RU2630616C1 - Method for reconstruction of inguinal canal deep ring and back wall - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: internal oblique and transverse muscles with a transverse fascia on both sides of the spermatic cord are fed and fixed to the deep section of the inguinal ligament without suture tension and without muscles squeezing. The medial sheet of aponeurosis of the external oblique abdominal muscle is slightly incised in front of the spermatic cord at a distance of 7-8 mm. The first suture is applied between the medial leg of the superficial ring of the inguinal canal and the periosteum of the pubic tubercle. The remaining sutures are applied to the medial sheet in the direction of the deep ring of the inguinal canal. The edges of the medial sheet incision are sutured to the middle part of the inguinal ligament. First, the second suture from below, then the suture between the medial leg of the superficial ring of the inguinal canal and the periosteum of the pubic tubercle, are tied. In the same way, the lateral sheet of the external oblique abdominal muscle aponeurosis is slightly incised, and the edges of the incision and the sheet itself are sutured along the medial sheet, forming a duplicate.

EFFECT: method does not lead to hernia recurrence by preventing the eruption of tissues used in plastic.

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Description

The invention relates to medicine, namely to surgery and can be used for hernioplasty in patients with inguinal hernias.

Analogs

Known methods of "tension" and "non-tension" inguinal hernioplasty. According to the principle of “tension” plastic, the anterior (according to Girard-Spasokukotsky) or posterior wall (according to Bassini, Postemsky) of the inguinal canal is strengthened by local tissues. The closest methods of surgical treatment of inguinal hernias to the method proposed by us are operations on Bassini, Girard-Spasokukotsky and Postemsky.

Criticism of analogues

These methods involve tissue tension when the edges come together, which, in turn, contradicts the basic surgical principles and is one of the main causes of hernia recurrence. The technique of performing plastic surgery with local tissues differs for all of the above methods. The most criticized method according to Girard-Spasokukotsky, because plastic surgery of the anterior wall is performed without reconstruction of the posterior wall and the deep ring of the inguinal canal. It is also necessary to criticize the version used both for plastic surgery of the anterior wall of the inguinal canal according to Girard-Spasokukotsky and plasticity of the posterior wall according to Postemsky. This capture and hemming of the aponeurosis and the lateral muscles of the inguinal canal to the inguinal ligament with one suture can reduce the number of sutures and shorten the duration of the operation. But a gain in quantity subsequently turns into a loss in quality. The number of relapses after Bassini surgery (aponeurosis and muscles are sutured separately) is from 8-12.5%, and according to the Postemsky method (aponeurosis and muscles are sutured together) from 13-30% (A.S. Aladin, A.V. Chukichev , VE Gunter, Analysis of Complications after Inguinal Hernioplasty and Their Prevention, Annals of Surgery. - 2008. No. 4. - P. 53-56). The difference is obvious. The reason is the way the ligature is sutured and tightened. With simultaneous hemming of the aponeurosis with the muscles to the inguinal ligament, the surgeon should tighten the seam as much as possible, since both sheets of the aponeurosis of the external oblique muscle of the abdomen must “fit” tightly (Fig. 1, pos. A - 1 and 2 - lateral and medial sheets of the external aponeurosis oblique muscle of the abdomen, 3 - suture with simultaneous capture of aponeurosis, muscles and transverse fascia with their fixation to the inguinal ligament). This negatively affects the muscles captured in the seam, contributing to their more frequent eruption (Fig. 1, pos. B - 4 - the muscles erupted). Then the seam between the leaves of the aponeurosis of the external oblique muscle of the abdomen relaxes and, if they are not firmly fused by this time, diverge from each other at the distance of the length of the girth by the muscle ligature, which significantly reduces the strength of the plastic (Fig. 1, pos. 5 - discrepancy of both leaflets for the length of the ligature, 6 - pendulum-like movements of the medial leaf made due to the work of muscles) (Fig. 1, pos. g - 7 - separation of the ligature from the medial leaf).

This explains the appearance of most relapses of inguinal hernia during the first year after surgery. According to domestic and foreign publications, it follows that up to 90% of relapses appear during the first year after surgery, the rest during 2-5 years (Yu.A. Nesterenko, R.M. Gaziev. Inguinal hernias. Reconstruction of the posterior wall of the inguinal canal. M .: BINOM. - 2005 .-- 143 p.).

Prototype

As a prototype, we took the plastic of an inguinal hernia according to Bassini, who was the first to perform a radical and anatomically substantiated operation that retained the oblique direction of the inguinal canal, high ligation of the hernial sac, strengthening the posterior wall of the inguinal canal with the help of the internal oblique, transverse abdominal muscles and transverse fascia of the hem pupartic ligament under the spermatic cord (NI Kukudzhanov. Inguinal hernias. - M .: Medicine. - 1969. - 440 p.).

Prototype criticism

The Bassini method also involves tensioning the tissues when the edges approach each other. The consequences of tying ligatures with tissue tension are complications in the postoperative period: pain, tissue ischemia, the development of infection in the wound, teething by superimposed ligatures, microbleeding and inflammation in the area where they are located, resulting in tissue discrepancy and the development of hernia recurrence (S.A. Aboev, Reconstruction of the abdominal wall with inguinal hernias, Vladikavkaz, 2011. - 156 p.).

The purpose of the invention

The aim of the proposed method is to increase the effectiveness of the treatment of inguinal hernias. This goal can be achieved using the proposed method for plastic inguinal hernia with local tissues.

SUMMARY OF THE INVENTION

A hernia repair is performed, following standard methods of hernioplasty: opening the inguinal canal, removing the hernial sac, isolating the spermatic cord to the deep inguinal ring, exposing the transverse fascia.

The essence of the proposed invention as a method is as follows. Plastic surgery is performed with local tissues, restoring the anatomy of the inguinal canal and preserving the morphology and function of stitched tissues and spermatic cord elements. Using the muscles of the inguinal canal with the capture of the transverse fascia and both sheets of the external oblique muscle of the abdomen, three layers are created around the spermatic cord, which restore and strengthen the deep ring of the inguinal canal. Of these, the muscle layer dominates. For reconstruction of the posterior wall throughout the inguinal canal, the lateral muscles of the inguinal canal are used with preservation of their innervation, blood circulation and, therefore, biomechanics, which is a leading factor in the prevention of recurrence of inguinal hernia. To firmly and reliably close the exit from the inguinal canal, the first suture between the medial leg of the superficial ring and the periosteum of the pubic tubercle is applied after an incision is made on the medial leaf. Thus, the essence of the proposed method is to restore and strengthen all the components of the inguinal canal: the deep ring, the posterior wall and the superficial ring of the inguinal canal. A detailed description and explanation is provided below.

Features of the invention, distinctive from the prototype

The difference of our proposed method for reconstructing the deep ring and posterior wall of the inguinal canal from the Bassini operation is as follows. We suggest restoring the inguinal canal with strengthening its posterior wall, as in the Bassini method, with separate hemming of the muscles and aponeurosis, making their corrections, which are illustrated in FIG. 2 (poses. A - 1-2 - aponeurosis sheets of the external oblique muscle of the abdomen, 3 - without tightening the ligature, muscles are fixed to the inguinal ligament, 5 - lateral abdominal muscles under the medial leaflet; pos. B - 4 - the seam between the medial leaf and inguinal ligament; pos. 6 - after tightening the ligature, muscles No. 5 are pressed more tightly and hold muscles No. 3 at the inguinal ligament, which significantly increases the reliability of the plastic).

Three layers are formed to restore and strengthen the deep ring of the inguinal canal: the first layer is the muscles, the second and third layers from the aponeurosis.

- The first layer - the muscles of the inguinal canal together with the transverse fascia from the medial and lateral sides of the spermatic cord are brought down and fixed to the deep section of the inguinal ligament (Fig. 3, pos. 5, 6). Knotted; without tightening the seam to preserve muscle biomechanics. The spermatic cord falls between the two sutures and covers itself around the circumference with the muscles of the inguinal canal. The distance between the joints should correspond to the diameter of the spermatic cord.

Before the formation of the following layers, the posterior wall is restored along the inguinal canal. The muscles, with the capture of the transverse fascia, are brought down and fixed to the deep part of the inguinal ligament without the traditionally used ligature tightening until it stops (Fig. 3, pos. 3). Tightening the ligature all the way promotes the "strangulation" of muscle tissue trapped in the seam, in the future it can erupt, tear off, or, in the best case, scar (Fig. 7, position 1 - scarring, 2 - eruption, 3 - separation).

- The second and third layers above the deep ring are formed using the medial and lateral sheets of the aponeurosis of the external oblique muscle of the abdomen. After incision of the medial leaf opposite the spermatic cord 7-8 mm long (Fig. 4, item 3), a first suture is made between the medial leg of the superficial ring and the periosteum of the pubic tubercle, to which, thanks to the notch, the medial leaf is lowered by an average of 1 cm (this is the distance between the edges of the medial leaf after the incision). The remaining seams are on the medial leaf towards the deep ring. The edges of the incision of the medial leaflet are sutured, grasping the spermatic cord and not squeezing its elements, to the middle part of the inguinal ligament (Fig. 5, pos. 3). The second seam is knotted first from the bottom, after the seam is sealed between the medial leg of the surface ring and the periosteum of the pubic tubercle. Such a sequence does not violate the anatomical structure of stitched tissues due to a decrease in tension, and also firmly and reliably closes the exit from the inguinal canal. In the same way, the lateral leaflet is cut (Fig. 5, pos. 5) and the edges of the incision and the leaf itself are hemmed over the medial leaf, forming a duplicate (Fig. 6, pos. 3).

Clinical Example

Patient K., 42 years old, Hospitalized September 30, 2013. Diagnosis: Oblique inguinal hernia on the right, type 11 according to Nyhus. 10/01/13, the operation - hernia repair with plastic by the proposed method. After processing the surgical field under local anesthesia with a 7-cm-long incision parallel to the inguinal ligament and 2 cm above it with dissection of the skin, subcutaneous tissue and aponeurosis of the external oblique muscle of the abdomen, the inguinal gap was isolated. The spermatic cord and hernial sac are stupidly and sharply separated from each other after opening it. The hernial sac is selected to the neck, stitched, bandaged and cut off. The internal oblique and transverse muscles with the capture of the transverse fascia are summed up and fixed to the deep section of the inguinal ligament above and below the spermatic cord according to its diameter without tension of the suture and without pressure of the muscles. In the same way, sutures were laid on the muscles of the inguinal canal throughout the entire posterior wall. Opposite the spermatic cord, an incision was made in the medial leaf of the aponeurosis of the external oblique muscle of the abdomen 6-7 mm long and their edges were sutured to the middle part of the inguinal ligament along the perimeter of the spermatic cord. The entire medial leaflet is hemmed to the middle part of the inguinal ligament with a suture on the aponeurosis of the rectus abdominis muscle and on the periosteum of the pubic tubercle. In the same way, an incision was made in the lateral leaf of the aponeurosis of the external oblique muscle of the abdomen. The edges of the incision and the lateral leaflet are hemmed over the medial leaflet, forming a duplicate. Leaving the spermatic cord under the fascia of the subcutaneous tissue, sutures were applied to the skin. Aseptic dressing.

Postoperative course without complications. Sutures were removed on the 7th day after surgery. The wound healed by primary intention. 10.10.13, the patient was discharged in satisfactory condition. Complete blood count: hemoglobin 148 g / l, white blood cells 6.2.10⋅9 / l, ESR 12 mm / h, sugar 6.2 mm / l. 2.5 years have passed, no relapse, no complaints, lives a full life.

According to the proposed method, over the past 3 years, 24 patients were operated on (these patients, whose inguinal gap was no more than 3 cm). In the postoperative period, scrotal edema and infectious complications from the side of the wound were not observed, and at present there is no recurrence of inguinal hernia. The method allows to reduce the frequency of relapses, early and late postoperative complications, and thereby improve the quality of life of patients.

The positive effect of the application of the proposed method

The proposed method is quite accessible for execution both in specialized and general clinical departments of city and district hospitals, including young practicing surgeons. It does not require special preparation, additional financial costs and special tools. A sleeve-ring created around the spermatic cord from the muscles of the inguinal canal with preservation of their functioning not only restores and reliably strengthens the deep ring, but also favorably affects the elements of the spermatic cord. When using a polypropylene mesh with a window cut for the spermatic cord, excessive formation of connective tissue occurs with the formation of adhesions and scars between the edges of the mesh and the spermatic cord, which negatively affects the elements of the spermatic cord. The second and third layers, created around the spermatic cord from both leaves of the aponeurosis, further strengthen the deep ring.

The proposed method allows the use of muscles for reliable cover and strengthen the posterior wall of the inguinal canal without damaging their morphological structure and without violating the function. Preservation of the biomechanics of these muscles is a leading factor in the prevention of recurrence of inguinal hernia.

The first seam between the medial leg of the superficial ring and the periosteum of the pubic tubercle, due to an incision on the medial leaf, is applied with much less tension, which ensures reliable and durable closure of the superficial ring.

Information sources

1. A.S. Aladin, A.V. Chukichev, V.E. Gunther. Analysis of complications after inguinal hernioplasty and their prevention. Annals of surgery. - 2008. - No. 4. - S. 53-56.

2. A.M. Borisov, S.E. Mitin, K.N. Movchan et al. Results of a differentiated approach to the choice of hernioplasty method in the treatment of inguinal hernia patients. Hernia alloplasty or traditional hernioplasty: advantages and disadvantages: Materials of the seminar of the Society of Herniologists. - M. RSCH RAMS. - 2003. - S. 6-7.

3. V.N. Egiev. Current status and prospects of herniology. Herniology. - 2006. - No. 2 (10). - S. 5-10.

4. J.W. Murphy. Use of the prolene hernia system for inguinal hernia repair: retrospective, comparative time analysis version other inguinal hernia repair systems. Am. Surg. - 2001. - Vol. 67 (10), Oct. - P. 919-923.

5. N.I. Kukujanov. Inguinal hernia. - M .: Medicine. - 1969 .-- 440 s. - The prototype.

Claims (1)

A method for reconstructing the deep ring and posterior wall of the inguinal canal, which consists in using local tissues for plastic surgery, characterized in that the internal oblique and transverse muscles with transverse fascia on both sides of the spermatic cord are brought down and fixed to the deep section of the inguinal ligament without tension of the suture and without pressing muscles, the medial leaf of the aponeurosis of the external oblique muscle of the abdomen is incised opposite the spermatic cord at a distance of 7-8 mm, the first suture is applied between the medial leg of the superficial ring of the inguinal ring of the fundus and periosteum of the pubic tubercle, the remaining sutures are laid on the medial leaf towards the deep ring of the inguinal canal, the edges of the incision of the medial leaf are sutured to the middle part of the inguinal ligament, first the second suture is tied down from the bottom, then the suture between the medial leg of the superficial inguinal ring is tied. of the canal and periosteum of the pubic tubercle, in the same way, the lateral leaf of the aponeurosis of the external oblique muscle of the abdomen is incised and the edges of the incision and the leaf itself are hemmed to the medial leaf forming a duplicate.

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