RU2303403C1 - Method for carrying out inguinal canal combined plastic repair without tension - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves transferring spermatic cord into prepiretoneal cellular tissue. Narrow lateral part of inguinal space is removed by suturing free interior oblique and transverse muscle end to the inguinal ligament. The remaining free space of medial inguinal space is covered with polypropylene net rag cut out corresponding to shape and size requirements. The rag is sutured to anterior surface of the internal oblique muscle in the upper part and to the inguinal ligament in the lower part. The rag is cut in the internal angle with linear incision from top to down 3-4 cm far from the internal rag edge to the middle of the superoinferior size. The whole spermatic cord is enveloped with the cut halves and fixed to deep direct muscle sheath leaf. New deep canal ring is formed for the spermatic cord from the polypropylene net. New superficial inguinal canal aponeurotic ring is produced in deep ring projection.

EFFECT: prevented spermatic cord flexion; avoided spermatic cord ingrowths into cicatricial tissue.

5 dwg

Description

The invention relates to medicine, namely to herniology, i.e. doctrine of hernias.

There are known methods in which the inguinal canal as such is eliminated and a new bed for the spermatic cord is created, namely, the methods of Holstedt and Wreden (1893), Krymov (1926), Kirchner (1933) and others (N.I. Kukujanov. Inguinal hernias .-- M .: Medicine, p. 181 and 182).

Among them, the closest to the claimed method are the Lichtenstein I. method, proposed in 1989 (V.V. Zhebrovsky, F.N. Ilchenko, “Atlas of operations for abdominal hernias.” - Simferopol, 2004, 92 pp.) And the combined tensionless method plastic inguinal canal according to Koshev-Petrov (a positive decision on the grant of a patent for an invention No. 2004103648/14 (003864) dated 09.02.2004). For plasty of hernia gates according to the Lichtenstein I. method, a polypropylene mesh is used, from which a patch of 6 × 12 cm is cut out. This flap of the polypropylene mesh is laid under the spermatic cord and fixed from the bottom with interrupted sutures to the inguinal ligament. The upper edge of the mesh is hemmed with interrupted sutures to the internal oblique muscle. An inner inguinal ring is formed by locating the spermatic cord in the section of the polypropylene mesh made in its middle in the lateral part of the flap of the polypropylene mesh and surround the spermatic cord with these parts of the dissected mesh in the form of a “dovetail”. The rounded lower end of the mesh is fixed with 2-3 sutures to the pubic tubercle with the capture of the scallop ligament in order to prevent the development of a femoral hernia.

However, the disadvantages of this method include the strengthening of only part of the weak spot in the posterior wall of the inguinal canal, namely the inguinal gap. The other part of the weak spot, located in the lateral part of the posterior wall of the inguinal canal, the deep canal ring, the fascial funnel of the testicular canal, is not eliminated, but only covered from the surface with rags of polypropylene mesh in the form of a "dovetail". Neglect of radical treatment of the fascial funnel of the testicular canal makes this method of plasty not completely reliable and gives 0.5% hernia recurrence in the postoperative period. According to the Koshev-Petrov combined tension-free method, only one third of the new deep canal ring is formed due to the polypropylene mesh and does not completely cover the spermatic cord, and when the surface ring for the spermatic cord is formed outward from the deep, it is sharply bent.

The aim of the invention is the radical strengthening of both the inguinal gap and the deep ring of the inguinal canal by tensionless technology using local tissues and a polypropylene mesh while using it to form a new deep ring for the spermatic cord, without bending it to form the surface ring.

The essence of the proposed method lies in the fact that after dissection of the anterior wall of the inguinal canal, isolation, processing and removal of the hernial sac by known methods, the spermatic cord is fully mobilized in the deep ring of the inguinal canal by circular dissection together with the muscle that lifts the testicle, its fascial membrane, and not limited only to partial removal of m. cremaster in the transitional section of the spermatic cord, thus preserving the fascial-muscular funnel and the possibility of hernia recurrence. The transverse fascia is dissected by a linear incision parallel to the inguinal ligament behind the spermatic cord towards the outer edge of the rectus sheath, the spermatic cord is moved into the preperitoneal tissue and the transverse fascia is sutured over it to the edge or with a duplicature using atraumatic needles with a continuous suture. The narrow, lateral part of the inguinal gap is closed without tension by local tissues, i.e. hem the free edge of the internal oblique and transverse muscles to the inguinal ligament with 3-4 sutures. A polypropylene mesh is placed on the sutured transverse fascia covering the spermatic cord, moved into the preperitoneal fiber, the inguinal space is covered with it and the edges are sewn with atraumatic needles, with a continuous suture: below to the inguinal ligament, and above to the front surface and the joint tendon of the internal oblique and transverse muscles. In the inner corner of the operative wound, the polypropylene mesh is dissected linearly from top to bottom, departing outward from the inner edge by 3-4 cm, parallel to its middle edge to the middle of the upper-lower size of the polypropylene mesh, cover the spermatic cord with formed patches, fix them to the deep aponeurotic leaf of the vagina the rectus muscle, on top of the spermatic cord removed from under the transverse fascia, and below its polypropylene mesh, is fixed to the pubic ligament, a new deep ring for the seminal the cord. Then atraumatic needles connect the edges of the dissected aponeurosis of the external oblique muscle from the outside inward with single interrupted edge-to-edge sutures. In the inner corner of the stitched aponeurosis create a new surface ring for the spermatic cord, located in the projection of the deep ring of the channel for the spermatic cord. Adaptation sutures restore the layering of surface tissues in the area of operative access.

The method is as follows. The operation is performed under combined endotracheal anesthesia. A gerniotomy is performed from operative access according to Kocher with dissection of the anterior wall of the inguinal canal. Isolation, revision, processing and removal of the hernial sac is performed by known methods.

Plastic surgery of the hernia gate begins with mobilization of the spermatic cord by circular dissection, together with the muscle that lifts the testis, of the fascial membrane (funnel) of the spermatic cord at the deep ring of the inguinal canal. Behind the spermatic cord, the transverse fascia is cut inwards from the deep ring of the inguinal canal, parallel to the inguinal ligament, to the outer edge of the rectus sheath (Fig. 1). Immerse the spermatic cord in the preperitoneal tissue and suture the dissected transverse fascia of the abdomen in front of the spermatic cord with a continuous suture with atraumatic needles or create duplicate from it (Fig.2).

Taking into account the advantages of combined tension-free technology, the narrow lateral part of the inguinal gap is closed with local tissues by suturing the internal oblique and transverse muscles to the inguinal ligament with 3-4 interrupted sutures without undue tension and compression of the tissues (Fig. 3). All the free space of the remaining inguinal gap, with the exception of the medial angle, where the spermatic cord is now located, is covered with a flap of polypropylene mesh cut in shape and size and hemmed from below to the inguinal ligament, iliac-pubic tract, and above to the outer surface of the internal oblique muscle 1.5-2 cm above its edge. In the inner corner of the surgical wound, the mesh is dissected by a linear incision from top to bottom, extending outward 3-4 cm from the inner edge of the polypropylene mesh, to the middle of the upper-lower size, parallel to its inner edge, covered with spermatic cord formed by rags, fix them to a deep aponeurotic leaf of the vagina the rectus muscle, on top of the spermatic cord removed from under the transverse fascia, and below it, the mesh is fixed to the pubic ligament, a new deep ring for the spermatic cord is formed (Fig. 4). Then, atraumatic needles connect the edges of the dissected aponeurosis of the external oblique muscle from the outside to the inside with single interrupted “edge to edge” sutures (Fig. 5). In the inner corner of the stitched aponeurosis, a new surface ring for the spermatic cord is created from it, located in the projection of the deep, newly formed deep ring of the inguinal canal. Adaptation sutures restore the layering of surface tissues in the area of operative access.

The inventive method is illustrated by drawings (Fig.1-5), reproducing the stages of plastic inguinal canal, where

1) spermatic cord;

2) The dissected fascial membrane of the spermatic cord along with the muscle that raises the testicle and dissected, parallel to the inguinal ligament, the transverse fascia (posterior wall of the inguinal canal);

3) the upper edge of the dissected aponeurosis of the external oblique muscle (the front wall of the inguinal canal);

4) The lower edge of the dissected aponeurosis of the external oblique muscle (the front wall of the inguinal canal);

5) the free edge of the internal oblique muscle (upper wall of the inguinal canal);

6) a polypropylene mesh covering the inguinal gap and taking part in the formation of the deep inguinal ring;

7) the newly formed deep inguinal ring;

8) a new superficial inguinal ring, in the projection of a deep ring;

9) inguinal ligament.

Example: a patient K.V.K., 51 years old, a worker, entered the surgical department of MSC-17 of Samara on December 7, 2004 for a planned operation (medical history - 2366). Diagnosis at admission: left-sided recurrent inguinal hernia. First time operated on for a left-sided oblique inguinal hernia in 1995. Relapse after 8.5 years. December 7, 2004, under combined endotracheal anesthesia, an operation was performed (surgeon — head of the surgical department Antipov V. D., operational journal No. 155) according to the proposed method. The patient was examined by an operating surgeon after 6 months. The results of the operation are good. The patient does not show complaints. There is no recurrence of a hernia.

The proposed method is less traumatic. It combines the advantages of the most effective modern methods of surgical treatment of inguinal hernias. From Sholdays, we borrowed from the deep multilayer plastic of the inguinal canal the stage of mobilization of the spermatic cord from the posterior wall by dissection of the fascial-muscular funnel, which directs the hernial sac under the membranes of the spermatic cord during the formation of oblique inguinal hernia. However, leaving the spermatic cord in the same place without forming a new deep ring is a drawback of the Goldies method, which we eliminate by moving the spermatic cord into the preperitoneal tissue. The principle of tension-free hernioplasty implemented in the method of Liechtenstein 1, from which we borrowed the principle of tension-free reinforcement of hernial gates and the technology of using a polypropylene mesh for this.

The disadvantages of the Liechtenstein method include the strengthening of the deep ring of the inguinal canal with a "dovetail" while maintaining its fascial-muscular funnel. This circumstance is the cause of recurrence of inguinal hernias in 0.5% of cases. The proposed method for improving the method of Liechtenstein by mobilizing the spermatic cord and moving it into the preperitoneal fiber eliminates this small percentage of relapses.

In contrast to the Koshev-Petrov method, in which one third of the circumference of a new deep ring is formed by means of a polypropylene mesh, we propose to cover the spermatic cord from all sides with a polypropylene mesh by creating a “dovetail” as Liechtenstein does in the first plastic method. This technique allows you to abandon the sharp bend of the spermatic cord with lateral abduction to form the surface ring of a new inguinal canal, to avoid the ingrowth of elements of the spermatic cord into the scar tissue.

For such cases, we offer a lightweight combined method of plasty of the inguinal gap with the complete elimination of the deep canal ring, reinforcing it with a polypropylene mesh, dissecting it in the medial corner with a cut into two flaps, which, covering the spermatic cord from all sides, allow you to form a new deep ring for the spermatic the cord. This method will be most effective for large, combined and recurrent inguinal hernias in the face of gross changes in the topography of the inguinal canal.

The claimed method can be recommended in medical practice.

Claims (1)

A method of tensionless combined inguinal canal plasty, including the formation of a new bed for the spermatic cord, new deep and superficial inguinal canal rings, characterized in that the spermatic cord is mobilized by circular dissection, together with the muscle raising the testicle, of the fascial membrane of the spermatic cord at the deep ring of the inguinal canal, dissect the transverse fascia behind the spermatic cord towards the outer edge of the rectus sheath, move the spermatic cord into the preperitoneal tissue and suture the transverse fascia with a continuous continuous suture, the narrow lateral part of the inguinal space is eliminated by suturing the free edge of the internal oblique and transverse muscles to the inguinal ligament, and the remaining free space of the medial part of the inguinal space is covered with a polypropylene mesh flap cut out in shape and size, and a flap is sewn from above to the front surface of the internal oblique muscle, and below - the inguinal ligament, in the inner corner the flap is dissected with a linear incision from top to bottom, retreating 3-4 cm from its internal about the edge, to the middle of the upper-lower mesh size, it covers the spermatic cord on all sides with its dissected halves and fixes them to the deep leaf of the rectus sheath, forms a new deep ring of the canal for the spermatic cord from the polypropylene mesh, connect the edges of the dissected with single interrupted sutures from the outside inward aponeurosis of the external oblique muscle, form a new superficial aponeurotic ring of the inguinal canal in the projection of the deep ring.

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