RU2253377C2 - Method for endosurgical treatment of incarcerated inguinal hernias and hernioscrotal hernias in children - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: it is necessary to perform laparoscopy and revision of abdominal organs to specify the size of hernial portae, under visual control one should remove incarcerated organ due to tightening the tissue of incarcerated organ after introduction of myorelaxing preparations, moreover, if its viability is not doubtful on should perform laparoscopic suturing in hernial portae at the level of internal inguinal ring without any mobilization of spermatic funiculus' elements, and in case of necrotic phenomena of incarcerated organs it is necessary to carry out herniolaparotomy and, if necessary, resection of altered section that decreases traumaticity and prevents postoperative complications.

EFFECT: higher efficiency of therapy.

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Description

The present invention relates to medicine, namely to pediatric surgery.

A known method of hernia repair for strangulated inguinal, inguinal-scrotal hernia in children is Martynov’s operation, with an oblique skin incision parallel to the inguinal fold with dissection of the inguinal canal (Surgical Surgery with Topographic Anatomy of Children 1989, edited by Yu.F. Isakov, p. 396-398). This method is based on the dissection of the aponeurosis of the external oblique muscle and the opening of the inguinal canal, after dissection of the skin of the abdomen and isolation of the hernial sac. With the remaining infringement following the release of the hernial sac, its dissection and revision of the hernial contents. To assess the viability of the strangulated organ, it is completely removed into the laparotomy wound by dissection of the strangulated internal inguinal ring. After the audit, in the absence of tissue necrosis, the organs are set into the abdominal cavity. Moreover, after ligation at the base of the hernial sac, it is cut off, and the dissected inguinal canal is sutured by suturing the inner leaf of the aponeurosis to the inguinal ligament from the inside and fixing the outer leaf of the aponeurosis from above in the form of a “coat floor”.

However, with this type of operation according to Martynov, when the hernial sac is isolated, elements of the spermatic cord are mobilized, which are severely injured in this case, which, according to data (V.A. Yarygin 1990, S. Schirren 1981), causes testicular ischemia and can cause infertility.

When using the endovideo surgical technique, it is possible directly from the abdominal side to go to the neck of the hernial sac and visualize its contents. In the hernial sac, the omentum, the loops of the intestine, the dome of the cecum with the appendix, the testicle, and the wall of the bladder are most often found. In girls, the contents are the ovary, tube, and sometimes the uterus. When fixing the restrained organs to the wall of the hernial sac, separation is performed using a blunt or sharp path with careful hemostasis by means of coagulation, and the vitality of the restrained organ is assessed.

The technical result is an increase in the quality of surgical treatment, a decrease in its morbidity, and prevention of postoperative complications.

The specified technical result is achieved due to the fact that upon admission of a patient with an impaired inguinal or inguinal-scrotal hernia, the patient undergoes diagnostic laparoscopy, while the organ is diluted under video control, while maintaining the viability of the organ that was impaired, laparoscopic suturing of the hernial portal is performed - the internal inguinal ring and the ungrown vaginal process of the peritoneum, and in the presence of signs of necrosis of the restrained organ, a herniolaparotomy is performed (from an autopsy thymus of the inguinal canal) and, if necessary, resection of the changed (necrotic) area.

A method for surgical treatment of strangulated inguinal and inguinal-scrotal hernias in children is as follows.

The operation is performed under intubation anesthesia. With the help of the endovideo surgical complex “Olympus”, endosurgical instruments “Medfarmservis”, “Karl Storz”. Monitors are located at the foot end of the operating table opposite the surgeon and assistant. The surgeon is opposite the area of operational interest.

The patient is on the operating table in a supine position. Under intubation anesthesia, after processing the surgical field, a 0.5 cm long incision is made along the upper edge of the umbilical ring, then a 5 mm trocar is inserted into the abdominal cavity for the optical system, and carboxyperitoneum is applied. A 5 mm “OLYMPUS” laparoscope is inserted into the abdominal cavity. An audit of the abdominal organs is performed, the location and sizes of the hernial gates are clarified, the restrained organ is visualized. Additionally, two 5 mm trocars for manipulators are introduced into the abdominal cavity: in the left and right iliac regions. Install two atraumatic clamps. The next dose of muscle relaxant is administered and, under visual control, reparations of the restrained organ are performed. Next, an assessment is made of the viability of the impaired organ, depending on which further tactics of surgical treatment are selected. If the vitality of the restrained organ is not in doubt, laparoscopic suturing of the hernia gate and the vaginal process of the peritoneum is performed at the level of the internal inguinal ring without mobilizing the elements of the spermatic cord. Methodology for performing laparoscopic dilatation and simultaneous hernioplasty: a needle holder is inserted into the abdominal cavity through a trocar in the right iliac region, and a clip with a non-absorbable thread on the atraumatic needle is inserted through the trocar into the left iliac region. Use the thread "Prolen" company "Ethicon" 2 \ 0 (USA). The curvature of the needle is 3 \ 8, the length of the thread is 16-18 cm. A purse string suture is placed on the neck of the hernial sac; in the short zone of projection of the elements of the spermatic cord, the peritoneum is not sutured, preventing mechanical action on the elements of the spermatic cord. Before tightening the purse string suture, the remaining fluid and carbon dioxide are evacuated from the testicles to the abdominal cavity. Then tighten the purse string suture. If necessary, an additional Z-shaped seam is applied. Careful monitoring of hemostasis and foreign bodies. Carbon dioxide is released from the abdominal cavity, skin wounds are sutured tightly.

Thus, when a patient with a strangulated inguinal or inguinal-scrotal hernia is admitted to the patient, a diagnostic laparoscopy is performed, and at the same time, a dilution is performed under video control and the condition of the strangulated organs is evaluated. While maintaining the viability of the organ that was impaired, laparoscopic suturing of the hernial portal is performed - the internal inguinal ring and the ungrown vaginal process of the peritoneum. If suspected non-viability of the impaired organ is indicated, surgical treatment is indicated - herniolaparotomy (with the opening of the inguinal canal) and, if necessary, resection of the changed (necrotic) site.

Endovideo-laparoscopic examination for strangulated inguinal and inguinal-scrotal hernia allows you to clearly, with great accuracy visualize tissue changes in the strangulated organ, and laparoscopic suturing of the internal inguinal ring allows the hernia gate to be eliminated with minimal trauma to the testicular vessels and vas deferens.

The authors in the medical, scientific and patent literature did not find information about the use of endovideolaparoscopic examination and suturing with strangulated inguinal and inguinal-scrotal hernia in children. Thus, the claimed invention meets the criterion of "novelty."

Injured hernias are a contraindication for laparoscopy (Endovideo surgical treatment of children with pathology of the vaginal process of the peritoneum 2001. Edited by M.V.Schebenkov, p.11.) Thus, we can say that the proposed method overcomes the prejudice of specialists about the impossibility of achieving that technical result which is obtained, and therefore the invention meets the criterion of “inventive step”.

Example 1. Patient P., 1 year, No. East. 158 was admitted to the hospital with a diagnosis of Constrained inguinal hernia on the right.

Complaints about a suddenly appeared protrusion in the right inguinal region, not setting in the abdominal cavity, anxiety. The duration of the disease is three hours.

Objectively: On palpation in the right inguinal region, a tumor-like formation of a dense-elastic consistency is determined that cannot be adjusted into the abdominal cavity.

After premedication in the form of intramuscular injection of Atropine solution 0.1% - 0.1 ml and Diphenhydramine solution 1% - 0.1 ml, the patient received intubation anesthesia. After processing the surgical field, a 5 mm trocar was installed in the supra umbilical region and a 5 mm OLYMPUS optical system was introduced; in addition, 5 mm trocars for working instruments were installed in the right and left iliac regions. An audit of the abdominal organs revealed a strangulated right ovary and a right fallopian tube. After the introduction of the muscle relaxant drug, while tightening with the endo-clamp for the restrained ovary, he settled, with a visual examination there were no signs of necrosis of the latter. Then, using the “PROLEN” 2 \ 0 thread on the atraumatic needle, the inner inguinal ring was sutured and the hernia was closed, and a Z-shaped suture was additionally applied. The trocars are recovered, carbon dioxide is released from the abdominal cavity. The skin accesses are sutured with silk sutures.

The postoperative period was uneventful. At the control examination after 3 months, no relapse was detected.

Example 2. Patient X., 3 years old, no. 198. Diagnosis: Restrained inguinal hernia on the left.

Complaints of a sudden protrusion in the left inguinal region, not settling in the abdominal cavity, anxiety, fever. The term of the disease is more than 18 hours.

Objectively: Upon palpation in the left inguinal region, a tumor-like formation is determined, a tense, dense consistency, not adjusted into the abdominal cavity, hyperemia.

On a survey radiography of the abdominal organs, Kloiber's bowls and other indirect signs of intestinal obstruction are determined. After premedication in the form of intramuscular injection of Atropine solution 0.1% - 0.1 ml and Diphenhydramine solution 1% - 0.1 ml, the patient received intubation anesthesia. After processing the surgical field, diagnostic laparoscopy was performed. An audit of the abdominal organs revealed a strangulated loop of the small intestine. After the introduction of muscle relaxants, the loop was diluted, it was visually revealed that the loops of the ileum were necrotic. It was decided to perform a herniolaparotomy. Measures aimed at restoring the vitality of the affected area are unsuccessful. Resection of a necrotic altered section of the intestine within healthy tissues was performed with the end-to-end anastomosis applied. The outcome is favorable.

Thus, when a patient with a strangulated inguinal or inguinal-scrotal hernia is admitted to the patient, a diagnostic laparoscopy is performed, and at the same time, a dilution is performed under video control and the condition of the strangulated organs is evaluated. While maintaining the viability of the organ that was impaired, laparoscopic suturing of the hernial portal is performed - the internal inguinal ring and the ungrown vaginal process of the peritoneum. When detecting necrotic changes in a restrained organ, surgical treatment is indicated - herniolaparotomy and, if necessary, resection of the changed area.

The method of endosurgical treatment of strangulated inguinal and inguinal-scrotal hernias in children can be used by children in conjunction with endoscopists, as well as other specialists involved in surgical pathology in children. The method is reproducible in a hospital environment and when it is used, the indicated technical result is achieved. Thus, the claimed invention meets the criterion of "industrial applicability".

Claims (1)

A method for endosurgical treatment of strangulated inguinal and inguinal-scrotal hernias in children, including laparoscopic dilatation by pulling endoscopic tissue of the strangulated organ after administration of muscle relaxants, laparoscopic suturing of the hernial portal at the level of the internal inguinal ring without mobilizing the elements of the spermatic cord with viable and restrained organ, if necessary resection of the changed area in the presence of signs of necrosis.