RU2398527C1 - Method of tension-free plasty in case of inguinal hernia - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to methods of surgical treatment, and can be used in surgical treatment of patients with inguinal hernias. Applied is mesh endoprosthesis, whose width equals two sizes of inguinal space. Cut and hole for spermatic cord on mesh endoprosthesis is formed with indent from medial edge of mesh equal 1/2 of inguinal space size. Mesh endoprosthesis is fixed to inguinal ligament with indent from its medial edge equal one inguinal space. Spermatic cord is placed on mesh, edges of dissected oblique abdominal muscle are sutured above it taking in the suture its free edge.

EFFECT: method allows to strengthen anterior wall of inguinal canal and inguinal ligament which prevents hernia recurrence.

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Description

The invention relates to medicine, namely to methods of surgical treatment, and can be used in surgical treatment of patients with inguinal hernias.

The most reliable and modern option for closing a defect in the anterior abdominal wall is atension grafting with implantation of a mesh endoprosthesis according to Lichtenstein (Egiev V.N., Chizhov D.V., Rudakov MN. Plastic surgery according to Liechtenstein with inguinal hernias. Surgery. 2000; 1; 2; : 19-20).

Until now, methods of plastic surgery of both the posterior wall of the inguinal canal and the anterior one (Zhebrovsky VV Surgery of abdominal hernias. M. MIA, 2005: 6, 70-75, 353-358) have been used in surgery of inguinal hernias (especially in the domestic one). . For example, when performing plastics according to Girard-Spasokukotsky, they fixate to the pupartic ligament in front of the spermatic cord of the aponeurosis of the external oblique muscle of the abdomen and internal oblique muscle, thus strengthening the front wall of the inguinal canal.

The disadvantage of the method according to Girard-Spasokukotsky is that the plastic is made of the anterior wall of the inguinal canal, then there is an inconsistency of the posterior wall of the inguinal canal or a defect in the region of the internal inguinal ring. In addition, with this method, the tension of the stitched tissues occurs, which can lead to the formation of an inferior scar and ultimately to relapse.

For the prototype of the present invention, a known method of atenoplasty with inguinal hernia is selected, including plastic of the posterior wall of the inguinal canal using a polypropylene mesh having a cut and an opening for the spermatic cord, by suturing the medial edge of the mesh behind the spermatic cord to the outer sheet of the vagina of the rectus muscle, internal oblique muscle of the abdomen (Egiev V.N., Chizhov D.V., Rudakov M.N.Lichtenstein plastic surgery for inguinal hernias. Surgery. 2000; 1: 19-20).

A known method is as follows.

With an inguinal hernia, the skin and subcutaneous fatty tissue are dissected, then the aponeurosis of the external oblique muscle of the abdomen, a hernia sac is extracted, removed or immersed in the abdominal cavity. A mesh endoprosthesis is prepared. For this, a cut is made on a rectangular polypropylene mesh in the middle and a hole is made for the spermatic cord. Next, plastic surgery of the posterior wall of the inguinal canal is performed by suturing the medial edge of the mesh endoprosthesis behind the spermatic cord to the outer sheet of the vagina of the rectus abdominis muscle, the internal oblique muscle of the abdomen. Then the spermatic cord is placed in front of the mesh, the previously dissected aponeurosis of the external oblique muscle of the abdomen is sutured above it.

However, the known method has disadvantages.

The method allows to strengthen only the back wall of the inguinal canal. In the case when the front wall of the inguinal canal is represented only by a weak, fibrous aponeurosis of the external oblique muscle of the abdomen and the pupartic ligament itself is flabby, atrophic and fibrous, relapse is almost inevitable. In addition, endoprostheses made of polypropylene are reduced in size by 30% during the year, which contributes to relapse [Shrinkage of polypropylene nets after implantation (experimental study) Klishe U., Konce I., Anurov M. Conference materials "Actual problems of herniology" . - M., 2002: 21).

The objective of the invention is the prevention of recurrence of inguinal hernia.

The problem is solved in that in the known method of atenoplasty with inguinal hernia, including plastic of the posterior wall of the inguinal canal using a mesh endoprosthesis having a cut and an opening for the spermatic cord, by suturing the medial edge of the mesh behind the spermatic cord to the outer sheet of the vagina of the rectus abdominis muscle, internal oblique muscle of the abdomen, a mesh endoprosthesis is used, the width of which is equal to two sizes of the inguinal gap, an incision and an opening for the spermatic cord on the mesh endoprosthesis for mimic, departing from the medial edge of the mesh by 1/2 the size of the inguinal gap, to the pupartial ligament, the mesh endoprosthesis is fixed, departing from its medial edge by an amount equal to 1 size of the inguinal gap, then the spermatic cord is laid on the mesh, the edges of the dissected external aponeurosis are sewn over it oblique abdominal muscles with capture in the seam of the free edge of the mesh.

The present invention meets the criteria of "novelty" and "inventive step", since the conducted patent information research did not reveal the sources of patent and scientific and medical information that would discredit the novelty of the invention, as well as technical solutions with essential features of the proposed method.

The present invention allows using the following positive effect.

1. By performing an incision and an opening on the mesh endoprosthesis at a distance equal to 1/2 of the inguinal gap from its edge and double shelter during plastic surgery, both the posterior wall of the inguinal canal and the anterior wall are strengthened with reinforcement of the pupartic ligament itself.

2. Strengthening of both walls of the inguinal canal is done by mesh endoprosthesis without tissue tension.

3. The method improves the quality of life of patients after an inguinal hernia repair.

The method allows to reduce the number of postoperative complications and is the prevention of recurrence of inguinal hernia.

To assess the effectiveness of the proposed method, we took the following indicators.

1. The general condition of patients.

2. The severity of pain.

3. Clinical blood tests.

4. The amount and nature of the exudate on the drainage of the wound.

5. Data from ultrasound of the abdominal cavity and wounds.

6. Intra-abdominal pressure.

The method used on the basis of the MLPU "City Hospital No. 35" of Nizhny Novgorod was performed in 45 patients. Complications and mortality in this group were not noted. We carried out a comparative analysis of the results of treatment of two groups of patients. In the main group (n = 45), we included patients operated on using the proposed method. The control group (n = 559) consisted of patients who underwent hernia repair according to the method of Liechtenstein. All patients received complex therapy according to the standards of medical care. The dynamics of the main indicators of the postoperative period was studied by us using statistical methods and student criterion. In the two groups of patients there were no significant differences in gender, age, clinical analysis indicators, or sizes of hernial defect. At the same time, it was found that in patients of the main and control groups, the course of the postoperative period had a number of significant differences. Complications were noted in the control group (n = 27, 4.8%): hematoma (2), infiltrate (16), orchitis (7), and others (2). In the main group - hematoma (n = 1, 2.2%), p = 0.14. There were no relapses.

The proposed method is illustrated by drawings.

Figure 1 - polypropylene mesh prepared for use by the proposed method.

In figure 1 is indicated:

1 - grid

2 - slot

3 - hole for the spermatic cord.

Figure 2 - stage of plastic surgery of the posterior wall of the inguinal canal.

In figure 2 is indicated:

4 - internal oblique muscle of the abdomen;

5 - spermatic cord

6 - pupartic ligament

7 - the free edge of the grid.

Figure 3 - stage of movement of the free edge of the endoprosthesis in the medial zone.

Figure 4 - stage prosthetics of the anterior wall of the inguinal canal

Figure 5 - the final stage of the operation in the sagittal plane.

Figure 5 marked

8 - leather

9 - subcutaneous tissue

10 - aponeurosis of the external oblique muscle of the abdomen

11 - mesh fixation point to the internal oblique muscle of the abdomen

12 - fixation point of the mesh to the inguinal ligament

13 - a seam capturing the free edge of the mesh, both edges of a previously dissected aponeurosis of the external oblique muscle of the abdomen.

Pre-prepare mesh endoprosthesis 1 (Fig.1) of polypropylene, the width of which is equal to two sizes of the inguinal gap. To do this, make a slot 2 and a hole 3 for the spermatic cord on the mesh. In this case, the slot and hole are located at a distance from the medial edge of the mesh, equal to 1/2 of the inguinal gap. Next, dissect the skin and subcutaneous fat. A hernial sac is isolated, immersed in the abdominal cavity or removed. Plastic surgery of the posterior wall of the inguinal canal is performed using a cut propylene mesh. Figure 2 shows the stage of plastic surgery of the posterior wall of the inguinal canal. The medial edge of the mesh endoprosthesis is sutured to the outer sheet of the vagina of the rectus abdominis muscle and the internal oblique muscle of the abdomen 4 behind the spermatic cord 5. To the pupartic ligament 6, the mesh endoprosthesis is fixed, departing from its medial edge by an amount equal to one inguinal interval. Figure 3 shows the moment of movement of the free edge 7 of the endoprosthesis 1 to the medial side for prosthetics of the anterior wall of the inguinal canal. Figure 4 shows the prosthesis of the anterior wall of the inguinal canal with a mesh by stitching the edges of a previously dissected aponeurosis of the external oblique abdominal muscle 8 and the free edge of the mesh 7. Figure 5 shows in sagittal projection the final stage when the anterior and posterior walls of the inguinal canal are prosthetized. In this case, the posterior wall of the inguinal canal is represented by mesh 1, sewn at point 11 to the internal oblique muscle of the abdomen, at point 12 - to the partartic ligament, and the front wall of the inguinal canal is formed from the free edge of the mesh 7, sewn at point 13 with the edges of the previously dissected external aponeurosis oblique muscle of the abdomen 8.

The method is as follows.

A mesh prosthesis made of polypropylene, the width of which is equal to two sizes of the inguinal gap, is preliminarily prepared. To do this, a slot and a hole for the spermatic cord are made on the mesh. In this case, the slot and hole are located at a distance from the medial edge of the mesh, equal to 1/2 of the inguinal gap. Next, dissect the skin and subcutaneous fat. A hernial sac is isolated, immersed in the abdominal cavity or removed. Plastic surgery of the posterior wall of the inguinal canal is performed using a cut propylene mesh. The medial edge of the mesh endoprosthesis is sutured to the outer sheet of the vagina of the rectus abdominis muscle and the internal oblique muscle of the abdomen behind the spermatic cord. The mesh endoprosthesis is fixed to the pupartic ligament, departing from its medial edge by an amount equal to one inguinal gap. The free edge of the endoprosthesis is moved to the medial side for prosthetics of the anterior wall of the inguinal canal. Prosthetics of the anterior wall of the inguinal canal is performed by mesh by stitching the edges of a previously dissected aponeurosis of the external oblique muscle of the abdomen and the free edge of the mesh. Thus, prosthetics of the anterior and posterior walls of the inguinal canal were performed. At the same time, the posterior wall of the inguinal canal is represented by a mesh sewn to the internal oblique muscle of the abdomen and to the apartparticular ligament, and the front wall of the inguinal canal is formed from the free edge of the mesh stitched with the edges of the previously dissected aponeurosis of the external oblique muscle of the abdomen.

Examples of specific performance are given in the form of extracts from medical records

Example. Patient S., 50 years old, medical history No. 4339, was admitted to the municipal hospital "City Hospital No. 35" with an inguinal hernia. A hernia repair with plastic mesh was performed according to the technique proposed by the authors. First, the skin and subcutaneous adipose tissue were dissected, then the aponeurosis of the external oblique muscle of the abdomen, the hernia sac was removed, and its removal was performed. A mesh endoprosthesis was used, the width of which is two sizes of the inguinal gap, while the incision and the hole for the spermatic cord on the mesh endoprosthesis were formed, departing from the medial edge of the mesh by 1/2 the size of the inguinal gap, the mesh endoprosthesis was hemmed to the pupartic ligament, departing from the medial edge by a distance equal to 1 size of the inguinal gap, then the spermatic cord was laid on the mesh, the edges of the dissected aponeurosis of the external oblique muscle of the abdomen were sewn over it with the free edge of the mesh seized in the suture. The postoperative period is smooth. Discharged for outpatient treatment on day 6. Inspected after a year. There are no signs of relapse.

Example. Patient S., 36 years old, medical history No. 5939, was admitted to the municipal hospital "City Hospital No. 35" with an inguinal hernia. A hernia repair with plastic mesh was performed according to the technique proposed by the authors. First, the skin and subcutaneous adipose tissue were dissected, then the aponeurosis of the external oblique muscle of the abdomen, the hernia sac was removed, and its removal was performed. A mesh endoprosthesis was used, the width of which is two sizes of the inguinal gap, while the incision and the hole for the spermatic cord on the mesh endoprosthesis were formed, departing from the medial edge of the mesh by 1/2 the size of the inguinal gap, the mesh endoprosthesis was hemmed to the pupartic ligament, departing from the medial edge equal to 1 size of the inguinal gap, then the spermatic cord was laid on the mesh, the edges of the dissected aponeurosis of the external oblique muscle of the abdomen were sewn over it with the free edge of the mesh seized in the suture. The postoperative period is smooth. Discharged for outpatient treatment on day 5. There are no complaints. Relapse is absent.

Example. Patient P., 67 years old, medical history No. 4705, was admitted to the municipal hospital "City Hospital No. 35" on September 19, 2007 with an inguinal hernia. A hernia repair with plastic mesh was performed according to the technique proposed by the authors. First, the skin and subcutaneous adipose tissue were dissected, then the aponeurosis of the external oblique muscle of the abdomen, the hernia sac was removed, and its removal was performed. A mesh endoprosthesis was used, the width of which is two sizes of the inguinal gap, while the incision and the hole for the spermatic cord on the mesh endoprosthesis were formed, departing from the medial edge of the mesh by 1/2 the size of the inguinal gap, the mesh endoprosthesis was hemmed to the pupartic ligament, departing from the medial edge equal to 1 size of the inguinal gap, then the spermatic cord was laid on the mesh, the edges of the dissected aponeurosis of the external oblique muscle of the abdomen were sewn over it with the free edge of the mesh seized in the suture. The postoperative period is smooth. Discharged for outpatient treatment on day 7. There are no signs of relapse.

Information sources

1. Plastic according to Liechtenstein for inguinal hernias. Egiev V.N., Chizhov D.V., Rudakov M.N., Surgery. 2000; 1: 19-20.

2. Egiev V.N., Lyadov K.V., Voskresensky P.K. Atlas of operative hernia surgery. M .: Medical practice. - M, 2003: 228.

3. Surgery of abdominal hernias. Zhebrovsky V.V., M. MIA, 2005: 6, 70-75, 353-358.

4. Shrinkage of polypropylene nets after implantation (experimental study) Cliché W., Konce I., Anurov M. Conference materials "Actual problems of herniology". - M., 2002: 21.

5. Inguinal hernia. Reconstruction of the posterior wall of the inguinal canal. Nesterenko Yu.A., Gaziev P.M. M., Binom 2005: 87, 106-110, 130-131.

6. Hernia of the abdominal wall. 2nd ed., Revised. and add. / Toskin K.D., Zhebrovsky V.V. - M.: Medicine, 1990 .-- 272 p.

7. The tension-free hemioplastic. Am J Surg Lichtenstein I.L. Schulman A.C., Amid P.K. 1989-157: 188.

Claims (1)

A method of atopic grafting with an inguinal hernia, including plastic surgery of the posterior wall of the inguinal canal using a mesh endoprosthesis having an incision and an opening for the spermatic cord, by suturing the medial edge of the mesh endoprosthesis behind the spermatic cord to the outer sheet of the vagina of the rectus abdominis muscle, the internal oblique muscle of the abdomen, characterized in that apply a mesh endoprosthesis, the width of which is equal to two sizes of the inguinal gap, the incision and the hole for the spermatic cord on the mesh endoprosthesis form I from the medial edge of the mesh is 1/2 the size of the inguinal gap, to the pupar ligament, the mesh endoprosthesis is fixed, departing from its medial edge by an amount equal to one inguinal gap, then they are laid on the mesh, the edges of the dissected oblique muscle of the abdomen are sewn over it with a grip in the suture free edge of the grid.

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