RU2468761C1 - Method of tension-free plasty in case of inguinal hernia - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to surgery for treatment of patients with inguinal hernias. Aponeurosis of external oblique abdominal muscle is dissected by additional cut more medially and higher than the first cut. Aponeurosis of external oblique abdominal muscle is displaced to inguinal ligament. Upper edge of aponeurosis of external oblique muscle is fixed by sutures to inguinal ligament together with lower edges of external oblique and internal oblique abdominal muscles. Spermatic cord is laid on aponeurosis of external oblique abdominal muscle. Lower edge of aponeurosis of external oblique abdominal muscle is sewn with aponeurosis of external oblique abdominal muscle above spermatic cord. Formed defect in aponeurosis of external oblique abdominal muscle is covered with polypropylene mesh, whose size exceeds size of aponeurosis defect by 2 cm in all directions. Upper edge of mesh is fixed by means of sutures to aponeurosis of external oblique abdominal muscle along entire length.

EFFECT: method prevents hernia recurrence and disruption of spermatogenesis.

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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.

A modern version of an operation for inguinal hernia is considered to be a non-tensioning plastic of the inguinal canal with implantation of a mesh endoprosthesis according to Lichtenstein [Egiev V.N., Lyadov K.V., Voskresensky P.K. Atlas of operative hernia surgery. M., Medical practice - M., 2003: 228; Timoshin A.D., Yurasov A.V., Shestakov A.L. Surgical treatment of inguinal and postoperative hernias of the abdominal wall. - M .: "Triad X" 2003: 144].

Until now, plastic surgery of both the posterior wall of the inguinal canal and the anterior [Zhebrovsky V.V. Surgery of abdominal hernias, M. MIA, 2005: 6, 70-75, 353-358]. For example, when performing plastic surgery according to Postempsky, fixation is made to the pupartic ligament behind the spermatic cord of the aponeurosis of the external oblique muscle of the abdomen and internal oblique muscle, thus strengthening the posterior wall of the inguinal canal. The disadvantage of the method according to Postempsky is that with this method, tension of the stitched tissues occurs, which can lead to the formation of an inferior scar and ultimately to relapse.

When performing plastics according to Girard-Spasokukotsky, fixation is made 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, tension of the stitched tissues occurs, which can lead to the formation of an inferior scar and ultimately to relapse.

The disadvantage of the Liechtenstein method is that only the back wall of the inguinal canal is strengthened. 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. The disadvantage of the Liechtenstein method is that after this type of plasty male infertility develops [Protasov A.V. et al. Morphological characteristics of the genitals of males after allotransplantation when modeling the operation of hernioplasty in the experiment. Herniology 2009; 1 (21): 30-31]. The fact is that the mesh in a significant area is in contact with the spermatic cord. This leads to the formation of coarse connective tissue in the ductus deferens zone and infertility. After implantation of the mesh into the inguinal canal, paraprosthetic granulomas form, the cord grows together with the mesh, the lumen of the ductus deferens narrows by 75%, and to the maximum in the area of the mesh edge and most often when musculus cremaster is removed [Junge K. et al., 2008]. Currently, the Liechtenstein method using a polypropylene mesh cannot be recommended for use in young men [Choice of the inguinal canal plasty method in young men. Parshikov V.V. and other problems of outpatient surgery. Moscow, 2010: 93-96].

For the prototype of the present invention, a well-known method of atopic plastic surgery for inguinal hernia according to Liechtenstein is selected, including plastic surgery of the posterior wall of the inguinal canal using a polypropylene mesh having an incision 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, the internal oblique muscle of the abdomen [Egiev V.N., Lyadov K.V., Voskresensky P.K. Atlas of operative hernia surgery. M., Medpraktika - M., 2003: 228.].

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 in the middle of 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 disadvantage of the Liechtenstein method is that only the back wall of the inguinal canal is strengthened. 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 the reconstruction scheme of the inguinal canal, the spermatic cord is inevitable to contact the mesh along the entire length, which leads to a thickening of the connective tissue plate, loss of elasticity, narrowing and obliteration of the lumen of the vas deferens and disturbance of the blood circulation of the testis in the contact zone, which causes a violation of spermatogenesis and azoospermia from the operative side interventions, as shown in the experiment Protasova A.V. (2009) [Protasov A.V. et al. Morphological characteristics of the genitals of males after allotransplantation when modeling the operation of hernioplasty in the experiment. Herniology 2009; 1 (21): 30-31].

The method of plastic inguinal canal polypropylene mesh according to Liechtenstein is taken as a prototype with the indicated disadvantages.

When developing a new method, the following tasks were posed.

1. During plastic surgery, strengthen both the posterior wall of the inguinal canal and the anterior wall.

2. Prevent contact of the spermatic cord with the mesh.

3. Improve the quality of life of patients after an inguinal hernia repair.

To solve the tasks we have proposed and successfully put into practice a method of tensile grafting with inguinal hernia.

The purpose of the invention is the prevention of recurrence of hernia and disorders of spermatogenesis in the treatment of inguinal hernias in young males.

The goal is achieved by the fact that with an inguinal hernia, the skin and subcutaneous tissue are cut parallel to the inguinal ligament and 2 cm higher, then the aponeurosis of the external oblique muscle of the abdomen is dissected, the hernia sac is isolated, it is removed or immersed in the abdominal cavity, then plastic surgery is performed (Fig. .1), characterized in that an additional incision 1 dissects the aponeurosis 2 of the external oblique abdominal muscle more medially and above its edge 3 by 4-5 cm (Fig. 2), the aponeurosis 2 of the external oblique abdominal muscle is displaced to the inguinal ligament in the direction shown by arrow 5 (Fig. 3), then the upper edge 3 of the aponeurosis 2 of the external oblique muscle is fixed with sutures A to the inguinal ligament 6 together with the lower edges of the external oblique 10 and the internal oblique 11 of the abdominal muscles (Fig. 1); they are placed on the aponeurosis of the external oblique abdominal muscle 2 spermatic cord 6, above the spermatic cord sutures B sew the lower edge 4 of the aponeurosis of the external oblique muscle of the abdomen with the aponeurosis of the external oblique muscle of the abdomen 2, and the defect 8 formed (Fig. 3) in the aponeurosis of the external oblique muscle of the abdomen is covered with a polypropylene mesh 9, the size of which exceeds the size defect apone rose 2 cm in all directions (Fig. 4), while the upper edge of the mesh is fixed with sutures C to the aponeurosis 2 of the external oblique abdominal muscle throughout, and the lower edge of the mesh is fixed with sutures D to the aponeurosis 2 of the external oblique muscle of the abdomen throughout ( figure 1, 4).

Thus, the course of the spermatic cord is changed, its contact with the mesh is prevented, and both the posterior and anterior walls of the inguinal canal are strengthened.

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-medical information that would discredit the novelty of the proposed invention, as well as technical solutions with essential features of the proposed method.

The method does not increase 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. Spermogram indicators.

7. Infrared thermography data.

The method was applied on the basis of the Federal State Institution “1586 OVKG MVO” of the Ministry of Defense of the Russian Federation Nizhny Novgorod in 36 patients. A comparative analysis of the results of treatment of two groups of patients. In the main group (n = 10), we included patients operated on using the proposed method. The control group (n = 26) 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 groups were comparable by sex, age, main and concomitant pathology, clinical analysis indicators, hernia defect sizes. The results were analyzed on an Emachines computer using Origin Pro 8 (Mann-Whitney test) in Windows 7. No lethality was noted. In patients of the main and control groups, the postoperative period did not have significant differences. There were no complications in the main group, 1 complication (hematoma) was noted in the control group, p = 0.57. There were no relapses in the main group, in the control group 1 relapse was observed, p = 0.57.

When analyzing the thermography data, it was revealed that there were no significant differences in the anisothermy indices (temperature difference in the operation zone and at the comparison point located contralaterally). When analyzing the results of the spermogram, it was revealed that patients of the main group have a higher sperm count and motility, and quality of life indicators on the MOS SF-36 scale are good.

Figure 1 - plastic surgery according to the method of the authors, the inguinal canal is shown after completion of the plastic in the sagittal plane.

In figure 1 is indicated:

1 - additional section

2 - aponeurosis of the external oblique muscle of the abdomen

3 - the upper edge of the aponeurosis of the external oblique muscle of the abdomen

4 - lower edge of the aponeurosis of the external oblique muscle of the abdomen

5 - direction of movement of the aponeurosis of the external oblique muscle of the abdomen

6 - spermatic cord

7 - inguinal ligament

8 - the resulting defect in the aponeurosis of the external oblique muscle of the abdomen

9 - mesh

10 - external oblique muscle of the abdomen

11 - internal oblique muscle of the abdomen

12 - subcutaneous fat

13 -skin

A - fixation with sutures of the upper edge 3 of the aponeurosis of the external oblique muscle of the abdomen to the inguinal ligament 7 behind the spermatic cord 6

B - fixation of the lower edge of the aponeurosis of the external oblique muscle of the abdomen to the aponeurosis of the external oblique muscle of the abdomen in front of the spermatic cord

C - fixation with sutures of the upper edge of the mesh to the aponeurosis of the external oblique muscle of the abdomen

D - fixation with sutures of the lower edge of the mesh to the aponeurosis of the external oblique muscle of the abdomen

Figure 2 - plastic surgery according to the method of the authors, the inguinal canal is shown in the frontal plane after hernia repair, an additional incision is made.

In figure 2 is indicated:

1 - additional section

2 - aponeurosis of the external oblique muscle of the abdomen

3 - the upper edge of the aponeurosis of the external oblique muscle of the abdomen

4 - lower edge of the aponeurosis of the external oblique muscle of the abdomen

5 - direction of movement of the aponeurosis of the external oblique muscle of the abdomen

6 - spermatic cord

7 - inguinal ligament

Figure 3 - plastic surgery according to the method of the authors, the inguinal canal is shown in the frontal plane after performing hernia repair, performing an additional incision and displacement of the upper edge of the aponeurosis to the inguinal ligament.

In figure 3 is indicated:

2 - aponeurosis of the external oblique muscle of the abdomen

3 - the upper edge of the aponeurosis of the external oblique muscle of the abdomen

4 - lower edge of the aponeurosis of the external oblique muscle of the abdomen

5 - direction of movement of the aponeurosis of the external oblique muscle of the abdomen

6 - spermatic cord

7 - inguinal ligament

8 - the resulting defect in the aponeurosis of the external oblique muscle of the abdomen

Figure 4 is a plastic diagram according to the method of the authors, the inguinal canal is shown in the frontal plane after completion of the plastic and closing the resulting aponeurosis defect with a mesh.

In figure 4 is indicated:

2 - aponeurosis of the external oblique muscle of the abdomen

4 - lower edge of the aponeurosis of the external oblique muscle of the abdomen

6 - spermatic cord

7 - inguinal ligament

9 - mesh

B - fixation of the lower edge of the aponeurosis of the external oblique muscle of the abdomen to the aponeurosis of the external oblique muscle of the abdomen in front of the spermatic cord

C - fixation with sutures of the upper edge of the mesh to the aponeurosis of the external oblique muscle of the abdomen

D - fixation with sutures of the lower edge of the mesh to the aponeurosis of the external oblique muscle of the abdomen

The method is as follows.

The skin and subcutaneous tissue are dissected parallel to the inguinal ligament and above it by 2 cm, then the aponeurosis of the external oblique abdominal muscle is dissected, the hernia sac is isolated, it is removed or immersed in the abdominal cavity, then plastic surgery is performed (Fig. 1), characterized in that an additional incision 1 dissect the aponeurosis 2 of the external oblique muscle of the abdomen medially and above its edge 3 by 4-5 cm (figure 2), the aponeurosis 2 of the external oblique muscle of the abdomen is displaced to the inguinal ligament in the direction shown by arrow 5 (figure 3), then upper edge 3 of aponeurosis 2 the external oblique muscle is fixed with sutures A to the inguinal ligament 6 together with the lower edges of the external oblique 10 and the internal oblique 11 of the abdominal muscles (Fig. 1), spermatic cord 6 is placed on the aponeurosis of the external oblique abdominal muscle 2, the lower edge 4 is sutured over the spermatic cord with sutures B aponeurosis of the external oblique muscle of the abdomen with aponeurosis of the external oblique muscle of the abdomen 2, and the defect 8 formed (Fig. 3) in the aponeurosis of the external oblique muscle of the abdomen is closed with a polypropylene mesh 9, the size of which exceeds the size of the aponeurosis defect by 2 cm in all directions (figure 4) , etc the upper edge of the mesh is fixed to the seams C 2 aponeurosis of the external oblique abdominal muscles throughout, and the lower edge of the mesh is fixed to the seams D 2 aponeurosis of the external oblique abdominal muscles throughout (1, 4).

Example 1. Patient S., 28 years old, medical history No. 343, was admitted to the Federal State Institution "1586 OVKG MVO" of the Ministry of Defense of the Russian Federation Nizhny Novgorod 01/26/2010 with inguinal hernia. We performed hernia repair with plastic mesh according to the method 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.

Next, plastic surgery was performed (Fig. 1), an additional incision 1 dissected the aponeurosis 2 of the external oblique abdominal muscle medially and above its edge 3 by 4-5 cm (Fig. 2), the aponeurosis 2 of the external oblique abdominal muscle was displaced to the inguinal ligament in the direction shown arrow 5 (figure 3), then the upper edge 3 of the aponeurosis 2 of the external oblique muscle was fixed with sutures A to the inguinal ligament 6 together with the lower edges of the external oblique 10 and the internal oblique 11 of the abdominal muscles (Fig. 1), to the aponeurosis of the external oblique abdominal muscle 2 laid the spermatic cord 6, over the spermatic cord sutures B sewn the lower to ai 4 aponeurosis of the external oblique muscle of the abdomen with aponeurosis of the external oblique muscle of the abdomen 2, and the defect 8 formed (Fig. 3) in the aponeurosis of the external oblique muscle of the abdomen was closed with a polypropylene mesh 9, the size of which exceeded the size of the aponeurosis defect by 2 cm in all directions (Fig. 4), while the upper edge of the mesh was fixed with sutures C to the aponeurosis 2 of the external oblique abdominal muscle throughout, and the lower edge of the mesh was fixed with sutures D to the aponeurosis 2 of the external oblique muscle of the abdomen throughout (Figs. 1, 4).

The postoperative period is smooth. Discharged for outpatient treatment on day 6. Inspected after a year. There are no signs of relapse.

Example 2. Patient S., 31 years old, medical history No. 452, was admitted to the Federal State Institution "1586 OVKG MVO" of the Ministry of Defense of the Russian Federation Nizhny Novgorod 02/08/2010 with inguinal hernia. We performed hernia repair with plastic mesh according to the method 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.

Next, plastic surgery was performed (Fig. 1), an additional incision 1 dissected the aponeurosis 2 of the external oblique abdominal muscle medially and above its edge 3 by 4-5 cm (Fig.2), the aponeurosis 2 of the external oblique abdominal muscle was displaced to the inguinal ligament in the direction shown arrow 5 (figure 3), then the upper edge 3 of the aponeurosis 2 of the external oblique muscle was fixed with sutures A to the inguinal ligament 6 together with the lower edges of the external oblique 10 and the internal oblique 11 of the abdominal muscles (Fig. 1), to the aponeurosis of the external oblique abdominal muscle 2 laid the spermatic cord 6, above the spermatic cord sutures B sewn the lower paradise 4 of the aponeurosis of the external oblique muscle of the abdomen with the aponeurosis of the external oblique muscle of the abdomen 2, and the defect 8 formed (Fig. 3) in the aponeurosis of the external oblique muscle of the abdomen was closed with a polypropylene mesh 9, the size of which exceeded the size of the aponeurosis defect by 2 cm in all directions (Fig. 4), while the upper edge of the mesh was fixed with sutures C to the aponeurosis 2 of the external oblique abdominal muscle throughout, and the lower edge of the mesh was fixed with sutures D to the aponeurosis 2 of the external oblique muscle of the abdomen throughout (Figs. 1, 4).

The postoperative period is smooth. Discharged for outpatient treatment on day 5. Inspected after a year. There are no complaints. Relapse is absent.

All our patients were discharged home in satisfactory condition.

Claims (1)

A method of atopic grafting with an inguinal hernia, including inguinal canal repair using a mesh endoprosthesis, characterized in that the aponeurosis of the external oblique abdominal muscle is cut medially and above the first incision, the aponeurosis of the external oblique abdominal muscle is displaced to the inguinal ligament, then the upper edge of the external oblique aponeurosis the muscles are fixed with sutures to the inguinal ligament together with the lower edges of the external oblique and internal oblique muscles of the abdomen, the spermatic cord is placed on the aponeurosis of the external oblique abdominal muscles, above m sew the lower edge, formed after the first incision of the aponeurosis of the external oblique muscle of the abdomen, with the aponeurosis of the external oblique muscle of the abdomen, with the formation of a defect in the aponeurosis of the external oblique muscle of the abdomen, which is closed with a polypropylene mesh whose size exceeds the size of the aponeurosis defect by 2 cm in all directions, while the upper and lower edges of the mesh are fixed throughout the defect with separate interrupted sutures to the aponeurosis of the external oblique muscle of the abdomen.

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