RU2376940C1 - Method of surgical treatment of recurrent inguinal hernias - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery, and can be applied for operative treatment of recurrent character of inguinal hernias. From adhesions hernia sac is exposed. High ligation of hernia sac is performed. Exposed are aponeurosis of abdominal external oblique muscle, external oblique and transverse muscle of abdomen without exposure of transverse fascia. After exposure of deep ring, complete preparation of spermatic cord, performed is dissection of cicatricially changed transverse muscle with transverse fascia, external oblique muscle in transversal direction to anatomically unchanged tissues. Deep ring of inguinal canal is displaced outside the edge of transverse muscle, more medially than stump of ligated hernia sac, giving spermatic cord S-shaped direction, creating over it carcass formed by internal oblique and transverse muscles of abdomen.

EFFECT: method allows to form new deep ring of inguinal canal with its additional fixation by means of muscle mass, create more favourable conditions for spermatic cord.

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Description

The invention relates to medicine, namely surgery, and can be used in surgical treatment of recurrent inguinal hernias.

From the practice of surgical treatment of inguinal hernias, the method of surgical treatment proposed by Postempsky (A.S. Kogan, G.I. Veronsky. Pathogenetic principles of surgical treatment of inguinal and femoral hernias. Irkutsk, 1990, p. 107-111) is known, in which after dissection the aponeurosis of the external oblique muscle of the abdomen and the secretion of the spermatic cord dissect the site of attachment of the internal oblique and transverse muscles to theparticular ligament to the lateral side of the deep ring of the inguinal canal to move the spermatic cord to the upper lateral angle of this azreza. Then the muscles are sutured, grabbing the edge of the rectus and transverse abdominal muscles and suturing under the spermatic cord to the inguinal ligament together with the lower aponeurosis flap of the external oblique abdominal muscle. With this type of plastic, the inguinal canal is completely eliminated, and the spermatic cord is located under the skin. A significant frequency of applying the Postempsky method is due to the fact that the method, subjectively perceived by the surgeon as a “more radical plastic” (however, not being such in the analysis of relapses), is used for significant tissue destruction or for recurrent hernias, where in most cases, especially in reproductive age, there are indications for another method of plastic surgery.

There is also a method of surgical treatment of inguinal hernias proposed by Bassini E. (V.N. Egiev. Tension hernioplasty. M., 2002, p. 5-7), when the lower edges of the internal oblique and transverse abdominal muscles are sutured and fixed to the inguinal the ligament behind the spermatic cord all the way from the deep inguinal ring to the pubic tubercle. A muscle defect is sutured with two to three sutures on the lateral side of the spermatic cord.

The closest method of surgical treatment of inguinal hernias to the method proposed by us is the method of plastic inguinal canal proposed by Ioffe I.L. (I.L. Ioffe. Surgical treatment of inguinal hernias. M., 1968, p. 36-40), consisting in suturing the medial section of the expanded deep ring of the inguinal canal due to fascial-aponeurotic elements, with the transition to the membrane of the spermatic cord.

However, the known methods have several disadvantages that affect the occurrence of recurrence of inguinal hernias:

- the peritoneum in the region of the posterior wall of the inguinal canal remains unfixed;

- for persons of reproductive age - the spermatic cord is located in unfavorable conditions for spermatogenesis;

- capture in the suture of the rectus muscle leads to additional tension during its contraction;

- strengthening of the posterior wall of the inguinal canal is performed without taking into account the anatomical location of the external and internal openings of the inguinal canal.

The aim of the invention is to improve the results of surgical treatment of recurrent inguinal hernias, increase the reliability of the plastic of the inguinal canal and restore physiological functions.

The goal is achieved in the invention by the fact that after isolation from the scar tissue and anatomical preparation of the spermatic cord with its elements, a hernial sac, aponeurosis of the external oblique muscle of the abdomen, internal oblique and transverse muscles with transverse fascia, hernia repair is performed with a high ligation of the hernial sac, and then dissection the internal oblique and transverse muscles of the abdomen in the transverse direction to anatomically unchanged tissues, thereby moving the deep ring of the inguinal canal more medially than the stump of the hernial sac over the edge of the transverse muscle, stitching the transverse fascia and the edges of the dissected internal oblique and transverse muscles of the abdomen with 2-3 sutures in the lateral section, forming a new S-shaped direction of the spermatic cord with the creation of a muscular skeleton over the moved deep ring of the inguinal canal, and the formed inguinal the triangle is eliminated by applying 2-3 sutures between the pupartic ligament and the internal oblique muscle of the abdomen, with the subsequent formation of the anterior wall of the inguinal canal by stitching 2-3 sutures of the aponeurosis of the external oblique abdominal muscles.

Decisive in the assessment of the effectiveness of various methods of surgical treatment of hernias is the rate of relapse. According to the literature (S.I. Emelyanov et al., 2001; V.N. Egieva et al., 2002; Orokhovsky, 2001; Nyhus, 1996), as well as on the basis of our many years of experience in the treatment of inguinal hernias, we believe that the cause of relapse of the disease is most often insufficient, and in some cases a complete lack of strengthening of the posterior wall of the inguinal canal. It is necessary to pay attention to the fact that it is more advisable to evaluate the effectiveness of numerous methods of treating hernias taking into account the main pathogenetic ideas.

The most frequent recurrence of hernia formation occurs against the background of cicatricial changes in tissues in the area of “muscle” plasty according to Bassini and in the medial section of the inguinal triangle. Excess scar tissue, tension, decreased elasticity and contractility of the muscles of the abdominal wall are the reason for the violation of the biomechanical properties of the inguinal canal. All these factors are a prerequisite for the return of the disease, a violation of the normal state of the elements of the spermatic cord and reproductive function.

We draw attention to the strengthening or even the formation of a new deep inguinal ring. This, of course, is the most important technical technique that allows you to affect the original place of formation and progression of a hernia. An increase in the defect in the deep ring area changes the direction of the inguinal canal, that is, makes it “rectilinear”, which leads to the development of recurrent inguinal hernias.

When relapses in the plastic area, a coarse, inelastic scar forms, the strength of which, due to extensive dystrophic and atrophic changes in it, is insufficient.

The implantation of a polypropylene mesh used in the vast majority of cases in case of recurrent hernias in various modifications can be limited by hyperergic reactions described in the literature and increasingly observed by us. Hernioplasty without tissue tension using mesh implants is also contraindicated in hernias that develop as a result of connective tissue diseases.

At the present stage of development of herniology, the isolated use of any one method of operation in the treatment of inguinal hernias is clearly insufficient to reduce the number of relapses of the disease. Consequently, there is a need for a significant reassessment of the attitude to surgical treatment of inguinal hernias, given the pathological changes in the anatomical structures of the inguinal canal (Timoshchin A.D. et al., 2001).

The proposed method for the surgical treatment of recurrent inguinal hernias, in addition to strengthening the posterior wall, involves restoring the valvular function of the inguinal canal, when the edges of the transverse and internal oblique muscles of the abdomen close the newly formed deep ring of the inguinal canal. The role of the valve is played precisely by the medial edge, as if closing the entrance to the inguinal canal with increasing intra-abdominal pressure. The main elements of the technique of performing our proposed method of plastic inguinal canal are - careful preparation of tissues with the release of all the anatomical structures; displacement of the deep ring of the inguinal canal and a change in its plane.

The essence of the invention is illustrated by drawings, where:

figure 1 - the movement of the spermatic cord;

figure 2 - the formation of the displaced deep inguinal ring;

figure 3 is the final view of the plastic.

Our proposed method was successfully tested in the surgical department of the MUZ GB No. 6 of Astrakhan in 9 patients. Below are the results of testing.

Example No. 1

Patient Sh. 20 years old, case history no. 1640/645, was admitted to the hospital № 6 with a diagnosis of recurrent right-sided inguinal hernia. The first operation a year ago, was performed plastic surgery of the posterior wall of the inguinal canal by Bassini.

08/23/2002 - under anesthesia, hernia repair with plastic surgery of the posterior wall with the movement of the deep ring of the inguinal canal.

Under intravenous anesthesia (diprivan) in the right inguinal region, the old postoperative scar was removed to the aponeurosis of the external oblique muscle of the abdomen. The aponeurosis is dissected with the removal of ligatures. Semen cord, hernial sac, internal oblique and transverse muscles of the abdomen with transverse fascia were isolated from scar-changed tissues, and all anatomical structures were carefully prepared. A hernial sac 5 × 6 × 4 cm in size, emerging from a deep ring, is selected to the neck, opened. The contents of the bag are a loop of the unchanged small intestine, which is immersed in the free abdominal cavity. The bag is stitched at the neck, bandaged, cut off. The deep ring of the inguinal canal is expanded to 3 cm in diameter. After crossing the transverse and internal oblique muscles of the abdomen in the transverse direction, the spermatic cord (see Fig. 1) and the inner ring are moved by suturing in the lateral section with three sutures of the transverse fascia dissected by the internal oblique and transverse muscles, giving the spermatic cord an S-shaped direction (see figure 2). Between the pupartic ligament and the lateral edge of the internal oblique muscle, two silk sutures are applied. The aponeurosis of the external oblique muscle of the abdomen is stitched edge to edge with three silk sutures (see figure 3).

Hemostasis. Layered seams on the wound.

The patient is allowed to get up on the second day, there was no swelling of the scrotum. During follow-up examinations after 4 months, 1 year, 2 years there is no pain, there are no signs of relapse, reproductive function is not impaired.

Example No. 2

Patient K., 63 years old, case history No. 38, was admitted to the hospital № 6 with a diagnosis of right-sided recurrent inguinal hernia. The first operation 6 months ago, plastic surgery of the inguinal canal according to Kukudzhanov was performed.

January 9, 2004 - under anesthesia, plastic of the posterior wall was performed with the movement of the deep ring of the inguinal canal.

From the scarred tissue, the spermatic cord, hernial sac, internal oblique and transverse abdominal muscles with transverse fascia were distinguished, and all anatomical structures were carefully prepared. A hernial sac 4 × 5 × 3 cm in size, emerging from a deep ring, is selected to the neck, opened. The contents of the bag is a lock of unchanged omentum, which is immersed in the free abdominal cavity. The bag is stitched at the neck, bandaged, cut off. The deep ring of the inguinal canal is expanded to 3.5 cm in diameter. After crossing the transverse and internal oblique muscles of the abdomen in the transverse direction, the spermatic cord and the inner ring are moved by stitching in the lateral section with two sutures of the transverse fascia dissected by the internal oblique and transverse muscles. Between the pupartic ligament and the lateral edge of the internal oblique muscle, two silk sutures are applied. The aponeurosis of the external oblique muscle of the abdomen is sewn edge to edge with three silk sutures.

The postoperative period was uneventful, the patient was allowed to get up on the second day, there was no swelling of the scrotum. At follow-up examinations after 6 months and 1 year, there were no signs of relapse.

The proposed method achieves the restoration of the posterior wall of the inguinal canal by forming a new deep ring, with additional strengthening of its muscle mass, creating more favorable anatomical conditions for the spermatic cord. These features of the operation are the conditions that improve both the processes of tissue regeneration in the plastic field and the results of the operation as a whole, helping to reduce the risk of postoperative complications and improve the quality of life of patients.

The developed method can be widely used in the practical work of surgical departments.

Claims (1)

A method for the surgical treatment of recurrent inguinal hernias, including suturing the medial section of the extended deep ring of the inguinal canal due to fascial-aponeurotic elements, characterized in that after isolation from the scar tissue and anatomical preparation of the spermatic cord with its elements, hernial sac, aponeurosis of the external oblique muscle abdominal, internal oblique and transverse muscles with transverse fascia perform hernia repair with high ligation of the hernial sac, and then dissection of the internal oblique and transverse of the abdominal muscles in the transverse direction to the anatomically unchanged tissues, they move the deep inguinal canal ring medial to the stump of the highly bandaged hernial sac, over the edge of the transverse muscle, by stitching in the lateral section of the transverse fascia and the edge of the dissected internal oblique and transverse abdominal muscles, forming a new S- the figurative direction of the spermatic cord with the creation of the muscular skeleton over the displaced deep ring of the inguinal canal, and the formed inguinal triangle is eliminated by applying 2-3 sutures between the pupars the ligament and the internal oblique muscle of the abdomen, with the subsequent formation of the anterior wall of the inguinal canal by stitching with 2-3 sutures of the aponeurosis of the external oblique muscle of the abdomen.

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