RU2384301C1 - Inguinal canal plasty technique - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: technique includes Liechtenstein's plasty with using a prolene mesh. The mesh is modeled by size of a posterior wall of inguinal canal and sutured so that it completely closes the posterior wall of inguinal canal and overlaid on abdominal internal oblique muscle and transverse muscles of abdomen. The medial end of the prolene mesh is sutured to inguinal ligament within an attachment to pubic spine, while the second end of the prolene mesh delivered into a cut-out aperture of spermatic cord is sutured to Poupart's ligament from the lateral side of inguinal ligament from its attachment to pubic spine at 0.5 cm. The medial and lateral ends of the prolene mesh below the aperture for spermatic cord are overlapped; therein two ends of the prolene mesh are sutured together, and the same third suture, between the first and second, are fixed to inguinal ligament. Then the medial end of the prolene mash is implanted between aponeurosis of abdominal external oblique muscle and abdominal internal oblique muscle, with sutures being fixed over aponeurosis of abdominal external oblique muscle. The lateral end of the mesh is fixed to inguinal ligament, with aponeurosis of abdominal external oblique muscle and abdominal internal oblique muscle included in the sutures.

EFFECT: more reliable plasty of the posterior wall of inguinal canal, reduced pyoinflammatory complications and recurrent hernias.

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Description

The invention relates to medicine, namely to surgery, and can be used in the treatment of inguinal hernias: direct, oblique and recurrent.

Studies on the medical, scientific and patent literature have revealed various methods of treating inguinal hernias.

There are a large number of techniques for plastic surgery of the inguinal canal, which include the use of soft tissues of the patient: during surgery, the surgeon dissects the inguinal canal, removes the hernia, and subsequently performs plastic surgery of the inguinal canal. This method is called inguinal canal plasty “with tissue tension” (Kukudzhanov NI Inguinal hernias. M. - 1969; Ioffe I. L. Surgical treatment of inguinal hernias. M. - 1968; Toskin KD, Zhebrovsky V. B. Hernia of the abdominal wall. M. - 1990, patents RU No. 20077128, 2147421, 2246903, 2295299, 2313289, etc.). Some surgeons with plastic surgery of recurrent hernias use de-epithelized skin flaps, fascial flaps. However, these methods are quite laborious, and in some cases traumatic. Secondly, they require preliminary skin preparation, often accompanied by infectious complications. Thirdly, there is a gradual replacement of the flaps with connective tissue, which reduces the effectiveness of plastics in the long term.

For oblique inguinal hernias with an extension of the inner inguinal ring, but retained by the posterior wall of the inguinal canal, it is advisable to use methods of plasty with your own tissues. However, the recurrence rate of hernias after surgical treatment reaches 10% in primary and up to 30% in repeated operations (Fingerhut A. Inquinal hernioplasty by Shouldice: gold standard. Results of randomized prospective traies. // Abstracts of the III International Congress on New Technologies. // Luxembourg. - 1995. - Endosurgery today. - 1995. - No. 3. - S.34-35.). Only in clinics specializing in herniology, the relapse rate does not exceed 2% in strictly selected groups of patients (Bendavid R. The Shouldice Repair. In: Hernia. / Edited by LMNyhus, RECondon; with 75 contributors; foreword by K. Kelly. - 4th ed. 1995. - P.217-227.).

Since the end of the 80s, the emergence of polypropylene as a prosthetic material and the development of video laparoscopic technology have made it possible to take a fresh look at the idea of strengthening the back wall of the inguinal canal. With the introduction of polypropylene mesh into the technique of inguinal hernia repair, a new opportunity has opened up to significantly reduce the occurrence of relapses after inguinal canal repair. These methods of plasty of the inguinal canal are called “without tissue tension” and are the most modern and progressive in the treatment of inguinal hernia.

The relapse rate in most statistics does not exceed 2%. However, recently there have been reports of a relapse rate of up to 6% with long follow-up periods. In addition, the method is technically complex and requires special training; complications are rare, but they are very serious when they occur; an expensive method and requiring general anesthesia (A.V. Yurasov, A.L. Shestakov, D.A. Fedorov, A.D. Timoshin. Modern approaches to the treatment of inguinal hernias. - http://www.med.ru/default .htm). These factors limit the use of laparoscopic hernioplasty with strict indications:

with recurrent and bilateral hernias, as well as if necessary to perform combined laparoscopic operations in the abdominal cavity (Nyhus L.M. Herniology 1948-1998: Evolution toward excellence.//Hernia. 1998; 2 (1): 1-5.). The use of modern mesh prostheses made of polypropylene and the large accumulated positive experience gradually overcome the surgeons' natural alertness to the implantation of synthetic materials.

There are several basic methods of plastic surgery of the inguinal canal “without tensioning the tissues”, the most common of which are:

- plastic using a flat mesh according to the method of Lichtenstein (Lichtenstein);

- plastic "plug and patch" or three-dimensional plastic of the inguinal canal;

- plastic using a mesh having a three-dimensional configuration of the Prolene Hernia System (PHS and UHS).

In Europe and Russia, the most popular technique in recent years has been the Lichtenstein hernioplasty technique (Lichtenstein IL, Shulman AG, Amid PK, Montllor MM // Am. J. Surg. 1989; 157: 188-193; Lichtenstein IL, Shulman AG, Amid PK , Willias PA AORN. J. - 1990. - Vol.52, N3. - P.559-565), which consists in strengthening the inguinal gap with synthetic mesh material. In this case, the graft is fixed to the connective tissue formations of the posterior wall of the inguinal canal without tensioning local tissues.

The disadvantages of this method are the lack of formation of the inner edge of the deep inguinal ring and the place of transition of the transverse fascia to the membranes of the spermatic cord, the restoration of the structure of which is given great importance in fundamental works on herniology (Kukudzhanov NI, 1969, Ioffe I.L., 1968); and the lack of ability of the sutured synthetic graft to withstand possible wound infections, which in some cases leads to rejection of the prosthesis (J. Bauer et al., 1987, J.S. Azagra et al., 1988).

The “plug and patch” technique or three-dimensional plastic of the inguinal canal is one of the varieties of the Liechtenstein operation. When it is performed, a hernial sac is secreted, which is immersed in the obturator (“plug”) in the form of a shuttlecock in the preperitoneal space. The back wall of the inguinal canal is strengthened with a patch network similar to plastic according to the Liechtenstein technique. A number of authors do not fix the mesh using a seamless technique (Kharitonov S.V. Inguinal hernia-http: //www.hernioplastika.ru/surgery_01_03.htm).

The disadvantages of hernia repair with inguinal canal plasty using the plug and patch technique are:

- not well protects against the formation of new hernias;

- the obstructive implant may be reduced in size, which increases the likelihood of its displacement and hernia recurrence;

- Some patients experience discomfort due to the fact that they feel the obturating implant through the skin.

The latest technology for surgical treatment of hernias, combining the advantages of previously developed methods for the treatment of hernias "without tissue tension" - the new device PROLENE Hernia System - PHS (manufactured by Ethicon Inc., Johnson & Johnson company).

The system consists of three components:

- an internal flap that provides reliable fixation on the inside of the abdominal wall;

- a connecting part having the form of a cork;

- “lining” (outer flap), which covers the abdominal wall.

The PHS prosthesis is made of highly porous polypropylene. A distinctive feature of the UHS prosthesis (lightweight version of PHS) is the composite composition of the lower disc, into which monocryl filaments are introduced.

A known method of preperitoneal hernioplasty of hernias of inguinal localization (patent RU No. 2160562, 2000.12.20), comprising separating the parietal peritoneum of the anterior abdominal wall, isolating the hernial sac and closing the zones of hernia formation with a polypropylene implant, characterized in that the parietal peritoneum is separated from the anterior abdominal wall through an incision made in the oblique direction in the iliac-inguinal region, by introducing a retroperitoneoscope into it towards the external inguinal ring until the internal opening the inguinal canal, spermatic cord and hernial sac, then, by successive advancing of the retroperitoneoscope, the external opening of the inguinal canal, the pubic joint are isolated, after which the blade of the retroperitoneoscope is turned perpendicular to the rectus abdominis muscle, the peritoneum is peeled from the anterior abdominal wall for 4-5 cm up from the achieving the amount of visualized space adequate to the size of the implanted mesh.

The disadvantage of this method is the great trauma using endoscopic techniques when performing hernioplasty not from the abdominal cavity.

A known method of plastic surgery for recurrent inguinal hernias (patent RU No. 2177734, 2002.01.10), including dissecting the aponeurosis of the external oblique muscle, isolating and excising the hernial sac, creating a bed of the spermatic cord in the tissue of the synthetic prosthesis by dissecting it with the formation of the inner inguinal ring, placing the spermatic cord in the bed, stitching the edges of the dissected aponeurosis of the external oblique muscle of the abdomen, characterized in that they re-dissect 3.0-4.0 cm of the previously stitched synthetic prosthesis with the movement of the internal groin a ring with the spermatic cord laterally and suturing of the defect in the prosthesis.

A known method of plasticity of the posterior wall of the inguinal canal during herniotomy (patent RU 2192787, 2002.11.20), comprising performing a skin incision at an angle to the inguinal fold of 30-40 ° and 2-3 cm above it in the projection of the internal inguinal ring. The subcutaneous fatty tissue is dissected to a length of 2-2.5 cm, in depth to the aponeurosis of the external oblique muscle of the abdomen. In a blunt way, fiber is separated from the aponeurosis - in the direction of the front wall of the inguinal canal. The patient is transferred to the position of Trendelenburg. A retractor blade is inserted into the wound, the skin and subcutaneous tissue are lifted up, the external oblique muscle aponeurosis is dissected throughout, the edges are mobilized. The hernial sac is mobilized from the elements of the spermatic cord, opened at the neck, sutured with a purse string suture and immersed in the abdominal cavity. The distal part of the hernial sac is not removed - an electric probe is inserted into it to the entire depth and phased electrocoagulation is performed. The membranes of the spermatic cord are sutured with interrupted sutures. Next, a non-tensile plastic surgery of the posterior wall of the inguinal canal is performed with a graft similar to the Liechtenstein method.

The disadvantages of this method:

1) the elusiveness of the necessary anatomical structures in the medial angle of the inguinal gap;

2) weakness of the anterior wall of the inguinal canal due to complete dissection of the aponeurosis of the external oblique muscle of the abdomen;

3) high injuries of the elements of the spermatic cord during mobilization and electrocoagulation of the hernial sac.

A known method of transplantation inguinal hernioplasty (patent RU No. 2213528, 2003.10.10), comprising fixing a synthetic mesh graft to the posterior wall of the inguinal canal, characterized in that a kapron mesh with antimicrobial action is used as a graft, which is modeled in the shape of the inguinal gap in this way that along the edge facing the base of the spermatic cord, two flaps are formed in two parallel cuts 1.5-2 cm long at a distance of 1 cm from the longitudinal line of the graft, antat on the back wall of the inguinal canal so that the lateral flaps formed cover the base of the spermatic cord on three sides, and the median flap bends to the inner surface of the spermatic cord with the formation of a duplicate of the inner edge of the deep inguinal ring, and the graft is fixed by the tendon elements of the transverse fascia and the sheath of the spermatic cord the cord.

A known method of plastic inguinal canal (patent RU No. 2231301, 2004.06.27) using a prosthesis, including access to the inguinal canal, processing a hernial sac, characterized in that they use a polytetrafluoroethylene prosthesis from two centrally connected plates with an opening in one of them for the seed the cord or the round ligament and the slots for conducting them into the hole, dissect the transverse fascia along the entire inguinal canal from its internal opening to the outer edge of the rectus abdominis muscle, revise the femoral canal and fix they fix the lower edge of one plate to the Cooper ligament, thereby closing the inner opening of the femoral canal, fix the medial edge of the inner plate of the prosthesis to the vagina of the rectus abdominis muscle, fix the upper edge of the inner plate to both the transverse abdominal muscle and the internal oblique muscle of the abdomen, then place the spermatic cord or a round ligament of the uterus into the opening of the outer plate of the prosthesis, after which the outer plate of the prosthesis is fixed with the lower edge to the inguinal ligament, the medial edge of this plate is fixed to the aponeurotic vagina of the rectus abdominis muscle, fix its upper edge to the tendon of the internal oblique muscle of the abdomen and simultaneously to the internal oblique muscle of the abdomen, form the external border of the internal inguinal ring, suture the aponeurosis of the external oblique muscle of the abdomen, suture the subcutaneous fat, and separately suture the skin.

A known method of tension-free combined plasty of the inguinal canal (patent RU No. 23033403, 2007.07.27), comprising forming a new bed for the spermatic cord, new deep and superficial rings of the inguinal canal, characterized in that the spermatic cord is mobilized by circular dissection together with the muscle raising the testicle , the fascial membrane of the spermatic cord near the deep ring of the inguinal canal, dissect the transverse fascia behind the spermatic cord in the direction up to the outer edge of the rectus sheath, move the spermatic cord to the pre the peritoneal tissue and the transverse fascia is sutured 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, 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, about going 3-4 cm from its inner edge to the middle of the upper-lower mesh size, it covers the spermatic cord from all sides with its dissected halves and fixes them to the deep leaf of the rectus sheath, form a new deep ring of the canal for the spermatic cord from the polypropylene mesh, single interrupted sutures from the outside inward connect the edges of the dissected aponeurosis of the external oblique muscle, form a new superficial aponeurotic ring of the inguinal canal in the projection of the deep ring.

The prototype of the proposed method is taken as a method of plasty of defects of the abdominal wall with inguinal hernias / Egiev V.N., Chizhov D.V., Rudakova M.N. Plastic surgery according to Liechtenstein for inguinal hernias. / Surgery - Journal of them. N.I. Pirogov. - M., 2000, No. 1, pp. 19-21 /. According to the dimensions of the posterior wall of the inguinal canal, a propylene mesh is modeled, which is hemmed so that it completely covers the posterior wall of the inguinal canal and is 1-2 cm superimposed on the internal oblique and transverse abdominal muscles. The mesh is fixed to the pupartic ligament and to the internal oblique muscle of the abdomen with separate sutures. The aponeurosis is sutured with a continuous suture, the skin with a cosmetic suture.

The disadvantage of this method is the movement of the spermatic cord upward and its contact with the polypropylene mesh, which can cause cicatricial changes in the spermatic cord and impaired blood supply to the testicle.

The task of the invention is to increase the reliability of the applied method of plastic inguinal canal while reducing the invasiveness of the method.

This object is achieved in that the claimed method of treatment includes plastic surgery according to Liechtenstein using a prolene mesh, which is modeled by the size of the posterior wall of the inguinal canal and is sutured so that it completely covers the posterior wall of the inguinal canal and is superimposed on the internal oblique muscle of the abdomen, and the prolene mesh is medial hem with the edge to the inguinal ligament in the area of attachment to the pubic tubercle, the second edge of the prolene mesh, after passing the spermatic cord into the cut hole, is hemmed to the navel to the articular ligament from the lateral side of the inguinal ligament, departing from its attachment to the pubic tubercle by 0.5 cm, while the medial and lateral edge of the prolene mesh below the opening for the spermatic cord overlap one on the other, stitch the two ends of the prolene mesh in this place, forming a size the external inguinal ring, and with the same third suture / between the first and second / fix to the inguinal ligament, then the medial end of the prolene mesh is implanted between the aponeurosis of the external oblique muscle of the abdomen to the internal oblique muscle of the abdomen, and the lateral edge prolene mesh is fixed to the inguinal ligament, with the inclusion in the seam of the aponeurosis of the external oblique abdominal muscles and internal oblique abdominal muscles.

Thus, the prolene mesh is modeled taking into account the anatomical and physiological features of the inguinal canal, and the method of fixation compares homogeneous tissues, as well as reducing the plane of contact of the spermatic cord with the mesh.

Our technique of plastic inguinal canal with a propylene mesh is used for direct, oblique and recurrent inguinal hernias.

The technical result of the invention is to increase the reliability of the plasticity of the posterior wall of the inguinal canal, reduce purulent-inflammatory complications, and, as a result, reduce the recurrence of hernias. When using the invention, the following technical results are also achieved:

1) it is possible to perform surgery in conditions of cicatricial and degenerative changes in the inguinal ligament;

2) it is possible to perform surgery in patients with giant inguinal-scrotal hernias;

3) provides the possibility of simultaneous treatment of both inguinal and femoral hernias;

4) there is almost no possibility of a displacement and development of relapses;

5) a small number of sutures reduces the risk of nerve damage;

6) a short recovery period.

The efficiency of the method is confirmed by a clinical example. Patient K-s Ya. A., age 61, medical history No. 7688.

Complaints: for the presence of protrusion in the right inguinal region, increasing with straining, setting in the abdominal cavity, periodically - pain in the protrusion region.

Anamnesis of the disease: It is sick for about a year when, after physical exertion, a protrusion appeared in the right inguinal region. The protrusion gradually increased in size, the last month joined periodic pulling pain in the protrusion. Examined by a surgeon, diagnosed with right-sided inguinal hernia, surgical treatment recommended. The patient was hospitalized in HO-2 of the Road Hospital on 04/16/08 for planned surgical treatment.

Objective data: In the right inguinal region, a protrusion of 6x8 cm is determined, oval, slightly painful on palpation, soft-elastic consistency, increasing with straining. The external opening of the right inguinal canal is expanded to 3 cm. The symptom of a cough push is positive.

Diagnosed with Right-sided inguinal hernia. 04.16.08 the patient underwent hernia repair according to the claimed technique. Cut the skin and subcutaneous fat in the inguinal region. A skin incision is made from the external inguinal ring obliquely vertically upward at a length of 10 cm parallel to the pupar ligament and medial from it by 2-3 cm. After dissection of the skin, the fascia fascia or Thomson plate is dissected. Below the Thomson plate, subcutaneous fat is dissected and the aponeurosis of the external oblique abdominal muscle is dissected along the aponeurotic fibers to the external inguinal ring, which is also dissected. The internal oblique muscle of the abdomen is exposed. A hernial sac is isolated, which with rectus abdominis muscles is located more medially than the spermatic cord. The transverse fascia of the abdomen is dissected, preperitoneal fat is secreted, in which the peritoneal leaf is secreted, the latter is dissected, i.e. open the hernial sac. Partially acute, partially stupidly produce peritoneum / hernial sac from the underlying tissue. The hernial sac is secreted to the neck, on the inner side of the peritoneum secrete to the transitional fold, and with the outer lower and upper maximum. The hernial sac is stitched at the base with a kapron ligature and cut off. The ligature that fixes the hernia sac is sutured to the inner surface of the internal oblique muscle of the abdomen, which allows you to change the direction of the peritoneum along the inguinal canal and plays a role in a possible relapse of the hernia.

Then plastic surgery of the inguinal canal is performed.

The transverse fascia is sutured and the inguinal canal is performed with a prolen mesh. The prolene mesh with the medial edge of the monolithic thread is sutured to the pupartic ligament in the area of attachment to the pubic tubercle. After passing the spermatic cord into the cut hole, the second edge of the prolene mesh is sutured to the pupartic ligament from the lateral side of the inguinal ligament, departing from its attachment to the pubic tubercle by 0.5 cm, while the medial and lateral edge of the prolene mesh below the spermatic opening overflow one other. At this point two ends of the prolene mesh are sutured and the same third suture / between the first and second / is fixed to the inguinal ligament, forming the size of the external inguinal ring. Subsequently, the medial end of the prolene mesh is implanted between the aponeurosis of the external oblique muscle of the abdomen and the internal oblique muscle of the abdomen. Hemming is performed with a monolithic thread to the internal oblique muscle of the abdomen. Thus, the medial edge of the prolene mesh is fixed. Depending on the size of the defect, the mesh is fixed with 7-10 seams.

The lateral edge of the prolene mesh is fixed as follows: the medial edge of the aponeurosis of the external oblique abdominal muscle is punctured, then the prolene mesh is pierced, including the internal oblique muscle of the abdomen, then the needle is drawn a second time, going from the inside outwards, through the muscle, the prolene mesh and the aponeurosis of the external oblique muscle the abdomen, and the inguinal ligament is captured with the same thread, while the edge of the internal flap of the aponeurosis is tucked under the edge of the muscles and it comes into close contact with the inguinal ligament. The suture is fixed above the aponeurosis of the external oblique muscle of the abdomen. The entire length of the aponeurosis and prolene mesh impose from 7-10 seams. Apply a polyamide thread. Thus, using the suture of Kimbarovsky, in which the prolene mesh is included, plastic inguinal canal is performed. The lateral edge of the aponeurosis of the external oblique muscle of the abdomen in the form of a duplicate is hemmed to the medial edge of the aponeurosis of the external oblique muscle of the abdomen, overlapping the previously superimposed suture line.

The subcutaneous fatty tissue is sutured with the aponeurosis being picked up in the suture to exclude the formation of a pocket between the subcutaneous fatty tissue and the aponeurosis of the external oblique muscle of the abdomen. The skin is sutured with an internal cosmetic suture.

The postoperative course - without complications, the pain syndrome on the first day after the operation is unexpressed, the patient is active, takes food in full, is monitored in the hospital on April 17-18, 08, receives analgesics, antibacterial therapy is carried out, dressings are carried out.

04/19/08 in satisfactory condition, the patient was discharged for outpatient treatment, a wound without signs of inflammation, minor complaints of pain, it is recommended that antibiotic therapy be continued.

The advantage of this technique is that the spermatic cord does not come into contact with the prolene mesh. The physiological position of the spermatic cord is restored.

Homogeneous tissues are compared, which grow together much faster than the prolene mesh with aponeurosis and muscles.

The postoperative period is only 3-4 days. No sutures are required. Full physical activity after 1 month. Thus, the use of the proposed method allows you to:

1) securely close the hernia gate with previously implanted synthetic material without squeezing the spermatic cord and tensioning the patient’s own tissues;

2) save the inguinal canal as an anatomical structure;

3) significantly reduce postoperative pain.

The inventive method has shown high clinical efficacy and can be recommended in wide clinical practice for use in urological hospitals.

Claims (1)

The method of plasty of the inguinal canal with inguinal hernias, including plastic according to Liechtenstein using a prolene mesh, which is modeled according to the size of the posterior wall of the inguinal canal and is hemmed so that it completely covers the posterior wall of the inguinal canal and is superimposed on the internal oblique and transverse abdominal muscles, characterized in that the prolene mesh with the medial edge is sutured to the inguinal ligament in the area of attachment to the pubic tubercle, the second edge of the prolene mesh, after passing the spermatic cord into the cut hole, suture to the pupartic ligament from the lateral side of the inguinal ligament, departing from its attachment to the pubic tubercle by 0.5 cm, while the medial and lateral edges of the prolene mesh below the opening for the spermatic cord overlap one on the other, the two ends of the prolene mesh are sutured in this place, forming the size of the external inguinal ring, and with the same third suture, between the first and second, fix to the inguinal ligament, then the medial end of the prolene mesh is implanted between the aponeurosis of the external oblique muscle of the abdomen and the internal oblique muscle of the abdomen, with iksatsiey seams of the aponeurosis of the external oblique abdominal muscles and lateral edge fixed to the inguinal ligament, with the inclusion in the seam of the aponeurosis of the external oblique abdominal muscles and internal oblique abdominal muscles.