RU2201151C2 - Surgical method for treating and preventing inguinal and femoral hernia manifestations - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves removing or setting hernial sack. Autodermal graft is medially sutured to Cooper's ligament to iliac blood vessels level, to inguinal aponeurotic fold and posterior surface of the musculus transversus abdominis. The autodermal graft is sutured to iliopubic tract laterally with respect to the spermatic cord. The superior portion of the skin graft is sutured to the musculus transversus abdominis. EFFECT: retained anatomical relations in testis and spermatic cord.

Description

 The invention relates to medicine and can be used in surgical treatment and to prevent the re-occurrence of all types of hernias in the inguinal and femoral areas.

 There is a method of surgical treatment of inguinal hernias, in which, under general anesthesia, traditional access to dissect the skin over the inguinal canal (Osipov V.I., Gusev A.I. Plastic surgery for oblique inguinal hernia. Journal. Journal of Surgery named after II Grekov, t 158, 6, 1999, pp. 83-85). The inguinal canal is opened to its entire length by dissection of the aponeurosis of the external oblique muscle of the abdomen along the fibers, retreating 0.5-1.0 cm more medially from the internal semicircle of the external inguinal canal, at the same time the medial leg of the aponeurosis is crossed. They find, separate, open the hernial sac and dissect it high. The spermatic cord is mobilized and the length of its semicircle is measured with the help of the ligature brought under the cord. Laterally and parallel to the first cut, stepping back a distance equal to the circumference of the cord (26-38 mm), a similar second cut of the aponeurosis is performed. The medial ends of the incisions are connected by a transverse incision, while crossing the lateral leg of the aponeurosis. As a result, a U-shaped aponeurotic flap is formed on the feeding leg with the base facing proximal. The spermatic cord is wrapped with a cut patch on all sides, and its edges are sutured behind the cord, forming a tube. The inner ring of the inguinal canal is narrowed to 1 mm by stitching the transverse fascia of the abdomen with the lateral end of the tube with separate sutures, and the outer ring is narrowed by stitching the medial end of the formed tube with the periosteum of the symphysis and pubic tubercle. The medial side of the tube is fixed with interrupted sutures to the lower edge of the internal oblique muscle, and the lateral to the inguinal ligament. The edges of the aponeurosis of the external oblique muscle of the abdomen, formed after cutting out the flap, are sutured over the created tube by the type "edge to edge". The surgical wound is sutured.

 The disadvantage of this method is that it cannot be applied with significant razvolenenii aponeurosis, atrophy and destruction of both the front and back walls of the inguinal canal. The method does not provide a reliable reduction in the diameter of the inner inguinal ring due to the use of weakened, degeneratively modified transverse fascia and muscles of the anterior muscular wall. The method is fraught with the risk of subsequent development of inguinal and femoral hernias.

 A known method of surgical treatment of inguinal hernias, carried out under general anesthesia with inguinal access (Prosyany E.V. Autodermal plastic surgery for surgery for a femoral hernia. Journal. Bulletin of Surgery named after II Grekov. Medicine, 1976, v. 116, 1, p . 65-69), which allows you to highly isolate and cut off the hernial sac and close the hernial gate in the area of the internal opening of the femoral canal using the most durable formations - the upper pubic and inguinal ligaments.

 At the same time, the aponeurosis of the external oblique muscle of the abdomen is dissected, the round ligament of the uterus or spermatic cord is lifted on a gauze bandage. The condition of the posterior wall of the inguinal canal is assessed and the presence of a concomitant direct or oblique inguinal hernia is detected, the possibility of using plasty of the posterior wall of the inguinal canal, lower edges of the deep abdominal muscles, the combined aponeurosis and the ileo-pubic cord is determined. The posterior wall of the inguinal canal is widely dissected - from the pubic tubercle to its deep ring. Preperitoneal fiber with peritoneum is pushed up. In the subcutaneous adipose tissue below the inguinal ligament, the hernial sac is freed from adhesions, and its neck is carefully isolated from the adhesions behind the inguinal ligament. The hernial sac is transferred to the inguinal region, thereby providing the possibility of high removal of the hernial sac of the femoral hernia and hernial sacs of concomitant hernias. Sew three to four, sometimes five sutures with an interval of 0.6-0.7 cm of the upper pubic ligament. In this case, the external iliac vessels are pushed outwards and protected by a hook. A pre-prepared autodermal flap is sewn with the upper edge to the lower edges of the internal oblique and transverse muscles of the abdomen, connected by an aponeurosis and the vagina of the rectus abdominis muscle with silk threads.

 Then they sew it to the upper bundle with the threads previously drawn through it. Lateral sutures are carried out as close as possible to the external iliac vessels. Sew the lower edge of the autodermal flap to the ilio-pubic strand and the posterior edge of the inguinal ligament, which provides a significant narrowing and reliable closure of the ligament in which the femoral canal ring is located. In this case, one of the sutures of the lower edge of the autodermal flap is located to the iliac-pubic strand and the posterior edge of the inguinal ligament, opposite the last suture through the upper pubic ligament. The penultimate suture, conducted through the superior pubic ligament, is passed through the inguinal ligament through / above the superficial opening of the femoral canal / and is tied, thereby ensuring reliable closure of the femoral canal. Then, the upper aponeurosis flap of the external oblique muscle of the abdomen together with the transverse fascia is sutured to the ileo-pubic cord and the posterior edge of the inguinal ligament, and the lower aponeurosis flap of the external oblique muscle of the abdomen is sewn to the upper type of duplicate. Subcutaneous tissue and skin are sutured in layers.

The disadvantage of this method is:
- the allocation of the spermatic cord from the front access, its displacement and tension;
- excision of the muscle raising the testicle;
- the intersection of the supply vessels and nerves;
- high invasiveness of the method with recurrent hernias;
- risk of loss of testicular function;
- the method does not provide sufficient strength along the line of hemming the skin flap to the lower edge of the muscles.

 The objectives of the present invention are the preservation of the anatomical relationships and the condition of the spermatic cord as a whole, the possibility of using the method in the treatment of all varieties of inguinal and femoral hernias, and the prevention of their formation.

 The technical essence of the invention is that typical exit sites of inguinal and femoral hernias of the inner ring of the femoral canal are covered from the inside with a skin flap - an autograft and fixed to the connective tissues through the iliac region to the upper edge of the pubic bone, inner surface of the rectus muscle, joint tendon, then after transplant cuts bring it under the elements of the spermatic cord, then to the inner surface of the transverse abdominal muscle lateral to its attachment to the inguinal mating and lateral to the lower epigastric vessels with the condition of simultaneous restoration of the anatomical correct ratios of the inguinal canal.

 The method is as follows.

 After adequate premedication under general or local / according to indications / anesthesia, an incision is made in the inguinal region until aponeurosis of the external oblique muscle of the abdomen. The aponeurosis is dissected with the transition to the anterior sheet of the vagina of the rectus abdominis muscle, exposing the preperitoneal tissue. A hernial sac is isolated and truncated, followed by suturing of the neck of the sac. Separate the transverse fascia, the lower epigastric vessels. An autodermal graft is cut out and prepared in the size corresponding to the indications. Stupidly separate the elements of the spermatic cord before entering the inner ring of the inguinal canal, exposing the iliac-pubic cord and the upper edge of the pubic bone medial to the iliac outer vessels. From the inside, the graft is sutured medially to the cooper ligament to the level of the iliac vessels, to the inguinal sickle and the posterior surface of the transverse abdominal muscle, and laterally to the spermatic cord to the iliac-pubic cord. Then, the skin graft is dissected in accordance with the need to maintain normal anatomical proportions, the lower end of the flap is brought under the elements of the spermatic cord, laying and fixing with separate sutures to the ilio-pubic tract, lateral to the site of attachment of the transverse abdominal muscle to the inguinal ligament. The upper strand of skin flap is sutured to the posterior surface of the transverse abdominal muscle. Both strands of the flap are sutured together, forming the inner ring of the inguinal canal so that the spermatic cord is in an anatomically normal position.

 After the toilet of the wound, it is sutured in layers and an aseptic dressing is applied.

Surgery for the prevention and treatment of hernias in this way have obvious advantages:
- provide reliable treatment and prevention of hernia formation in the inguinal canal and femoral area;
- maintain normal anatomical and functional relationships in the testis and spermatic cord.

 The method expands the scope of application in the treatment of hernias, as it allows for rehabilitation operations in patients with recurrent and repeatedly recurrent hernias of this zone.

 As shown by observations of 43 patients aged 38 to 66 years who underwent surgery for the treatment of inguinal hernias and femoral hernias with the proposed method, carried out for three years, there were no relapses of hernia.

 These results indicate that during surgical treatment of hernias according to the proposed method, the tasks set during the development of this invention are solved.

 Example. Patient B., born in 1931, was admitted to the coloproctology department on December 16, 1997. Diagnosis: recurrent right-sided oblique hernia repair. Appointed hernia repair from preperitoneal access, autodermal plastic of the inguinal space.

 Under general anesthesia, a transverse incision was made in the right inguinal region, preperitoneal tissue was exposed. A hernial sac up to 5 • 4 cm in size is sharply and bluntly highlighted. It goes under the skin more medially than the spermatic cord. Lateral to the spermatic cord is a triangular fissure 1.5 • 0.8 cm. The ilio-pubic cord, the lower epigastric vessels to the external iliac, the lateral edge of the rectus abdominis muscle and pubic tubercle are separated. A skin autograft was prepared, which was hemmed from the inside in the preperitoneal layer with the closure of the femoral fissure of both inguinal fossae with the formation of an internal inguinal ring and maintaining anatomical normal proportions. Performed the control of hemostasis. The wound of the muscular-aponeurotic layer is sutured by the ticron. The skin-subcutaneous layer is sutured with polyglycolite. An aseptic dressing is applied.

 The postoperative period without complications. Healing by first intention. Discharged after 2 weeks in satisfactory condition. Control examination 02/12/2001: the state of health is good, performs physical activity without restrictions, no complaints.

Claims (1)

 A method of surgical treatment and prevention of re-formation of inguinal and femoral hernias, including removal or reduction of the hernial sac and autodermal plastic of the hernia gate, characterized in that the medially autodermal flap is sutured to the cooper ligament to the level of the iliac vessels, to the inguinal sickle and posterior surface of the transverse abdominal muscle, and lateral to the spermatic cord - to the ilio-pubic tract, then the skin graft is dissected, the lower end of the flap is brought under the elements of the spermatic cord, fixi yn individual seams to the ilio-pubic tract, whereupon the upper strand skin flap sutured to the back surface of transverse abdominal muscle.