RU2545413C2 - Method for combined inguinal hernioplasty - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves opening an inguinal canal by dissecting an aponeurosis of abdominal external oblique muscle from an upper edge of an external opening of the inguinal canal in parallel with a femoral arch. A spermatic cord is separated. Forming an aponeurotic flap aiming at reinforcing a posterior wall additionally and separating the spermatic cord from a prosthesis is ensured by making a second incision of the aponeurosis of abdominal external oblique muscle in parallel with the first one and 2 cm higher. An endoprosthesis is shaped after an inguinal space; its lower edge is fixed behind the spermatic cord to an iliac-pubic tract and deep layers of the inguinal ligament with forming an arched internal opening of the inguinal canal along a lower edge of the endoprosthesis so that the arch diameter exceeds the spermatic cord diameter by 2-3 mm. An upper edge of the endoprosthesis is fixed to the common aponeurosis of the external and internal abdominal oblique muscles, passing into a leaf of rectus sheath. The aponeurotic flap formed of the aponeurosis of the abdominal external oblique muscle is placed behind the spermatic cord onto the endoprosthesis. The lower edge of the aponeurotic flap is fixed to the deep layers of the inguinal ligament to form an opening for the spermatic cord according to its diameter. The upper edge of the aponeurotic flap is anchored to the underlying endoprosthesis. The spermatic cord is placed onto the aponeurotic flap, and free ends of the aponeurosis of the abdominal external oblique muscle is sutured together above the spermatic cord to form an external opening of the inguinal canal up to 1.5 cm in diameter.

EFFECT: method prevents recurrences and postoperative complications by fixing the lower edge of the endoprosthesis to the iliac-pubic tract and the deep layers of the inguinal ligament, with its upper edge fixed to a junction of the aponeurosis of the external and internal abdominal oblique muscles, fixing the lower edge of the aponeurosis of the abdominal external oblique muscle to the deep layers of the inguinal ligament, with the upper edge fixed to the underlying endoprosthesis.

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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.

Among surgical pathology, hernias take the third place, and in terms of the number of operations they are in second place after appendectomy and make up from 8 to 24% of all surgical interventions, with the vast majority (up to 75%) being inguinal.

Pronounced trophic changes with the destruction of the structures of the inguinal canal make it impossible to perform hernioplasty reliably at the expense of their own tissues, urging the surgeon to prosthetic plastic. Due to the widespread introduction of prosthetic surgery for hernias, the recurrence rate significantly decreased, however, there were specific problems caused by the use of an endoprosthesis - prosthetic-associated complications, the frequency of which is more than 1% [1, 2]. And yet, in certain situations, prosthetic repair is the only reliable way to ensure the strength of the abdominal wall. Based on the foregoing, it becomes obvious the need to minimize the likelihood of prosthetic-associated complications, while maintaining all its positive qualities and making it more reliable against relapse.

Most often, a polypropylene (prolene) mesh endoprosthesis is used as an endoprosthesis for inguinal hernia repair. Polypropylene has been proposed for F.C. hernia repair. Usher in 1958 [6], but only in the 90s of the XX century, thanks to the work of Irving Lichtenstein and his students, prosthetic inguinal hernioplasty was recognized as the “gold standard” [4]. As experience gained, it turned out that contact of the elements of the spermatic cord with the prosthesis leads not only to technical difficulties in the case of an operation for a relapse of the disease, but also to complications arising from deformation of the tubular structures of the spermatic cord in the periprosthetic scar. Such complications include varicocele, hydrocele, testicular atrophy with outcome in infertility [3]. R. Witkowski and E. Trabucco, as well as D. Shin et al., Reasonably believe that one of the main causes of impaired fertility is the contact of the spermatic cord with the endoprosthesis. The studies they conducted showed the development of a fibroplastic process around a polypropylene endoprosthesis. As a result of the emerging periprosthetic fibrosis, testicular vessels and the vas deferens are involved in the scar, which first leads to their deformation, and in severe cases, obliteration [5, 7, 8]. To reduce the risk of possible complications, the authors, as well as some domestic herniologists (V.I. Belokonev), propose anatomically delimiting the mesh from the spermatic cord by stitching the abdominal external oblique muscle above the prosthesis, thereby expelling the spermatic cord under the skin. This arrangement of the spermatic cord in comparison with the classical operation of Liechtenstein improves fertility, but does not restore the inguinal canal and its closure mechanism, which plays an important role in the occurrence of relapse of the disease.

Of the closest to the technical essence, the method of hernioplasty without tension was proposed by Irving Lichtenstein, according to which plastic surgery of the posterior wall of the inguinal canal is performed by using a polypropylene endoprosthesis to strengthen the posterior wall of the inguinal canal, which is fixed to the inguinal ligament and the internal oblique muscle of the abdomen [4 ].

With plastic by the method of Liechtenstein, there are certain disadvantages:

- fixation of the upper edge of the endoprosthesis to the internal oblique muscle of the abdomen is unreliable and can lead to eruption of the suture due to the partially preserved closure mechanism of the inguinal canal and displacement of the internal oblique muscle under various functional conditions of the abdominal wall, for example, under tension of the abdominal press. Otherwise, this fixation option, when forming a dense fibrous process, can lead to the loss of the closure mechanism, which makes the plastic less physiological;

- with a high inguinal gap, especially when the transverse fascia is destroyed, a situation arises when the newly formed posterior wall of the inguinal canal is represented only by the endoprosthesis and does not include its own tissues, similar to the “in lay” position of the endoprosthesis with plastic hernias of mid and lateral localization with all its known disadvantages . It was found that even despite the tension of the stitched tissues during hernioplasty with the location of the “sub lay” endoprosthesis, due to the strengthening of the plastic zone with own tissues, and most importantly, more reliable fixation of the prosthesis due to its subaponeurotic location, better results are achieved with fewer relapses in comparison with in lay plastic;

- the location of the spermatic cord on the grid inevitably leads to changes in the tubular structures of the spermatic cord and the associated complications. In the case of repeated operations with a relapse of the disease, difficulties arise with the allocation of spermatic cord, which sometimes leads to the inability to differentiate the vas deferens and isolate it without damage.

The above shortcomings prompted us to develop a combined method of inguinal hernia repair with reinforcing the posterior wall of the inguinal canal, which is based on the use of the displaced aponeurosis of the external oblique muscle of the abdomen to strengthen the posterior wall of the inguinal canal and delimiting the spermatic cord from the endoprosthesis.

The essence of the proposed method lies in the fact that with a combined inguinal hernioplasty, based on the strengthening of the posterior wall of the inguinal canal with an endoprosthesis and an aponeurotic flap of the external oblique muscle of the abdomen, according to the invention, the first step is the fixation of the lower edge of the endoprosthesis to the iliac-pubic tract and deep layers of the inguinal ligament , upper - to the junction of the aponeurosis of the external oblique and internal oblique muscles of the abdomen. The second stage is the isolation and movement of the aponeurosis flap of the external oblique muscle of the abdomen with fixation of the lower edge of the latter to the deep layers of the inguinal ligament, and the upper to the underlying endoprosthesis.

This combination of new features with the known allows, firstly, to provide a more reliable fixation of the upper edge of the endoprosthesis and maintain the function of the closure mechanism of the inguinal canal. Secondly, to strengthen the posterior wall of the inguinal canal due to its own tissues with an additional layer, using the most dense connective tissue structure of the inguinal canal. Thirdly, to increase the reliability of fixation of the endoprosthesis according to the type of subaponeurotic location. Fourth, to isolate the endoprosthesis from the spermatic cord, while preserving the anatomy of the inguinal canal and its valve function by stitching over the spermatic cord the free edges of the aponeurosis of the external oblique muscle of the abdomen.

The proposed method of combined inguinal autogernioplasty is illustrated by drawings. Figure 1 shows the layout of the implant and the formation of a flap of the aponeurosis of the external oblique muscle of the abdomen: 1 - inguinal ligament; 2 - spermatic cord; 3 - endoprosthesis; 4 - a flap of aponeurosis of the external oblique muscle of the abdomen; 5 - a place for additional dissection of the aponeurosis of the external oblique muscle of the abdomen; 6 - aponeurosis of the external oblique muscle of the abdomen; 7 - internal oblique muscle of the abdomen; 8 - transverse muscle of the abdomen; 9 - transverse fascia; 10 - deep layers of the inguinal ligament and the iliac-pubic tract. Figure 2 shows a diagram of the fixation of the aponeurosis flap of the external oblique muscle of the abdomen to the endoprosthesis. Figure 3 shows the final diagram of the operation.

The method of combined inguinal hernioplasty 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 by dissecting the aponeurosis of the external oblique muscle of the abdomen from the upper edge of the external opening of the inguinal canal parallel to the inguinal ligament. The spermatic cord is isolated. To form an aponeurotic flap in order to further strengthen the posterior wall of the inguinal canal and to delimit the spermatic cord from the prosthesis, a second incision of the aponeurosis of the external oblique muscle of the abdomen is performed parallel to the first incision and 2 cm higher. The endoprosthesis is modeled according to the shape of the inguinal space and its lower edge is fixed behind the spermatic cord to the iliac-pubic tract and the deep layers of the inguinal ligament, forming the inner opening of the inguinal canal along the lower edge of the endoprosthesis in the form of an arch so that the diameter of the arch exceeds the diameter of the spermatic cord 2-3 mm. The upper edge of the endoprosthesis is fixed to the combined aponeurosis of the external and internal oblique muscles of the abdomen, passing into the anterior sheet of the vagina of the rectus muscle. The aponeurotic flap formed from the aponeurosis of the external oblique muscle of the abdomen is placed behind the spermatic cord on the endoprosthesis. The lower edge of the aponeurotic flap is fixed to the deep layers of the inguinal ligament, forming an opening for the spermatic cord in accordance with its diameter. The upper edge of the aponeurotic flap is sutured to the underlying endoprosthesis. The spermatic cord is placed on the aponeurotic flap, after which the free edges of the aponeurosis of the external oblique muscle of the abdomen are sutured above the spermatic cord, forming the external opening of the inguinal canal with a diameter of up to 1.5 cm. The operation is completed by suturing the skin wound.

The first operation in the clinic was performed on January 23, 2014 to a patient M., 64 years old, with a diagnosis of recurrent inguinal-scrotal hernia on the right (Nyhus 3b). Esfil-standard polypropylene endoprosthesis manufactured by Linteks LLC (St. Petersburg, Russia) was used as an endoprosthesis. Postoperative course without complications. Active mode 12 hours after surgery. Pain is not pronounced. Discharged on the 5th day. Repeated examinations on February 6, 2014 and February 20, 2014. There are no complaints, the patient returned to his usual activities. On examination, the seam on the skin is wealthy. There are no inflammatory changes in the plastic zone. Testicular edema was not noted.

Information sources

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

2. Amid P.K. Radiologic images of meshoma: a new phenomenon causing chronic pain after prosthetic repair of abdominal wall hernias // Arch Surg. - 2004 .-- 139 - P.p.1297-1298.

3. Homonnai Z.T., Fainman N., Paz G.F., David M.P. Testicular function after herniotomy. Herniotomy and fertility // Andrologia. - 1980. - 12. - P.p. 115-120.

4. Lichtenstein I.L. Herniorrhaphy: a personal experience with 6321 cases // American Journal of Surgery. - 1987. - Jun. 153 (6). - Pp. 553-562.

5. Shin D., Lipshultz L.I., Goldstein M. et al. Herniorrhaphy with polypropylene mesh causing inguinal vasal obstruction: a preventable cause of obstructive azoospermia // Ann Surg. - 2005 - 241 (4). - P.p. 553-558.

6. Usher F.C., Ochsner J., Tuttle L.I. Use of Marlex® mesh in the repair of incisional hernias // The American Surgeon. - 1958.- Dec.24 (12). - Pp. 969-974.

7. Witkowski P. What Can We Do To Decrease the Risk of Vas Deferens Injury due to Inguinal Hernioplasty? In: Volker Schumpelick, Robert J. Fitzgibbons (Eds.) New York: Hernia Repair Sequelae 2010; 49-57.

8. Witkowski P., Trabucco E.E. Is there an increased risk of vas deferens occlusion after mesh inguinal hernioplasty and what we can do about it? // Ann Surg. - 2007. - 245 (1) - P.p. 153-154.

Claims (1)

A method of combined inguinal hernioplasty, including reinforcing the posterior wall of the inguinal canal with an endoprosthesis, characterized in that the inguinal canal is opened by dissecting the aponeurosis of the external oblique muscle of the abdomen from the upper edge of the external opening of the inguinal canal parallel to the inguinal ligament, the spermatic cord is isolated, an aponeurotic flap is formed to further strengthen the posterior the walls of the inguinal canal and the demarcation of the spermatic cord from the prosthesis, performing a second incision of the aponeurosis of the external oblique abdominal muscle of the steam Along the first incision and 2 cm higher, the endoprosthesis is fixed behind the spermatic cord to the iliac-pubic tract and the deep layers of the inguinal ligament, the inner opening of the inguinal canal is formed along the lower edge of the endoprosthesis in the form of an arch 2-3 mm greater than the diameter of the spermatic cord, the upper edge the endoprosthesis is fixed to the combined aponeurosis of the external and internal oblique muscles of the abdomen, passing into the anterior sheet of the vagina of the rectus muscle, formed from the aponeurosis of the external oblique muscles of the abdomen, the aponeurotic flap is placed on rear the spermatic cord on the endoprosthesis, fix the lower edge of the aponeurotic flap to the deep layers of the inguinal ligament, forming an opening for the spermatic cord in accordance with its diameter, the upper edge of the aponeurotic flap is sutured to the underlying endoprosthesis, the spermatic cord is placed on the aponeurotic flap with the aprosoneurotic flap, oblique muscle of the abdomen above the spermatic cord with the formation of the external opening of the inguinal canal with a diameter of up to 1.5 cm.

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