RU2633946C1 - Modified method for laparoscopic percutaenous, paracentetic suturing of non-obliterated internal ring in children - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: mini trocar is placed in the internal ring projection. A ligature is directed around the anterior and posterior semicircles of the internal ring of the inguinal canal without involving the patient's anterior abdominal wall.

EFFECT: method reduces the risk of dropsy recurrence, improves testicular hemodynamics in the postoperative period, ensuring preservation of gonads reproductive function, by preperitoneal shaping and by node conducting directly to the vaginal process of the peritoneum during treatment of non-obliterated internal ring in children.

4 dwg

Description

The invention relates to medicine, in particular to pediatric surgery, pediatric urology, and can be used in the surgical treatment of children with unbleached vaginal process of the peritoneum.

After the active introduction in the early 90s of laparoscopic elimination of the defect of the unclosed vaginal process of the peritoneum, a large number of methods appeared that were devoted to various techniques for performing this type of intervention. The stages of transformation of laparoscopic treatment of an unclosed vaginal process of the peritoneum in children are reduced to using the least invasive methods of treatment with maximum effectiveness and a cosmetic result (Ozgediz D., Roayaie K., Lee N. et al. Subcutaneous endoscopically assisted ligation (SEAL) of the internal ring for repair of inguinal hernias in children: report of a new technique and early results // Surg. Endosc. - 2007. - Vol. 21. - P. 1327-1331).

A known method of laparoscopic transdermal suturing of the internal inguinal ring is based on the fact that in the projection of the internal inguinal ring on the anterior abdominal ring, a puncture needle 18G is pierced through all layers of the inserted into the lumen of the needle non-absorbable monofilament thread folded into the loop, then the back semicircle is circumvented retroperitoneally inner inguinal ring, starting from the lateral margin, followed by a puncture of the peritoneum and insertion of a loop into the abdominal cavity, then the needle is removed leaving a ligature loop in the abdominal cavity, then the needle is passed through the same puncture on the skin, and the anterior semicircle of the inner inguinal ring is circumvented, already on the medial side, leaving space above the vas deferens and testicular vessels, then a second non-absorbable monofilament is inserted into the lumen of the needle. the thread, which is threaded into the existing ligature loop, after which the needle is removed and the second end of the thread is brought out with the ligature loop, followed by extracorporeal formation node m and closing the vaginal lumen process peritoneum (Patkowski D., Czernik J., Chrzan R. et al. Percutaneous internal ring suturing: a simple minimally invasive technique for inguinal hernia repair in children // J. Laparoendosc. Adv. Surg Techn. - 2006. - Vol. 16. - P. 513-517).

There is also known a method of laparoscopically assisted igiopuncture extraperitoneal herniography with congenital inguinal hernias in children (RF patent No. 2566495, published October 27, 2015, "The first experience of using laparoscopically assisted extraperitoneal ignopuncture herniasis with inguinal hernias in A. neonates, / N. A. Podshivalin, T.I. Omarov // Reproductive health of children and adolescents. - 2014. - No. 1. - P. 71-75).

The method consists in the fact that under the control of a laparoscope installed in the umbilical region, and with the help of a dissector inserted into the working channel of the laparoscope, a Tuoha needle is safely held along the lateral side of the internal opening of the inguinal ring to hold the braided non-absorbable suture material under the peritoneum, leaving its end in the free abdominal cavity. Then a needle is drawn along the medial side of the non-obliterated vaginal process of the peritoneum and ligatures are removed from the abdominal cavity, for which endoscopic forceps are inserted into the lumen of the needle. After removing the ends of the thread outside the abdominal cavity, an extracorporeal node is formed, which tightens the defect of the internal inguinal ring, and immerses the node under the subcutaneous fatty tissue.

These methods of laparoscopic suturing of the internal inguinal ring have a significant drawback. When performing a puncture with a needle, bypassing the posterior semicircle of the internal inguinal ring and ligating into the abdominal cavity, the puncture needle is pulled out and another puncture is performed with the same needle to bypass the anterior semicircle of the inguinal ring and insert the second ligature into the existing ligature loop. When a node is formed, an array of tissues is involved in the seam in the form of an aponeurosis of the external oblique muscle of the abdomen and muscle fibers of the internal oblique muscle of the abdomen, which can lead to failure of the node and relapse of the disease.

The objective of the invention is to reduce the risk of recurrence of the disease in the postoperative period.

This problem is solved by the proposed method of a modified technique of laparoscopic percutaneous puncture closure of an unbleached inguinal ring, the distinguishing feature of which is that a mini-trocar with a diameter of 2 mm is installed at the site of the projection of the internal inguinal ring, which is passed through all layers of tissues to the parietal peritoneum under the control of the laparoscope, which allows ligature around the front and back semicircles of the inner ring of the inguinal canal without involving tissue in the seam eredney abdominal wall as mini trocar, settling preperitoneal allows to bring the generated node directly to the vaginal appendages peritoneum.

The technical result of the method is the ability to avoid the formation of hydrocele and improve the reproductive function of the gonads.

The invention is illustrated by photographs, where

photo 1 shows a mini-trocar inserted through all tissue layers to the parietal peritoneum in the projection of the internal inguinal ring,

photo 2 shows the holding of the second ligature in a loop of the first thread;

photo 3 shows a view of the sutured inner inguinal ring,

photo 4 shows a mini-trocar.

The method of the modified technique of laparoscopic percutaneous puncture closure of the non-obliterated inguinal ring is as follows.

A 3 mm skin incision is performed in the paraumbilical region. The pneumoperitoneum is superimposed with a Veress needle. The pressure created in the abdominal cavity depends on the age parameters of the patient and is 7-12 mm Hg. The Veress needle is removed and a 3 mm trocar is inserted. Laparoscopy is performed to assess the presence of non-closure of the internal inguinal ring on both sides. A mini-trocar with a diameter of 2 mm is installed in the projection of the non-obliterated internal inguinal ring (see photo 1, photo 4), which, under the control of a laparoscope, is passed through all layers of tissues of the anterior abdominal wall to the parietal peritoneum in the region of the internal inguinal ring without being inserted into the abdominal cavity. An 18G puncture cannula is inserted through the mini-trocar with a monofilament non-absorbable suture wound in a loop looped into its lumen. A puncture needle bypasses the posterior semicircle of the inguinal ring and ligature singing in the abdominal cavity (photo 1). The puncture needle is removed. Then, through the same mini-trocar, a puncture needle 18G with the second monofilament non-absorbable thread inserted into its lumen is wound up again. Similarly, the anterior semicircle of the inner inguinal ring is circumvented with the departure from the elements of the spermatic cord. The needle is inserted into the existing ligature loop in the abdominal cavity and the end of the second ligature is inserted into it (photo 2). The needle is removed. The ligature loop of the first thread leads outward to the end of the second thread. Extracorporeal knot formation and suturing of the non-obliterated inner inguinal ring are performed without involving the aponeurosis and fibers of the external oblique muscle of the abdomen in the suture (photo 3). Due to the channel formed by the mini-trocar, the node is superimposed directly on the parietal peritoneum. The formed node is immersed under the skin. Laparoscope and trocars are removed. The skin wound is sutured.

A modified method of laparoscopic percutaneous, puncture closure of an unbleached inner inguinal ring is presented by a clinical example.

Patient B., 3 years. Diagnosis: Communicating dropsy of testicular membranes on both sides. The mother of the child turned to the children's urologist andrologist at the polyclinic GBU RO CSTO in Rostov-on-Don with complaints of a periodic increase in the volume of the scrotum on both sides. Upon examination of the patient, the diagnosis was established: Communicating edema of testicular membranes on both sides. The patient was hospitalized as planned in the uroandrological department of the CSTO in Rostov-on-Don for surgical treatment. Under general anesthesia, in a supine position with a cushion under the lumbar region, a paraumbilical incision was made. Using the Veress needle, pneumoperitoneum was applied. A 3 mm trocar was inserted into the abdominal cavity, then a laparoscope. On examination, the non-obliterated inner inguinal ring from 2 sides was visualized. In the projection of the inner ring of the inguinal canal, a mini-trocar was installed, which was drawn through the tissues of the anterior abdominal wall to the parietal peritoneum in the region of the non-obliterated inner inguinal ring. Through the installed mini-trocar, with the help of a puncture needle 18G, the inner inguinal ring was bypassed with a non-absorbable monofilament suture material. An extracorporeal node was formed directly on the parietal peritoneum with subsequent closure of the defect of the internal inguinal ring. Similarly, suturing of the inner inguinal ring from the opposite side was performed. The postoperative period was uneventful. Anesthesia was not required. The day after the operation, the child was discharged from the hospital in satisfactory condition. When viewed after 3, 6, 9 months, dropsy was not noted.

The method allows to exclude involvement of the anterior abdominal wall tissue array in the suture with ligature applied directly to the parietal peritoneum in the region of the internal inguinal ring, which reduces the number of dropsy relapses, improves testicular hemodynamics in the postoperative period, ensuring the preservation of the gonad reproductive function.

Claims (1)

A modified method of laparoscopic transdermal, puncture closure of an unbleached internal inguinal ring in children, characterized in that under the optical control of the laparoscope, a mini-trocar with a diameter of 2 mm is placed in the projection of the internal inguinal ring, which is passed through all layers of tissues to the parietal peritoneum in the region of an unclosed internal inguinal rings, through the installed mini-trocar, a puncture needle 18G is inserted with a loop from non-absorbable monophiles drawn into its lumen filament, which is first performed retroperitoneally bypasses the posterior semicircle of the inner inguinal ring, followed by puncture of the parietal peritoneum and insertion of the loop of thread into the abdominal cavity, while the puncture needle is removed while maintaining the ligature loop in the abdominal cavity, then the puncture needle is re-inserted through the mini-trocar followed by retroperitoneal circumvention of the anterior semicircle of the inner inguinal ring, while a second non-absorbable monofilament thread is inserted into the lumen of the needle, the end of which is under control Lemma laparoscope threaded ligature loop to previous yarns, by removing the puncture needle and mini trocar simultaneously taken out by means of ligature loop and the second end of the thread forming assembly is performed in vitro, followed by closing the lumen neobliterirovannogo internal inguinal ring.

Images