RU2605150C1 - Method of inguinal and femoral hernia plastics - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery for hernioplasty of inguinal hernia. Mesh prosthesis is used with triangular flap cut out on one side. One side of flap is fixed to pectineal ligament covering femoral ring and not affecting femoral vessels. Rounded end of mesh is fixed to pubic tubercle. Mesh is fixed to inguinal ligament with interrupted sutures with interval of 0.7-1.0 cm, wherein last suture is placed more lateral than internal inguinal ring. Then upper medial mesh edge is fixed to internal oblique and transverse abdominal muscles and to vagina rectus, wherein after internal inguinal ring at least 5-7 cm of mesh are left.

EFFECT: method enables reinforcing of posterior wall of inguinal channel and femoral ring.

1 cl, 2 ex, 1 dwg

Description

The invention relates to medicine, in particular to surgery, namely to herniology, and can be used for hernia repair of inguinal hernias mainly in women.

The first plastic operations of inguinal hernias were proposed in 1885, I. Championiere in France, but the basic principles of modern autoplasty of inguinal hernias were laid down by E. Bassini in 1887, describing his method of surgery with strengthening the posterior wall of the inguinal canal. The use of the Cooper ligament was first proposed in 1892 by J. Ruggie. At the same time, a high percentage of hernia recurrence of a given localization and difficulty in diagnosis were always noted.

The most important stage in the development of hernia surgery was the experimental work and the introduction into the practice of the surgeon of the use of xenogenic, allogeneic and synthetic materials to close hernia defects in order to create non-tensile types of plastics.

For plasty of the femoral canal J. Rives proposed the so-called "French method" of tensionless hernioplasty, which consists in inguinal access to the femoral canal. After opening the inguinal canal, dissecting the transverse fascia and preparing the latter caudally to the obturator foramen, and cranially to the arcus aponeuroticus, a rectangular mesh prosthesis 10 × 15 cm in size is cut with an incision to exit the spermatic cord and is fixed to the scallop ligament with 3-4 sutures. The medial (caudal) edge of the explant is located in the separated space behind the pubic bone. Then, the cranial edge of the mesh endoprosthesis is tightened with four U-shaped sutures, and thus the explant is located in the preperitoneal position between the abdominal and transverse fascia. After fixation of the endoprosthesis, the spermatic cord is removed from under the mesh at the deep inguinal ring with the formation of the latter and laying of the cord in the inguinal canal [Surgical treatment of hernias of the anterior abdominal wall. Volume 1 (inguinal and femoral hernias) / Yu.S. Vinnik, S.I. Petrushko, S.V. Miller, R.A. Pakhomova, N.S. Gorbunov, Yu.A. Nazaryants, N.M. Markelov. - Krasnoyarsk, 2011. - 207 - 209 p.].

The disadvantages of the method.

1. The shape of the mesh endoprosthesis does not prevent the formation of a typical femoral hernia.

2. Traumatic surgery with large tissue dissection. Lack of fixation of the prosthesis to the inguinal ligament and cooper ligament as the most durable structures.

3. Difficulties in plastic surgery of direct inguinal hernias with complete destruction of the posterior and upper walls of the inguinal canal.

A known method of non-stretch plastic according to Liechtenstein, proposed in 1989 and adopted by the authors as a prototype.

The skin incision is made laterally from the pubic tubercle, parallel to the pupartic ligament 5-6 cm. After the skin incision and dissection of the subcutaneous fat, the aponeurosis of the external oblique muscle of the abdomen and the external ring of the inguinal canal are opened. The upper leaf of the aponeurosis of the external oblique abdominal muscle is mobilized from the underlying internal oblique abdominal muscle by 3-4 cm. Then the spermatic cord is mobilized. If the hernia is oblique, then among the elements of the spermatic cord a hernial sac is found. With direct hernias, it is invaginated into the abdominal cavity. After isolation of the hernial sac, the inguinal canal is carefully examined, and through the Borgos space, the femoral canal is examined for the presence of femoral hernias. For plastic hernia gates, most authors use a polypropylene mesh. A patch of a certain shape with a size of 6 × 12 cm is cut out of the mesh. Having drawn the cord up, the rounded end of the mesh is fixed with a monofilament thread to the pubic tubercle. To the inguinal ligament, the mesh is fixed with 4-5 interrupted sutures or a continuous suture. The last suture on the inguinal ligament should be located lateral to the inner inguinal ring. On the outer edge of the mesh, an incision is made parallel to the inguinal ligament, forming two ends: wide (2/3) above and narrower (1/3) below. The upper, wide, end is held over the spermatic cord, it crosses and is located on top of the narrow one. Thus, the spermatic cord passes through a window in the mesh. Both ends of the mesh are sewn with interrupted seams. Then, the upper medial edge of the mesh is fixed with 4-5 interrupted sutures to the internal oblique and transverse muscles of the abdomen and to the vagina of the rectus muscle. The excess mesh along the lateral edge is cut off, while at least 5-7 cm of mesh is left behind the inner ring. The remainder is brought under the aponeurosis of the external oblique muscle of the abdomen, which is then sutured over the cord with a non-absorbable end-to-end non-absorbable suture (Surgical treatment of hernias of the anterior abdominal wall. Volume 1 (inguinal and femoral hernias) / Yu.S. Vinnik, S.I. Petrushko, S.V. Miller, R.A. Pakhomova, N.S. Gorbunov, Yu.A. Nazaryants, N.M. Markelova. - Krasnoyarsk, 2011 .-- 75-78 p.).

The disadvantages of the method.

1. The femoral ring does not strengthen.

2. Increases the risk of femoral hernia.

3. The shape of the mesh endoprosthesis does not prevent the formation of a typical femoral hernia.

The objective of the invention is to improve the quality of treatment by strengthening the posterior wall of the inguinal canal and femoral ring with a mesh prosthesis having an additional triangular flap.

The task is achieved by the method of plastic inguinal and femoral hernias with a prosthesis made of polypropylene mesh, which is fixed to the pubic tubercle, to the inguinal ligament, to the vagina of the rectus muscle, from the upper medial side to the internal oblique and transverse muscles.

A mesh prosthesis with a triangular flap cut on one side is used. One of the sides of the flap is fixed to the scallop ligament, covering the femoral ring and without affecting the femoral vessels. The rounded end of the mesh is fixed to the pubic tubercle. The mesh is also fixed to the inguinal ligament with interrupted sutures with an interval of 0.7-1.0 cm, with the last suture being lateral to the inner inguinal ring. Then, the upper medial edge of the mesh is fixed to the internal oblique and transverse muscles of the abdomen and to the vagina of the rectus muscle, while at least 5-7 cm of mesh is left behind the internal inguinal ring.

The novelty of the invention.

- The mesh prosthesis additionally has a triangular flap. One of the sides of the flap is fixed to the scallop ligament, covering the femoral ring and without affecting the femoral vessels. A triangular flap allows you to further strengthen the femoral ring.

- The rounded end of the mesh is fixed to the pubic tubercle. A mesh prosthesis is fixed to the inguinal ligament with interrupted sutures with an interval of 0.7-1.0 cm, with the last suture being lateral to the inner inguinal ring, which allows the round ligament of the uterus to pass between the sutures.

- Then, the upper medial edge of the mesh is fixed to the internal oblique and transverse muscles of the abdomen and to the vagina of the rectus muscle, while at least 5-7 cm of mesh is left behind the internal inguinal ring.

The set of essential features of the invention allows to obtain a new technical result.

1. At the same time, strengthen both the posterior wall of the inguinal canal and the femoral ring.

2. Prevent the formation of a typical femoral hernia.

3. To reduce the morbidity.

4. Get the opportunity to have a femoral hernia repair from inguinal access.

The invention is illustrated in FIG. one.

In FIG. 1 is a diagram of the implementation of the fixation of the mesh transplant for hernioplasty, where 1 is the suture, 2 is the lateral edge of the rectus abdominis muscle, 3 is the mesh prosthesis made of polypropylene mesh, 4 is the round ligament, 5 is the inguinal ligament, 6 are the femoral vessels, 7 is a triangular flap, 8 - scallop ligament, 9 - pubic tubercle.

The mesh prosthesis 3 on one side has a triangular flap 7.

The method of plastic inguinal and femoral hernias is as follows.

A skin incision is made laterally from the pubic tubercle, parallel to the inguinal ligament. After a skin incision and dissection of the subcutaneous fat, the aponeurosis of the external oblique muscle of the abdomen and the outer ring of the inguinal canal are opened. The upper leaf of the aponeurosis of the external oblique abdominal muscle is mobilized from the deep-lying internal oblique abdominal muscle by 3-4 cm. With an oblique inguinal hernia, after removal of the sac, a deep inguinal ring is restored. With a direct inguinal hernia, the intact transverse fascia is dissected only above the hernial sac. The hernial sac, if possible, in an unopened state is inserted into the abdominal cavity. If necessary, the transverse fascia is opened in the projection of the scallop ligament. The pubic bone, pubic tubercle (9), scallop ligament (8) with visualization of the femoral vessels (6) are distinguished. We visualize the space of Borgos and, when revealing a femoral hernia, immerse the hernial contents in the abdominal cavity, while the peritoneum and inguinal ligament do not dissect. For the repair of hernia gates, a mesh prosthesis made of polypropylene mesh 6 × 12 cm in size is used (3). The mesh prosthesis on one side has an additional triangular flap 7, one of the sides of which is cut from the fixation point to the pubic tubercle 9 towards the scallop ligament 8 to the fixation point to it. The rounded end of the mesh is fixed to the pubic tubercle. The second side is cut from the fixation point to the scallop ligament 8 towards the side of the prosthesis fixed to the inguinal ligament 5 to the femoral vessels 6, so that the flap covers the femoral ring. The third side of the triangle from the pubic tubercle 9 to the femoral vessels 6 is a portion of the side of the prosthesis facing the inguinal ligament 5. The mesh prosthesis is fixed. Retracting the uterine round ligament, the lower end of the polypropylene mesh, fix the monofilament thread to the pubic tubercle 9 (atraumatic polypropylene thread (0). Fix the triangular flap 7 to the scallop ligament 8 with three or four sutures. The mesh prosthesis covers the femoral ring and does not affect the femoral vessels which prevents the femoral hernia from escaping, moreover, when fixing to the inguinal ligament, 5 nodal sutures are applied at intervals of 0.7-1.0 cm, the last suture on the inguinal ligament is lateral to the inner inguinal ring. the shaft allows the round ligament of the uterus to pass between the sutures.Then the upper medial edge of the mesh is fixed with nodal sutures to the internal oblique and transverse muscles of the abdomen and to the vagina of the rectus muscle.The excess mesh is cut along the lateral edge, while at least 5-7 cm of mesh is left behind the inner inguinal ring The remainder is brought under the aponeurosis of the external oblique muscle of the abdomen, which is then sutured over the cord with an end-to-end non-absorbable suture.

Example 1

Patient S. 36 years. She was hospitalized in a hospital with a diagnosis of inguinal hernia on the left, confirmed by MSCT OMT data (a descriptive part on her hands).

Locally: in the left inguinal region, in the projection of the inguinal ligament, there is a hernial protrusion of about 3 cm in diameter, dense, elastic, adjustable into the abdominal cavity. Clinically, a diagnosis was made with a femoral hernia on the left. Examined, prepared for surgery.

Under the MCA, the inguinal canal on the left is opened with typical inguinal access. A round ligament of the uterus is highlighted. A 3 × 3 cm hernia sac was revealed in the projection of the posterior wall of the inguinal canal. The transverse fascia was opened, the scallop ligament and the pubic bone were distinguished. Femoral vessels visualized. The femoral ring is not expanded, with a diameter of 0.5 cm. There are no signs of a femoral hernia. Polypropylene mesh 6 × 12 cm in size. An additional triangular flap was cut from the lower edge of the mesh prosthesis from the side fixed to the inguinal ligament to cover the femoral ring, which will further impede the emergence of a typical femoral hernia. The mesh is laid on the back wall of the inguinal canal and is fixed with polypropylene suture with single interrupted sutures to the lateral edge of the rectus abdominis muscle down to the pubic tubercle. Then - to the scallop ligament. The mesh edge was fixed to the inguinal ligament, going lateral to the inner inguinal ring. The upper edge of the mesh is hemmed to the internal oblique and transverse muscles. The natural course of the postoperative period.

Example 2

Patient A., 44 years old. Hospitalized with a diagnosis of recurrent inguinal hernia on the right. From the anamnesis it is known that a year ago plastic was performed with a mesh prosthesis of an inguinal hernia. A month later, the patient began to notice discomfort and pulling pain in the scar. About 5 months after the operation, a tumor-like formation in the projection of the scar began to be noted. Examined by a surgeon, a diagnosis of recurrent inguinal hernia on the right, indications for planned surgical treatment. Examined on an outpatient basis, prepared for surgery.

Locally: in the left inguinal region, in the projection of the postoperative scar of the right inguinal region there is a hernial protrusion of about 4 cm in diameter, soft, elastic, does not completely reset into the abdominal cavity. The cough push is positive. The skin over the formation is not changed. Examined, prepared for surgery.

Under the SMA, an old postoperative scar was excised. Typical inguinal access revealed the inguinal canal on the left. The joints between the prosthesis and the leaves of the aponeurosis of the external oblique muscle of the abdomen are sharply divided. The back wall of the inguinal canal is dense, no defects have been identified. An audit of the Borgos space revealed an enlarged femoral ring in which a femoral hernia is fixed. The old mesh prosthesis is partially excised. The adhesions of the femoral ring are sharply divided. The hernial protrusion is immersed in the abdominal cavity. The transverse fascia of the projection of the Borgos space was opened, the scallop ligament and the pubic bone were distinguished. Femoral vessels visualized. A femoral ring with a diameter of 2.0 cm. A 6 × 12 cm polypropylene mesh was prepared. An additional triangular shape flap was cut from the lower edge of the mesh prosthesis from the side fixed to the inguinal ligament, which is then fixed to the scallop ligament, covering the femoral ring, which will further obstruct the exit of a typical femoral hernia. The mesh is laid on the back wall of the inguinal canal and is fixed with polypropylene suture with single interrupted sutures, first to the lateral edge of the rectus abdominis muscle down to the pubic tubercle, then to the scallop ligament. The mesh edge was fixed to the inguinal ligament, going lateral to the inner inguinal ring to the upper medial side. The upper edge of the mesh is hemmed to the internal oblique and transverse muscles. The natural course of the postoperative period.

Claims (1)

The method of plastic inguinal and femoral hernias with a polypropylene mesh prosthesis that is fixed to the pubic tubercle, to the inguinal ligament, to the vagina of the rectus abdominis muscle, from the upper medial side to the internal oblique and transverse muscles, characterized in that they use a mesh prosthesis with a triangular cut on one side with a flap, one of the sides of the flap is fixed to the scallop ligament, covering the femoral ring and without affecting the femoral vessels, the rounded end of the mesh is fixed to the pubic tubercle, the mesh is also fixed to the inguinal ligament nodal sutures with an interval of 0.7-1.0 cm, the last suture being lateral to the internal inguinal ring, then the upper medial edge of the mesh is fixed to the internal oblique and transverse muscles of the abdomen and to the vagina of the rectus muscle, while at least 5 are left behind the internal inguinal ring -7 cm mesh.

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