RU2313292C2 - Surgical method for treating inguinal and femoral hernia cases oblique transverse inguinal preperitoneal miniapproach - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves making incision in inguinal region, 1 cm above the deep inguinal canal orifice projection, towards the middle point of inguinal fold. Parietal peritoneum is detached to expose hypogastric blood vessels. The deep inguinal canal orifice projection is sonographically determined for the miniapproach purposes.

EFFECT: avoided inferior abdominal nerve branches injury; prevented denervation and relaxation of inferior direct abdominal muscle segment.

2 cl, 2 dwg

Description

The invention relates to medicine, namely to surgical methods of treatment, and can be used in surgical treatment of inguinal and femoral hernias without opening the inguinal canal.

External abdominal hernias are one of the most common surgical diseases and occur in 7% of the population. Among the external hernias of the abdominal wall, the most common are inguinal, which account for 65-80% of the total number of hernias (Toskin K.D., Zhebrovsky V.V. Hernia of the abdomen. M., 1983; 137-155. Toskin K.D., Zhebrovsky VV Hernia of the abdominal wall. M., 1990. Cherenko MP and other Abdominal hernias. Kiev, 1995). The frequency of operations for inguinal hernias are in one of the first places among all planned surgical interventions. More than 1 million operations for inguinal hernias are performed annually in the world. In Russia, they are performed more than 200 thousand a year (Fedorov V.D. et al. Principles of surgical treatment of inguinal hernias. Surgery, 1991; 1; 59-63. Cherenko MP and other Abdominal hernias. Kiev, 1995) .

The urgency of the problem of surgical treatment of inguinal hernias is explained by a rather large number of relapses without a tendency to decrease (up to 10% with conventional and up to 30% with complex types of hernias), as well as other postoperative complications - neurin, epididymitis, ischemic orchitis, purulent-inflammatory complications from operating wounds, etc. (Nesterenko Yu.A., Serochkin G.G. Results of surgical treatment of recurrent inguinal hernias. Vestn. Khir., 1986; 2; 57-59. Fedorov V.D. et al. Principles of surgical treatment of inguinal hernias. Surgery, 1991; 1; 59-63. Kananovich EP). Currently, in the treatment of inguinal hernias, endovascular surgical techniques with closing hernial glands with synthetic explants (polypropylene mesh) are becoming more widespread. In addition to this method of "non-tight" reconstruction of the inguinal canal, an operation developed by I. Lichtenstein et al. Is widely used. In 1989-1991 (Lichtenstein I. L. et al. The tension-free hemioplasti. Am. J. Surg. 1989; 157: 188-193). This option of strengthening the posterior wall of the inguinal canal without tension ensures low invasiveness of the surgical intervention, a favorable course of the postoperative period, and quick medical and social rehabilitation of patients. The use of synthetic implants significantly reduced the rate of hernia recurrence - to 1.1-2.2% (Toy F.K., Smoot RT Laparoscopic hernioplasty upelate. Laparoendosc Surg. 1992; 2: 197-205. Toy FK, Smoot RT Toy- Smoot laparoscopic hernioplasty. Surg. Laparosc. Endosc. 1991; 1, 3: 151-155).

There is a method of surgical treatment of inguinal and femoral hernias, which consists in the fact that pararectal access to the preperitoneal space of Pirogov-Bogro is carried out by a vertical incision along the lateral edge of the rectus abdominis muscle (J. "Surgery", 1994, No. 7, p. 48-50). The incision has a length of 8-10 cm and sequentially dissects the anterior and posterior walls of the rectus sheath. Access is carried out below the lunar line, where the posterior wall of the rectus sheath is only the transverse fascia, which is dissected during the medial abduction of the rectus muscle. Plastic surgery is performed using the sickle aponeurosis of the transverse muscle and the iliac-pubic tract. Vertical pararectal access provides good visibility to all anatomical structures of interest and greater freedom of manipulation in the wound.

The disadvantages of this method are: denervation and relaxation of the lower segment of the rectus abdominis muscle, which may cause the formation of a postoperative hernia, the inability to close the groin and femoral ring due to tissue tension due to tissue tension.

A known method of laparoscopic extra-abdominal hernioplasty (Grigoriev S.G. Laparoscopic extra-abdominal hernioplasty. Endoscopic surgery, 1998; 1; 16). It is carried out from an incision in the inguinal region 2.5 cm long using mini-lifting devices. In the slit-like space under the aponeurosis of the external oblique muscle under the control of optics, the spermatic cord is isolated from the underlying tissues - thepartis ligament, transverse fascia, muscles. Isolation and processing of the hernial sac is carried out in an open way. Then, a pre-modeled polypropylene implant is placed under the spermatic cord, which is fixed with a hernial stapler to the pupart and cooper ligaments, transverse fascia.

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 transabdominal extraperitoneal laparoscopic hernioplasty proposed by G. Ferzli et al. (Ferzli GS, Massad A., Albert P. // J. Laparoendosc. Surg. - 1992. - Vol.2, N 6. - P. 281-286 ) Under endotracheal anesthesia, an incision is made in the skin and subcutaneous tissue up to 2.0-2.5 cm under the navel. Aponeurosis is distinguished and dissected in the transverse direction for 2.0-2.5 cm. A balloon device is introduced into the preperitoneal space towards the pubic joint and the parietal peritoneum is peeled off from the anterior abdominal wall by air injection. After removing the balloon device, a trocar 12 mm in diameter is inserted into the incision with a laparoscope. The resulting cavity is maintained by insufflating nitrous oxide into it under a pressure of 8 mm Hg. In the middle of the distance between the navel and the womb along a pararectal line, working trocars with dissectors (5- and 12 mm) are introduced from both sides, with the help of which a hernial sac is released. The pubic bone, inguinal ligament, elements of the spermatic cord, Cooper ligament and lower epigastric vessels are exposed. Next, a polypropylene mesh (with dimensions of at least 13 × 9 cm) is introduced into the preperitoneal space through a 12-mm trocar. The prosthesis is placed in such a way that it covers the zone of formation of a direct and oblique hernia. After installing the implant in the peritoneal space, Redon drainage is introduced through a separate puncture in the inguinal region. Trocars are removed. 1-2 sutures are applied to the wound under the navel.

However, this method is difficult due to the small amount of work space. The number of local complications increases on average 2 times (Tetic C., Frregui M.E. Prevention of Complications of Open and Laparoscopic Repair of Groin Hernias. Principles of Laparoscopic Surgery. Basic and Advanced Techniges. Springer - Veriag, 1995; 439-449 ) One of the unpleasant complications that discredit the technique is damage to the peritoneum, especially in patients with a history of operations (appendectomy). The resulting pneumoperitoneum makes visualization even more difficult, and defects are difficult to seal hermetically, and sometimes even see. Other disadvantages that limit the widespread use of this operation are the high cost, the need for general anesthesia, multiple punctures of the anterior abdominal wall, and mesh migration.

The prior art method for the same purpose and having the greatest number of common features with those declared according to RU 2160562, publication 12/20/2000: oblique transperitoneal mini-access, separation of the parietal peritoneum from the anterior abdominal wall by introducing a retroperitoneoscope into the mini-access towards the inner, outer rings of the inguinal canal , isolation of the pubic articulation, detachment of the peritoneum to the edge of the rectus abdominis muscle until the visualized space is adequate to the size of the implanted mesh. As the retroperitoneoscope advances, its blades are successively replaced from smaller to larger. The advantages of the proposed method of surgical treatment is the use of a retroperitoneoscope avoids the negative effects of intense pneumoperitoneum.

The disadvantages of this method are: the invasiveness of the operation, both due to the size of the incision and remote manipulation during the plastic surgery of the inguinal canal, the impossibility of reliable fixation of the mesh in the preperitoneal space due to the significant depth of the wound and the small angle of the surgical action.

The technical result consists in improving the quality of surgical treatment of patients with inguinal and femoral hernias with the use of a preperitoneoscope, preoperative echolocation of the deep inguinal ring to access its projection, which reduces the distance between the surgical correction zone and the surgical wound, facilitating and increasing the reliability and safety of manipulations to strengthen all the "weak" places of the inguinal region.

The technical result is achieved by the fact that the method of surgical treatment for inguinal and femoral hernias with oblique inguinal preperitoneal mini-access is performed using a preperitoneoscope, after preliminary ultrasound mapping of the deep opening of the inguinal canal, in its projection, which provides reliable visual control while strengthening all the "weak" places of the inguinal region , due to a decrease in the depth of the wound and an increase in the angle of surgical action.

A method is proposed for the surgical treatment of inguinal and femoral hernias, including oblique inguinal mini-access, isolation and removal of the hernial sac with subsequent closure of the hernial portal, plastic surgery and layer-by-layer wound closure.

The essence of our proposed method of preperitoneal hernioplasty from oblique transverse inguinal mini-access is as follows.

An oblique inguinal mini-approach is performed after ultrasonography of the inguinal region from the hernial protrusion on the ALOKA SSD-1700 with a 7.5 MHz convex probe. Against the background of the Valsalva test, with straining, a deep hole of the inguinal canal was located on the side of the hernial protrusion. Then a point was set 1.0 cm above (cephalically) the projection of the deep opening of the inguinal canal, which is the medial incision angle. Further from this point, an incision was made up to 3.0 cm in length towards the middle of the inguinal ligament. Sequentially dissected the skin, subcutaneous tissue, aponeurosis of the external oblique muscle of the abdomen. The oblique muscles of the abdomen were stupidly diluted, the transverse fascia was dissected in the direction of the skin incision, and it was stupidly exfoliated from the parietal peritoneum. The spermatic cord was isolated, it was taken on a holder. As a general rule, a hernial sac was treated. Using a preperitoneoscope, a pocket was formed in the preperitoneal space in the zone of "weak" places of the inguinal region for subsequent implantation of a mesh prosthesis. The internal and external opening of the inguinal canal, the pubic joint, the Cooper scallop ligament, the medial edge of the rectus abdominis muscle, and the lower hypogastric vessels served as a reference point for the boundaries of the formation of a space adequate to the size of the implanted mesh. After the stage of herniotomy, in order to strengthen all the weaknesses of the inguinal region, a mesh polypropylene explant was introduced through this access into the peritoneal space using two Billroth clamps in a “twisted” form. Reliable fixation of the explant in the preperitoneal space, after its expansion, is achieved by exposure to intraperitoneal pressure in a limited detachable pocket.

The difference of the proposed method is that the use of the proposed method of preperitoneal hernioplasty from oblique inguinal mini-access for hernias of inguinal localization allows to solve the main problems of preperitoneal hernioplasty and has several advantages compared to the prototype.

1. Provides good exposure and freedom of manipulation in all weak areas of the inguinal region due to additional exfoliation to the lower hypogastric vessels with their preservation (in the deep hole of the inguinal canal, medial inguinal fossa, inner femoral ring, iliac and internal hypogastric vessels); minimizes the depth of the surgical wound.

2. It is less traumatic than all known preperitoneal accesses, as it avoids damage to the branches of the lower abdominal nerves and, therefore, denervation and relaxation of the lower segment of the rectus abdominis muscle.

3. Provides free and reliable installation of a mesh explant, covering all the weaknesses of the inguinal region at the same time.

The invention is illustrated by drawings, where figure 1 shows a section for performing oblique inguinal mini-access in the projection of the "weak" places of the inguinal region, figure 2 is a view of the surgical wound when performing plastic from the side of the peritoneal space.

Figure 1 marked: 1 - the projection of the location of the synthetic prosthesis implanted in the preperitoneal space to strengthen the "weak" places of the inguinal region; 2 - skin incision when performing oblique transverse inguinal mini-access; 3 - projection of the deep opening of the inguinal canal; 4 - the surface ring of the inguinal canal; 5 - femoral ring.

Figure 2 marked: 1 - projection a. et v. epigastrica inferior; 2 - the location of the synthetic prosthesis implanted in the preperitoneal space to strengthen the "weak" places of the inguinal region; 3 - skin incision when performing oblique transverse inguinal mini-access; 4 - projection of the deep opening of the inguinal canal; 5 - the surface ring of the inguinal canal; 6 - femoral ring.

The significance of the differences lies in the fact that the invented method allows to reduce the invasiveness of the operation, to simultaneously close the hernia gate (inguinal, femoral and deep rings) and to reduce the likelihood of complications in the postoperative period by performing preliminary ultrasound mapping of the deep opening of the inguinal canal. That allows you to access the preperitoneal space to all the weaknesses of the inguinal region with a minimum depth of the wound and the greatest angle of the surgical action. Technical simplicity, low invasiveness and freedom of manipulation in the preperitoneal space, under reliable visual control.

Thus, due to the totality of the features of the invention, an improvement in the quality of surgical treatment, reduction in surgical injury, prevention of undesired denervation and relaxation of the lower segment of the rectus abdominis muscle are achieved; guaranteeing the strengthening of all the weaknesses of the inguinal region, reducing the time of inpatient and outpatient treatment, which leads to an economic effect. The method can be illustrated by example.

Example. Patient T., 60 years old, medical history 7559.

He entered the surgical department for planned surgical treatment for a right-sided inguinal hernia. The term hernias is 2 years.

The operation was performed. A hernia repair was performed with hernioplasty with a mesh polypropylene explant on the right from the inguinal oblique transperitoneal mini-access.

Operation progress: a skin incision was made 3 cm long by 1 cm above the projection of the internal inguinal ring, subcutaneous tissue, aponeurosis of the external oblique muscle, the internal oblique muscle, the transverse muscle were stupidly diluted. Through the mini-access, a preperitoneoscope was inserted into the preperitoneal space. A bluntly preperitoneoscope and tupfer formed a pocket in the preperitoneal space in the zone of "weak" places of the inguinal region for subsequent implantation of a mesh prosthesis. The spermatic cord is taken on a holder. The hypogastric vessels are visualized. A hernial sac was found, isolated, bandaged and cut off. Hemostasis control is persistent. The mesh polypropylene explant was inserted into the preperitoneal space using two Billroth clamps in a “twisted” form so that it overlapped the zones of the femoral ring and both inguinal fossae. Layered stitches on the wound. Aseptic dressing.

The immediate postoperative period was uneventful. Postoperative wound healing by primary intention. Discharged from the hospital on day 3 for outpatient aftercare.

The patient was examined after 6 months, 2 years and 3 years after surgery. No complaints related to the operation. No relapse was detected.

From the above example it is seen that the technical result of the method is achieved.

Claims (2)

1. A method for surgical treatment of inguinal and femoral hernias with an oblique inguinal preperitoneal mini-access, including the isolation of the hernial sac, separation of the parietal peritoneum from the anterior abdominal wall by introducing a preperitoneoscope into the mini-access towards the inner, outer rings of the inguinal canal, highlighting the pubic straight junction, and detaching the abdominal margin abdominal muscles until the required volume of the visualized space is reached, adequate to the size of the implanted mesh, closing the zones of formation of the inguinal and thighs hernias with a polypropylene explant, characterized in that in the inguinal region 1 cm above the projection of the deep opening of the inguinal canal, an incision is made towards the middle of the inguinal fold, the parietal peritoneum is further exfoliated to the hypogastric vessels. 2. The method according to claim 1, characterized in that the projection of the deep opening of the inguinal canal for mini-access is determined sonographically.

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