RU2787969C1 - Method for preperitoneal hernioplasty of bilateral inguinal hernia - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery, hernioplasty. The transverse fascia of the abdomen is separated along with the peritoneum. A mesh endoprosthesis is cut out with cutouts for the external iliac vessels and the bladder, as well as windows for the elements of the spermatic cord in the form, as in Fig.1. In the lower part of the mesh in the region of the cutouts for the external iliac vessels, a mesh incision is made on both sides. The elements of the spermatic cord are placed in the window and the cuts are sutured. The mesh endoprosthesis is fixed at 6 points: to the abdominal wall at points 2 cm below and lateral to the anterior superior iliac spines on both sides, to the Cooper ligament on both sides, to the symphysis and at a point below the navel along the white line of the abdomen.

EFFECT: method allows to perform hernioplasty in one stage; minimizes cases of opening of the abdominal cavity during hernioplasty and eliminates the development of adhesions; allows to exclude damage to the vas deferens and the development of adhesions and the structure of the duct along its course, which can significantly affect the gender function of the patient, prevents the migration of the endoprosthesis and eliminates the recurrence of the disease.

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Description

The invention relates to medicine, namely to the field of surgery, and can be used for plastic surgery of the abdominal wall in inguinal hernias.

A large number of operations have been proposed for the surgical treatment of inguinal hernias. All of them are divided into prosthetic (non-stretch) and non-prosthetic (plasty with local tissues by stretching muscle aponeuric structures). Currently, prosthetic tension techniques are most often used for the treatment of inguinal hernias, of which the most commonly used are: Lichtenstein, Trobucco, Wontz, Stoppe operations, laparoscopic hernioplasty options. With prosthetic methods, endoprostheses are placed preperitoneally and extraperitoneally. (Toskin K.D. and coauthors, 1990; Nesterenko Yu.A. and coauthors, 1986; Fedorov V.D. and coauthors, 1991; Protasov A.V. and coauthors, 2016; Agadzhanyan V.V. and coauthors, 2019 ).

Analogues

• A known method of preperitoneal hernioplasty of inguinal hernia according to Vonts. According to this method, a large unilateral defect in the region of the Hesselbach's triangle is closed with a mesh prosthesis by placing it preperitoneally. The technique consists in displacing the abdominal sheet in a cranial direction with the placement of a diamond-shaped mesh inserted over the Cooper's ligament, to which it is fixed, as well as to the anterior abdominal wall. This does not mean cutting the mesh and fixing it to the Cooper's ligament. The spermatic cord is displaced by the mesh in the lateral direction of the endoprosthesis, fixed to the abdominal wall. (Stages and technique of preperitoneal inguinal hernia repair according to Wontz, Stoppe, 2019).

• There is also a method of preperitoneal closure of bilateral inguinal hernia according to R. Stoppe. In this case, hernial defects are treated by closing the Hesselbach's triangle with an endoprosthesis on both sides, that is, they are carried out accordingly in the form of a chevron. In the transverse direction, the mesh covers the area located between the superior anterior iliac spines, and in the longitudinal direction, the area between the umbilicus and the symphysis. In this case, the mesh freely adapts to the funnel-shaped shape of the bone pelvis and is installed according to the shape of the pelvis. Mesh fixation is not carried out, with the exception of a single stitch at a point below the navel along the white line of the abdomen.

Criticism of analogues

• The Wontz operation is designed to close the Hesselbach triangle on one side. Mesh fixation is weak. That is, the endoprosthesis is fixed to the Cooper ligament and the anterior abdominal wall. The shape of the pattern of the mesh prosthesis is diamond-shaped and does not quite correspond to the funnel-shaped shape of the bone pelvis. In these situations, the possibility of endoprosthesis migration and disease recurrence is very high.

• Operation R. Stoppe is designed for plastic surgery of bilateral inguinal hernia. At the same time, the mesh endoprosthesis, placed directly on the peritoneum (under the transverse fascia) and mobilized on the transverse vas deferens with gonadal vessels, remains on the transverse fascia and is in contact with the endoprosthesis with great attraction, which may affect the tender function due to the involvement of these structures in the cicatricial process with a high probability of obliteration of the duct.

When the fascia is separated from the peritoneum, the latter is often damaged and the peritoneum is opened. The fascia is also damaged, which naturally delays surgery due to the restoration of their integrity.

In case of bilateral hernia in one-stage plasty, a wide exposure of the preperitoneal space is required, that is, the external iliac vessels, the femoral ring, the external inguinal rings, the lower epigastric vessels, the spermatic cord are exposed, and the technique provides for the closure of all three places where the hernial protrusion exits. In this situation, the shape of the mesh endoprosthesis blank in the form of a chevron is not entirely successful. The endoprosthesis should go to the places where the hernial protrusion exits by 2-3 cm, it can be in constant contact with the bladder, with the iliac and lower epigastric vessels. The contact of the mesh endoprosthesis with the bladder, with the iliac and lower epigastric vessels can have a negative impact on them. The mesh endoprosthesis according to the R. Stoppe method is fixed at one point (below the navel on the white line), which does not guarantee the migration of the endoprosthesis.

Prototype

As a prototype, the method of hernioplasty according to R. Stoppe was taken.

Hernioplasty for bilateral inguinal hernia using this technique is performed as follows.

Lower median access, dissection of the aponeurosis along the white line of the abdomen, dilution of the rectus abdominis muscles, dissection of the transverse fascia, reduction of the hernial contents, removal of the hernial sac, or its displacement dorsally. Next, the hernial defect is closed from both sides with the simultaneous attachment of all weak points in this area with a chevron-shaped mesh-blank. The mesh is fixed at a point below the navel along the white line of the abdomen.

In the transverse direction, the mesh endoprosthesis covers the area located between the upper anterior iliac spines, and in the longitudinal direction - the area between the navel and the symphysis. In this case, the elements of the spermatic cord mesh in the lateral direction.

Criticism of the prototype

The disadvantages of the prototype include the following:

• Dissection of the transverse fascia and its separation from the peritoneum, which often leads to damage to the peritoneum and fascia, delaying surgery, as well as the development of adhesions in the abdominal cavity due to soldering of the abdominal organs to the site of injury.

• Contact of the elements of the spermatic cord with the mesh endoprosthesis for a long time on both sides, which can lead to the development of adhesions.

Purpose of the invention

The purpose of the invention is:

To improve the results of surgical treatment of senile patients with bilateral inguinal hernia by using the technique of preperitoneal placement of a mesh endoprosthesis according to the R. Stoppe method for hernioplasty in modifying the cutting of the implant and its fixation to the structures of the pelvic funnel.

The essence of the invention

The essence of the invention is illustrated in Fig. 1.

The essence of the invention is as follows:

A mesh endoprosthesis is formed in the form of "snowboarder goggles" with cutouts for the external iliac vessels and bladder, as well as windows for the elements of the spermatic cord. In the lower part of the mesh in the area of the cutouts for the external iliac vessels, a mesh cut is made on both sides, the elements of the spermatic cord are placed in the window and the cuts are sutured; The mesh endoprosthesis is fixed at 6 points: to the abdominal wall from both sides, to the Cooper's ligament from both sides, to the symphysis and at a point below the navel along the white line of the abdomen.

The essential features of the invention are:

- placement of a mesh endoprosthesis over the transverse fascia, and not on the peritoneum;

- no separation of the peritoneum from the transverse fascia;

- formation of a mesh endoprosthesis in the form of "snowboarder glasses" with cutouts for the external iliac vessels and the bladder, as well as windows for the elements of the spermatic cord;

- in the lower part of the mesh in the area of the cutouts for the external iliac vessels, a mesh cut is made on both sides, the elements of the spermatic cord are placed in the window and the cuts are sutured;

- fixation of the mesh endoprosthesis at 6 points: to the abdominal wall from both sides, to the Cooper's ligament from both sides, to the symphysis and at a point below the navel along the white line of the abdomen.

Indications for changing the proposed method are:

• Postoperative ventral hernia M4;

• Bilateral femoral hernia.

The technical result is achieved by dorsally separating the peritoneum and the transverse fascia of the abdomen from the underlying structures; cutting out a mesh endoprosthesis in the form of "snowboarder goggles" with cutouts for the external iliac vessels and windows for the elements of the spermatic cord; free adaptation of the endoprosthesis to the funnel-shaped form of the bone pelvis; fixation of the mesh endoprosthesis to the abdominal wall at a point 2 cm laterally and below the anterior iliac spine on both sides, to the Cooper's ligament on both sides; making a mesh incision in the area of the cutouts for the external iliac vessels, placing the elements of the spermatic cord into the window on both sides and suturing the incisions made; fixing the mesh to the symphysis and at a point below the navel along the white line of the abdomen.

Examples of specific implementation of the method

Patient G., 63 years old, was admitted to the General Surgery Clinic on June 13, 2018 with a diagnosis of Bilateral inguinal hernia. Indications of clinical and biochemical analyzes of blood and urine are within the normal range. Status localis: in the inguinal regions, tumor-like formations are determined: on the left, 6.0 × 5.0 cm in size, on the right, 7.6 × 5.5 cm. Formations of a taut-elastic consistency, the contents are freely reduced into the abdominal cavity. The vas deferens are palpable to the medial side of the hernial protrusion. Superficial inguinal rings pass 2 transverse fingers, the course of the hernial protrusion is oblique. Clinical diagnosis "Bilateral oblique inguinal hernia". Concomitant pathology was not identified. On the second day after admission to the clinic, the patient underwent surgery under general anesthesia. Lower median access, dissection of the aponeurosis along the entire line of the abdomen. Further, the rectus abdominis muscles are separated to the sides, the transverse fascia of the abdomen is exfoliated along with the peritoneum to expose the Cooper ligaments, the symphysis of the external iliac vessels. Then the hernial sacs were isolated, the contents were set into the abdominal cavity, and they were displaced dorsally. Next, a mesh endoprosthesis was cut in the form of "snowboarder goggles" with cutouts for the external iliac vessels and windows for the elements of the spermatic cord. The mesh prosthesis is adapted in the preperitoneal space, cuts are made in the region of cutouts for vessels on both sides, elements of the spermatic cord are installed, and sutures are placed in the windows on the cuts. The mesh is fixed to the Cooper ligaments, to the symphysis, to the abdominal wall at a point 2 cm below and lateral to the anterior superior iliac spine on both sides, and to the transverse fascia below the umbilicus. The operation was completed by layer-by-layer suturing of the abdominal wall with the introduction of active drainage. The latter was removed on the second day, the course of the postoperative period was smooth, wound healing by primary intention, and was discharged in a satisfactory condition for outpatient treatment. Examination after 7 months, no recurrence of the disease.

Patient M., 74 years old, was admitted to the clinic of general surgery of the Federal State Budgetary Educational Institution of the Russian Federation "DSMU" of the Ministry of Health of the Russian Federation on December 14, 2018 with a diagnosis of "Bilateral inguinal hernia". The patient's condition upon admission to the clinic is satisfactory. Indicators of clinical and biochemical blood and urine tests for the purposes of the norm. The following concomitant pathology was revealed: ischemic heart disease, hypertension, stage II arterial hypertension. BP at admission 150/90 mm Hg. Status localis: Tumor-like formations 8.0 × 6.0 and 7.0 × 5.0 cm in size are determined in the inguinal regions. Rounded formations do not descend into the scrotum, of a tight elastic consistency, the contents are pushed into the abdominal cavity, the vas deferens is palpated from the lateral side from hernial protrusion. Superficial inguinal rings pass 2.5 transverse fingers, the course of the hernial canal is straight. A clinical diagnosis of "Bilateral direct inguinal hernia" was made. After correction of functional disorders of the cardiovascular system, surgery was performed under peredural anesthesia. Lower middle access, dissection of the aponeurosis of the white line of the abdomen. The rectus abdominis muscles are pushed apart stupidly. The transverse fascia, together with the peritoneum, was detached from the presenting structures to the exposure of the symphysis, Cooper's ligaments, and external iliac vessels. Selected hernial sacs, the latter bandaged and removed. A mesh was cut out in the form of "snowboarder's goggles" with cutouts for the iliac vessels with windows for the elements of the spermatic cord. The mesh endoprosthesis is adapted in the preperitoneal space, cuts are made in the lower sections, that is, cuts for the vessels are formed, the elements of the spermatic cord are passed through the windows, the cuts are sutured. Further, the meshes are fixed with a prolene to the Kupper ligaments, to the symphysis, to the abdominal wall at points 2 cm below and lateral to the anterior iliac spines and to the transverse fascia below the umbilicus. The operation was completed by tight suturing of the abdominal wall with the introduction of active drainage. The course of the postoperative period is smooth, the patient was discharged from the hospital in a satisfactory condition. Inspection after 6 months, there are no recurrences of hernial protrusions.

Patient A., 78 years old, was admitted to the clinic of general surgery of the FGBOU VO "DSMU" of the Ministry of Health of the Russian Federation on January 13, 2020 with a diagnosis of "Bilateral inguinal hernia". The patient's condition upon admission to the clinic is satisfactory. Concomitant pathology “General atherosclerosis, ischemic heart disease, hypertension, atherosclerotic lesions of the vessels of the lower extremities. Indicators of clinical and biochemical blood and urine tests were within the normal range. Status localis: In the inguinal regions, hernial protrusions are determined with dimensions of 5.0 × 4.0 and 5.5 × 5.0 cm. The course of the hernial canals is straight. A clinical diagnosis was made: "Bilateral direct inguinal hernia". After appropriate preparation, surgery was performed under peredural anesthesia. Lower median access, dissection of the aponeurosis along the white line of the abdomen. The rectus abdominis muscles are spread apart. The transverse fascia, together with the peritoneum, was detached from the presenting structures to the exposure of the symphysis, Cooper's ligaments. Selected hernial sacs, the latter bandaged and removed. A mesh was cut out in the form of "snowboarder goggles" with cutouts for the external iliac vessels for the elements of the spermatic cord. The mesh endoprosthesis is adapted in the preperitoneal space, cuts are made in the region of the cutouts for the vessels, the elements of the spermatic cord are passed through the windows, prolene sutures are placed on the cuts of the endoprosthesis. Further, the mesh endoprosthesis is fixed with a prolene to the Cooper ligaments, to the symphysis, to the abdominal wall at points 2 cm below and lateral to the anterior superior iliac spines and to the transverse fascia below the umbilicus. The operation was completed by layer-by-layer suturing of the abdominal wall with the introduction of active drainage. The course of the postoperative period is smooth, wound healing by primary intention. The patient was discharged in a satisfactory condition for further outpatient treatment.

Features of the invention, different from the prototype:

• The peritoneum is not cut off from the transverse fascia of the abdomen, they are separated by the presenting structures together and pushed back dorsally;

• The mesh endoprosthesis is cut out in the form of "snowboarder glasses" with cutouts for the external iliac vessels and with windows for the elements of the spermatic cord;

• Elements of the spermatic cord are not separated from the peritoneum throughout, but are passed through the windows in the mesh endoprosthesis, and can come into contact with it only within the window;

• The mesh endoprosthesis is adapted in the preperitoneal space and is fixed to the Cooper's ligaments, to the symphysis, to the abdominal wall 2 cm below and lateral to the anterior superior iliac spine, and to the transverse fascia of the abdomen below the umbilicus.

Prototype Features

• The peritoneum is separated from the transverse fascia and often they are damaged and have to be restored;

• Elements of the spermatic cords are separated from the peritoneum for 8-9 cm. In this case, their damage is possible;

• Mesh endoprosthesis is fixed at one point to the transverse fascia below the navel.

The positive effect of the application of the invention

• The proposed method will make it possible to perform plasty of the abdominal wall or bilateral hernia in one stage;

• The method will allow minimizing the cases of opening of the abdominal cavity during hernioplasty and exclude the development of adhesions;

• The method will make it possible to exclude damage to the vas deferens and the development of an adhesive process and the structure of the duct along its course, which can significantly affect the gender function of the patient;

• The method will prevent the migration of the endoprosthesis and exclude the recurrence of the disease.

The proposed method was used for hernioplasty in 58 patients with bilateral inguinal hernia. Of these, oblique inguinal hernia was present in 8 (13.7%) patients; oblique - on the one hand, direct - on the other side was present in 6 (10.3%) and bilateral direct inguinal hernia in 44 (76.0%) cases, damage to the peritoneum and transverse fascia was not noted, there was also no damage to the elements of the seminal cord. Seromas occurred in 3 (58.1%) cases, hematomas - in 2 (3.4%). There were no lethal outcomes, the average stay of patients in the hospital was 7.4±1.6 days. No recurrence of the disease was noted.

Sources

1. Toskin K.D., Zhebrovsky V.V. Hernia of the abdomen. M., 1983; 137-155.

2. Toskin K.D., Zhebrovsky V.V. Hernias of the abdominal wall. M., 1990.

3. Nesterenko Yu.A., Serochkin G.G. Results of surgical treatment of recurrent inguinal hernias. Vestn. hir., 1986; 2; 57-59.

4. Fedorov V.D. etc. Principles of surgical treatment of inguinal hernias. Surgery, 1991; 1; 59-63.

5. Majidov R.T.

6. Protasov A.V., Bogdanova D.Yu., Ermakova N.A. Inguinal hernia repair with PROGRIP implants. M., 2016; 154.

7. Agadzhanyan V.V., Krylov Yu.M., Tarasov A.L. Method for preperitoneal hernioplasty of inguinal hernias.

8. Stages and technique of preperitoneal hernioplasty of inguinal hernia according to Vontz, Stoppe.

Claims (1)

A method for preperitoneal hernioplasty of a bilateral inguinal hernia, including separation of the peritoneum of the anterior abdominal wall, isolation of the hernial sac on both sides from the lower median access, installation of an endoprosthesis, characterized in that the transverse fascia of the abdomen is separated along with the peritoneum, a mesh endoprosthesis is cut out with cutouts for the external iliac vessels and urinary bladder, as well as windows for the elements of the spermatic cord in the form, as in figure 1, in the lower part of the mesh in the area of the cutouts for the external iliac vessels, a mesh cut is made on both sides, the elements of the spermatic cord are installed in the window and sutures are placed on the cuts, the mesh is fixed endoprosthesis at 6 points: to the abdominal wall at points 2 cm below and lateral to the anterior superior iliac spines on both sides, to the Cooper ligament on both sides, to the symphysis and at a point below the umbilicus along the white line of the abdomen.

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