RU2549478C2 - Method of treating complicated inguinal-scrotal hernias by combining open and laparoscopic approaches - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to herniology. The method involves the following stages: effecting a laparoscopic approach, applying a pneumoperitoneum and inspecting a hernia defect area, specifying a diagnosis and localising a mini-incision point. That is followed by making the inguinal mini-incision max. 3 cm long in a projection of the superficial inguinal ring. The cremaster muscle is dissected longitudinally; the hernia sac which is inflated and is easy to differentiate after applying the pneumoperitoneum is separated from spermatic cord elements. The hernia sac is underrun at the base and dissected away. The expanded superficial inguinal ring is closed to 1-1.5 cm in diameter. The spermatic cord continuity is restored by closing the cremaster muscle. The skin wound is sutured. Under laparoscopic control the peritoneum with the hernia sac stump is mobilised. A mesh implant is inserted onto the prepared floor; the mesh is fastened with the use of a herniostapler. The abdominal cavity is de-gassed; the instruments are removed, and the skin wounds are closed.

EFFECT: method reduces intraoperative complications by inflating the hernia sac and underrunning the hernia sac at the base until dissecting away.

2 cl, 6 dwg

Description

The invention relates to medicine, namely to herniology, and is intended for the surgical treatment of complex inguinal-scrotal hernias.

The inguinal canal, canalis inguinalis, is the gap through which the spermatic cord, funiculus spermaticus, passes. It is placed in the lower abdominal wall on either side of the abdomen, immediately above the inguinal ligament, and goes from top to bottom, from the outside inward, from back to front. Its length is 4.5-5.5 cm.

An inguinal-scrotal hernia is a hernia characterized by the presence of a hernial protrusion in the inguinal region that extends beyond the inguinal canal and descends into the scrotum. When the hernia descends into the scrotum, but does not reach the testicle, it is a cord-inguinal-scrotal hernia. In the case when the hernia reaches the testicle and is located in its environment, it is the testicular inguinal-scrotal hernia.

The following differentiation of complex hernias was also proposed (Anischenko V.V., Semenov S.A. Complex hernias - classification possibilities. Non-governmental public health institution “Road Clinical Hospital”, Novosibirsk, Russia, 2012):

complex technically (giant recurrent hernias, giant or multi-chamber hernias with a pronounced adhesive process, with a pronounced decrease in the volume of the abdominal cavity, previously existing prosthetic repair, paracolostomy hernias),

complex tactically (difficulty in choosing the method of operation, the presence of an infected prosthesis),

complex diagnostic (all internal hernias),

complex somatic (concomitant diseases),

complex for obesity (obesity and obesity),

combined hernias (two or more defects of the abdominal wall exceeding a diameter of 5 cm).

The invention is directed to the surgical treatment of technically complicated inguinal-scrotal hernias.

The clinic uses both a laparoscopic hernia removal technique and the usual one with an incision of more than 5 cm, with a mesh prosthesis.

A known method of inguinal hernioplasty according to Liechtenstein, which provides for the implementation of traditional front access to the inguinal canal and the plastic of its posterior wall with a polypropylene mesh. After opening the inguinal canal, the inguinal ligament and spermatic cord are isolated, the hernial sac is isolated and treated. The fibers of the muscle raising the testis cross to the level of the internal opening of the inguinal canal. The polypropylene mesh is modeled on the shape of the inguinal canal and fixed with a continuous suture to the inguinal ligament to the inner inguinal ring. With separate sutures, the mesh is fixed to the internal oblique muscle (Chizhov D.V., Shurygin S.N., Voskresensky P.K., Filatkina N.V. Plastic surgery of the inguinal canal according to Liechtenstein and its modifications. - Herniology, 2004, No. 1, p. .43-51). The aponeurosis of the external oblique muscle with plastic sutures the edge to edge without tension.

The known method allows you to reliably strengthen the back wall of the inguinal canal, and the use of biologically inert synthetic material does not cause a reaction on the part of the tissues in the area of its location. The technical simplicity of the technique makes it accessible to a wide range of surgeons. However, the operation, being traumatic for the patient, involves the dissection of the fibers of the muscle that raises the testicle to the level of the internal opening of the inguinal canal. This leads to a loss or weakening of the contractility of the muscles that raise the testicle.

For the patient, the most preferred treatment is laparoscopic. The main advantages of laparoscopic hernioplasty are the absence of an extended skin incision and a high cosmetic effect due to performing only 3 punctures of the anterior abdominal wall 0.5-1 cm long and, as a result, lower pain intensity in the postoperative period. Laparoscopic hernioplasty is especially beneficial for patients with bilateral inguinal hernias, because the hernia repair on the opposite side is performed through the same 3 punctures, whereas conventional hernia repair of 2 inguinal hernias requires 2 incisions up to 10 cm long. Laparoscopic intervention consists in the fact that instead of large and long traditional incisions, small incisions are used through which trocars are introduced, and already through them the corresponding laparoscopic instruments. The entire course of the operation is visible on the monitor screen. However, the implementation of such operations requires a highly qualified surgeon, a long time and is not applicable in particularly difficult cases.

The closest analogue to the proposed method for the treatment of inguinal-scrotal hernias is the method of laparoscopic transabdominal preperitoneal hernioplasty disclosed in Russian patent No. 2303408. The essence of the known method is as follows: with laparoscopic transabdominal preperitoneal hernioplasty, a hernial sac is secreted, the peritoneum is circularly dissected at the level of the neck. Invaginate it in the abdominal cavity. Fix it with soft clamps and perform electrocoagulation demucosis of the peritoneum of the hernial sac using a ball electrode, which prevents the appearance of seromas and hernia recurrence.

Comparative work was carried out to optimize the method for the correction of inguinal-scrotal hernias (Abolmasov A.V. Choice of the optimal method for the correction of inguinal-scrotal hernias. Pleshcheevskaya CRH, Oryol Regional Hospital. Orel. 2012), in which patients were operated on in four ways: laparoscopic TAPP hernioplasty with isolation of the bag (I), laparoscopic TAPP hernioplasty without isolation of the bag (II), laparoscopic TAPP hernioplasty with coagulation of mesothelium of the hernial sac (III) and the classical operation of Liechtenstein (IV). As a result of the work, it was found that regardless of the method of surgical intervention, the early postoperative period is complicated by the development of seromas.

The known method is carried out with the preservation of the hernial sac, which makes the installation of a mesh prosthesis difficult, leads to an increase in the duration of the operation and an increase in the likelihood of intraoperative complications and subsequent relapses. The implementation of the known method takes a considerable time.

In addition, in the presence of a large inguinal-scrotal hernia, the isolation of a hernial sac, most often located in tight adhesions with elements of the spermatic cord and hernial contents, using only laparoscopic technique presents significant technical difficulties. In complex cases of inguinal-scrotal hernia, this method is not applicable at all.

Thus, there is a need to develop an improved methodology for the treatment of complex inguinal-scrotal hernias, devoid of the disadvantages of known methods and combining the advantages of traditional open and laparoscopic approaches.

The problem to which the invention is directed, is to develop a method of hernia repair of technically complex hernias, which allows to reduce the incidence of intraoperative and postoperative complications, to reduce and simplify the operation itself.

The technical result that is achieved by the implementation of the invention is to reduce the morbidity by performing a small incision to cut off the hernial sac and time for surgery due to a combination of direct and laparoscopic access methods, reducing intraoperative complications and subsequent relapses.

The specified technical result is achieved due to the fact that when implementing the method of treating inguinal-scrotal hernias by a combination of open and laparoscopic approaches, the following steps are performed:

carry out laparoscopic access by performing three punctures of the anterior abdominal wall at standard points, apply pneumoperitoneum and examine the area of the hernial defect, clarify the diagnosis and location of the mini-incision;

a mini-incision is made in the inguinal region in the projection of the superficial inguinal ring with a length of not more than 3 cm, the muscle lifting the testicle is cut longitudinally, the hernial sac is isolated from the elements of the spermatic cord, which, after application of pneumoperitopeum, is inflated and easily differentiated, the hernial sac is stitched at the base and cut off, the expanded superficial inguinal ring is sutured up to 1-1.5 cm in diameter, the integrity of the spermatic cord is restored by suturing the muscle that lifts the testicle, sutures are applied to the skin wound;

under the control of a laparoscope, the peritoneum is mobilized with a stump of the hernial sac, a mesh implant is placed, mesh fixation is performed with a herniostapler or a manual suture. After peritonization of the mesh, a drainage tube is installed in the space between the mesh and the peritoneum for 1 day, bringing it to the skin through a 5 mm trocar puncture. Gas and instruments are removed from the abdominal cavity, and skin wounds are sutured.

The essence of the method and the possibility of achieving a technical result will be more clear from the following description, which is given with reference to the accompanying graphic materials, where

figure 1 shows a photograph of a patient suffering from recurrent inguinal-scrotal hernia after 6 operations,

figure 2 is a photograph of a hernial sac after application of pneumoperitoneum,

figure 3 shows the hernia sac isolated through the incision,

figure 4 - the bag is stitched and cut off,

figure 5 is a view of a sutured wound,

and Fig.6 shows a view of the inguinal region from the inside after cutting off the hernial sac.

A method of treating complex inguinal-scrotal hernias by a combination of open and laparoscopic accesses according to the invention is as follows.

The patient is placed on the operating table on his back in the Trendelenburg position: lying on his back at an angle of 30 ° -45 ° with the pelvis raised relative to the head.

The operating table is tilted 15 degrees from the horizontal plane to the right or left, depending on the location of the hernia. In this position, the internal organs are displaced, releasing the inguinal region. The surgeon and video assistant are located at the head of the patient. The monitor is installed at the patient’s feet to the right of the operating table. An operating nurse with an instrument table is located to the left of the operating table.

The operation is performed under general (endotracheal) anesthesia.

At the first ethane of the operation, standard laparosconic access is performed. Impose pneumoperitoneum; gas is injected into the abdominal cavity through a Veress needle inserted into the puncture. We install trocars at three standard points. A trocar for a laparoscope is installed in the navel area, the abdominal cavity and the hernia defect are examined, the diagnosis and location of the mini-incision are specified. The other two are left and right along the outer edges of the rectus abdominis muscles at the level of the navel. In this case, a 12-mm trocar for a hernial stapler is introduced on the left, and a 5-mm trocar for scissors and a dissector to the right of the midline. The surgeon uses a two-handed technique of conducting the operation, and the assistant provides visualization of the surgical field, working with a laparoscope.

Then proceed to the second "open" phase of the operation. This stage is performed according to the gentle method with minimal incisions. A mini-incision is performed in the inguinal region in the projection of the superficial inguinal ring with a length of not more than 3 cm. An incision of 2-3 cm in size is usually sufficient, in contrast to the generally accepted technique in which an incision is made with a length of 5 cm or more. Next, longitudinally dissect the muscle that raises the testicle. Of the elements of the spermatic cord, a hernial sac is isolated, which, after application of pneumoperitoneum, is swollen and easily differentiated from other structures. However, this stage of the operation requires a good knowledge of the anatomy of the spermatic cord and careful preparation to exclude damage to the vessels of the spermatic cord and the vas deferens. The hernial sac is stitched at the base and cut off. The expanded superficial inguinal ring is sutured with 2-4 interrupted sutures up to 1-1.5 cm in diameter. This allows for additional strengthening of the anterior wall of the inguinal canal and separation of the superficial and deep inguinal rings in the sagittal plane, which is especially important for hernias with a destroyed posterior wall and a straightened inguinal canal, since it significantly reduces the risk of recurrence of the disease. Restore the integrity of the spermatic cord by suturing the muscle that lifts the testicle. Suture the skin wound.

Proceed to the third - laparoscopic - stage of the operation. Under the control of a laparoscope, the peritoneum is mobilized using a standard method with a hernial sac stump, after which a site is prepared for laying a mesh implant.

Mobilization of the peritoneum in the area of the mesh prosthesis installation is greatly simplified in the absence of a hernial sac (the latter is already removed with an open stage). This allows you to reduce the time of surgery and reduce the number of intraoperative complications. The mesh of a standard size 10 × 15 cm is fixed to dense fabrics with titanium clips using any herniostapler or a manual seam. After peritonization of the mesh, a drainage tube is installed in the space between the mesh and the peritoneum for 1 day, bringing it to the skin through a 5-mm trocar puncture. Gas and instruments are removed from the abdominal cavity, skin wounds are sutured.

Clinical studies were conducted on three groups of patients aged 23 to 70 years. The first group underwent operations using a combined technique. Patients of two control (second and third) groups underwent laparoscopic transabdominal preperitoneal hernioplasty and the operation of traditional anterior access to the inguinal canal and plastic of the posterior wall with a polypropylene mesh, respectively. After surgery, patients were observed for 6 months. Relapses were absent in all groups. Clinical studies have shown good tolerability of the combined technique, the absence of relapse and the rapid recovery of patients after surgery

The advantages of the invention are as follows:

1. The technique can significantly facilitate the operation and with minimal trauma to strengthen the abdominal wall.

2. Open access through a mini-incision is carried out precisely, without trauma to the elements of the spermatic cord (blood and lymph vessels of the testis, vas deferens). With an open method of processing a hernial sac, the operating time is significantly reduced.

3. Mobilization of the peritoneum in the area of the mesh prosthesis installation is greatly simplified in the absence of a hernial sac, which has already been removed at the open stage, this also reduces the time of surgery and reduces the number of intraoperative complications.

4. Suturing of the enlarged superficial inguinal ring with several interrupted sutures allows strengthening the front wall of the inguinal canal and separation of the superficial and deep inguinal rings in the sagittal plane, which is especially important for hernias with a destroyed posterior wall and a straightened inguinal canal, since it significantly reduces the risk of recurrence of the disease .

Thus, the invention allows to combine the advantages of both methods of performing operations (open and laparoscopic) in the treatment of complex inguinal-scrotal hernias.

On the one hand, the method provides less trauma for the patient, easier postoperative period and faster wound healing, lower risk of postoperative complications characteristic of laparoscopic interventions.

And, on the other hand, the method is characterized by a short operation time, simplicity of execution, the ability to completely remove the hernial sac and the availability of mastering the technique for a wide range of surgeons inherent in traditional methods.

The given specific example of the method is intended for purposes of illustration, and not to limit the nature and scope of the invention. The scope of the invention is determined solely by the claims attached to this description, given without highlighting the restrictive part, in order to more clearly show the sequence of stages of the operation.

Claims (2)

1. A method of treating inguinal-scrotal hernias by a combination of open and laparoscopic approaches, comprising the steps of: performing laparoscopic access by performing three punctures of the anterior abdominal wall at standard points, applying pneumoperitoneum, while the hernial sac is inflated after applying pneumoperitoneum, and the hernia zone is examined defect, specify the diagnosis and location of the mini-incision; a mini-incision is made in the inguinal region in the projection of the superficial inguinal ring with a length of not more than 3 cm, the muscle lifting the testicle is longitudinally dissected, the hernial sac is isolated from the elements of the spermatic cord, which is swollen and easily differentiated, the hernial sac is stitched at the base and cut off, the expanded superficial inguinal the ring is sutured up to 1-1.5 cm in diameter by stitching with interrupted sutures, the integrity of the spermatic cord is restored by suturing the muscle that lifts the testicle, sutures are applied to the skin wound; under the control of a laparoscope, the peritoneum is mobilized from the stump of the hernial sac, the polypropylene mesh is laid, the mesh is fixed to the dense tissues with titanium staples with a herniostenler, gas and instruments are removed from the abdominal cavity, and skin wounds are sutured. 2. The method according to claim 1, characterized in that after peritonization of the mesh into the space between the mesh and the peritoneum for 1 day establishes a drainage tube, bringing it to the skin through a trocar puncture.

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