RU2187970C1 - Method for setting implant in performing preperitoneal hernioplasty - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves separating parietal peritoneum of the anterior abdominal wall by means of retroperitoneoscope device. Hernial sack is selected. Implant rolled at its lower edge retaining the upper edge free. The upper edge is fastened with fixing members through pierces in the anterior abdominal wall. One of the fixing members is set on the median line at 4.0-4.5 cm from the symphysis edge, the second one is set in parallel to the first one along the pararectal line. Then the net is rolled out. EFFECT: accelerated net installation. 4 dwg

Description

 The invention relates to medicine, in particular surgery.

 External abdominal hernias are one of the most common surgical diseases and occur in 3-7% of the population, i.e. more than 50 out of 10,000 people. Among the external hernias of the abdominal wall, inguinal, which make up 65-80% of the total number of hernias, are most often found. (Toskin K.D., Zhebrovsky V.V. Hernias of the abdomen. M., 1983 - p.137-155; Toskin K.D., Zhebrovsky V.V. Hernias of the abdominal wall. M., 1990; Cherenko M.P. . and other Abdominal hernias. Kiev, 1995). The frequency of operations for inguinal hernias are in one of the first places among all planned surgical interventions performed in a hospital. In particular, in Russia they are performed up to 200 thousand a year, in the USA - more than 500 thousand (Fedorov V.D. et al. Principles of surgical treatment of inguinal hernias. Surgery, 1991; 1; 59-63. Cherenko M. P. and other Abdominal hernias. Kiev, 1995).

 The urgency of the problem of surgical treatment of inguinal hernias is explained by a rather large number of relapses without a tendency to decrease (up to 10% with ordinary and up to 30% with complicated types of hernias), as well as other complications - postoperative neuromas, epididymitis, ischemic orchitis, purulent-inflammatory complications from operating wounds, etc. (Nesterenko Yu.A., Serochkin G.G. Results of surgical treatment of recurrent inguinal hernias. News. Chir. 1986; 2; 57-59. Fedorov V.D. et al. Principles of surgical treatment of inguinal hernias. Surgery 1991; 1; 59-63). Currently, in the treatment of inguinal hernias, endoscopic and endovascular surgical techniques with closing hernial gates with a special implant (polypropylene mesh) are becoming more widespread. The use of synthetic implants significantly reduced the percentage of hernia recurrences - to 1.1-2.2% (Toy FK Smoot RT Laparoskopik hernioplasty upelate. Laparoendosc. Surg. 1992; 2: 197-205. Toy F. K., Smoot RT Toy - Smoot laparoscopic hernioplasty. Surg. Laparosc. Endosc. 1991; 1.3: 151-155).

 With all types of these operations, the most time-consuming step is the installation of an implant. Depending on the type of implant, this stage takes from 15 to 40 minutes: with a rigid structure ("Prolen", etc.) - an average of 17 minutes, with a soft structure ("Cor-tex", "Plastopolymer") - on average 28 minutes Of course, the speed of this stage of the operation depends on the manual abilities of the surgeon and the degree of training. Foreign and domestic researchers are trying to solve this problem by introducing self-healing implants and using special tools.

 A known method of placing an implant in body tissue using levers into which a peripheral portion of a surgical implant is removably inserted (US Pat. No. 5,405,360 A dated 07/22/93, published 04/11/95, class A 61 B 17/00). After insertion through the trocar, when the surgical implant is deployed, the delivery arms stretch the peripheral portion of the implant.

 The disadvantage of this method is the multiple punctures of the anterior abdominal wall, the need for general anesthesia, expensive equipment and special complex instruments, as a result of which high cost.

 A known method of installing a prosthesis from elastic tissue in an endoscopic manner, which consists in the fact that using a tubular case in which a prosthesis (implant) is placed in a rolled state, the latter is brought through the trocar to the surgical site (French patent N 2705225 A 1, from 05.21.93 , published 11/25/94, M. cl. A 61 B 17/00). From the slots in the case, the prosthesis unfolds with a fork-like part by rotation.

 The disadvantage of this method is the difficulty of manipulation due to the small volume of the working space, multiple punctures of the anterior abdominal wall, the need for general anesthesia and expensive equipment.

 Closest to the claimed method is transabdominal extraperitoneal laparoscopic hernioplasty proposed by G. Ferzli et al. (Ferzli G. S., Massad A. Albert P. // J. Laparoendosc. Surg. - 1992. - Vol. 2, N6. - P. 281-286). Under endotracheal anesthesia, an incision is made in the skin and subcutaneous tissue up to 2.0-2.5 cm under the navel. Aponeurosis is isolated and dissected in the transverse direction for 2.0-2.5 cm. A balloon device is introduced into the peritoneal space towards the pubic joint and the parietal peritoneum is peeled off from the anterior abdominal wall by air injection. After removing the balloon device, a trocar 12 mm in diameter is inserted into the incision with a laparoscope. The cavity formed is maintained by insufflating nitrous oxide into it under a pressure of 8 mm Hg. Art. In the middle of the distance between the navel and the womb along the pararetal line, working trocars with dissectors (5- and 12 mm) are introduced from both sides, with the help of which the hernial sac is released. The pubic bone, inguinal ligament, elements of the spermatic cord, Cooper ligament and lower epigastric vessels are exposed. Next, a polypropylene mesh is inserted into the preperitoneal space through a 12-mm trocar, clamped at one of the corners with an endo-clamp and rolled up into a tube (at least 13x9 cm in size). The prosthesis is placed in such a way that it covers the zone of formation of a straight, oblique and femoral hernia. After the implant is inserted into the peritoneal space, Redon drainage is introduced through a separate puncture in the inguinal region. Trocars are removed. 1-2 sutures are placed on the wound under the navel.

 However, this method is difficult due to the small amount of work space. The number of local complications increases on average 2 times (Tetic C., Frregui M.E. Prevention of Complications of Open and Laparoscpic Repair of Groin Hernias. Principles of Laparoscpic Surgeri. Basic and Advanced Techniges. Springer - Verlag 1995; 439-449) . One of the unpleasant complications that discredit the technique is damage to the peritoneum, especially in patients with a history of operations (appendectomy). Other disadvantages that limit the widespread use of this operation include high cost, the need for general anesthesia, multiple punctures of the anterior abdominal wall, and mesh migration.

 The objective of the invention is to increase the efficiency of hernioplasty operations and reduce the time of surgery. The task is achieved by the fact that in the prepared preperitoneal space, for example, with the help of a retroperitoneoscope, an implant is rolled up with a clamping device, rolled up behind the lower edge into the tube, leaving the upper edge free, which is fixed with clamps through the punctures of the anterior abdominal wall, while one clamp is installed in the midline at a distance of 4.0-4.5 cm from the symphysis, the second parallel to the first along the pararectal line, after which the mesh is deployed, covering the hernia formation zone.

The novelty of the method:
1. Introduction under a retroperitoneoscope into the prepared space of a rolled up mesh in the tube ensures ease of implant insertion and a significant reduction in operation time.

 2. Fixing the free upper edge of the mesh with latches provides the freedom of manipulation of the surgeon.

 3. The deployment of the mesh after fixation prevents the migration of the latter.

 The invention is illustrated in the drawing, where in Fig.1 shows a diagram of the operation, in Fig. 2 - the front wall of the abdomen and pelvis from the inside (1/2) with "clamps" and a folded mesh in the clamping device, figure 3 - the position of the mesh and "clamps" in the side projection, figure 4 - the front wall of the abdomen and pelvis from the inside with implanted mesh.

 The essence of the method is as follows.

 The patient lies on his back. Epidural anesthesia. The skin incision is up to 3.0-3.5 cm (1) in the ileo-inguinal region in the oblique direction (appendicular), departing from the upper anterior spine by 3-4 cm. The aponeurosis is cut over 3.0-3.5 cm Stupidly, the hooks of Farabef spread the muscles to the peritoneum. The parietal peritoneum exfoliates with a tuffer in a limited area for the introduction of a retroperitoneoscope. The patient is transferred to the Trendelenburg position and on the side opposite to the operation, after which a retroperitoneoscope is inserted towards the external inguinal ring and the parietal peritoneum is exfoliated with a retroperitoneoscope blade and a tupfer. The inner opening of the inguinal canal (2), the spermatic cord with a hernial sac, stands out. The hernial sac bluntly and sharply stands out from the spermatic cord to the neck. Further, the parietal peritoneum continues to exfoliate with a retroperitoneoscope and tupfer. As you progress, the blades of the retroperitoneoscope change from smaller to larger, usually two blades are enough.

 The external opening of the inguinal canal (3), the pubic joint, are distinguished, after which the retroperitoneoscope blade rotates perpendicular to the rectus abdominis muscle and the peritoneum exfoliates from the anterior abdominal wall for 4-5 cm from the pubic joint. The detachment is carried out until a sufficient volume of the visualized space is achieved, adequate to the size of the implanted mesh, which subsequently achieves mesh stability, i.e. its migration is absent. The retroperitoneoscope remains in the preperitoneal space. The lower edge of the mesh is clamped in the clamping device (6) and wrapped in a tube, leaving the upper edge free by a value of 1.5-2.0 cm. When folded, the mesh is installed in the prepared pocket, the upper edge is fixed with 2 "clips" (7) through punctures of the anterior abdominal wall; one fixer along the midline at a distance of 4.0-4.5 cm from the symphysis, the second parallel to the first along the pararectal line. The mesh is straightened so that it covers the formation of inguinal and femoral (5) hernias. Remove the clamping device. Further, drainage along the Redon is established preperitoneally on the mesh, which is removed through a separate puncture in the iliac-inguinal region. Drainage is set for 24 hours, and then removed. The patient is returned to their original position, remove the "clamps". The retroperitoneoscope is removed. Seams on a wound in layers.

 Patients were allowed to walk 8-10 hours after surgery, the administration of painkillers was not required, they were discharged from the hospital for 3-4 days. Full rehabilitation in 5-7 days. Complications in the postoperative period were not observed.

Example:
The patient, A. Bastrikov, 39 years old, medical history 5041 was admitted to the clinic on August 22, 2000 with complaints of a hernial protrusion in the right inguinal region. A hernial protrusion appeared about 1 year ago after heavy physical exertion, it is increasing in size, and pains began to disturb. Objectively: in the right inguinal region there is a correctable hernial protrusion of an oval shape, 7x5 cm in size, soft-elastic, painless, descends into the scrotum. The skin above it is not changed.

 Diagnosis: Adjustable oblique inguinal-scrotal hernia on the right.

 After examination 23. 08. 2000 at 10 hours 20 minutes the operation was performed - preperitoneal plastic mesh. Epidural anesthesia. The incision in the right ileo-inguinal region is up to 3.0 cm. Hemostasis. Aponeurosis is distinguished, dissected for 3.0 cm. The muscles are bluntly dilated with Farabef hooks to the peritoneum. The parietal peritoneum is peeled off with a tupper for 2-3 cm from the edges of the wound. A retroperitoneoscope with a 5 cm blade in the direction of the external inguinal ring is inserted into the lower corner of the wound. The patient was transferred to the Trendelenburg position at an angle of 30 degrees and on the left side at an angle of 20 degrees. With the help of a retroperitoneoscope and tupfer, the parietal peritoneum is peeled off, the internal opening of the inguinal canal, the spermatic cord with a hernial sac, are isolated. The hernial sac is bluntly and acutely isolated from the spermatic cord to the neck, 7x5 cm in size. Next, a 8 cm long retroperitoneoscope blade is replaced, the detachment of the parietal peritoneum continues. Highlighted the internal opening of the inguinal canal, pubic joint. The blade of a retroperitoneoscope is deployed perpendicular to the rectus abdominis muscle, the parietal peritoneum of the anterior abdominal wall is exfoliated for 4-5 cm upwards from the pubic joint. In the formed preperitoneal space, a clamping device introduced a polypropylene mesh measuring 15x9 cm, rolled up into a tube. The upper edge of the grid is fixed with 2 "clips". The mesh is straightened and laid in such a way that it covers the site of the formation of inguinal and femoral hernias. Redon drainage is laid on the mesh, removed through a separate puncture in the right iliac region. The patient was transferred to the supine position, the “installer” of the mesh and the “clips” were removed. 1 Z-shaped catgut suture is applied to the muscles. 3 sutures per aponeurosis. 2 seams on the skin. Aseptic dressing. The operation lasted 16 minutes.

 At 18 hours the patient walks around the ward on his own. Complaints of mild pain in the area of postoperative wounds that do not require painkillers. The temperature is normal. Urinates on his own. He spent the night calmly, no analgesics needed. 08.24.2000, drainage was removed along Redon. The seams are calm. The temperature is normal. Complains of weak pains only when walking, alone pain does not bother. 26. 08. 2000 the patient was discharged home. No complaints. Temperature throughout the postoperative period remained normal. The seams are calm. 29. 08. 2000 seams were removed. The postoperative scar is calm. No complaints. Performs work at home associated with physical activity.

 Thus, 16 patients were operated on at the State Center for Nuclear Medicine. Complications in the postoperative period were not observed. All patients were allowed to walk 8-10 hours after surgery. The pain syndrome stopped by the end of 1-2 days. The introduction of painkillers was not required. The sutures were removed on the 6-7th day, healing in all by primary intention. After 5-7 days, patients could perform work associated with moderate physical activity. After 14-17 days, patients performed heavy physical work. All patients were examined 3 months after surgery. No complaints. Perform any heavy physical exertion.

Claims (1)

 A method of installing a mesh in preperitoneal hernioplasty of inguinal localized hernias, including separating the parietal peritoneum of the anterior abdominal wall, isolating the hernial sac and installing a polypropylene implant folded into the tube with the closure of the hernia formation zone, characterized in that the peritoneal space is inserted into the peritoneum the implant folded over the lower edge, leaving the upper edge free, which is fixed with clamps through punctures of the anterior abdominal st henna, while one latch is installed along the midline at a distance of 4.0-4.5 cm from the symphysis, the second is parallel to the first along the pararectal line, after which the mesh is expanded.

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