RU2262312C1 - Method for tension-free combined plasty of inguinal canal - Google Patents

Abstract

FIELD: medicine, herniology.

SUBSTANCE: the present innovation deals with plasty of inguinal canal at operative treatment of hernias. One should mobilize spermatic funiculus due to dissecting a testicle-lifting muscle, fascial membrane of spermatic funiculus at a deep inguinal ring, dissect cross-sectional fascia behind spermatic funiculus towards external edge of sheath of rectus muscle, replace a spermatic funiculus into preabdominal fiber, suture cross-sectional fascia with a blanket uninterrupted suture, liquidate a narrow part of inguinal space due to suturing a free edge of internal oblique and cross-sectional muscles to inguinal ligament, cover the rest space of inguinal space with a fragment of synthetic material, form new deep ring of inguinal canal, replace spermatic funiculus laterally to apply it onto a fragment, connect the edges of dissected aponeurosis of external oblique muscle, form new surface aponeurotic ring of inguinal canal. The innovation enables to exclude excessive tissue tension while removing high inguinal space.

EFFECT: higher efficiency of plasty.

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Description

The invention relates to medicine, namely to herniology, i.e. doctrine of hernias.

There are known methods in which the inguinal canal as such is eliminated and a new bed for the spermatic cord is created, namely, the methods of Holstedt and Wreden (1893), Krymov (1926), Kirchner (1933) and others (N.I. Kukujanov. Inguinal hernias .-- M .: Medicine, p. 181 and 182).

Among them, the closest to the claimed method is the method of radical plasticization of the inguinal canal with the complete elimination of the inguinal gap and the creation of a new bed for the spermatic cord, with the formation of a new deep and superficial ring for him, proposed by V.I.Koshev, E.S. Petrov and others . (2003) (Patent for the invention 2213522, issued on 10.10.2003, by application No. 2000133111, with the date of receipt of 29.12.2000).

However, the disadvantages of this method include excessive tissue tension during the elimination of the high inguinal gap, insufficient, in some cases, the strength of a cut U-shaped flap from a poorly developed aponeurosis of the internal oblique muscle during the formation of a new deep ring for the spermatic cord.

The aim of the invention is to strengthen the inguinal gap by a tensionless technology, using synthetic mesh and at the same time using it to form a new deep ring for the spermatic cord.

The essence of the proposed method lies in the fact that after dissection of the anterior wall of the inguinal canal, isolation, processing and removal of the hernial sac by known methods, the spermatic cord is mobilized in the deep ring of the inguinal canal by circular dissection, together with the muscle that lifts the testicle, of its fascial membrane. The transverse fascia is dissected by a linear incision parallel to the inguinal ligament behind the spermatic cord towards the outer edge of the rectus sheath, the spermatic cord is moved into the preperitoneal tissue and the transverse fascia is sutured over it to the edge or with a duplicature using atraumatic needles with a continuous suture. The narrow, lateral part of the inguinal gap is closed with local tissues, i.e. hem the free edge of the internal oblique and transverse muscles to the inguinal ligament with 3-4 sutures. A synthetic mesh, for example, made of polypropylene or PTFE, is laid on the sutured transverse fascia covering the spermatic cord, moved into the peritoneal fiber, it is covered with the inguinal gap and the edges are sutured with atraumatic needles, with a continuous suture: at the bottom to the inguinal ligament and at the top to the front surface and the joint tendon of the internal oblique and transverse muscles. In the inner corner of the surgical wound, the mesh is fixed to the outer edge of the rectus sheath, above the spermatic cord derived from under the transverse fascia, and below it, the mesh is fixed to the pubic ligament. Thus, the following deep formations limit the new deep ring for the spermatic cord: 1) the outer edge of the rectus sheath is medially, 2) the pubic ligament is from the bottom, and 3) the edge of the sutured synthetic mesh is outside. Then the spermatic cord is moved in the lateral direction, laid on a mesh and covered with an aponeurosis of the external oblique muscle, the edges of which are connected by separate interrupted sutures. The spermatic cord is removed from under the aponeurosis of the external oblique muscle through a new superficial ring, which is formed 3.5-4 cm lateral to the new deep ring. Adaptation sutures restore the layering of surface tissues in the area of operative access.

The method is as follows. The operation is performed under combined endotracheal anesthesia. A gerniotomy is performed from operative access according to Kocher with dissection of the anterior wall of the inguinal canal. Isolation, revision, processing and removal of the hernial sac is performed by known methods.

Plastic surgery of the hernia gate begins with mobilization of the spermatic cord by circular dissection together with the muscle that lifts the testis, the fascial membrane (funnel) of the spermatic cord at the inner ring of the inguinal canal. Behind the spermatic cord, the transverse fascia is cut inwards from the deep ring of the inguinal canal, parallel to the inguinal ligament, to the outer edge of the rectus sheath (Fig. 1). Immerse the spermatic cord in the preperitoneal tissue and suture the dissected transverse fascia of the abdomen in front of the spermatic cord with a continuous suture with atraumatic needles or create duplicate from it (Fig.2).

Given the advantages of the combined tension-free technology, the narrow lateral part of the inguinal gap is closed with local tissues by suturing the internal oblique and transverse muscles to the inguinal ligament with 3-4 interrupted sutures without undue tension and compression of the tissues. All the free space of the remaining inguinal gap, with the exception of the medial angle, where the spermatic cord is now located, is covered with a flap of synthetic mesh cut in shape and size and hemmed to the pubic ligament, iliac-pubic tract, to the external surface of the internal oblique muscle by 1.5 -2 cm above its edge and the anterior wall of the rectus sheath (Fig. 3). The free edge of the mesh passing over the spermatic cord closes the new deep ring outside.

Thus, a new deep ring for the spermatic cord is formed: the outer edge of the rectus sheath - medially, the pubic ligament - from below and the edge of the sutured synthetic mesh - from the outside. The spermatic cord is moved in the lateral direction with the holders and laid on a grid. Single interrupted sutures connect the edges of the dissected aponeurosis of the external oblique muscle above the spermatic cord. It is taken out from under the aponeurosis of the external oblique muscle through a new surface ring, which is formed 4 cm lateral to the new deep ring (Fig. 4). Adaptation sutures restore the layering of surface tissues in the area of operative access.

The inventive method is illustrated in figures 1, 2, 3, 4, reproducing the stages of plastic inguinal canal, where:

1 - spermatic cord;

2 - dissected fascial membrane of the spermatic cord along with the muscle raising the testis, and transverse fascia (posterior wall of the inguinal canal), dissected parallel to the inguinal ligament;

3 - the upper edge of the dissected aponeurosis of the external oblique muscle (the front wall of the inguinal canal);

4 - the lower edge of the dissected aponeurosis of the external oblique muscle (the front wall of the inguinal canal);

5 - free edge of the internal oblique muscle (upper wall of the inguinal canal);

6 - synthetic mesh covering the inguinal gap and taking part in the formation of the deep inguinal ring;

7 - a newly formed deep inguinal ring;

8 - a new superficial inguinal ring.

Example: a patient T-in S.M., 45 years old, working as a foreman in one of the Samara OAO, on 05.08.2003 he entered the surgical department of MSCh-17 in Samara for a planned operation (medical history - 1459). Diagnosis at admission: left-side direct inguinal hernia. On August 6, 2003, an operation was performed under combined endotracheal anesthesia (surgeon — head of the surgical department Antipov V.D., operation journal No. 118) using the proposed method. The patient was examined by an operating surgeon after 5 months. The results of the operation are good. The patient does not show complaints. There is no recurrence of a hernia.

The proposed method is less traumatic. It combines the advantages of the most effective modern methods of surgical treatment of inguinal hernias. From Sholdays, we borrowed from the deep multilayer plastic of the inguinal canal the stage of mobilization of the spermatic cord from the posterior wall by dissection of the fascial-muscular funnel, which directs the hernial sac under the membranes of the spermatic cord during the formation of oblique inguinal hernia. However, leaving the spermatic cord in the same place without the formation of a new deep ring is a drawback of the Sholdays method, which we eliminate by moving the spermatic cord into the preperitoneal tissue, as is done in the Koshev-Petrov method (patent No. 2213522). In addition, this technique allows you to save a. cremasterica, the nourishing membrane of the spermatic cord.

The principle of tension-free hernioplasty is implemented in the method of Liechtenstein, from which we borrowed the principle of tension-free reinforcement of hernial gates and the technology of using synthetic nets for this.

The disadvantages of the Liechtenstein method include the strengthening of the deep ring of the inguinal canal with a "dovetail" while maintaining its fascial-muscular funnel. This circumstance is the cause of recurrence of inguinal hernias in 0.5% of cases. The proposed method for improving the method of Liechtenstein by mobilizing the spermatic cord and moving it into the preperitoneal fiber eliminates this small percentage of relapses.

The disadvantages of the Koshev-Petrov method include the impossibility of its use in rare cases of a weak, thinned aponeurosis of the internal abdominal muscle, when the flap from it cannot be used to create a new deep ring for the spermatic cord. As a rule, this happens with an initially high (4-4.5 cm) inguinal gap.

For such cases, we offer a lightweight combined method of strengthening the inguinal gap with a synthetic mesh, the free medial edge of which is used to create a new deep ring. This method will be most effective for large, combined and recurrent inguinal hernias in the face of gross changes in the topography of the inguinal canal.

The claimed method can be recommended in medical practice.

Claims (1)

A method of lightweight combined inguinal canal plasty, including the formation of a new bed for the spermatic cord, new deep and superficial inguinal canal rings, characterized in that the spermatic cord is mobilized by circular dissection, together with the muscle raising the testicle, of the fascial membrane of the spermatic cord at the deep ring of the inguinal canal, dissect the transverse fascia behind the spermatic cord towards the outer edge of the rectus sheath, move the spermatic cord into the preperitoneal tissue and suture transverse fascia with a continuous continuous suture, the narrow lateral part of the inguinal gap is eliminated by suturing the free edge of the internal oblique and transverse muscles to the inguinal ligament, and the remaining free space of the medial part of the inguinal gap is covered with a synthetic fabric cut in shape and size, and a flap is sewn from above to the front surface of the inner surface oblique muscle, and below - to the inguinal ligament, in the inner corner the flap is fixed to the outer edge of the vagina of the rectus muscle and to the pubic ligament, leaving I free the patch of flap from under which the spermatic cord comes out, forming a new deep ring of the inguinal canal, then move the spermatic cord in the lateral direction, lay on the flap, connect the edges of the dissected external oblique muscle with single interrupted sutures, covering the spermatic cord lying on the mesh, they bring it 4-5 cm outwards from the deep inguinal ring and, suturing the aponeurosis of the external oblique muscle outwards from the spermatic cord, form a new superficial aponeurotic ring of the inguinal canal.

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