RU2343851C1 - Method of restoration of inguinal ligament at relapsing inguinal hernias - Google Patents

Abstract

FIELD: medicine; surgery.

SUBSTANCE: exsect old postoperative cicatrix by realisation of the cut bordering hernial diverticulum of a skin and a hypodermic fat. Then from the surrounding tissues allocate the hernial sac to neck and remove at slanting hernias, and at straight lines - invaginate in abdominal cavity. In the subsequent, by means of uniform mesh endoprosthesis, liquidate defect of abdominal wall of inguinal area and restore absent inguinal ligament single-step by anchoring of mesh endoprosthesis from the medial side to the pectineal ligament and to an upper edge of a pubic symphysis using four noose sutures. Further edges of the endoprosthesis, located anteperitoneal, fix to fascia of lumbar muscle, and fix its lateral extremity in front to the remained scraps of the lateral part of inguinal ligament and the top anterior ileal arista. Then endoprosthesis is bent in cranial direction and fix medially to the anterior leaf of vagina of the abdominal rectus muscle. Then, from the cranial side in an endoprosthesis make a cut to a deep inguinal ring for deducing of a seed funicle or round ligament of a uterus. Take in the formed legs of endoprosthesis from the cranial side from the deep inguinal ring in the form of reduplication for formation of deep inguinal ring from the implanted endoprosthesis. And an endoprosthesis fix on all surface of overlapping of an abdominal wall a continuous suture. As a thread use polypropylene thread 2/0, and the mesh endoprosthesis is executed mainly from the polypropylene fibers.

EFFECT: effective restoration of inguinal ligament.

5 cl

Description

Technical field

The invention relates to medicine, in particular to surgery, and can be used for relapse of inguinal hernias with restoration of the inguinal ligament and at the same time strengthening the medial region of the inguinal gap using synthetic endoprostheses.

State of the art

With recurrent inguinal hernias with destruction of the inguinal ligament and a common inguinal-femoral defect in the abdominal wall, surgical intervention is necessary. Currently, surgical treatment of recurrent inguinal hernias with implants is widely used. So, there is a method of surgical treatment of recurrent inguinal hernias with restoration of the inguinal ligament, which is carried out as follows: an exposure is performed in the form of an arc of the skin and subcutaneous tissue up to 1 cm and parallel to the inguinal ligament. Then the inguinal canal is opened and the spermatic cord or uterine ligament is raised upwards, the hernial sac is mobilized, tied around the neck and cut off. After removal of the hernial sac, plastic is performed on the posterior wall of the inguinal canal with local residual tissues. Then, the prepared autodermal flap is sutured at the top for the aponeurosis of the internal oblique muscle of the abdomen, medially and at the bottom for the ligament of Zimbbernati and for the residual scar tissue of the inguinal ligament. At the same time, in the lateral part of the inguinal canal, the flap is sutured for the upper anterior iliac spine, and a new inner inguinal ring is modeled for the lateral edge of the flap. After fixing the skin flap, the spermatic cord or uterine round ligament is placed in the previous position and the front wall of the inguinal canal is duplicated, and then the subcutaneous tissue and skin are sutured (MD 2628 G2 from 11.30.05).

The disadvantage of this method of surgical treatment of inguinal hernias is muscle tension, which contributes to reactive inflammation and significantly negatively affects the patient's vital activity, the resulting tissue tension around the spermatic cord leads to swelling of the scrotum and testicle, as well as a significant number of relapses.

The closest technical solution to the claimed method is a method of surgical treatment of recurrent inguinal hernias, including forming access to the inguinal canal, cutting an aponeurosis of the external oblique muscle of the abdomen, mobilizing the walls of the inguinal canal, taking the spermatic cord to the holder, isolating and removing the hernial sac, cutting the transverse fascia and its detachment from the abdominal tissue, plastic surgery of the posterior wall of the inguinal canal, reconstruction of the inguinal ligament with a polypropylene mesh, fixation of the mesh to the pubic tubercle, cooper the ligament, the remnants of the inguinal ligament, the periosteum of the anterior superior iliac wing and to the transverse aponeurosis and internal oblique muscle of the abdomen (UA 1966 U from 12.15.06).

The disadvantage of this method is delayed complications - muscle tension and the occurrence of late relapses.

Disclosure of invention

The objective of the present invention is to develop a surgical method of plasty in case of recurrent inguinal hernias, which allows to simultaneously restore the inguinal ligament and eliminate the defect of the abdominal wall using a single mesh endoprosthesis.

This problem is solved by implementing a surgical method for restoring the inguinal ligament with recurrent inguinal hernias, in which the old postoperative scar is excised by making an incision bordering the hernial protrusion of the skin and subcutaneous tissue, then the hernial sac is removed from the surrounding tissues to the neck and the hernial sac is removed with oblique hernias, and in direct cases, the hernial sac is invaginated into the abdominal cavity by suturing the transverse fascia, subsequently using a single mesh endoprosthesis at the same time of inguinal region and restore missing inguinal ligament eliminate defects of the abdominal wall by suturing the prosthesis mesh with the medial side to the pectinate ligament and the upper edge of the pubic symphysis four interrupted sutures further part of the endoprosthesis positioned preperitoneal, around the edge fixed to the fascia m. psoas, and its lateral end in front is fixed to the remaining scraps of the lateral part of the inguinal ligament and Spina iliaca anterior superior, after which the endoprosthesis is bent in the cranial direction and fixed medially to the anterior sheet of the vagina of the rectus abdominis muscle, then an incision is made from the cranial side in the endoprosthesis to the deep inguinal rings for excretion of the spermatic cord or uterine round ligament, the formed legs of the endoprosthesis are sutured from the cranial side of the deep inguinal ring in the form of a duplicature to form a deep groin th ring of the implanted endoprosthesis wherein the endoprosthesis is fixed across the abdominal wall surface of the overlap a continuous suture.

2/0 polypropylene suture is used as the thread, and implants made primarily of polypropylene fibers (Prolene, Surgipro, Surgimesh, ESFIL) are used as a mesh endoprosthesis.

Moreover, with a direct hernia, the hernia is eliminated by isolating the hernial sac and immersing it in the abdominal cavity, and with an oblique inguinal hernia, the hernia is eliminated by excising the hernial sac at the level of the crescent edge of the transverse fascia at the inner opening of the inguinal canal.

Using this method of restoring the inguinal ligament with recurrent inguinal hernias allows you to achieve the following technical result:

- minimize early postoperative complications (lack of suppuration and a small percentage of seromas) due to the anatomy and low invasiveness of the intervention,

- prevents the possibility of a femoral hernia,

- avoids the tension of muscle tissue,

- postoperative good condition of the femoral vessels under the newly formed inguinal ligament,

- lack of edema of the lower extremities,

- reduce the percentage (35%) of edema of the scrotum and testis or labia.

According to this technique, we operated on 33 patients. Evaluation of the effectiveness of the method was carried out in the long term from 1 year to 3 years with a direct examination of patients. In the long term, with the proposed method for restoring the inguinal ligament with recurrent inguinal hernias, there are no negative subjective sensations (pain, sensation of an endoprosthesis), and the quality of life of patients improves. Delayed complications, such as swelling of the testicle and its membranes or labia, as well as relapses of inguinal hernias and the occurrence of femoral hernias, were not observed after surgery with this method.

The implementation of the invention

The method of restoring the inguinal ligament with recurrent inguinal hernias includes the main stages of restoration of the inguinal ligament:

- excise the old postoperative scar by performing an incision of the skin and subcutaneous tissue that borders the hernial protrusion,

- a hernial sac is isolated from the surrounding tissue to the neck and the selected sac is opened, bandaged at the base and cut off with oblique hernias, and with direct hernial sac invaginated into the abdominal cavity by suturing the transverse fascia,

- using a single mesh endoprosthesis, immediately eliminate the defect of the abdominal wall of the inguinal region and restore the absent inguinal ligament by suturing the mesh endoprosthesis from the medial side to the scallop ligament and to the upper edge of the pubic symphysis with four interrupted sutures,

- further along the entire edge of the endoprosthesis, located preperitoneally, fix to the fascia m. psoas, and its lateral end, slightly in front, is fixed to the remaining scraps of the lateral part of the inguinal ligament and Spina iliaca anterior superior,

- after completion of fixation of the endoprosthesis to the upper edge of the pubic symphysis, scallop ligament, fascia m. psoas and Spina iliaca anterior superior endoprosthesis are bent in the cranial direction and fixed medially to the anterior sheet of the vagina of the rectus abdominis muscle with subsequent wide overlap of the internal oblique muscle. Thus, the cranial part of the implant widely covers the inguinal-iliac region.

- from the cranial side in the endoprosthesis, an incision is made to the deep inguinal ring for excretion of the spermatic cord or uterine round ligament,

- the formed legs of the endoprosthesis are sutured from the cranial side of the deep inguinal ring in the form of a duplicature to form a deep inguinal ring from the implanted endoprosthesis,

- the endoprosthesis is fixed over the entire surface of the overlapping abdominal wall with a continuous suture.

The endoprosthesis was fixed with suture, for example, Prolene 2/0.

Patient B., 40 years old (medical history No. 2903/2005), was operated on in a planned manner in 2002. At the site of the operation, in the right inguinal region, in 2005 a hernial protrusion appeared, which subsequently began to increase in size. With a diagnosis of recurrent right-sided oblique inguinal hernia, the patient was hospitalized at the Institute for surgical treatment.

12.12.2005, under epidural anesthesia, the operation was performed by the proposed method in accordance with the above main stages of the operation. After suturing the surgical wound, an antiseptic dressing is applied. There were no complications during the operation. The patient feels satisfactory after surgery. 17 months after surgery, there are no complaints and recurrence of a hernia.

The proposed method for restoring the inguinal ligament with recurrent inguinal hernias is less traumatic, anatomical, provides good immediate and long-term results. Doppler ultrasound shows a good functional state of the femoral vessels under the newly formed inguinal ligament. Clinical examination of the operated patients after 1-3 years showed that they had a good condition of the inguinal region without signs of inguinal or femoral hernia.

Claims (5)

1. A surgical method for restoring the inguinal ligament with recurrent inguinal hernias, in which the old postoperative scar is excised by making an incision bordering the hernial protrusion of the skin and subcutaneous tissue, then the hernial sac to the neck is removed from the surrounding tissues and removed, subsequently using a single mesh endoprosthesis eliminate the defect of the abdominal wall of the inguinal region and restore the absent inguinal ligament by suturing the mesh endoprosthesis from the medial side to the comb the ligament and to the upper edge of the pubic symphysis with four interrupted sutures, then the edges of the endoprosthesis preperitoneally are fixed to the fascia of the lumbar muscle, and its lateral end is fixed to the remaining scraps of the lateral part of the inguinal ligament and upper anterior iliac spine, after which the endoprosthesis is bent in the cranial direction and fix medially to the anterior sheet of the vagina of the rectus abdominis muscle, then make an incision from the cranial side in the endoprosthesis to the deep inguinal ring to excrete the seminal Atik or round ligament formed Endoprosthesis stem is sutured to the cranial side of the deep inguinal ring to form duplikatury for forming deep inguinal ring from the implanted endoprosthesis wherein the endoprosthesis is fixed over the entire surface covering the abdominal wall with a continuous suture. 2. The method according to claim 1, characterized in that with a direct hernia, the hernia is eliminated by isolating the hernial sac and immersing it in the abdominal cavity by suturing the transverse fascia. 3. The method according to claim 1, characterized in that in oblique inguinal hernia, the hernia is eliminated by excision of the hernial sac at the level of the crescent edge of the transverse fascia at the inner opening of the inguinal canal. 4. The method according to claim 1, characterized in that the thread is used polypropylene thread 2/0. 5. The method according to claim 1, characterized in that the mesh endoprosthesis is made mainly of polypropylene fibers.