RU2480168C1 - Method of hernioplasty of entrapped inguinal hernia - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, namely to herniology. If it is impossible to de-entrap and reduce hernia content under action of myorelaxants, laparoscopic instruments are removed, laparoports and pneumoperitoneum are preserved. Linear skin cut is performed on 3-5 cm, starting with the point, located 1.5-2 cm higher than projection on skin of pubic tubercle parallel to inguinal ligament. Subcutaneous adipose cellular tissue, aponeurosis and fibres of external inguinal ring, if it is entrapped, are dissected. Attempt to reduce entrapped organ is repeated. In case of entrapment in internal inguinal ring, retractor blade is introduced into wound along inguinal canal, its traction is performed by handle upward to create operation field. Slight incision of fibres of internal oblique and transverse muscles is made on valleculate probe, reduction is performed. Laparoscopic instrument is introduced and viability of de-entrapped organ is assessed. In case of direct inguinal hernia: in case of organ viability, hernia sac is reduced into abdominal cavity without opening or, in case of nonviability of de-entrapped organ, opening of hernia sac is performed, organ is extracted into wound, nonviable section is resected, in case of entrapped organ resection opened hernia sac is sewn before reduction. In case of oblique inguinal hernia: hernia sac is opened, sewn near base, dissected on anterior wall to the bottom without complete mobilisation and resection. Operation field in area of inguinal canal is created by traction by retractor handle upward, mobilisation is carried out and spermatic cord is taken on tourniquet, non-tension plasty of posterior wall of inguinal canal is carried out with synthetic transplant with hole for bringing out spermatic cord.EFFECT: increase of method efficiency.2 ex, 2 dwg

Description

The invention relates to medicine, in particular to surgery, namely to herniology.

The modern history of the treatment of inguinal hernias begins in 1884, when Bassini first described his method of surgery for inguinal hernias and laid the foundations for a modern understanding of the role of the posterior wall of the inguinal canal in hernia formation. However, this problem is far from being resolved. So according to the authors (K.D. Toskin, V.V. Zhebrovsky, V.N. Egiev, D.V. Chizhov), the frequency of hernias varies from 3.7-5%, while the most common hernias of the inguinal localization are up to 5% of the male population.

According to statistics, with conventional methods of hernia repair, recurrence of inguinal hernia occurs in 7-8% of the operated patients, and with repeated hernia repair in 30%.

The use of endosurgical techniques significantly reduced the percentage of relapses to 4.5%. Currently, there are two main options for the placement of a synthetic implant relative to the peritoneum: preperitoneal (TAPP) and intra-abdominal (IPOM) [Ruttenburg G.M. 2002; Gastinger I. 2008]. The use of a prolene mesh without release coating requires preperitoneal placement of the implant. Intra-abdominal placement of a synthetic implant is a technically simpler method, but it requires the use of expensive consumables (Parietex Composite release mesh and AbsorbaTack endoerniostapler). It is noteworthy that despite the widespread use of laparoscopic hernioplasty in elective surgery, with restrained hernias, the technique has not been widely used [Rutenburg G.M. 2008; Strizheletsky V.V. 2009; Emelyanov S.I. 2010, Sazhin V.P. 2010].

A known method of applying a laparoscopic technique for strangulated inguinal and inguinal hernia. Authors: Badma-Goryaev OV, Naurbaev M.S., Bogdanov D.Yu., Alishikhov Sh.A. Moscow 1) RUDN University, 2) MGMSU. [Electronic resource]. - Access mode: http://www.Laparoscopy.ru/doktoru/view_thesis.php?theme_id=//.

Laparoscopic hernioplasty was performed according to a standard technique using 5 mm laparoports and instruments. After carrying out diagnostic laparoscopy and clarifying the diagnosis and verification of the restrained organ, the infringement was eliminated and the organ was sent to the abdominal cavity by traction with the atraumatic clamps of the restrained organ and manual impact on the hernial protrusion from the abdominal wall, against the background of the introduction of the next dose of muscle relaxants. Assessment of the vitality of the impaired organ was carried out according to the Kerte method.

In the postoperative period, two complications were recorded (10.53%) - the development of postoperative peritonitis, caused in one case by necrosis of a previously restrained intestinal loop, and in the second case, by intraoperative electrocoagulation damage to the wall of the restrained intestinal loop, not detected during surgery. It should be noted that both complications arose after operations for strangulated inguinal-scrotal hernias, i.e. in the presence of significant technical difficulties in the allocation of an infringed area of the intestine. In all other cases, there were no such most common complications as wound infection, neuralgia, postoperative scrotal edema, dysuric phenomena.

Thus, laparoscopic hernioplasty for strangulated inguinal hernias is a methodologically justified method of surgical treatment, and in the presence of strangulated inguinal-scrotal hernias, it should be used selectively.

Disadvantages:

1. The lack of methods for safe demolition of hernial contents when it is impossible to reposition.

2. Selectivity of application of the technique for strangulated inguinal-scrotal hernias.

The closest is the method of performing laparoscopic hernioplasty, developed and implemented in practice by the Scientific Research Institute of the Joint Venture named after N.V. Sklifosovsky, using a combined implant - a Parietex PPL prolene mesh in combination with lyophilized dura mater (TMO) (patent application No. 2010125351 of 06.22.2010). Authors: Yartsev P.A., Kirsanov II, Dreyer M.N., Levitsky V.D., Mamedov K.A. Moscow, NII SP them. N.V. Sklifosovsky. [Electronic resource]. - Access mode: http://www.Laparoscopy.ru/doktoru/view_thesis.php?theme_id=//.

At the first stage, a synthetic implant (SI) with an Absorbatack 5 mm endogeniostepler was fixed to the anterior abdominal wall, closing the hernial gates around the perimeter every 3-4 cm. The TMT was fixed over the SI, extending 1-2 cm around the perimeter. The hernial sac was drained with a silicone drainage tube (TMMK No. 18).

Indications for laparoscopy with strangulated hernias of the anterior abdominal wall: 1) suspicion of parietal (Richter) infringement (local abdominal pain, unclear clinical picture, absence of hernial protrusion on the abdominal wall); 2) state after infringement; 3) restrained inguinal hernia.

It was noted that relaxation and insufflation of gas into the abdominal cavity led to the extension of the infringing ring and to the self-reduction of the infringed organ in 12 patients (37.5%), and in 20 patients (62.5%) it was necessary to dissect the infringing ring with an instrument with the LigaSure effect. In all cases, the infringed organ was recognized as viable and no resection was performed.

After IPOM hernioplasty in 1 patient (3.1%) with POVH in the postoperative period, ultrasound revealed fluid accumulation in the supernatant space (hernial sac), which required 55 ml of puncture and aspiration of seroma. After analyzing this observation, drainage of the supernumerary space (hernial sac cavity) and perforation of TMT were recognized as necessary.

When using laparoscopic hernioplasty, the following advantages were revealed: reduction in the severity of pain after surgery; activation of patients occurred in the first hours after surgery versus 1.2 ± 0.3 days after the "traditional" operation; reduction of treatment time for patients to 3.5 + 0.5 days versus 8.5 + 1.5 days after the "open" operation.

Disadvantages:

1. The need for lyophilized dura mater (TMT).

2. The need for the use of an endogeniostepler "Absorbatack" 5 mm.

3. The need to use a tool with the LigaSure effect to dissect the pinch ring.

4. The need for drainage of the supernumerary space (cavity of the hernial sac) and perforation of TMT.

The closest is the method of hernioplasty of restrained inguinal hernias, including exposure and opening of the hernial sac, evacuation of hernia water, dissection of the restraining ring, herniolaparotomy with dissection of the posterior wall of the inguinal canal and plastic surgery of the inguinal canal to prevent postoperative complications (V.V. Zherbovsky Surgery. , MIA, M., 2005, p.232).

The operation is traumatic, as it is not minimally invasive.

The need to dissect the posterior wall of the inguinal canal leads to additional tissue trauma, which can cause bleeding, pain, and increases the period of disability.

The objective of the proposed method is to reduce the morbidity of surgical intervention for strangulated inguinal and inguinal-scrotal hernias by using videoassisted inguinal hernioplasty from the mini-access. Shortening treatment time.

The task is achieved by the method of hernioplasty of restrained inguinal hernias, including exposure of the hernial sac, evacuation of hernial water, dissection of the restraining ring, inguinal canal plasty. Preliminary perform diagnostic laparoscopy. If it is impossible to dilute and reposition the hernial contents under the action of muscle relaxants, laparoscopic instruments are removed, laparoports and pneumoperitoneum are retained. Perform a linear skin incision 3-5 cm long, starting from a point located 1.5-2 cm above the projection onto the skin of the pubic tubercle, parallel to the inguinal ligament. Subcutaneous fatty tissue, aponeurosis and fibers of the external inguinal ring are then dissected, if it is infringing, and the attempt to reposition the infringed organ is repeated. When infringement is made in the inner inguinal ring, a retractor blade is inserted into the wound along the inguinal canal, traction is carried out by the handle upward to create the surgical field, the fibers of the internal oblique and transverse muscles are cut from the grooved probe, and the reduction is performed. A laparoscopic instrument is introduced and the viability of the dilute organ is evaluated. With direct inguinal hernia: when the organ is viable, the hernial sac is inserted into the abdominal cavity without opening; or if the diluted organ is not viable, the hernia sac is opened, the organ is removed into the wound, the non-viable area is resected, and the opened hernia sac is sutured before resection. With oblique inguinal hernia: the hernial sac is opened, stitched at the base, dissected along the front wall to the bottom without complete mobilization and resection. Traction for the handle of the retractor up creates an operating field in the area of the inguinal canal, performs mobilization and takes the spermatic cord on the turnstile. Perform a non-tension plastic surgery of the posterior wall of the inguinal canal with a synthetic graft with an opening for removing the spermatic cord.

The novelty of the invention:

- Preliminary perform diagnostic laparoscopy. If it is impossible to dilute and reposition the hernial contents under the action of muscle relaxants, laparoscopic instruments are removed, laparoports and pneumoperitoneum are left to maintain the extension of the inner inguinal ring.

- Perform a linear skin incision 3-5 cm long, starting from a point located 1.5-2 cm above the projection onto the skin of the pubic tubercle, parallel to the inguinal ligament. Subcutaneous fatty tissue, aponeurosis and fibers of the external inguinal ring are then dissected, if it is infringing. Repeat the attempt to reduce the impaired body. The small access size reduces the invasiveness of the operation, bleeding of tissues. Access localization allows you to place the retractor blade closer to the pubic bone, which provides further convenience when fixing the mesh in the medial part of the inguinal canal.

- In case of infringement in the inner inguinal ring, the retractor blade is inserted into the wound along the inguinal canal, traction is carried out by the hilt upwards to create the surgical field, the fibers of the internal oblique and transverse muscles are notched along the grooved probe, and they are directed. A laparoscopic instrument is introduced and the viability of the dilute organ is evaluated.

- In case of direct inguinal hernia: when the organ is viable, the hernial sac is inserted into the abdominal cavity without opening.

- Or, if the diluted organ is not viable, the hernia sac is opened, the organ is removed into the wound, the non-viable area is resected, and the opened hernia sac is sutured before being resected.

- In case of oblique inguinal hernia: the hernial sac is opened, stitched at the base, cut along the front wall to the bottom, to prevent congestion, without complete mobilization and resection, thereby preserving the integrity of the structures of the spermatic cord, accordingly, the injuries of the elements of the spermatic cord are reduced.

- Traction for the handle of the retractor up creates an operating field in the area of the inguinal canal. They perform mobilization and take the spermatic cord on the turnstile. Perform a non-tension plastic surgery of the posterior wall of the inguinal canal with a synthetic graft with an opening for removing the spermatic cord.

The use of mini-access allows safely, without the use of expensive endoscopic instruments, to perform dissections of the restraining ring both at the level of the internal and external inguinal rings.

Thus, the proposed method allows to provide low invasiveness and maximum accessibility to the elements of the inguinal gap. The possibility of dissection of the restraining ring both at the level of the internal and external inguinal rings, which is impossible with laparoscopic hernioplasty. The effectiveness of surgical intervention and, as a result, faster adaptation of the patient and restoration of his disability increases.

The method is illustrated by the drawings presented in figure 1 and figure 2.

Figure 1 shows a diagram of the operation.

Figure 2 - the location of the cut and the position of the retractor.

In Figures 1 - the internal inguinal ring, 2 - a linear incision, 3 - the beginning point of the incision, located 1.5-2 cm above the projection of the pubic tubercle on the skin, 4 - pubic tubercle, 5 - retractor blade, 6 - retractor, 7 - spermatic cord, 8 - mesh, 9 - pupartic ligament, 10 - free edges of the internal oblique and transverse muscles.

The method is as follows.

A patient lying on his back under endotracheal anesthesia undergoes laparoscopy according to the standard method using a 10-mm laparoport in the umbilical region. After carrying out diagnostic laparoscopy and clarifying the diagnosis, the infringement was eliminated - directing the organ into the abdominal cavity by manual exposure to the hernial protrusion from the abdominal wall, against the background of the introduction of the next dose of muscle relaxants. If necessary, a 5 mm laparoport was additionally installed in a counterposition relative to the side of the operation for traction with atraumatic clamps of the restrained organ, its revision and assessment of viability.

If it was impossible to dilute and reposition the hernial contents, laparoscopic instruments were removed, laparoports and pneumoperitoneum were preserved. A linear incision is made 2 of the skin 3-5 cm long, starting from a point located 1.5-2 cm above the projection of the pubic tubercle on the skin 3, having a direction parallel to the inguinal ligament. Subcutaneous fatty tissue, aponeurosis and fibers of the external inguinal ring are then dissected, if it is infringing, this leads to the reduction of the hernial contents. If the result is negative, if the inner inguinal ring is infringing, a retractor blade is inserted into the wound along the inguinal canal. The design of the retractor is described in patent No. 2207068, IPC A61B 17/02, publ. 06/27/2003, Bull. Number 18. Traction for the handle 6 of the retractor upward creates an operating field in the area of the inguinal gap. We carry out a dilution of the organ by cutting the fibers of the internal oblique and transverse muscles along the grooved probe.

A laparoscopic instrument is introduced, an audit and assessment of the viability of the dilute organ are performed.

With the viability of the dilute organ with a direct inguinal hernia, the hernial sac was inserted into the abdominal cavity without opening.

When the organ was not viable, the hernia sac was opened, the organ was removed into the wound, and a non-viable area was resected.

In case of resection of the restrained organ before sinking, the hernial sac was sutured. With oblique inguinal hernia, the hernial sac was always opened, stitched at the base, dissected along the front wall to the bottom, to prevent congestion, without excision.

Traction for the handle 6 of the retractor upward creates an operating field in the area of the inguinal gap. Then the spermatic cord 7 is mobilized and taken to the turnstile.

The main stage of the operation is performed - performing non-tension plastic surgery of the posterior wall of the inguinal canal with a graft 8 of polypropylene mesh. The graft 8 is cut out according to the size and shape of the inguinal gap. The front wall of the inguinal canal maximally rises, which makes visual inspection of the anatomical structures necessary for fixation of the transplant 8 available: pupartic ligament 9, pubic tubercle 4, vagina of the rectus abdominis muscle, free edges of the internal oblique and transverse muscles 10. Seed cord 7 rises afterwards Traction for the turnstile. The graft 8 is placed under the spermatic cord, closing the inguinal gap. By single interrupted sutures, the graft 8 is fixed to the pubic tubercle 4, to the edge of the vagina of the rectus abdominis muscle, to the edge of the internal oblique and transverse muscles of the abdomen 10 and the medial half of the pupartic ligament 9. In a fixed graft 8 without its deformation, cut a hole corresponding to the diameter of the spermatic cord 7 above inner inguinal ring 1. The spermatic cord is removed. The integrity of the graft is restored with one or two interrupted sutures and its fixation ends in the lateral half of the pupartic ligament 9. This is achieved by transferring the retractor blade in the desired direction to the anatomical structures: pubic tubercle 4, the edge of the vagina of the rectus abdominis muscle, pupartic ligament 9 and the internal inguinal ring 1 and the displacement of the performed surgical access 2 due to the elasticity of the skin and subcutaneous fat. Control of hemostasis, suturing of the aponeurosis of the external oblique muscle, subcutaneous fat. Suturing of the skin wound. Aseptic dressing. Jockstrap.

Anesthesia was carried out by non-narcotic analgesics if necessary. A control ultrasound scan was performed for congestion and relapse. After 15-18 hours, patients intensified. After 3 days, patients are discharged from the hospital.

Example No. 1.

Patient S., 22 years old, was hospitalized in the clinic with complaints of protrusion in the left inguinal region for 2 months. Within 11 hours, does not set in the stomach, severe pain in the area of hernial protrusion.

Objectively: in the left ileo-inguinal region, a round formation of 8 × 12 cm is determined, sharply painful on palpation, irreducible into the abdominal cavity. Percussion - tympanitis, no skin changes.

Diagnosis: restrained inguinal hernia on the left.

After conducting the necessary examinations, the operation is videoassisted hernioplasty from the mini-access.

The patient's position on the back lying horizontally. Endotracheal anesthesia. A laparoport of 10 mm was inserted above the navel, pneumoperitoneum was applied. Audit. In the left inguinal region, a loop of the small intestine is introduced into the inner inguinal ring, the leading loop is expanded to 5-6 cm, and the discharge loop is collapsed. By manual action on the hernial protrusion from the abdominal wall, against the background of the introduction of the next dose of muscle relaxants, the loop of the small intestine settled into the abdomen, hernial water was light, about 150 ml. An infringed area of 20 cm is recognized as viable. Sanitation of the abdominal cavity, taking hernia water for sowing. Desupilation of pneumoperiotoneum, laparoport removal.

In the left inguinal region 1.5 cm above the projection of the pubic tubercle parallel to the inguinal fold, a linear incision of the skin, subcutaneous tissue and aponeurosis of the external oblique muscle of the abdomen is 3.5 cm long. A retractor is inserted into the wound and the anterior wall of the inguinal canal is raised upwards, which ensures the operating space. Stupidly mobilized spermatic cord 2.5 cm in diameter to the pubic tubercle. The hernial sac is located outside the elements of the spermatic cord. The hernial sac is inserted into the abdominal cavity. A graft was cut from a polypropylene mesh measuring 10 × 5 cm, corresponding to the size of the inguinal gap. By the traction for the turnstile, the spermatic cord was raised, a prepared transplant was laid under it. By separate interrupted sutures with a polypropylene thread “0”, the graft is fixed to the pubic tubercle, the edge of the vagina of the rectus abdominis muscle, internal oblique and transverse muscles, and to the medial half of the pupartic ligament. A hole has been cut in the laid graft above the inner inguinal ring with a diameter of 1.3 cm, corresponding to the diameter of the spermatic cord. Separate interrupted sutures restored transplant integrity. Its fixation to the lateral half of the pupartic ligament with separate interrupted sutures is completed.

Control of hemostasis. Stitches for aponeurosis, subcutaneous tissue, skin. Aseptic dressing.

The postoperative period was uneventful, after 12 hours the patient began to walk. Anesthesia was performed once - at night in / m Ketorol 2.0 ml. Three days later, a control ultrasound examination was performed - there were no accumulations in the area of operation, the symptom of a cough push was negative. The patient was released home for outpatient aftercare. The wound healed by first intention, the sutures were removed on the 9th day.

Example No. 2.

Patient P., 62 years old, was hospitalized with complaints of severe pain in the area of hernial protrusion in the right inguinal region for 10 hours. Hernial carriage for 2 years, adjusted independently. Within 10 hours does not set in the stomach, severe pain in the area of hernial protrusion.

Objectively: in the right inguinal region, a round formation of 10 × 18 cm is determined, descending into the scrotum, sharply painful on palpation, irreducible into the abdominal cavity. Percussion - tympanitis, no skin changes.

Diagnosis: strangulated inguinal hernia on the right.

After conducting the necessary examinations, the operation is videoassisted hernioplasty from the mini-access.

The patient's position on the back lying horizontally. Endotracheal anesthesia. A laparoport of 10 mm was inserted above the navel, pneumoperitoneum was applied. Audit. In the left inguinal region, a loop of the small intestine is introduced into the inner inguinal ring, the leading loop is expanded to 7-6 cm, and the discharge loop is collapsed. By manual action on the hernial protrusion from the abdominal wall, against the background of the introduction of the next dose of muscle relaxants, the loop of the small intestine did not settle.

In the left inguinal region, 1.5 cm above the projection of the pubic tubercle, a linear incision of the skin, subcutaneous tissue and aponeurosis of the external oblique muscle of the abdomen, 3.5 cm long, is parallel to the inguinal fold. The external inguinal ring is dissected, the contents have settled into the abdominal cavity. A laparoscopic audit was performed: hernial water was light, about 150 ml. The restrained area is 25-28 cm, recognized as viable. Sanitation of the abdominal cavity, taking hernia water for sowing. Pneumoperitoneum desufflation, laparoport removal.

A retractor is introduced into the wound and the front wall of the inguinal canal is raised upward by traction, which ensures the operating space. Stupidly mobilized spermatic cord 2.5 cm in diameter to the pubic tubercle. The hernial sac is located among the elements of the spermatic cord. The hernial sac is opened, stitched at the neck, cut along the front wall to the bottom. A graft was cut from a polypropylene mesh measuring 10 × 5 cm, corresponding to the size of the inguinal gap. By the traction for the turnstile, the spermatic cord was raised, a prepared transplant was laid under it. By separate interrupted sutures with a polypropylene thread “0”, the graft is fixed to the pubic tubercle, the edge of the vagina of the rectus abdominis muscle, internal oblique and transverse muscles, and to the medial half of the pupartic ligament. A hole has been cut in the laid graft above the inner inguinal ring with a diameter of 1.5 cm, corresponding to the diameter of the spermatic cord. Separate interrupted sutures restored transplant integrity. Its fixation to the lateral half of the pupartic ligament with separate interrupted sutures is completed.

Control of hemostasis. Stitches for aponeurosis, subcutaneous tissue, skin. Aseptic dressing.

The postoperative period was uneventful, after a day the patient began to walk. Anesthesia was carried out as necessary, non-narcotic analgesics - v / m ketorol 2.0 ml. Three days later, a control ultrasound examination was performed - there were no accumulations in the area of operation, the symptom of a cough push was negative. The patient was released home for outpatient aftercare. The wound healed by first intention, the sutures were removed on the 9th day.

This method provides a minimum amount of operating injury, maximum accessibility to the elements of the inguinal gap. Possibility of safe dissection of the restraining ring both at the level of the internal and external inguinal ring. The formed access is located closer to the medial part of the inguinal canal, which provides a better overview of the anatomical structures in the medial part of the inguinal canal, without the difficulty of working in the area of the internal inguinal ring.

The effectiveness of surgical intervention and, as a result, faster adaptation of the patient and the restoration of his working ability are increased, the length of hospital stay is reduced to three days.

Claims (1)

The method of hernioplasty of restrained inguinal hernias, including exposure of the hernial sac, evacuation of hernial water, dissection of the restraining ring, plastic of the inguinal canal, characterized in that preliminary diagnostic laparoscopy is performed, if it is impossible to dilute and reposition the hernial contents under the influence of muscle relaxants, laparoperoportic instruments are removed, save, perform a linear skin incision 3-5 cm long, starting from a point located 1.5-2 cm above the projection onto the skin th tubercle parallel to the inguinal ligament, then cut the subcutaneous fatty tissue, aponeurosis and fibers of the external inguinal ring, if it is infringing, repeat the attempt to reduce the infringed organ; in case of infringement in the inner inguinal ring, a retractor blade is inserted into the wound along the inguinal canal, traction is carried out by the handle up to create the surgical field, the fibers of the internal oblique and transverse muscles are notched along the grooved probe, they are cut, the laparoscopic instrument is inserted and the viability of the diluted body; in case of direct inguinal hernia: when the organ is viable, the hernial sac is inserted into the abdominal cavity without opening or, if the diluted organ is not viable, the hernial sac is opened, the organ is removed into the wound, the non-viable area is resected, when the resected organ is resected, the opened hernial sac is sutured before being repaired; with oblique inguinal hernia: the hernial sac is opened, stitched at the base, dissected along the front wall to the bottom without complete mobilization and resection, traction by the retractor handle creates an operative field in the inguinal canal, mobilize and take spermatic cord on the turnstile, perform non-tension plastic the back wall of the inguinal canal with a synthetic graft with a hole for excretion of the spermatic cord.

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