RU2654610C1 - Method of non-stretching hernioplasty for inguinal hernia - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery in the treatment of inguinal hernias. Perform a layer-by-layer opening of the inguinal canal with the isolation of the spermatic cord. Hernial sac is isolated from surrounding tissues, stitched at the neck, bandaged and cut off. Spermatic cord is placed in a groove formed from the transverse fascia, followed by the reduction and cross-linking of the transverse fascia above the spermatic cord. Infiltrate the spermatic cord with 5–10 ml of ozonized saline with an ozone concentration of 4–5 mg/l. Cut out polypropylene mesh, the width of which is more than the height of the inguinal space by 3–4 cm and fix it on top of the cord to the Poupart's ligament, to the periosteum of the lumbar tubercle, to the aponeurosis of the rectus muscle. Apply a net on the internal oblique muscle with an overlap of 3–4 cm and hem to the net with the capture of the transverse abdominal muscle. Between tubercle of the pubic bone and the rectus muscle, a diastase is left for the exit of the spermatic cord. Suture the upper and lower flaps of the aponeurosis of the outer oblique abdominal muscle.

EFFECT: method ensures prevention of male infertility by preventing direct contact of the spermatic cord with the material of the mesh explant throughout the inguinal canal, which in combination with the infiltration of the elements of the spermatic cord with an ozonized saline solution, prevents the development of postoperative cicatricial-adhesive process and pain syndrome.

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Description

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

The most reliable option for closing the defect in the anterior abdominal wall, the “gold standard” is considered non-tension plastic with implantation of mesh endoprosthesis according to Liechtenstein. This method involves closing with a synthetic endoprosthesis a defect in the posterior wall of the inguinal canal, the spermatic cord is guided through the hole created in the mesh and placed directly on the endoprosthesis. However, this method has several disadvantages: after such a plastic surgery, azoospermia develops, associated with the formation of coarse connective tissue in the area of the implanted endoprosthesis, deformation and obstruction of the vas deferens occurs, which leads to the development of male infertility. These complications are associated with close contact of the mesh with the spermatic cord.

Currently, the so-called insulating or protective methods of hernioplasty, which involve the use of methods to protect the spermatic cord from the mesh, are becoming increasingly relevant.

Thus, from the prior art, a method of non-tension plastic surgery for inguinal hernia is known (RU 2460469 C1, 09/10/2012), according to which the transverse fascia is cut 4 cm more medially from the pupar ligament L-shaped with respect to the inner ring of the inguinal canal, the transverse fascia leaves are separated from the preperitoneal fiber, prepared in size polypropylene mesh is fixed to the upper leaf of the transverse fascia throughout the interrupted sutures, the spermatic cord is wrapped in the lower leaf of the transverse fascia, the lower leaf of the transverse fascia is fixed they are tied to the pupartic ligament at a distance of 0.5-1 cm from its free edge with interrupted sutures, the lower edge of the mesh is brought under the spermatic cord wrapped in fascia and fixed to the subpartic ligament with interrupted sutures, while the threads are drawn from the inside outwards with the semen retained after closing free edge of the transverse fascia, with interrupted sutures, fixate to the pupartic ligament in front of the spermatic cord of the aponeurosis of the external oblique muscle of the abdomen. Thus, they prevent contact of the spermatic cord with the mesh and strengthen both the posterior and the anterior walls of the inguinal canal. The disadvantages of this method is the change in the course of the spermatic cord, which causes its tension and trauma, as well as the complexity of the method, which lengthens the time of the operation.

Closest to the claimed method is the implementation of plastics according to Girard (Fig. 3b), according to which the front wall of the inguinal canal is strengthened by suturing the internal oblique and transverse abdominal muscles throughout the inguinal canal to the inguinal ligament over the spermatic cord with separate interrupted silk sutures. The medial (upper) flap of the aponeurosis of the external oblique muscle of the abdomen is sutured with the second row of sutures to the inguinal ligament. A lateral (lower) flap of the aponeurosis of the external oblique muscle of the abdomen is sutured to the medial one, forming duplicature (G.E. Ostroverkhoye et al. Surgical Surgery and Topographic Anatomy. Kursk, 1996, pp. 555-558). The disadvantage of this technique of inguinal canal plasty is that it relates to stretching operations - tension of the stitched tissues occurs, which can lead to the formation of an inferior scar (which is also facilitated by stitching of dissimilar tissues) and, ultimately, to relapse, as well as to the occurrence of long-term pain in the postoperative period. In addition, as a result of plastics, an insufficiently strong muscle-aponeurotic layer is created.

The technical result of the claimed invention is the prevention of male infertility by preventing direct contact of the spermatic cord with the material of the mesh explant throughout the inguinal canal, which, together with the infiltration of the elements of the spermatic cord with ozonized physiological saline, prevents the development of postoperative scar-adhesion process and pain; the absence of even the slightest tension of the elements of the spermatic cord in the process of hernioplasty also ensures the prevention of its trauma; The method provides reliable strengthening of the anterior wall of the inguinal canal due to the creation of a durable layer: aponeurosis of the external oblique muscle of the abdomen + polypropylene mesh, as well as the posterior wall of the inguinal canal due to the creation of duplicate transverse fascia, which minimizes the possibility of recurrence of hernias.

The technical result is achieved due to the fact that during non-tension hernioplasty with inguinal hernias, including a layered opening of the inguinal canal, isolation of the spermatic cord, the hernial sac is isolated from surrounding tissues, sutured from the neck, bandaged and cut, the spermatic cord is laid in a gutter formed from the transverse fascia followed by mixing and stitching of the transverse fascia over the spermatic cord, the spermatic cord is infiltrated with 5-10 ml of ozonized physiological solution with an ozone concentration of 4 -5 mg / l, they cut out a polypropylene mesh, the width of which is 3-4 cm greater than the height of the inguinal gap and fix it on top of the cord to theparticular ligament, to the periosteum of the pubic tubercle, to the aponeurosis of the rectus muscle, lay the mesh on the internal oblique muscle with an overlap of 3 -4 cm and hem the mesh with the capture of the transverse abdominal muscle, diastasis is left between the pubic tubercle of the pubic bone and the rectus muscle to exit the spermatic cord, the upper and lower flap of the aponeurosis of the external oblique abdominal muscle are sutured.

The inventive method is illustrated in graphic material.

In FIG. 1 shows the step of covering the spermatic cord with the transverse fascia.

1 - aponeurosis of the rectus abdominis muscle

2 - internal oblique muscle of the abdomen

3 - transverse fascia

4 - seam ties

5 - spermatic cord

6 - aponeurosis of the external oblique muscle

In FIG. 2 shows the step of fixing the mesh.

7 - external oblique muscle

8 - inguinal canal

9 - polypropylene mesh

10 - pupartic ligament

In FIG. 3a shows a plastic scheme according to the method of the authors, the sagittal plane

11 - transverse abdominal muscle

12 - peritoneum

In FIG. 3b shows the Girard plastic surgery scheme (prototype), sagittal plane

The method is as follows:

1. Under spinal anesthesia carry out a layered opening of the inguinal canal and the allocation of spermatic cord. The hernia sac is hydrotreated from the surrounding tissues with an ozonized saline solution with an ozone concentration of 4-5 mg / l. The hernial sac is stitched at the neck, bandaged and cut off.

2. The spermatic cord 5 is laid in the gutter formed from the transverse fascia 3, followed by the reduction and stitching of the transverse fascia over the spermatic cord (Fig. 1, Fig. 3a, suture A). Thus, provide isolation of the spermatic cord from the mesh throughout the inguinal canal. In addition, the resulting duplication of the transverse fascia strengthens the posterior wall of the inguinal canal.

3. To improve “tissue respiration”, the fastest repair of the elements of the spermatic cord and prevention of the cicatricial process, the spermatic cord is infiltrated with 5-10 ml of ozonized physiological solution with an ozone concentration of 4-5 mg / l.

4. Next, alloplasty of the inguinal canal is made with a polypropylene mesh 9 with fixation of the mesh over the cord 5 (Fig. 2). Pre-cut mesh, the width of which is greater than the height of the inguinal gap by 3-4 cm. Figures 2 and 3a show the stages of plastic surgery of the anterior wall of the inguinal canal: mesh 9 is fixed to the pupartic ligament 10 - suture B in FIG. 3a, to the periosteum of the pubic tubercle, to the aponeurosis of the rectus muscle 1. A mesh is applied to the internal oblique muscle 2 with an overlap of 3-4 cm to prevent eruption of sutures and the mesh is sewn to the internal oblique muscle 2 with the capture of the transverse abdominal muscle 11 - suture C in FIG. . 3a. Between the tubercle of the pubic bone and the rectus muscle, we leave diastasis passing the tip of the finger for free exit of the spermatic cord. Thus, in this method, the spermatic cord lies beneath the "mesh". Suture the upper and lower flaps of the aponeurosis of the external oblique muscle of the abdomen 6 - suture D in Fig. 3a. The front wall of the inguinal canal is reliably strengthened by a double layer: aponeurosis of the external oblique muscle of the abdomen and a mesh securely fixed to the anatomical structures listed above. In our method, it is not necessary to cut a hole for the spermatic cord in the mesh, which reduces the operation time. In addition, the course of the spermatic cord does not change, which prevents the tension of its elements and trauma.

Clinical example

Patient K., 41, turned for planned surgical treatment. An outpatient clinical and laboratory examination, ultrasound, ECG, chest x-ray were performed. Examined by an anesthesiologist, therapist: no contraindications for surgery were identified.

Diagnosis: Giant inguinal-scrotal hernia on the right.

The operation is indicated: inguinal hernia repair, alloplasty of the inguinal canal on the right under SM A. Consent of the patient is obtained.

A cut parallel to and above the right inguinal fold folds open the inguinal canal. The hernial sac lies laterally from the spermatic cord. The bag is opened, empty, separated from the adhesions with the spermatic cord. The medial wall of the hernial sac is the bladder. The bag is stitched at the neck, bandaged, cut off. The spermatic cord is immersed along the entire inguinal canal in a gutter formed from the transverse fascia, with subsequent reduction and stitching of the fascia over the cord. Infiltration of spermatic cord 5 ml of ozonized physiological solution with an ozone concentration of 5 mg / l. Alloplasty of the inguinal canal with a polypropylene mesh according to the author's method with fixing it on top of the cord: cut out a polypropylene mesh, the width of which is 3-4 cm greater than the height of the inguinal gap and fix it over the cord to the pupartic ligament, to the periosteum of the pubic tubercle, to the aponeurosis of the rectus muscle, lay a mesh on the internal oblique muscle with an overlap of 3-4 cm and hem the mesh to it with the capture of the transverse abdominal muscle. At the same time, diastasis was passed between the pubic tubercle of the pubic bone and the rectus muscle, allowing the tip of the finger to pass through for free exit of the spermatic cord. Sew the upper and lower flaps of the aponeurosis of the external oblique muscle of the abdomen. Control for hemostasis. Stitches on the wound. Ace. sticker.

The postoperative period was uneventful. Pain is negligible. On the 1st day, the patient began to walk independently. Discharged on the 3rd day. Control examination every 6 months. No complaints, local status without features. When viewed after 1 year, no relapse was noted.

Claims (1)

A method of non-tension hernioplasty for inguinal hernias, including a layered opening of the inguinal canal, isolation of the spermatic cord, the hernial sac is isolated from the surrounding tissues, stitched at the neck, ligated and cut off, plastic surgery of the anterior wall of the inguinal canal is carried out, characterized in that the spermatic cord is laid in formed from the transverse fascia gutter, followed by mixing and stitching the transverse fascia over the spermatic cord, carry out the infiltration of the spermatic cord 5-10 ml of ozonized physiological solution ra with an ozone concentration of 4-5 mg / l, cut out a polypropylene mesh, the width of which is 3-4 cm greater than the height of the inguinal gap, and fix it on top of the cord to theparticular ligament, to the periosteum of the pubic tubercle, to the aponeurosis of the rectus muscle, lay the mesh on the inner oblique muscle with an overlap of 3-4 cm and hem the mesh with the capture of the transverse abdominal muscle, diastasis is left between the pubic tubercle of the pubic bone and the rectus muscle to exit the spermatic cord, and the upper and lower aponeurosis flaps of the external oblique abdominal muscle are sutured.

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