RU2537769C2 - Inguinal ligament repair technique applied for recurrent hernias - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to the surgical management of inguinal hernias. The technique involves incising the inguinal skin, separating a hernial sac from surrounding tissues up to a neck, and removing the hernial sac in case of oblique hernias and invaginating into the abdominal cavity in case of straight ones. An iliac wing is mobilised. A duct is formed of a mesh endoprosthesis, which is fixed throughout to the iliac wing. That is followed by a tension-free hernioplasty with a lateral edge of the mesh prosthesis fixed to the formed duct.

EFFECT: technique prevents recurrent inguinal hernias.

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Description

In case of recurrent and recurrent inguinal hernias, when the hernia is performed repeatedly and the inguinal gap, the inguinal ligament becomes weak, shapeless, sprained, since all known methods of hernia repair aimed at strengthening one of the walls of the inguinal canal involve the use of the inguinal ligament for plastic.

The known method of plastic inguinal canal (Toskin VV, Mohammed Tom Elbashir. Surgery of abdominal hernias and eventings. Simferopol: Business - Inform, 2002. - P.276-278), by hernia repair using plastic for the back wall of the inguinal canal and the internal opening of the femoral canal of the transplant from the dura mater, which consists in the fact that the operation is started by inguinal access, the transverse fascia is dissected, isolated, treated and the hernia sac is removed. From the edge of the femoral vein and to the lacunar ligament at a distance of 5 mm from each other, several sutures are placed that capture the upper edge of the dissected transverse fascia and the superior pubic ligament. Before tying the sutures, the middle part of the graft is additionally sutured along its longitudinal axis, then these sutures are tied. At the next stage, the graft is sewn around the circumference to the defect, and the upper edge of the graft is sewn to the lower edges of the internal oblique and transverse muscles, their connected tendon, rectus sheath and pubic tubercle. Next, the anterior wall of the inguinal canal is made over the spermatic cord by creating a duplicate aponeurosis of the external oblique muscle of the abdomen. Subcutaneous fat layer and skin are sutured in layers.

The disadvantage of this method is the use of foreign cadaveric tissue, which can cause an allergic reaction, in addition, when creating a duplicate over the spermatic cord, tissue tension occurs, which reduces the effectiveness of treating a femoral and recurrent inguinal hernia with a destroyed inguinal ligament.

Closest to the claimed is a method of restoring the inguinal ligament with recurrent inguinal hernias according to the patent of the Russian Federation No. 2343851, in which the old postoperative scar is excised by making an incision bordering the hernial protrusion of the skin and subcutaneous tissue, then the hernial sac is isolated from the surrounding tissue to the neck and the hernia is removed with oblique hernias, and with direct hernias, the hernial sac is invaginated into the abdominal cavity by suturing the transverse fascia, subsequently using a single mesh endoprosthesis at the same time o eliminate the defect of the abdominal wall of the inguinal region and restore the absent inguinal ligament by suturing the mesh endoprosthesis from the medial side to the scallop ligament and to the upper edge of the pubic symphysis with four interrupted sutures, then the part of the endoprosthesis located preperitoneally around the edge is fixed to the fascia m. psoas, and its lateral end in front is fixed to the remaining scraps of the lateral part of the inguinal ligament and Spina iliaca anterior superior, after which the endoprosthesis is bent in the cranial direction and fixed medially to the anterior sheet of the vagina of the rectus abdominis muscle, then an incision is made from the cranial side in the endoprosthesis to the deep inguinal rings for excretion of the spermatic cord or uterine round ligament, the formed legs of the endoprosthesis are sutured from the cranial side of the deep inguinal ring in the form of a duplicature to form a deep groin th ring of the implanted endoprosthesis wherein the endoprosthesis is fixed across the abdominal wall surface of the overlap a continuous suture. 2/0 polypropylene suture is used as the thread, and implants, mainly made of polypropylene fibers (Prolene, Surgipro, Surgimesh, ESFIL), are used as a mesh endoprosthesis.

The disadvantages of the method are the technical complexity of the implementation, the use of plastic remnants of the inguinal ligament, which is not a reliable fixation of the endoprosthesis, to suture the endoprosthesis along the entire lateral margin to the fascia m. Psoas fails and the upper lateral part of the endoprosthesis remains until Spina iliaca anterior superior, which is fixed to the transverse fascia, which is also not a reliable fixation, the formation of a single graft for plastic and inguinal ligament and posterior wall of the inguinal canal and the use of a continuous suture, with the development of insolvency one of the nodes is fraught with migration of the endoprosthesis and the development of hernia recurrence.

The objective of the invention is the creation of conditions for performing effective hernioplasty with recurrent and recurrent inguinal hernias, by forming a strong inguinal ligament.

The invention:

The operation is performed from semilunar access to the inguinal canal by cutting the skin and subcutaneous tissue 1 cm medially and parallel to the inguinal fold, while the length of the incision is 5-6 cm, the skin mobility and the semilunar incision, increasing visual visibility, allows you to move the hooks from the incision such lengths to perform hernioplasty in full. The aponeurosis of the external oblique muscle of the abdomen is dissected as laterally as possible along the fibers up and down, while the inguinal canal opens, and, as a rule, due to the failure of the inguinal ligament, the hernial sac is also located there, the hernial sac is isolated from the surrounding tissues to the neck and the hernial sac is removed with oblique hernias, and with direct hernias, the hernial sac is invaginated into the abdominal cavity by suturing the transverse fascia. Regardless of previously performed operations, the lateral edge of the dissected aponeurosis and the remains of the inguinal ligament are unsuitable for inguinal canal repair. The index finger, stupidly, mobilizes the iliac wing to the anteroposterior iliac spine above and the pubic joint below. Next, the mesh is modeled in the form of a duplicate 1 cm wide, up to 12-15 cm long, then the simulated mesh prosthesis is fixed with interrupted sutures to the anterior superior iliac spine on one side with 2 sutures and the pubic joint with the other 2 sutures, and is fixed to the ilium wing, while the sutures are superimposed with an atraumatic surgical thread such as "Prolen" No. 1.0 or 2.0 to the periosteum. A 1 cm suture step, thus forming a strong inguinal ligament from the mesh prosthesis, fixed to the bone formation of the pelvis, then performing non-tensioning hernioplasty, with the difference that the lateral edge of the mesh prosthesis is fixed not to its inguinal ligament, but to the formed strong cord. Layer closure of the surgical wound.

Clinical example 1:

Patient K., 45 years old, was hospitalized in the surgical department No. 2 of the Republican Clinical Hospital in Nalchik from 02.06.2010 to 09.06.2010

Diagnosis: Recurrent right-sided inguinal hernia

In the department, the patient was examined clinically and laboratory:

- UAC: er.5.6 * 10 ^ 12 hb53 cp 1.o.

- ECG: sinus rhythm 108 beats. in minutes Signs of left ventricular hypertrophy.

- Lake 6.0 * 10 ^ 9 p 7, s 66, l 30.soe 11 mm / h.

- OAM: color s / f, reaction: acid, transparency: gender. Ud.100100. Protein neg., Sugar neg., Flat 5-6 in s / s.

- Total protein: 74 g / l.

- Total bilirubin: 15.Ommol / L.

- Coagulogram: bird 100%, fibrinogen 3.75 g / l

- Blood sugar: 4.6 mmol / L.

- RW: Neg.

The patient was operated on: During the operation, it was found that the inguinal ligament was flabby, flabby, in places with tears (unsuitable for plastic surgery), and therefore hernia repair was performed with plastic surgery according to the claimed method.

In the postoperative period, on the second day, the patient was activated, received antibacterial therapy for 3 days. The patient was discharged from the hospital on the 5th day. There was no relapse for the entire observation period.

Clinical example 2:

Patient M., 62 years old, was admitted with a diagnosis of Recurrent left-sided inguinal hernia.

The patient was examined clinically and laboratory:

- ECG: sinus rhythm 79 beats per minute. Signs of left ventricular hypertrophy.

- OAK: er.5.6 * 10 ^ 12 hbl53 cp l.o.

- Lake 6.0 * 10 ^ 9 p 7, s 66, l 30.soe 11 mm / h.

- OAM: color s / f, reaction: acid, transparency: gender. Ud.weight 1009. Protein neg., Sugar neg., Flat 5-6 in s / s,

- Total protein: 74 g / l.

- Total bilirubin: 15.0 mmol / L.

- Coagulogram: bird 100%, fibrinogen 3.75 g / l.

- Blood sugar: 4.6 mmol / L.

The patient has been operated on twice before (plastic surgery according to Bassini and Liechtenstein). In operation, the mesh prosthesis could not be differentiated. Operational finding - inguinal hernia, inconsistency of the posterior wall of the inguinal canal and inguinal ligament. The latter is spanned all over. The patient underwent hernia repair with plastic surgery according to the claimed method.

In the postoperative period, on the second day, the patient was activated, received antibacterial therapy for 3 days. The patient was discharged from the hospital on the 6th day. There was no relapse for the entire observation period.

Clinical example 3:

Patient G., 78 years old, was hospitalized in the surgical department No. 2 of the Republican Clinical Hospital in Nalchik with a diagnosis of recurrent right-sided inguinal hernia.

The patient in the department was examined clinically and laboratory:

- ECG: sinus rhythm 77 beats. Signs of left ventricular hypertrophy. Incomplete blockade of the right bundle branch block.

- Fl. OGK within the physiological norm.

- OAK: er. 4.2 * 10 ^ 12 hd130 cp 1.o. Lake 5.2 * 10 ^ 9 n 7, s 74, l 17.soe 12 mm / h.

- OAM: color s / f, reaction: acid, transparency: gender. Ud.weight 1009. Protein neg., Sugar neg., Flat 5-6 in p / s.

- Total protein: 78 g / l.

- Total bilirubin: 5.0 mmol / l

- Coagulogram: poultry 98%, fibrinogen 4.5 g / l.

- Blood sugar: 5.3 mmol / L.

- RW: Neg.

The patient was operated on; hernia repair with plastic surgery was performed according to the claimed method.

In the postoperative period, on the first day, the patient was activated, received antibiotic therapy. The patient was discharged from the hospital on the 6th day. There was no relapse for the entire observation period.

Technical result:

- effective restoration of the destroyed inguinal ligament;

- compliance with all the principles of non-tension hernioplasty in the absence of conditions for its implementation;

- effective non-tension hernioplasty;

- the possibility of use with recurrent and recurrent inguinal hernias.

Claims (1)

A method for plasty of the inguinal ligament in case of recurrent hernias, including a skin incision in the inguinal region, isolation of the hernial sac from the surrounding tissue to the neck and removal of the hernial sac in oblique hernias, and intussusception in the abdominal cavity with straight by suturing the transverse fascia, subsequently using a mesh endoprosthesis , the formation of the inguinal ligament by suturing to the Spina iliaca anterior superior and to the upper edge of the pubic symphysis, characterized in that the ilium wing is mobilized and the mesh is formed from the mesh during fixation comfort to the wing of the ilium, and then perform pull hernioplastics, the lateral edge of the mesh of the prosthesis is fixed to the formed tyazhu.