RU2445928C1 - Method of inguinal autohernioplasty - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, specifically to hernia surgery. An inguinal canal is opened by incising an aponeurosis of an abdominal external oblique muscle along an upper border of an external opening of the inguinal canal parallel to an inguinal ligament. A spermatic cord, an aponeurotic arch of a transverse muscle of abdomen and an iliac pubic tract are separated. The aponeurotic arch and the iliac pubic tract are sutured together from their medial border to an internal opening of the inguinal canal. The upper border of the incised aponeurosis of the abdominal external oblique muscle behind the spermatic cord to the inguinal ligament, and the internal opening of the inguinal canal is formed. The aponeurosis of an abdominal external oblique muscle is incised the full length of the inguinal canal at one and a half to two centimetres upwards from a line of the previous suture to form an aponeurotic flap to reinforce a posterior wall of the inguinal canal. The upper border of the aponeurotic flap is fixed to the aponeurosis of the abdominal external oblique muscle. Above the spermatic cord, the free aponeurotic ends of the abdominal external oblique muscle are sutured together to form the external opening of the inguinal canal according to common requirements.

EFFECT: improved efficiency of the method.

1 ex, 5 dwg

Description

The proposed method relates to medicine, namely to surgery, and can be used for plastic surgery of primary and recurrent inguinal hernias in patients of working, elderly and senile age with preserved aponeurosis of the external oblique muscle of the abdomen.

About 5% of the population of our planet are hernia carriers, which determines the relevance of research aimed at finding new ways of hernioplasty. The greatest prevalence of inguinal hernias among males is associated with the anatomical and physiological characteristics of the inguinal period, physical activity in patients of working age and trophic changes in elderly and senile patients. Marked trophic changes with the destruction of not only the posterior wall of the inguinal canal, but also the dissociation of the aponeurosis of the external oblique muscle of the abdomen make it impossible to perform hernioplasty reliably at the expense of its own tissues, urging the surgeon to prosthetic plastic. The use of synthetic endoprostheses can be associated with the development of complications associated with the prosthesis, the frequency of which is 1% or higher [1]. Based on this, it becomes apparent a certain advantage of plastics with their own tissues.

All methods of hernioplasty with their own tissues involve more or less tension of the stitched tissues, however, despite this, many of them give good results.

The closest in technical essence to the known ones is the method of hernioplasty with own tissues with reinforcement of the posterior wall of the inguinal canal without tension, which was proposed by the Indian surgeon Mohan Desard [2], according to which plastic surgery of the posterior wall of the inguinal canal is performed due to the dissected aponeurosis flap of the external oblique muscle of the abdomen, which fix to the inguinal ligament and the internal oblique muscle of the abdomen, simulating the so-called "front" location of the endoprosthesis, as is the case with prosthetic hernioplasty. The author himself calls this method of plastics physiological, and studies conducted in comparison with this method of plasty with the results of the Liechtenstein operation showed that, in terms of efficiency and reliability, regarding the formation of relapse, these two methods are equally effective [3].

With plastic by the method of Desard, there are certain disadvantages.

- with a weak aponeurosis and destroyed transverse fascia, the newly formed posterior wall is represented only by these two formations and does not seem to be a very reliable protection against relapse;

- fixation of the aponeurosis plate along the medial edge to the internal oblique muscle of the abdomen is unreliable due to the possible eruption of muscle fibers and the formation of an insolvent scar due to the stitching of heterogeneous tissues;

- with a weak aponeurosis and a high inguinal gap during plastic surgery according to the Desard method, there is a high probability of “lower relapse” due to eruption of sutures in the area of fixation of the aponeurosis plate to the inguinal ligament;

- with a high inguinal gap, greater tension is created when applying the first row of sutures between the aponeurosis of the external oblique muscle of the abdomen and the inguinal ligament, as well as when stitching the free edges of the aponeurosis at the end of the operation.

The above shortcomings prompted us to develop a method of plastic inguinal hernias with reinforcing the posterior wall of the inguinal canal, which is based on the use of the displaced aponeurosis of the external oblique abdominal muscle to strengthen the posterior wall of the inguinal canal.

The essence of the proposed method lies in the fact that with inguinal autogernioplasty based on strengthening the posterior wall of the inguinal canal due to transposition of the aponeurotic flap of the external oblique muscle of the abdomen, according to the invention, the first step is the stitching of the aponeurotic arch of the transverse abdominal muscle with the iliac-pubic tract, which ensures reduction the upper wall of the inguinal canal, creating conditions for fixing the upper edge of the moved flap of the aponeurosis of the external oblique muscle of the abdomen to the apon the eurotic part of the internal oblique abdominal muscle.

This combination of new and known features allows, firstly, to strengthen the posterior wall of the inguinal canal due to its own tissues, with an additional layer using the most physiological comparison of connective tissue structures, which, in contact, form the basis of the posterior wall of the inguinal canal and are the first line of defense against the occurrence of a hernia fine; secondly, to reduce the tension on subsequent, the main joints of the plastic by reducing the inguinal gap and lowering the upper wall of the inguinal canal; thirdly, to sew the upper edge of the aponeurotic plate with the aponeurotic part of the internal oblique muscle of the abdomen, thereby creating a metered tension and uniformity of stitched tissues around the entire perimeter of the plastic.

The proposed method of a tensionless inguinal autogernioplasty is illustrated by drawings.

Figure 1 shows a diagram of the inguinal canal with a dissection site of the aponeurosis of the external oblique muscle of the abdomen: 1 - inguinal ligament; 2 - spermatic cord; 3 - aponeurosis of the external oblique muscle of the abdomen; 4 - the place of dissection of the aponeurosis of the external oblique muscle of the abdomen; 5 - internal oblique muscle of the abdomen; 6 - aponeurotic part of the internal oblique muscle of the abdomen; 7 - transverse muscle of the abdomen; 8 - transverse fascia; 9 - aponeurotic arc of the transverse abdominal muscle; 10 - ileo-pubic tract.

Figure 2 shows a diagram of the fixation of the aponeurotic arch of the transverse abdominal muscle to the iliac-pubic tract: 11 - suture fixing the aponeurotic arch of the transverse abdominal muscle to the iliac-pubic tract.

Figure 3 shows a diagram of the fixation of the aponeurosis of the external oblique muscle of the abdomen to the inguinal ligament and the formation of the aponeurotic flap from the external oblique muscle of the abdomen: 12 - a suture that fixes the aponeurosis of the external oblique muscle of the abdomen to the inguinal ligament; 13 - the site of the dissection of the aponeurosis of the external oblique muscle of the abdomen for the formation of the aponeurotic flap.

Figure 4 shows a diagram of the strengthening of the posterior wall of the inguinal canal due to the aponeurosis flap of the external oblique muscle of the abdomen: 14 - the suture that fixes the aponeurosis flap of the external oblique muscle of the abdomen to the tendon of the internal oblique muscle of the abdomen; 15 - a flap of aponeurosis of the external oblique muscle of the abdomen; 16 - suture on the aponeurosis of the external oblique muscle of the abdomen.

Figure 5 shows the final diagram of the operation.

The method of inguinal autogernioplasty is as follows. Access: a skin incision 8-10 cm long is produced 2 cm higher and parallel to the inguinal ligament. The inguinal canal is opened, dissecting the aponeurosis of the external oblique muscle of the abdomen parallel to the inguinal ligament along the upper edge of the external opening of the inguinal canal. The spermatic cord is isolated. The hernial sac is treated classically. After completing manipulations with the hernial sac, two of the most important structures of the posterior wall of the inguinal canal are verified and the aponeurotic arch of the transverse abdominal muscle and the iliac-pubic tract are checked and the structures are sutured with a continuous suture, starting from their medial edge to the inner opening of the inguinal canal, which ensures reduction the internal oblique muscle of the abdomen closer to the inguinal ligament. Then fix the upper edge of the dissected aponeurosis of the external oblique muscle of the abdomen behind the spermatic cord to the inguinal ligament, forming the inner opening of the inguinal canal. After this, the aponeurosis of the external oblique muscle of the abdomen is dissected for the entire length of the inguinal canal, departing from one and a half to two centimeters from the line of the previous suture, forming an aponeurotic flap that will be used to strengthen the inguinal canal. The specified incision passes through a defect in the aponeurosis, corresponding to the exit site of the ileo-inguinal nerve. In this case, unlike the Desard technique, after the dissection of the aponeurosis, it is not the muscle but the aponeurotic part of the internal oblique muscle of the abdomen that is exposed to which the upper edge of the resulting aponeurotic flap is fixed with separate nodal sutures. Above the suture, the edges of the aponeurosis of the external oblique muscle of the abdomen remaining free are stitched.

The first operation according to the described method was completed on December 21, 2009. A patient M., 56 years old, was operated on in a planned manner (surgical department No. 2 of the MUZ City Clinical Emergency Hospital, Penza, medical history No. 2683), with a diagnosis of direct inguinal hernia on the left, type 3A, L.M. NYhus classification. Postoperative course without complications, activated in the first day after surgery. The patient returned to his usual activities within 21 days after surgery. Observation in terms of 3, 6, 9, 12 months after surgery: discomfort in the intervention area does not mark, testicle on the intervention side without signs of atrophy, no hernia recurrence.

From December 21, 2009 to December 31, 2010, according to the described method, 28 patients with inguinal hernias were operated on. There were no complications in the early period after surgery and up to 12 months of follow-up.

Information sources

1. Amid R.K. Surgical treatment of postherniorraphy neuropathic inguinodynia: triple neurectomy with proximal end implantation. Contemporary Surgery. 2003.6: 276-5.

2. Desarda M.P. Physiological repair of inguinal hernia: a new technique (study of 860 patients). Hernia. 2006; 10: 143-4.

3. Mitura K., Romanczuk M. Comparison between two methods of inguinal hernia surgery - Lichtenstein and Desarda. Pol Merkur Lekarski. 2008 May; 24 (143): 392-5.

Claims (1)

Method of inguinal autogernioplasty, including strengthening the posterior wall of the inguinal canal, characterized in that the inguinal canal is opened by dissecting the aponeurosis of the external oblique muscle of the abdomen along the upper edge of the external opening of the inguinal canal parallel to the inguinal ligament, the spermatic cord, aponeurotic arch of the transverse abdominal muscle and iliac tract are isolated stitching of the aponeurotic arch and iliac tract with a continuous suture is performed, starting from their medial edge to the inner opening of the inguinal canal, then fix the upper edge of the dissected aponeurosis of the external oblique muscle of the abdomen behind the spermatic cord to the inguinal ligament and form the internal opening of the inguinal canal, dissection of the aponeurosis of the external oblique muscle of the abdomen along the entire length of the inguinal canal, departing from one and a half to two centimeters upward from the line of the previous suture, forming an aponeurotic flap to strengthen the posterior wall of the inguinal canal and exposing the aponeurotic part of the internal oblique muscle of the abdomen, the upper edge of the aponeurotic flap is fixed to the aponeuron cal part of the internal abdominal oblique muscle separate interrupted sutures over the spermatic cord crosslinked remaining free edges of the aponeurosis of the external oblique abdominal muscles to form the external opening of the inguinal canal by conventional requirements.

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