RU2286721C1 - Method for surgical treatment of inguinal hernias - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: the present innovation deals wit treating inguinal hernias surgically due to applying a reticulated polypropylene endoprosthesis. One should dissect lateral edge of endoprosthesis into two parts: 1/3 above and 2/3 below a spermatic funiculus, dissect the upper edge of endoprosthesis after its fixation in its middle part, in the site of iliohypogastricus nerve location for the length that corresponds to 1/6 against the width of endoprosthesis. The innovation enables to avoid compression of n.iliohypogastricus and prevent neuralgia.

EFFECT: higher efficiency of therapy.

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Description

The invention relates to medicine, namely to surgery, and can be used in the surgical treatment of inguinal hernias using mesh endoprostheses.

A widely known method for the surgical treatment of inguinal hernias using a mesh endoprosthesis according to the Liechtenstein technique. The method consists in the fact that the mesh endoprosthesis is intraoperatively cut according to the size of the posterior wall of the inguinal canal by dissecting the lateral edge of the endoprosthesis into 2 parts: 1/3 above and 2/3 below the spermatic cord, with a hole underneath (Orekhovsky V.I. Hannover-Donetsk-Cottbus, 2000, p.136).

However, when using this method, cases of ischemic orchitis were observed, which is associated with compression of the spermatic cord between the lateral edges of the mesh endoprosthesis (Egiev V.N. Non-tensioned hernioplasty. Moscow: Medpraktika-m, 2002, p. 28).

Also known is a hernioplasty method, which is a modification of the Liechtenstein method. The method was modified by A. Gilbert in 1992 (Egiev V.N. Non-tensioned hernioplasty. Moscow: Medpraktika-m, 2002, p. 28). The method consists in plugging the area of the inner inguinal ring with a propylene mesh folded in the form of an umbrella, which prevents the formation of an oblique inguinal hernia and thereby reduces the number of relapses.

However, one of the complications of this method is the development of neuralgia, which may be associated with trauma caused by mesh endoprosthesis (Egiev V.N. Non-tensioning hernioplasty. Moscow: Medpraktika-m, 2002, p. 28).

According to the closest technical essence, the method of Lichtenstein hernioplasty, modified by M. Kich in 1993, was selected as a prototype. The author supplemented the section of the lateral part of the graft with the dovetail type by cutting a round hole for the spermatic cord (Orokhovsky V. I. Basic herniotomy. Hanover Donetsk-Cottbus, 2000, p.136), which prevented the recurrence of a hernia through the opening for the passage of the spermatic cord, as well as prevent the development of ischemic orchitis.

One of the complications of this method is neuralgia, which occurs as a result of compression of nerve fibers by a mesh endoprosthesis. According to published data, pain in the postoperative period occurs from 5-12% (Penchet P., Damas GM, Blum D. Presse Med. 2001 Mar. 30-31 p: Shmitz R., Treckman G., Shah S. Chirurg 1999 sep. 70 (9) p.

The objective of the invention is to preserve iliohypogastricus from nerve compression and the prevention of neuralgia.

The problem is solved in that the mesh endoprosthesis is intraoperatively cut to the size of the posterior wall of the inguinal canal by dissecting the lateral edge of the endoprosthesis into 2 parts: 1/3 above and 2/3 below the spermatic cord, and also cut a hole under it, after fixing the upper edge of the mesh dissected in the middle part to a length corresponding to 1/6 of the width of the mesh polypropylene endoprosthesis.

The method is as follows.

After preparation of the surgical field under local anesthesia, an incision is made in the skin, subcutaneous tissue and superficial fascia 8-10 cm long, 2 cm above the level of the inguinal fold. The aponeurosis of the external oblique muscle of the abdomen is exposed, exfoliating it from the subcutaneous fat. The aponeurosis is dissected from the outside - inward to the external inguinal ring. The spermatic cord is allocated and taken to the holders. With external oblique inguinal hernias, to expose the hernial sac, the membranes of the spermatic cord are dissected. After exposure of the hernial sac, the latter is seized at the bottom, opened. If the bag contains hernial contents, it is carefully inserted into the abdominal cavity. The bag is stitched at the neck and cut off 1.5-2 cm distal to the ligation site. With direct inguinal hernias, the bag is placed unopened and the transverse fascia is sutured. The reconstruction phase begins with mesh modeling. Polypropylene mesh is cut to the size of the back wall of the inguinal canal. An incision is made in the lateral edge of the mesh, dividing it into 2 parts: 1/3 above and 2/3 below the spermatic cord, and a hole is cut under it. Next, the mesh is laid on the back wall of the inguinal canal, behind the spermatic cord. The first seam mesh is hemmed to the periosteum of the pubic bone. Then, the lower edge of the mesh is continuously sutured to the inguinal ligament, going beyond the inner opening of the inguinal canal. The upper edge of the mesh is sutured to the vagina of the rectus abdominis muscle. At the nerve passage site iliohypogastricus, the upper edge of the mesh is cut to a length corresponding to 1/6 of the width of the endoprosthesis. The lateral part of the mesh with interrupted sutures is sutured to the tendon of the internal oblique muscle. The internal edges of the cut "tail" of the endoprosthesis after passing through the spermatic cord are sewn together with each other with the formation of a new internal inguinal ring. The operation is completed by restoring the anterior wall of the inguinal canal and suturing the skin wound.

An essential distinguishing feature of the proposed method is the dissection of the upper edge of the mesh in its middle part by a length corresponding to 1/6 of the width of the mesh polypropylene endoprosthesis. Dissection is carried out after fixing the upper edge of the grid. Dissection of the upper edge of the mesh is carried out in the middle part to free up space for the nerve iliohypogastricus, passing in this zone. The length of the cut corresponds to 1/6 of the width of the prosthesis, since such a length is sufficient for the free passage of the nerve iliohypogastricus, which prevents its compression.

Examples of specific performance:

Example 1

Case history No. 18523 Patient A. 66 years. Ds. Bilateral oblique inguinal hernia. The duration of the disease is 3 years. The grid of the company "Linteks", 12/17/03. operation.

In the left inguinal region, after preparing the surgical field under local anesthesia, an incision was made in the skin, subcutaneous tissue and superficial fascia 10 cm long, 2 cm above the level of the inguinal fold. Exposed aponeurosis of the external oblique muscle of the abdomen, exfoliated from subcutaneous fat. The aponeurosis is dissected from the outside - inward to the external inguinal ring. The spermatic cord is isolated and taken to the holders. The shells of the spermatic cord were dissected, a hernial sac of 4-5 cm was isolated, processed, and crossed. Polypropylene mesh is cut according to the size of the posterior wall of the inguinal canal. An incision was made in the lateral edge of the mesh, dividing it into 2 parts: 1/3 above and 2/3 below the spermatic cord, and a hole was cut under it. Next, the mesh is laid on the back wall of the inguinal canal, behind the spermatic cord. The first seam mesh was sewn to the periosteum of the pubis. Then, the lower edge of the mesh is fixed with a continuous suture to the inguinal ligament above the internal opening of the inguinal canal. The upper edge of the mesh is hemmed to the vagina of the rectus abdominis muscle. At the nerve passage site iliohypogastricus, the upper edge of the mesh in its middle part is dissected to a length corresponding to 1/6 of the width of the endoprosthesis. The lateral part of the mesh with interrupted sutures is sutured to the tendon of the internal oblique muscle. The inner edges of the cut "tail" of the endoprosthesis after passing through the spermatic cord are sewn together with the formation of a new internal inguinal ring. The operation was completed by restoration of the anterior wall of the inguinal canal and suturing of the skin wound.

In the right inguinal region, after preparing the surgical field under local anesthesia, an incision was made in the skin, subcutaneous tissue and superficial fascia 10 cm long, 2 cm above the level of the inguinal fold. Exposed aponeurosis of the external oblique muscle of the abdomen, exfoliated from subcutaneous fat. The aponeurosis is dissected from the outside - inward to the external inguinal ring. The spermatic cord is isolated and taken to the holders. The membranes of the spermatic cord were dissected, a hernial sac of 4-3 cm was isolated, processed, and crossed. Polypropylene mesh is cut according to the size of the posterior wall of the inguinal canal. An incision was made in the lateral edge of the mesh, dividing it into 2 parts: 1/3 above and 2/3 below the spermatic cord and a hole was cut under it. Next, the mesh is laid on the back wall of the inguinal canal, behind the spermatic cord. The first seam mesh was sewn to the periosteum of the pubis. Then, the lower edge of the mesh is fixed with a continuous suture to the inguinal ligament above the internal opening of the inguinal canal. The upper edge of the mesh is hemmed to the vagina of the rectus abdominis muscle. At the nerve passage site iliohypogastricus, the upper edge of the mesh in its middle part is dissected to a length corresponding to 1/6 of the width of the endoprosthesis. The lateral part of the mesh with interrupted sutures is sutured to the tendon of the internal oblique muscle. The inner edges of the cut "tail" of the endoprosthesis after passing through the spermatic cord are sewn together with the formation of a new internal inguinal ring. The operation was completed by restoration of the anterior wall of the inguinal canal and suturing of the skin wound.

Example 2

Case history No. 2138 Patient H. 72 years. Ds. Bilateral direct inguinal hernia. The duration of the disease is 12 years. 02/05/04. operation of the proposed method. Grid of Linteks firm.

In the left inguinal region, after preparing the surgical field under local anesthesia, an incision was made in the skin, subcutaneous tissue and superficial fascia 10 cm long, 2 cm above the level of the inguinal fold. Exposed aponeurosis of the external oblique muscle of the abdomen, exfoliated from subcutaneous fat. The aponeurosis is dissected from the outside - inward to the external inguinal ring. The spermatic cord is isolated and taken to the holders. The hernial sac 6-6 cm in size is set unopened and the transverse fascia is sutured. Polypropylene mesh is cut according to the size of the posterior wall of the inguinal canal. An incision was made in the lateral edge of the mesh, dividing it into 2 parts: 1/3 above and 2/3 below the spermatic cord, and a hole was cut under it. Next, the mesh is laid on the back wall of the inguinal canal, behind the spermatic cord. The first seam mesh was sewn to the periosteum of the pubis. Then, the lower edge of the mesh is fixed with a continuous suture to the inguinal ligament, above the inner opening of the inguinal canal. The upper edge of the mesh is hemmed to the vagina of the rectus abdominis muscle. At the nerve passage site iliohypogastricus, the upper edge of the mesh in its middle part is dissected to a length corresponding to 1/6 of the width of the endoprosthesis. The lateral part of the mesh with interrupted sutures is sutured to the tendon of the internal oblique muscle. The inner edges of the cut "tail" of the endoprosthesis after passing through the spermatic cord are sewn together with the formation of a new internal inguinal ring. The operation was completed by restoration of the anterior wall of the inguinal canal and suturing of the skin wound.

In the right inguinal region, after preparing the surgical field under local anesthesia, an incision was made in the skin, subcutaneous tissue and superficial fascia 10 cm long, 2 cm above the level of the inguinal fold. Exposed aponeurosis of the external oblique muscle of the abdomen, exfoliated from subcutaneous fat. The aponeurosis is dissected from the outside - inward to the external inguinal ring. The spermatic cord is isolated and taken to the holders. The hernial sac 6-4 cm in size is set unopened, the transverse fascia is sutured. Polypropylene mesh is cut according to the size of the posterior wall of the inguinal canal. An incision was made in the lateral edge of the mesh, dividing it into 2 parts: 1/3 above and 2/3 below the spermatic cord, and a hole was cut under it. Next, the mesh is laid on the back wall of the inguinal canal, behind the spermatic cord. The first seam mesh was sewn to the periosteum of the pubis. Then, the lower edge of the mesh is fixed with a continuous suture to the inguinal ligament, above the inner opening of the inguinal canal. The upper edge of the mesh is hemmed to the vagina of the rectus abdominis muscle. At the nerve passage site iliohypogastricus, the upper edge of the mesh in its middle part is dissected to a length corresponding to 1/6 of the width of the endoprosthesis. The lateral part of the mesh with interrupted sutures is sutured to the tendon of the internal oblique muscle. The inner edges of the cut "tail" of the endoprosthesis after passing through the spermatic cord are sewn together with the formation of a new internal inguinal ring. The operation was completed by restoration of the anterior wall of the inguinal canal and suturing of the skin wound.

Example 3

Case history No. 5535. Patient M., 59 years old. Ds. Right oblique inguinal hernia. The duration of the disease is 2 years, 03/31/04. operation. Netting company "Ethikon".

In the right inguinal region, after preparing the surgical field under local anesthesia, an incision was made in the skin, subcutaneous tissue and superficial fascia 10 cm long, 2 cm above the level of the inguinal fold. Exposed aponeurosis of the external oblique muscle of the abdomen, exfoliated from subcutaneous fat. The aponeurosis is dissected from the outside - inward to the external inguinal ring. The spermatic cord is isolated and taken to the holders. The shells of the spermatic cord were dissected, the hernial sac of 2-2 cm was isolated, processed, and crossed. Polypropylene mesh is cut according to the size of the posterior wall of the inguinal canal. An incision was made in the lateral edge of the mesh, dividing it into 2 parts: 1/3 above and 2/3 below the spermatic cord, and a hole was cut under it. Next, the mesh is laid on the back wall of the inguinal canal, behind the spermatic cord. The first seam mesh was sewn to the periosteum of the pubis. Then, the lower edge of the mesh is fixed with a continuous suture to the inguinal ligament above the internal opening of the inguinal canal. The upper edge of the mesh is hemmed to the vagina of the rectus abdominis muscle. At the nerve passage site iliohypogastricus, the upper edge of the mesh in its middle part is dissected to a length corresponding to 1/6 of the width of the endoprosthesis. The lateral part of the mesh with interrupted sutures is sutured to the tendon of the internal oblique muscle. The inner edges of the cut "tail" of the endoprosthesis after passing through the spermatic cord are sewn together with the formation of a new internal inguinal ring. The operation was completed by restoration of the anterior wall of the inguinal canal and suturing of the skin wound.

Example 4 (by the prototype method).

Case history No. 16305 Patient K. 63, Ds. Bilateral direct inguinal hernia. Duration of the disease 2 years, operation 11.11.04. Grid of Linteks firm.

In the right inguinal region, after preparing the surgical field under local anesthesia, an incision was made in the skin, subcutaneous tissue and superficial fascia 10 cm long, 2 cm above the level of the inguinal fold. Exposed aponeurosis of the external oblique muscle of the abdomen, exfoliated from subcutaneous fat. The aponeurosis is dissected from the outside - inward to the external inguinal ring. The spermatic cord is isolated and taken to the holders. The hernial sac 3-4 cm in size is set unopened, the transverse fascia is sutured. Polypropylene mesh is cut according to the size of the posterior wall of the inguinal canal. An incision was made in the lateral edge of the mesh, dividing it into 2 parts: 1/3 above and 2/3 below the spermatic cord, and a hole was cut under it. Next, the mesh is laid on the back wall of the inguinal canal, behind the spermatic cord. The first seam mesh was sewn to the periosteum of the pubis. Then, the lower edge of the mesh is fixed with a continuous suture to the inguinal ligament, above the inner opening of the inguinal canal. The upper edge of the mesh is hemmed to the vagina of the rectus abdominis muscle. The lateral part of the mesh with interrupted sutures is sutured to the tendon of the internal oblique muscle. The inner edges of the cut "tail" of the endoprosthesis after passing through the spermatic cord are sewn together with the formation of a new internal inguinal ring. The operation was completed by restoration of the anterior wall of the inguinal canal and suturing of the skin wound.

In the left inguinal region, after preparation of the operating room, the field under local anesthesia, an incision was made of the skin, subcutaneous tissue and superficial fascia 10 cm long, 2 cm above the level of the inguinal fold. Exposed aponeurosis of the external oblique muscle of the abdomen, exfoliated from subcutaneous fat. The aponeurosis is dissected from the outside - inward to the external inguinal ring. The spermatic cord is isolated and taken to the holders. The hernial sac 4–4 cm in size is set unopened and the transverse fascia is sutured. Polypropylene mesh is cut according to the size of the posterior wall of the inguinal canal. An incision was made in the lateral edge of the mesh, dividing it into 2 parts: 1/3 above and 2/3 below the spermatic cord, and a hole was cut under it. Next, the mesh is laid on the back wall of the inguinal canal, behind the spermatic cord. The first seam mesh was sewn to the periosteum of the pubis. Then, the lower edge of the mesh is fixed with a continuous suture to the inguinal ligament above the internal opening of the inguinal canal. The upper edge of the mesh is hemmed to the vagina of the rectus abdominis muscle. The lateral part of the mesh with interrupted sutures is sutured to the tendon of the internal oblique muscle. The inner edges of the cut "tail" of the endoprosthesis after passing through the spermatic cord are sewn together with the formation of a new internal inguinal ring. The operation was completed by restoration of the anterior wall of the inguinal canal and suturing of the skin wound.

In the postoperative period throughout the year, the patient K., 63 years old, who 11.11.04. the operation was performed according to the prototype method, pain remained in the area of the postoperative wound on the left, which corresponds to the innervation zone of n.iliohypogastricus, and is associated with its compression.

The total number of operated patients with inguinal hernias according to the claimed method was 100 people who during the years 2001-2004 underwent hernioplasty "without tension" using mesh polypropylene implants.

The group is represented by 88 men and 12 women. The average age was 69.5 ± 6.8 years and ranged from 55 to 92 years. Most patients were between 65 and 75 years old (56%). The average patient weight was 70.1 ± 8.0 kg and ranged from 45 to 120 kg. The duration of hernias was from 1 month to 30 years and averaged 4.3 ± 0.9 years.

Most patients had a right-sided inguinal hernia (49 patients - 49%). In 18 cases (18%), bilateral inguinal hernia was detected. Oblique hernias occurred in 53 patients (53%), direct in 38 (38%). In 7 cases, a combination of a direct and oblique hernia was noted with bilateral lesions of the inguinal regions (7%). Inguinal-scrotal hernia was detected in 17 patients (17%).

Compared with the prototype of the proposed method can reduce the number of neuralgia. According to the literature, when using the prototype method, pain in the postoperative period occurs from 5% -12% (Penchet P., Damas GM, Blum D. Presse Med. 2001 Mar. 30-31: Shmitz R., Treckman G., Shah S. Chirurg 1999 sep. 70 (9) p. In the proposed method, neuralgia is 1%, which can be caused by involvement of nerve fibers in the scar formation zone (the number of examined 100 people).

Claims (1)

A method for the surgical treatment of inguinal hernias, including the use of a mesh polypropylene endoprosthesis, dissection of the lateral edge of the endoprosthesis into two parts: 1/3 above and 2/3 below the spermatic cord, forming holes in the endoprosthesis for the spermatic cord, characterized in that after the upper edge of the endoprosthesis is fixed, dissect the upper edge of the endoprosthesis in the middle part, at the site of passage of the nerve iliohypogastricus, to a length corresponding to 1/6 of the width of the endoprosthesis.