sufficient volume of the visualized space is achieved, adequate to the size of the implanted mesh, which subsequently achieves the stability of the mesh, i.e. its migration is absent. The retroperitoneoscope remains in the preperitoneal space. The lower and upper edge of the mesh (4) is clamped in two clamping devices (6) and wrapped in a tube by rotating the clamping devices towards each other until they close. In a rolled-up form, with a diameter of up to 1.0-1.5 cm, the mesh is installed in the prepared pocket and straightened by rotating the clamping devices on opposite sides until the mesh is completely expanded so that it covers the areas of inguinal and femoral formation (5) hernias. Further, drainage along the Redon is established preperitoneally on the mesh, which is removed through a separate puncture in the iliac-inguinal region. Drainage is set for 24 hours, and then removed. The patient is returned to their original position, the "installers" are deleted. The retroperitoneoscope is removed. Seams on a wound in layers.

 Patients were allowed to walk 8-10 hours after surgery, the administration of painkillers was not required, they were discharged from the hospital for 3-4 days. Full rehabilitation in 5-7 days. Complications in the postoperative period were not observed.

 Example.

 Patient Akimov ND, 74 years old, medical history 4688, was admitted to the clinic on 2.08.2000 with complaints of the presence of hernial protrusions in both inguinal areas. Hernial protrusions appeared about 1 year ago after heavy physical exertion, increase in size, and pain began to disturb. Objectively: in both inguinal regions there are regular hernial protrusions of a rounded shape, up to 5 cm in diameter, soft-elastic, painless. The skin above them is not changed.

 Diagnosis: bilateral correctable direct inguinal hernias.

 After the examination on August 3, 2000, at 10 h 20 min, an operation was performed - preperitoneal plastic mesh. Epidural anesthesia. The incision in the right ileo-inguinal region is up to 3.0 cm. Hemostasis. Aponeurosis is distinguished, dissected for 3.0 cm. The muscles are bluntly dilated with Farabef hooks to the peritoneum. The parietal peritoneum is peeled off with a tupper for 2-3 cm from the edges of the wound. A retroperitoneoscope with a 5 cm blade in the direction of the external inguinal ring is inserted into the lower corner of the wound. The patient was transferred to the Trendelenburg position at an angle of 30 degrees and on the left side at an angle of 20 degrees. With the help of a retroperitoneoscope and tupfer, the parietal peritoneum was peeled off, the inner opening of the inguinal canal, spermatic cord, the external opening of the inguinal canal with a hernial sac were highlighted. The hernial sac is bluntly and sharply outlined to the neck, 5x4 cm in size. After replacing the blade by 10 cm, detachment of the parietal peritoneum of the opposite side is continued. The external opening of the inguinal canal with a hernial sac, 5x4 cm in size, the internal opening of the inguinal canal, spermatic cord are highlighted. A polypropylene mesh, 22x9 cm in size, rolled up into a tube, with a diameter of up to 1.5 cm, was inserted into the resulting preperitoneal space with two clamping devices.The mesh was straightened and laid so that it covered the sites of inguinal and femoral hernia formation. Clamping devices removed. Redon drainage is laid on the mesh, removed through a separate puncture in the right iliac region. The patient was transferred to a position on his back, the "installers" of the mesh were removed. 1 Z-shaped catgut suture is applied to the muscles. 3 sutures per aponeurosis. 2 seams on the skin. Aseptic dressing. The operation lasted 12 minutes.

 At 18 hours the patient walks around the ward on his own. Complaints of mild pain in the area of postoperative wounds that do not require painkillers. The temperature is normal. Urinates on his own. He spent the night calmly, no analgesics needed. On August 4, 2000, drainage along Redon was removed. The seams are calm. The temperature is normal. Complains of weak pains only when walking, alone pain does not bother. August 6, 2000 the patient was discharged home. No complaints. Temperature throughout the postoperative period remained normal. The seams are calm. 08/09/2000, the seams were removed. The postoperative scar is calm. No complaints. Performs work at home associated with physical activity.

 Thus, 18 patients were operated on in the GNCC OZS. Complications in the postoperative period were not observed. All patients were allowed to walk 8-10 hours after surgery. The pain syndrome stopped by the end of 1-2 days. The introduction of painkillers was not required. Sutures were removed for 6-7 days, healing in all by primary intention. After 5-7 days, patients could perform work associated with moderate physical activity. After 14-17 days, patients performed heavy physical work. 15 patients were examined 2 months after surgery. No complaints. Perform any heavy physical exertion.

Claims (1)

 A method of installing a mesh in preperitoneal hernioplasty of inguinal localized hernias, including separation of the parietal peritoneum using a retroperitoneoscope, isolating a hernial sac and installing a polypropylene mesh in the hernia formation zone, characterized in that the mesh is folded up by two clamping devices by rotating them towards each other to close and in this form is introduced into the prepared preperitoneal space, and the closure of the zone of formation of hernias by the mesh is carried out by rotating the clamping devices in opposite sides to each other.

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