RU2369340C1 - Method of hernioplasty of inguinal and femoral hernias - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgical methods of treatment, and can be used in operative treatment of inguinal and femoral hernias without inguinal canal opening. Operation starts with creation of pararectal preperitoneal access. Structures of posterior surface of inguinal region are exposed. Hernial bandage is removed or inverted into peritoneum cavity. Plasty is performed by installing in preperitoneal space net explant, which is sewn with matrix sutures to pubic ligament from pubic hillock to iliac vessels and to iliac-pubic tract from its medial part to outer edge of deep inguinal ring. When sutures are being applied, valve is created by leaving 2.0-2.5 cm wide free cavity of explant for spermatic cord and elimination of possibility of hernia recurrence. Explant is placed into prepared bed and fixed in it, after which aponeurosis edges are sutured with simultaneous sewing of explant, and wound is sutured layer-by-layer.

EFFECT: reduction of pain syndrome and reduction of inflammatory complications due to installation of net endoprosthesis in preperitoneal space over spermatic cord and formation of valve in form of free exoprosthesis strip.

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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.

A known method of surgical treatment of inguinal and femoral hernias, including the creation of pararectal preperitoneal access, isolation and removal or inversion of the hernial sac with subsequent closure of the hernial portal, plastic surgery and layered wound closure (RF patent No. 22005050, class 7 A61B 17/00, filed 02.04 .2003, published November 20, 2004, BI No. 32).

The main advantage of this method is low-traumatic access, good visibility of the posterior wall of the inguinal canal and other organs located in the incision area, the absence of tension when lowering the transverse muscle with a high inguinal gap, the possibility of simultaneously closing the inguinal gap and femoral ring, etc. It should be noted that performing hernia repair from preperitoneal access does not injure the spermatic cord, which allows you to maintain the reproductive function of men.

The disadvantages of the known method of surgical treatment of inguinal and femoral hernias include the presence of pain due to compression of the small nerves by the sutures and the possibility of relapse in patients with high intra-abdominal pressure during the eruption of sutures.

The development of herniology as a science of hernias at the present stage is characterized by studies of the results of the new principle of tissue repair after hernia repair. This principle of the so-called "non-tension hernioplasty" is to close the hernial defect without any tension due to the mesh prosthesis.

Known non-tension hernioplasty according to Liechtenstein, including traditional inguinal access and hernia sac treatment. A feature of the known technique is that in the form of the posterior wall of the inguinal canal, a polypropylene mesh is modeled, which is laid under the spermatic cord, forming the internal opening of the inguinal canal in it, and fixed with sutures to the periosteum of the pubic bone, pupartic ligament and internal oblique muscle of the abdomen, and the operation is completed restoration of the anterior wall of the inguinal canal and suturing of the skin wound (Non-tightening hernioplasty. Under the general editorship of V.N. Egieva. M., Medpraktika - M., - 2002. - P.26-36). The main advantage of this method is a significant reduction in the percentage of relapses and a decrease in pain. The main disadvantages are associated with the introduction of a foreign synthetic tissue into the human body, which often causes a powerful inflammatory reaction.

The study of such inflammatory complications leads to the conclusion that the greatest number of them is observed when the mesh endoprosthesis is placed in the subcutaneous tissue or in the abdominal cavity. In addition, the implementation of plastics according to Liechtenstein, when the prosthesis is installed in the inguinal canal, leads to involvement of the spermatic cord in the cicatricial inflammatory process.

The technical result of the invention is to reduce pain and reduce inflammatory complications by installing a mesh endoprosthesis in the preperitoneal space above the spermatic cord and forming a valve in the form of a free strip of the endoprosthesis.

A method is proposed for hernioplasty of inguinal and femoral hernias, including the isolation of the structures of the posterior surface of the inguinal region, the isolation and removal or inversion of the hernial sac in the peritoneal cavity, followed by closing of the hernial portal, performing plastic surgery and layer-by-layer suturing of the wound.

The difference is that a mesh explant is cut out adequately to the length of the inguinal canal, which is installed in the preperitoneal space, sutured with mattress sutures to the pubic ligament from the pubic tubercle to the iliac vessels and to the ilio-pubic tract in the lateral direction to the outer edge of the deep inguinal ring and below the line of application these sutures form a valve by leaving a loose strip of mesh explant 2.0-2.5 cm wide, after which the peritoneum with transverse fascia is exfoliated from the rectus abdominis muscle and form a bed in which the upper edge of the explant is placed and the aponeurosis is sutured with a mesh explant stitched for fixation and layer-by-layer suturing of the surface tissues.

The positive effect of the proposed method of hernioplasty is as follows:

- the spermatic cord is not injured;

- the use of mesh explant allows you to perform non-tension plastic, when your own tissues are not stitched together to close the hernial defect;

- reduced pain and the duration of disability of patients;

- the installation of the explant in the preperitoneal space reduces the possibility of the formation of fluid accumulations in its area, because intra-abdominal pressure presses the peritoneum to the explant and the slightly pliable anterior abdominal wall;

- fixing the lower edge of the explant with mattress sutures and the formation of a valve from its free strip prevents the peritoneum from being inserted under the prosthesis and, accordingly, eliminates the possibility of a hernia recurrence.

The invention is illustrated in the drawing, where Fig. 1 shows a section for creating pararectal preperitoneal access, Fig. 2 is a view of the posterior surface of the inguinal region when performing plastic surgery, Fig. 3 is a method for suturing an aponeurosis with fixation of the prosthesis.

To obtain pararectal preperitoneal access, a semilunar incision 1 of the skin and subcutaneous tissue is performed in the projection of the outer edge of the rectus abdominis muscle 3, starting at 1.5 cm above the pubic tubercle 2 and continuing upward 6-8 cm long to a point located 4-5 cm higher superficial inguinal ring 4, i.e. access is performed in accordance with RF patent No. 220050 (class A61B 17/00). The steps of the operation before installing the mesh explant do not differ from those specified in the said patent, i.e. after the incision, the entire posterior surface of the inguinal region and femoral ring is examined, defects and weaknesses of this zone are revealed, the hernial sac is opened and removed or inverted into the abdominal cavity using a purse string suture placed on the neck of the sac. After performing these works, a rectangular mesh explant is cut that is adequate to the length of the inguinal canal. For the pubic ligament from the pubic tubercle 5 to the iliac vessels 6 are superimposed, but not tied, and the threads are taken onto the clamps, which then form the mattress sutures 7. For the convenience of work and prevention of suturing the walls of the iliac vessels, suturing of the iliac-pubic tract 8 is performed at the same time pulling up the previous seam. This stage ends with the application of threads 9 on the iliac-pubic tract 8 at the medial and lateral edges of the deep inguinal ring. With these superimposed threads, the mesh explant is sequentially stitched with 10 mattress sutures 7 and 9 so that the explant strip 11 is 2.0-2.5 cm wide below the suture line for valve formation. This free strip works like a valve - with an increase in intra-abdominal pressure, it is pressed against the abdominal wall and prevents the introduction of the peritoneum under the explant. The threads are tied, and the lower edge of the prosthesis is fixed to the posterior surface of the inguinal region. The spermatic cord 12 passes through the hole formed by the iliac-pubic tract 8 and the mesh explant 10 stitched to it, and is covered for 2.0-2.5 cm by a valve from the free strip 11. After this, the peritoneum with transverse fascia is peeled from the rectus muscle 13 14 to create a bed in which the upper edge of the explant 10 is placed, which is expanded and laid in it so that there are no cavities in the preperitoneal space.

Suturing of the upper 15 and lower 16 edges of the aponeurosis of the anterior vaginal wall of the rectus muscle while suturing the mesh explant 10 is done with sutures 17, without grasping the rectus muscle 18, subcutaneous tissue and skin are sutured in layers.

The proposed method of preperitoneal hernioplasty of inguinal and femoral hernias with a mesh explant was tested in the Kemerovo Regional Clinical Hospital and was recommended for widespread use.

Claims (1)

A method of hernioplasty of inguinal and femoral hernias, including performing pararectal preperitoneal access, isolating the structures of the posterior surface of the inguinal region, isolating and removing or inverting the hernial sac into the peritoneal cavity, followed by closing the hernial portal, performing plastic surgery and layer-by-layer wound closure, characterized in that it is adequate to the length of the inguinal a mesh explant is cut out of the canal, which is installed in the preperitoneal space, hemmed with mattress sutures to the pubic ligament from the pubic tubercle to the subplant osteal vessels and to the iliac tract in the lateral direction to the outer edge of the deep inguinal ring and form a valve by leaving below the line of imposition of these sutures a free strip of mesh explant with a width of 2.0-2.5 cm for passage of spermatic cord underneath into the deep inguinal ring, after whereupon the peritoneum with transverse fascia is exfoliated from the rectus abdominis muscle and a bed is formed in which the upper edge of the explant is placed, after which the aponeurosis is sutured with a mesh explant stitched for fixation and produce layer-by-layer suturing of surface tissues.

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