RU2626556C1 - Method for extraperitoneal endoscopic hernioplasty - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: device is used, including a blade made in the form of a steel tray with a longitudinal section of 1/3 of the diameter of the tube with an internal diameter of 10 mm, length of 180 mm, curvature radius of 200 mm, combined with a light source, a gas pipe and olive, 20 mm long, up to 12 mm wide. The device blade together with the laparoscope inserted into its tray is injected through the hypoumbilical incision to create a cavity into which a 5 mm trocar is inserted along the middle line, 5 cm above the pubic symphysis. The second 5 mm trocar is injected in the middle of the distance between the hypoumbilical incision and the access above the pubic symphysis for the first trocar introduction. A bed is created to accommodate the mesh implant so that it covered the area of inguinal and femoral hernias formation. For patients younger than 50 years, with a body mass index of less than 30, with the largest size of hernial gates less than 3.5 cm , the implant is not fixed. For patients older than 50 years, the lower inner area of the implant is fixed with spirals to the Cooper ligament, the upper inner area of the implant is fixed to the posterior surface of the outer edge of the rectus and pyramidal muscles of the abdomen. For patients with a body mass index of more than 30, with the hernial gate size exceeding 3.5 cm, the outer upper corner of the expanded implant is additionally fixed to the transverse fascia by a spiral directed forward from the back.

EFFECT: method allows to prevent damage to the parietal peritoneum, adjacent vessels and bladder wall, to create sufficient space for the safe installation of trocars, and to determine objective criteria for the need for implant fixation, depending on the local and general premorbid background.

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Description

The invention relates to medicine, namely to endoscopic surgery.

When studying special and patent literature, the following methods of extraperitoneal endoscopic hernioplasty were revealed.

A known method of implant placement in extraperitoneal endoscopic hernioplasty [2, 3], in which under endotracheal anesthesia under the umbilicus an incision of the skin and subcutaneous tissue is performed 2.0-2.5 cm. Aponeurosis is isolated and dissected in the transverse direction for 2.0 2.5 cm. A balloon device is introduced into the preperitoneal space towards the pubic joint, with which the parietal peritoneum is peeled from the anterior abdominal wall. After removing the balloon device, a trocar 12 mm in diameter is inserted into the incision with a laparoscope. The resulting cavity is supported by insufflating the gas under a pressure of 8 mm Hg. In the middle of the distance between the navel and the womb, trocars with dissectors (5- and 12-mm) are introduced from both sides along a pararectal line, a hernial sac is isolated. The pubic bone, inguinal ligament, elements of the spermatic cord, Cooper ligament and lower epigastric vessels are exposed. A polypropylene mesh with dimensions of at least 13 cm × 9 cm is inserted into the preperitoneal space through a 12 mm trocar. The polypropylene mesh is placed so that it covers the areas of formation of a direct and oblique hernia. After installing the implant through a separate puncture in the inguinal region, the Redon drainage is installed in the preperitoneal space. The trocars are removed. The wound under the navel is sutured.

The disadvantage of this method is the need to use a special disposable balloon-dissector, which increases material costs and limits its routine use in the absence of a disposable balloon-dissector. The advancement of a dissector balloon in a layer of loose prebubble fiber is associated with a risk of perforation of the bladder wall and parietal peritoneum.

The well-known "Method of preperitoneal hernioplasty of hernias of inguinal localization" [RU 2160562, published 12/20/2000], in which the parietal peritoneum is separated through an oblique incision in the iliac-inguinal region. A retroperitoneoscope is inserted in the direction of the external inguinal ring. Allocate the internal opening of the inguinal canal, spermatic cord and hernial sac, the external opening of the inguinal canal, pubic joint. The retroperitoneoscope blade is rotated perpendicular to the rectus abdominis muscle. At the same time, the peritoneum is peeled off for 4-5 cm upwards from the pubic joint to reach the volume of the visualized space.

The disadvantages of the method are related to the fact that the indicated front access to the peritoneal space limits the review and identification of important anatomical structures - femoral and lower epigastric vessels, as well as possible vascular anomalies (corona Mortis), varicose veins of the pelvis, which can be injured when forming the site for the implant. The use of the method is limited in case of recurrent hernias, in conditions of scar-changed tissues and changes in the topography of the inguinal canal and its elements. Bilateral inguinal hernia requires symmetrical access, which will increase surgical trauma and rehabilitation time.

The well-known "Method of implant placement in preperitoneal hernioplasty" [RU 2187971, published 08.27.2002], in which the parietal peritoneum is separated using a retroperitoneoscope. A hernial sac is isolated. Two clamping devices, by rotating them towards each other, fold the polypropylene mesh before closing. In this form, it is introduced into the prepared preperitoneal space. The closure of the hernia formation zone by the mesh is carried out by rotating the clamping devices in opposite sides to each other.

The disadvantages of this method is the need to achieve the preperitoneal tissue of the inguinal triangle with “open” access, through all layers of the anterior abdominal wall, with the formation of an operative wound that requires full rehabilitation in the postoperative period. With bilateral hernia, there is a need to perform a symmetric operation, which increases the duration of the operation and surgical trauma, the patient's rehabilitation time. The method involves the use of "clamping devices." The use of additional devices (retroperitoneoscope and clamping devices) complicates operational techniques.

The well-known "Method for surgical treatment of inguinal and femoral hernias with oblique transverse inguinal preperitoneal mini-access" [RU 2313292, published 12.27.2007], including the allocation of a hernial sac, separation of the parietal peritoneum from the anterior abdominal wall by introducing a preperitoneoscope into the mini-access towards the inner, outer canal of the inguinal ring , isolation of the pubic articulation, detachment of the peritoneum to the edge of the rectus abdominis muscle until the required volume of the visualized space is reached, which is adequate to the size of the implanted mesh, ytie zones formation of inguinal and femoral hernias polypropylene explant, characterized in that in the groin area 1 cm above the projection deep hole inguinal incision is performed toward the middle of the inguinal fold, further peeled parietal peritoneum to gipogastralnoy vessels. The projection of the deep opening of the inguinal canal for mini-access is determined sonographically.

The disadvantages of the method are due to greater operational trauma compared to known endosurgical methods, this is due to the need for acute access to the preperitoneal space. The method is technically limited in patients with a body mass index of more than 35, with recurrent inguinal hernias, with primary inguinal-scrotal or irreducible hernias. Bilateral hernia requires symmetrical interventions, which increases the time of surgery, the amount of surgical trauma and the duration of rehabilitation.

The prototype of the invention, as the closest in combination of features to the claimed method, is a method of extraperitoneal laparoscopic preperitoneal hernioplasty, known from the literature [1], in which the preperitoneal space is created by a dissecting balloon. By accessing the paraumbilical region, the skin is dissected, the anterior vaginal wall of the rectus abdominis is mobilized and dissected, the muscle is pushed laterally to the side and lifted by a lift, under the latter they penetrate into the peritoneal space with a dissector balloon and create a preliminary cavity in the peritoneal space. Pneumopreperitoneum is created by injecting carbon dioxide at a rate of 14 liters per minute. Then, working trocars are installed: the first 5 mm trocar is installed 2 cm above the pubic articulation in the midline and the third 5 mm trocar is in the middle of the distance between the previously installed trocars. The location of the lower epigastric vessels, the Retzius space, the Hesselbach triangle is determined. Identify and secrete a hernial sac. A fully isolated hernial sac is immersed in the abdominal cavity. A bed for the implant is created, the mesh implant is positioned so as to block all possible openings of the exit of hernial protrusions and to prevent the development of hernia recurrence. The free edge of the mesh implant should be 3-4 cm from the edge of the hernial defect. For large hernial defects, when the defect with a direct inguinal hernia is more than 3 cm, and with an oblique inguinal hernia more than 5 cm, respectively, the mesh implant is fixed with absorbable clips. For direct hernias, the recommended fixation points of the clips are two in the Cooper ligament, one or two clips in the rectus abdominis muscle, as well as one or two clips lateral to the lower epigastric vessels and above the inguinal connection.

The disadvantages of the method are the need to use additional disposable equipment - balloon dissector, herniostapler, equipped with absorbable clips. This increases the material costs of the operation, limits its routine performance in the absence of tools, and can also cause conversion with insufficient equipment. Holding a dissector balloon into the prevesical space is associated with a risk of perforation of the peritoneum or bladder wall.

The task of the invention is to increase the effectiveness of endoscopic total preperitoneal hernioplasty, reduce the conversion rate, the risk of perforation of the peritoneum, damage to the bladder and blood vessels of the inguinal region, simplifying the operation.

The problem is achieved by the fact that a reusable device is used, including a steel grooved profile with a longitudinal section of 1/3 of the diameter, with an inner diameter of 10 mm, a length of 180 mm, a curvature of 200 mm, combined with a light source, gas duct and olive 20 mm, up to 12 mm wide , the device, together with a laparoscope, is inserted into the preperitoneal space to create a cavity into which a 5 mm trocar is inserted along the midline 5 cm above the pubic symphysis, a second 5 mm trocar is inserted in the middle of the distance between the accesses, in patients older 50 is fixed the lower inner portion of the implant to the Cooper's ligament, the upper inner portion of the implant is fixed to the outer edge of the forward and pyramidal muscles, with the index of patient body weight over 30, hernial ring size of more than 3.5 cm, the outer upper corner of the implant is fixed to the lateral fascia.

The method is as follows. After processing the surgical field, under conditions of endotracheal anesthesia, a transverse skin incision of 2.0 cm is performed in the hypoumbilical region. The anterior sheet of the vagina of the rectus abdominis muscle is selected, which is cut transversely for 1.0-1.5 cm, expose the rectus abdominis muscle, displace straight muscle outwards. On the edge of the incision of the anterior sheet of the vagina of the rectus abdominis muscle, U-shaped sutures are applied, the sutures are not tied. The back sheet of the vagina of the rectus abdominis muscle is exposed, the working part of the device is installed into the incision [Fig. one]. The device includes: a blade [Fig. 1, pos. 1], represented by a grooved profile — a longitudinal section 1/3 of the diameter of a steel tube 1 mm thick, 10 mm inner diameter, 180 mm long, the blade has a curvature of 200 mm radius; handle [Fig. 1, pos. 2] - a sealed hollow metal cylinder for accommodating batteries with technical characteristics corresponding to a light source located on the working part of the device [Fig. 1, pos. 7]; knot and blade attachment unit [Fig. 1, pos. 3]; the blade of the device is combined with the gas duct [Fig. 1, pos. 5], which is a hollow metal tube, with an external diameter of 1.5 mm, an internal diameter of 1.2 mm, with a gas supply valve [Fig. 1, pos. four]; the mouth of the gas duct with an inner diameter of 1.2 mm [Fig. 1, pos. 6] is located on the working part of the blade of the device; 2.5 W medical lamp; at the end of the working part of the device is a polished olive with a length of 20 mm and a maximum width of 12 mm [Fig. 1, pos. 8]. Elements of the device comply with the requirements for medical devices, resistant to repeated sterilization. When using the device, the working part is directed along the back sheet of the vagina of the rectus abdominis muscle. A 10 mm 30 ° laparoscope is inserted into the device’s gutter, under the visual control of the laparoscope, the device’s blade is moved down, along the midline to the pubic bone. U-shaped seams on the front sheet of the vagina of the rectus abdominis muscle tighten. Carbon dioxide is supplied through a gas duct at a pressure of 14 mm Hg. Pendulum-like translational movements of the laparoscope perform dissection of the preperitoneal tissue. 5 cm above the pubic symphysis along the midline create a cavity sufficient for safe insertion under the visual control of a 5 mm trocar, and under visual control along the midline 5 cm above the pubic symphysis, a 5 mm trocar is introduced. Remove the device with a laparoscope of 10 mm 30 °. A laparoscope of 10 mm 30 ° is re-introduced into the cavity through the Hasson cannula.

Install a second working trocar of 5 mm through the incision in the middle of the distance between the access in the hypoumbilical region and the access 5 cm above the pubic symphysis. After this, the anatomical landmarks of the inguinal region are visualized, namely, hernial gates, lower epigastric vessels, Retzius space, Hesselbach triangle. A hernial sac is isolated, the largest size of the hernial gate is determined. Through a tube of Hasson's cannula, a tight gauze ball is inserted into the preperitoneal space on the ligature. The ball is captured with an endo-dissector or endo-clamp. Further dissection along the Cooper ligament outwardly is performed with a gauze ball until the piriformis is visualized, medially and deep into the area of the femoral ring. A bed is created for the location of a mesh implant with dimensions of 15 cm × 10 cm. An implant is inserted and placed so that it covers the areas of formation of a direct and oblique inguinal hernia, as well as a femoral hernia. In patients younger than 50 years old, with a body mass index of less than 30, with the largest hernia gate size less than 3.5 cm, the implant is not fixed. In patients older than 50 years of age, a lower internal portion of the implant is fixed to the Cooper ligament with 5 mm spirals, and an upper internal portion of the implant is fixed to the posterior surface of the outer edge of the rectus and pyramidal muscles of the abdomen. In patients with a body mass index of more than 30, with the largest hernia gate size of more than 3.5 cm, the outer upper corner of the expanded implant is additionally fixed to the transverse fascia with a 5 mm spiral inserted in the direction from rear to front. Decompression of preperitoneal fiber is performed. Wounds are sutured.

The method was tested in 6 patients in the surgical department of the Central district hospital of the Veselovsky district of the Rostov region.

Examples of the method

Example 1. A woman, 45 years old, was admitted to the surgical department of the Central district hospital of the Veselovsky district of the Rostov region in a planned manner. Diagnosis: right-sided inguinal hernia for surgical treatment. Body mass index 22.1. 06/09/2014 performed total extraperitoneal endoscopic hernioplasty. After processing the surgical field, under ETN conditions, a transverse skin incision of 2.0 cm was performed in the hypoumbilical region, the anterior sheet of the vagina of the rectus abdominis muscle was cut, which was dissected transversely for 1.5 cm, the rectus abdominis muscle was exposed, and the rectus muscle was displaced outwards. U-shaped sutures were placed on the edges of the incision of the anterior sheet of the vagina of the rectus abdominis muscle, the sutures were not tied. The back sheet of the vagina of the rectus abdominis muscle was exposed, the working part of the device was installed into the incision. The working part of the device was sent along the back sheet of the vagina of the rectus abdominis muscle. A 10 mm 30 ° laparoscope was inserted into the device’s gutter, under the visual control of the laparoscope, the device’s blade was moved down, along the midline to the pubic bone. U-shaped sutures on the front sheet of the vagina of the rectus abdominis muscle were tied. Carbon dioxide was supplied through the device’s gas line at a pressure of 14 mmHg. Pendulum translational movements of the laparoscope performed dissection of the preperitoneal tissue. A cavity was created along the midline, and a 5 mm trocar was introduced under visual control along the midline 5 cm above the pubic symphysis. A device with a laparoscope of 10 mm 30 ° was removed. A laparoscope of 10 mm 30 ° was reintroduced into the cavity through the Hasson cannula. A second working trocar of 5 mm was placed through a cut in the middle of the distance between the access in the hypoumbilical region and the access 5 cm above the pubic symphysis. The gauze ball on the ligature and the endo-dissector divided the connective tissue jumpers in the Retzius space, visualized the pubic tubercle, the lower epigastric vessels and the iliac-pubic tract on the right, the round ligament of the uterus, the internal inguinal ring - without features. Medial to the lower epigastric vessels and the uterine round ligament, a round defect was identified in the anterior abdominal wall with the largest transverse size 3.0 cm, in which a 3.0 × 1.0 × 2.0 cm lipoma was loosely fixed. The lipoma was dislocated from the hernial defect. Prepared an implant pad. The implant was inserted and placed so that it covered the areas of formation of a direct and oblique inguinal hernia, as well as a femoral hernia. The implant was not fixed. The wounds are gone. In the postoperative period, symptomatic and antibacterial therapy were prescribed. The postoperative period is smooth. 06/19/2014 the patient was discharged in satisfactory condition.

Example 2. A woman, 53 years old, was hospitalized in the surgical department of the Central district hospital of the Veselovsky district of the Rostov region in a planned manner on 02/25/2014 with complaints of a hernial protrusion in the right inguinal region. Diagnosis: right-sided inguinal hernia. Body mass index 22.4. 02/26/2014 performed total extraperitoneal endoscopic hernioplasty. After processing the surgical field, under ETN conditions, a transverse skin incision of 2.0 cm was performed in the hypoumbilical region, the anterior sheet of the vagina of the rectus abdominis muscle was cut, which was dissected transversely for 1.5 cm, the rectus abdominis muscle was exposed, and the rectus muscle was displaced outwards. U-shaped sutures were placed on the edges of the incision of the anterior sheet of the vagina of the rectus abdominis muscle, the sutures were not tied. The back sheet of the vagina of the rectus abdominis muscle was exposed, the working part of the device was installed into the incision. The working part of the device was sent along the back sheet of the vagina of the rectus abdominis muscle. A 10 mm 30 ° laparoscope was inserted into the device’s gutter, under the visual control of a laparoscope, the device’s blade was moved down the midline to the pubic bone. U-shaped sutures on the front sheet of the vagina of the rectus abdominis muscle were tied. Carbon dioxide was supplied through the device’s gas line at a pressure of 14 mmHg. Pendulum translational movements of the laparoscope performed dissection of the preperitoneal tissue. A cavity was created along the midline, under visual control, a 5 mm trocar was introduced along the midline 5 cm above the pubic symphysis. A device with a laparoscope of 10 mm 30 ° was removed. A laparoscope of 10 mm 30 ° was reintroduced into the cavity through the Hasson cannula. A second working trocar of 5 mm was installed through an incision in the middle of the distance between the access in the hypoumbilical region and the access 5 cm above the pubic symphysis. The gauze tupfer and endo-dissector divided the connective tissue jumpers in the Retzius space, visualized the pubic tubercle, the lower epigastric vessels and the iliac-lobar tract on the right, the round ligament of the uterus, and the internal inguinal ring - without features. Medial to the lower epigastric vessels and the round ligament of the uterus, a round defect was identified in the anterior abdominal wall with the largest transverse size of 3.5 cm, in which a 3.5 × 1.0 × 2.0 cm lipoma was loosely fixed. The lipoma was dislocated from the hernial defect. Prepared an implant pad. The implant was inserted and placed so that it covered the areas of formation of a direct and oblique inguinal hernia, as well as a femoral hernia. The lower inner portion of the implant was fixed to Cooper’s ligament with a 5 mm spiral, 5 mm spirals, and the upper inner portion of the implant was fixed to the posterior surface of the outer edge of the rectus and pyramidal muscles of the abdomen. The duration of the operation is 65 minutes. In the postoperative period, symptomatic and antibacterial therapy were prescribed. The postoperative period is smooth. 03/01/2014 the patient was discharged in satisfactory condition, 03/11/2014 started to work.

Example 3. A man, 61 years old, was hospitalized in the surgical department of the Central district hospital of the Veselovsky district of the Rostov region in a planned manner 01.10.2014. Diagnosis: right-sided oblique inguinal hernia. Body mass index 32.0. Under ETN on 02.10.2014, total extraperitoneal endoscopic hernioplasty was performed. A transverse skin incision of 2.0 cm was performed in the hypoumbilical region, the anterior sheet of the vagina of the rectus abdominis muscle was selected, which was cut transversely for 1.5 cm, the rectus abdominis muscle was exposed, and the rectus muscle was displaced outwards. U-shaped sutures were placed on the edges of the incision of the anterior sheet of the vagina of the rectus abdominis muscle, the sutures were not tied. The back sheet of the vagina of the rectus abdominis muscle was exposed, the working part of the device was installed into the incision. The working part of the device was sent along the back sheet of the vagina of the rectus abdominis muscle. A 10 mm 30 ° laparoscope was inserted into the device’s gutter, under the visual control of the laparoscope, the device’s blade was moved down, along the midline to the pubic bone. U-shaped sutures on the front sheet of the vagina of the rectus abdominis muscle were tied. Carbon dioxide was supplied through the device’s gas line at a pressure of 14 mmHg. Pendulum translational movements of the laparoscope performed dissection of the preperitoneal tissue. A cavity was created along the midline, under visual control, a 5 mm trocar was introduced along the midline 5 cm above the pubic symphysis. A device with a laparoscope of 10 mm 30 ° was removed. A laparoscope of 10 mm 30 ° was reintroduced into the cavity through the Hasson cannula. A second working trocar of 5 mm was installed through an incision in the middle of the distance between the access in the hypoumbilical region and the access 5 cm above the pubic symphysis. The gauze ball on the ligature and the endo-dissector divided the connective tissue jumpers in the Retzius space, visualized the anatomical landmarks of the inguinal region, namely, hernial gates, lower epigastric vessels, and the Hesselbach triangle. A hernial sac was isolated, a hernial protrusion came out with the spermatic cord through the inner inguinal ring. The hernial sac dislocated their inguinal canal. A 15 × 10 cm polypropylene mesh implant was inserted through the video port into the peritoneal space and straightened over the anterior abdominal wall so that the implant covered the hernial defect, the femoral fossa, and the projection of the external and internal inguinal rings. The implant was fixed with a herniostapler, 5 mm spirals: the lower inner portion of the implant - to the Cooper ligament, the upper inner portion of the implant - to the posterior surface of the outer edge of the rectus and pyramidal muscles of the abdomen, the upper upper corner of the implant was fixed to the transverse fascia with a 5 mm helix inserted backward forward . The duration of the operation is 65 minutes. In the postoperative period, symptomatic and antibacterial therapy were prescribed. The postoperative period is smooth. Discharged on October 11, 2014 in satisfactory condition. The immediate and distant postoperative period was uneventful.

Compared with the prototype, the method allows to prevent damage to the parietal peritoneum, adjacent vessels and the wall of the bladder, create sufficient space for the safe installation of trocars, and also determine objective criteria for the need for fixation of the implant depending on the characteristics of the local and general premorbid background of the patient.

Information sources

1. Egiev V.N., Voskresensky P.K. Hernias. - M., Medpraktika-M, 2015 .-- 480 p.

2. Bittner R., Arregui M.E., Bisgaard T. et al. Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment for inguinal hernia // International Endohernia Society of IE (IEHS)]] // Surg. Endosc. - 2011 .-- T. 25, No. 9. - P. 2773-2843.

3. Ferzli G.S., Massad A., Albert P. Extraperitoneal endoscopic inguinal hernia repair // J. Laparoendosc. Surg. - 1992. - Vol. 2, No. 5. - P. 281-286.

Claims (4)

1. The method of extraperitoneal endoscopic hernioplasty access in the paraumbilical region, characterized in that they use a device comprising a blade made in the form of a steel grooved profile with a longitudinal section 1/3 of the diameter of the tube with an inner diameter of 10 mm, a length of 180 mm, a curvature of a radius of 200 mm, combined with a light source, gas duct and olive with a length of 20 mm, a width of up to 12 mm, the blade of the device, together with a laparoscope inserted into its gutter, is inserted through a hypoumbilical incision to create a cavity into which a 5 mm trocar is introduced into the midline 5 cm above the pubic symphysis, a second 5 mm trocar is inserted in the middle of the distance between the hypoumbilical incision and access above the pubic symphysis to introduce the first trocar, a bed is created to accommodate the mesh implant so that it covers the areas of inguinal and femoral hernia formation . 2. The method of extraperitoneal endoscopic hernioplasty according to claim 1, characterized in that in patients younger than 50 years old, with a body mass index of less than 30, with the largest hernia gate size less than 3.5 cm, the implant is not fixed. 3. The method of extraperitoneal endoscopic hernioplasty according to claim 1, characterized in that in patients older than 50 years old, the lower inner portion of the implant is fixed with coils to the Cooper ligament, the upper inner portion of the implant is fixed to the posterior surface of the outer edge of the rectus and pyramidal muscles of the abdomen. 4. The method of extraperitoneal endoscopic hernioplasty according to claim 1, characterized in that in patients with a body mass index of more than 30, with a hernia size greater than 3.5 cm, the outer upper corner of the expanded implant is additionally fixed to the transverse fascia with a helix inserted back to front .

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