RU2723508C1 - Method of video assisted percutaneous ligation of hernial sac in inguinal hernias in children - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely pediatric surgery. Tuohy needle, inside and outside of which the suture forming the loop, is punctured in the anterior abdominal wall tissues in the projection of the internal inguinal ring up to the hernial sac neck, bypassing the lateral semi-circle of the hernial sac necklace bypassing the elements of the spermatic cord or round ligament of the uterus, the needle is pricked out into the abdominal cavity and a thread loop is inserted into it. Conductor is inserted into needle lumen, and needle is removed. Tuohy needle is guided along the guide to the upper edge of the hernial sac neck; the guide is removed; the Tuohy needle circumvents the medial semi-circle of the hernial sac neck; the needle is pricked out into the abdominal cavity at the same point. Needle Tuohy is threaded. Through the Tuohy needle lumen, an end of the non-absorbable suture is drawn inside the loop; the needle is removed. End of the non-absorbable suture around the lateral semi-circumference of the hernial sac neck is brought out with the help of the loop and brought out. Hernial sac neck is ligatured. In implementing the disclosed method, the ligature does not include preperitoneal cellulose, aponeurosis and subcutaneous fat, which eliminates recurrent hernia and developing hydrocele.EFFECT: method does not require mandatory installation of an additional laparoport and is technically simpler, eliminated risk of Tuohy needle exit from formed puncture of anterior abdominal wall outside in asthenic children, eliminated displacement of anatomical landmarks during surgery, virtually eliminates recurrent hernia and development of hydrocele.1 cl, 12 dwg

Description

The invention relates to medicine, namely to pediatric surgery.

Inguinal hernias in children are one of the most common pathologies diagnosed in 2-5% of the entire pediatric population and make up 65-92% of all types of hernias of the anterior abdominal wall.

A large number of minimally invasive video-assisted surgical techniques for the treatment of inguinal hernias in children, including intracorporeal and extracorporeal methods, have been described. However, most of the proposed methods do not allow ligature application in isolation on the neck of the hernial sac (without trapping the tissues of the anterior abdominal wall under the ligature around the neck of the hernial sac) without installing additional ports [4, 5, 6].

Below are descriptions of three known methods that can serve as analogues of the claimed invention.

1) There is a method of subcutaneous endoscopically assisted suturing of a hernial sac with inguinal hernia in children (Ozgediz D., Roayaie K., Lee N., Nobuhara KK, Farmer DL, Bratton B., Harrison MR 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; 21: 1327-1331).

The essence of this method is extraperitoneal conduction of the suture and subcutaneous ligation of the neck of the hernial sac with monofilament polypropylene suture at the level of the internal inguinal ring. The method is performed under general anesthesia, accompanied by intubation of the trachea, the child is in the Trendelenburg position. After installing the laparoport, applying the pneumoperitoneum and revising the abdominal organs, a skin incision is made in the projection of the internal inguinal ring. Under endoscopic control, a large-radius atraumatic needle with non-absorbable suture material is carried out around the neck of the hernial sac bypassing the spermatic cord or uterine ligament, and the needle is not punctured from the opposite side, but only with its sharp end. Next, the sharp end of the needle is captured by the needle holder, the heel of the needle is passed through the subcutaneous tissue, and the needle is brought out through the above skin incision. Then a knot is formed and high ligation of the hernial sac is made [1].

The knotting during the implementation of this method occurs over the aponeurosis, i.e. preperitoneal tissue, aponeurosis and subcutaneous fatty tissue fall under the ligature. In the future, the ligature can cut through them, which will lead to a weakening of the ligature loop around the neck of the hernial sac and to a relapse of the hernia or the development of dropsy of the testicle shells.

The method involves performing a skin incision to remove the heel of the needle.

The sharp needle used in this method makes it relatively technically difficult to safely hold it over the elements of the spermatic cord or the round ligament of the uterus, eliminating their damage.

2) There is a known method of laparoscopically assisted igiopuncture extraperitoneal herniography with congenital inguinal hernias in children, developed by Akramov N., Yafyasov R., Podshivalin A., Omarov T., Zakirov A. (patent RU 2566495).

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 Tuohy needle is safely guided along the lateral side of the inner inguinal ring to hold the braided, non-absorbable suture material under the peritoneum, leaving its end in the free abdominal cavity. The needle is removed, then reinserted through the same puncture on the anterior abdominal wall and is carried out along the medial side of the non-obliterated vaginal process of the peritoneum. Nippers are inserted into the lumen of the needle, grab the ligature and bring its end of the thread outside the abdominal cavity. An extracorporeal node is formed and immersed under subcutaneous fatty tissue [2].

The method allows to exclude damage and getting into the suture of the testicular vessels and the vas deferens or round ligament.

The method is relatively simple to perform, if necessary, allows for hydrodissection of preperitoneal fiber to facilitate the holding of a needle over the elements of the spermatic cord or uterine round ligament. The method is minimally invasive since one laparoport and an additional puncture with a diameter of 1.2 mm are used.

However, knotting occurs over the aponeurosis, which increases the likelihood of eruption of tissues that have fallen under the ligature, and its weakening in the future, which will lead to relapse of the hernia or the development of dropsy of the testicle membranes.

3) A method is known for the complete extraperitoneal endoscopically assisted subsidizing of a hernial sac in an inguinal hernia in children (patent RU 2688026 C9, prototype).

Perform general anesthesia with cannulation of the trachea and neuroaxial blockade. A laparoport with an optical system is installed, an atraumatic clamp is used, and the internal inguinal ring is inspected and its structures are identified. The Tuohy needle is inserted percutaneously into the projection of the outer edge of the inner inguinal ring under visual control until it appears in the preperitoneal space. The end of the needle is advanced under the parietal sheet of the peritoneum until the elements of the spermatic cord or the round ligament of the uterus are bypassed, followed by a needle in the free abdominal cavity. Two ligatures of different colors are introduced, one of which is herniated and gripped by an atraumatic clamp, followed by drawing out the needle by 5-7 cm from the lumen. Then, the needle is removed so that its end is in the preperitoneal space at the site of the initial injection. Repeated advancement of the needle is carried out extraperitoneally to bypass the upper semicircle of the hernial sac. Then the needle is punctured into the free abdominal cavity at the point where the hernia ligature was previously removed. The end of the hernia ligature is placed in the loop using an atraumatic clamp and it is pulled out so that two ends of the hernia ligature come out through one hole on the skin. A nodal suture is applied until it appears in the prepperitoneal space under optical control [3].

The method allows to reduce the invasiveness of treatment, increase the effectiveness of surgical reconstruction of inguinal hernias in children and reduce the incidence of postoperative complications.

The proposed technique of laparoscopic extraperitoneal ligation of the vaginal process allows a complete extraperitoneal bypass of the neck of the hernial sac with tying and placement of the hernia ligature node at the peritoneal level without interposition of the abdominal wall tissues into the node, which completely excludes the mechanism of disease recurrence or hydrocele formation as a result of eruption of the abdominal wall tissue abdominal fascia, muscles and adipose tissue), existing when using other known extraperitoneal methods of hernioraphia.

However, to implement this method, you must install an additional port.

The method is relatively technically complex. When the Tuohy needle passes from the lower semicircle of the neck of the hernial sac to the upper in asthenic children, there is a risk of the needle leaving the formed puncture out. The tension of the hernia thread during the transition from the lower semicircle of the neck of the hernial sac to the upper one can bias the anatomical landmarks necessary for the high-quality implementation of the method.

Disclosure of the invention

The proposed method of video-assisted percutaneous ligation of a hernial sac in inguinal hernias in children, like the prototype, involves puncture of the tissues of the anterior abdominal wall with a Tuohy needle (hereinafter, when using the word “needle” we mean a Tuohy needle) in the projection of the internal inguinal ring up to the neck of the hernial sac, using a Tuohy needle and a loop of non-absorbable suture (hernia suture, ligature) around the neck of the hernial sac, bypassing the elements of the spermatic cord or round ligament of the uterus, tying a knot with non-absorbable suture.

The inventive method is distinguished by the following features.

The Tuohy needle, inside and outside of which the loop-forming thread passes, puncture the abdominal wall tissues, bypass the lateral semicircle of the neck of the hernial sac and puncture the needle into the abdominal cavity in the region of the lower medial quadrant of the inner inguinal ring.

The thread loop is carried out in the abdominal cavity. A conductor is introduced into the lumen of the needle, the needle is pulled out.

A Tuohy needle is passed through the conductor up to the upper edge of the neck of the hernial sac, the conductor is removed.

The medial semicircle of the neck of the hernial sac is bypassed with a Tuohy needle, the needle is punctured into the abdominal cavity in the same place as after the lateral semicircle of the neck of the hernial sac is bypassed.

A Tuohy needle is passed into a thread loop located in the abdominal cavity, the end of a non-absorbable thread is passed through the lumen of the Tuohy needle into the loop, the needle is removed.

By tensioning (traction) the loop, the end of the non-absorbable thread located in it around the lateral semicircle of the neck of the hernial sac is drawn and brought out, the neck of the hernial sac is ligated.

The technical results of the proposed method

1. When implementing the proposed method, preperitoneal tissue, aponeurosis of the external oblique abdominal muscle, internal and transverse abdominal muscles and subcutaneous fatty tissue do not fall under the ligature, which practically eliminates the recurrence of hernia and the development of hydrocele.

2. The proposed method, unlike the prototype, does not require the installation of an additional port, the use of a clamp to pull the hernial ligature into the abdominal cavity and hold it when the Tuohy needle is moved back.

3. The proposed method is technically relatively simpler.

3.1. In the proposed method and the prototype method, two stages of implementation can be distinguished. At the first stage, the Tuohy needle is carried out from the puncture site of the anterior abdominal wall around one semicircle of the neck of the hernial sac (in the proposed method, lateral, in the prototype lower) to the abdominal cavity. At the second stage, the Tuohy needle is carried out from the place where it first appeared in the prepperitoneal space after the abdominal fascia and muscles were punctured, around the other semicircle of the neck of the hernial sac (in the proposed method, the medial, in the prototype, the upper) to the abdominal cavity. In the proposed method, the Tuohy needle in the first stage contains only a thread loop, in the second - only a hernial thread. In the prototype method, the needle at both stages contains both a thread loop and a hernial thread. In view of this circumstance, during the transition from the first to the second stage of the prototype method, when the Tuohy needle is rotated almost 180 °, the hernial thread is pulled and can cause a displacement of the anatomical landmarks necessary for the high-quality implementation of the method.

When implementing the proposed method, the specified offset is excluded.

3.2. When implementing the proposed method in asthenic children, the risk of Tuohy needle leaving the formed puncture of the anterior abdominal wall to the outside is eliminated, which can happen in the prototype method with the above needle rotation during the transition from the first to the second stage.

List of figures illustrative material

FIG. 1. Tuohy needle with thread passing inside and outside the needle and forming a loop.

FIG. 2. The appearance of a Tuohy needle with a filament loop in the preperitoneal tissue. 1 - a round ligament of the uterus in a girl, 2 - Tuohy needle.

FIG. 3. Poke the Tuohy needle into the free abdominal cavity after bypassing the lateral portion of the neck of the hernial sac. 1 - a round ligament of the uterus, 2 - a Tuohy needle, 3 - a filament loop.

FIG. 4. Poke a Tuohy needle into the free abdominal cavity after bypassing the lateral portion of the neck of the hernial sac in the boy. 2 - Tuohy needle, 3 - thread loop, 7 - testicular vessels, 8 - vas deferens.

FIG. 5. The introduction of a filament loop into the free abdominal cavity. 1 - a round ligament of the uterus in a girl, 2 - a Tuohy needle, 3 - a filament loop.

FIG. 6. Insertion of the conductor through the Tuohy needle. 1 - a round ligament of the uterus, 2 - a Tuohy needle, 3 - a filament loop, 4 - a conductor.

FIG. 7. Left in the abdominal cavity thread loop and the front end of the conductor, inside view. 1 - round ligament of the uterus, 3 - filament loop, 4 - conductor.

FIG. 8. Outside view of the ends of the loop and conductor left in the abdominal cavity. 4 - conductor.

FIG. 9. Insert the Tuohy needle through the conductor up to the upper edge of the hernial sac. 1 - a round ligament of the uterus, 2 - a Tuohy needle, 3 - a filament loop, 4 - a conductor.

FIG. 10. Tuohy needle with a non-absorbable thread in the lumen, bypassed by the medial portion of the neck of the hernial sac and inserted into the loop of the thread. 1 - round ligament of the uterus, 2 - Tuohy needle, 3 - thread loop, 5 - non-absorbable thread.

FIG. 11. Holding a non-absorbable suture along the lateral portion of the neck of the hernial sac using loop traction. 1 - round ligament of the uterus, 3 - filament loop, 5 - non-absorbable thread.

FIG. 12. The ligated neck of the hernial sac. 1 - round ligament of the uterus, 6 - ligature, superimposed by non-absorbable thread.

The implementation of the invention

After establishing the fact of inguinal hernia in the child, his standard preoperative examination is performed.

Under general anesthesia, accompanied by cannulation of the trachea or installation of a laryngeal mask, in the position of the child on the back in the Trendelenburg position with the head end lowered by 15 °, a laparoport, for example, with a diameter of 3 mm, is installed in the navel in which the optical system with a high-resolution camera is placed .

Gas is insufflated into the abdominal cavity, pressure and flow rate are determined individually - they depend on the age and associated pathology in the child.

The neck of the hernial sac is visualized.

Through the cannula of the Tuohy hollow needle, the end of the thread is inserted into its channel (lumen) and brought out through the front (sharp) end of the needle. The thread is bent back along the outer wall of the needle to the cannula, the thread forms a loop (Fig. 1). The ends of the thread along with the needle cannula are in the surgeon's hand.

With a Tuohy needle and a loop of thread, the skin and tissues of the anterior abdominal wall are punctured in the projection of the upper edge of the internal inguinal ring up to the neck of the hernial sac and appear in the preperitoneal space (Fig. 2).

The Tuohy needle is carried out over the parietal sheet of the peritoneum, a lateral portion (lateral semicircle) of the neck of the hernial sac is bypassed with a round of the uterine ligament (Fig. 3) or spermatic cord elements (Fig. 4). A needle in the free abdominal cavity is punctured in the lower medial quadrant of the inner inguinal ring.

By pushing, feeding forward the thread located in the lumen of the needle, the loop is inserted into the abdominal cavity (Fig. 5). Following it, a conductor, for example, a conductor from the Foley urethral catheter, is inserted through the lumen of the Tuohy needle (Fig. 6).

The needle is pulled out, leaving a loop of thread and the front end of the conductor in the abdominal cavity (Fig. 7, 8).

At the next stage, the Tuohy needle is guided along the conductor in the initial way: through the initial skin puncture and puncture of the tissues of the anterior abdominal wall in the projection of the inner inguinal ring up to the upper edge of the neck of the hernial sac, where it first appeared in the prepperitoneal space (Fig. 9).

The conductor is removed, the medial portion (medial semicircle) of the neck of the hernial sac is bypassed with a needle. A needle in the abdominal cavity is punctured at the same place in the parietal peritoneum as when the needle was held around the lateral semicircle of the neck of the hernial sac into the abdominal cavity.

A Tuohy needle is inserted into a thread loop located in the abdominal cavity. On the needle by pushing from the outside, feed forward spend the end of the non-absorbable thread inside the thread loop (Fig. 10). The other end of the thread remains outside.

The needle is removed from the abdominal cavity to the outside. Using the tension (traction) of the loop, the end of the non-absorbable hernial filament located in it around the lateral semicircle of the neck of the hernial sac is drawn and the loop with the end of the filament is brought out (Fig. 11). The incoming and outgoing ends of the hernial filament are in the same channel, formed by a needle in the anterior abdominal wall.

The thread loop is removed. The neck of the hernial sac is ligated by tying the hernial suture (Fig. 12) while expelling air from the hernial sac. Under optical control, the node and hernial ligature located perperitoneally are visualized.

The gas is expelled from the abdominal cavity, the trocar is removed.

When using a laparoport with a diameter of more than 3 mm, it is recommended that suturing of the aponeurosis of the external oblique muscle of the abdomen at the puncture site to avoid the development of trocar hernias.

The effectiveness of treatment is determined visually intraoperatively, as well as in the postoperative period through follow-up observation.

The method was carried out in 30 children of different age groups with inguinal hernias.

In one case, the child required the installation of an additional 3 mm port due to changes in the parietal peritoneum of a fibrous nature in the area of the hernia, associated with frequent injuries to the inguinal hernia in the anamnesis.

The maximum duration of follow-up of patients in the postoperative period at the outpatient stage was 6 months. Early and late postoperative complications after the implementation of the proposed method were not identified.

The group of children treated by the proposed method was compared with the group of children treated in accordance with the prototype method. There were no statistically significant differences in the anthropometric indicators of children in the first and second groups. Evaluation of the treatment results in the groups showed that there were no statistically significant differences between them in the duration of surgery, the number of postoperative hospital days. When using both methods, there were no complications.

List of sources of information used in the text:

1. Ozgediz D. 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 // Surgical endoscopy. - 2007. - T. 21. - No. 8. - C. 1327-1331.

2. The method of laparoscopically assisted igiopuncture extraperitoneal herniography with congenital inguinal hernias in children: RF patent No. 2566495. Application No. 2014129712/14; declared 07/18/14; publ. 10/27/15. Bull. No. 30.

3. The method of complete extraperitoneal endoscopically assisted ligation of the hernial sac with inguinal hernia in children: RF patent No. 2688026 C9. Application No. 2018122136; declared 06/18/18; publ. 09/06/19. Bull. Number 25.

4. Kozlov Yu.A. et al. Laparoscopic inguinal herniography - a modern method of treating inguinal hernias in young children // Russian Bulletin of Pediatric Surgery, Anesthesiology and Resuscitation. - 2011. - No. 4.

5. Ignatiev R.O. The principle of minimal trauma in the choice of the method of endosurgical treatment of children with inguinal hernias // Russian Bulletin of Pediatric Surgery, Anesthesiology and Resuscitation. - 2012 .- T. 2. - No. 1.

6. Kozlov Yu.A. et al. Technology of a single laparoscopic approach in the treatment of inguinal hernias in young children // Annals of surgery. - 2013. - No. 6.

Claims (1)

A method for video-assisted percutaneous ligation of a hernial sac in inguinal hernias in children, including puncture of the tissues of the anterior abdominal wall with a Tuohy needle in the projection of the inner inguinal ring up to the neck of the hernial sac, using a Tuohy needle and a loop of non-absorbable suture around the neck of the hernial sac with a bypass of elements or a round ligament of the uterus, characterized in that the puncture of the tissues of the abdominal wall is carried out with a Tuohy needle, inside and outside of which a thread passes, forming a loop; A Tuohy needle and a loop go around the lateral semicircle of the neck of the hernial sac, a needle is punctured into the abdominal cavity, a thread loop is inserted into the abdominal cavity, a conductor is inserted into the lumen of the needle, the needle is removed, a Tuohy needle is passed through the conductor up to the upper edge of the neck of the hernial sac, the conductor is removed, the medial semicircle of the neck of the hernial sac is bypassed with a needle, the needle is punctured into the abdominal cavity in the same place, the Tuohy needle is inserted into the thread loop, the end of the non-absorbable thread is drawn through the lumen of the Tuohy needle, the needle is pulled out, the end of the non-absorbable thread is drawn around the loop lateral semicircle of the neck of the hernial sac and out, ligated neck of the hernial sac.

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