RU2355323C2 - Giant strangulated and incarcerated inguinal hernia surgery technique - Google Patents

Abstract

FIELD: medicine; surgery.

SUBSTANCE: preperitoneal approach is followed with herniotomy from T-incision and prosthetics of anterior abdominal wall with prolene implant.

EFFECT: abdominal wall defect closure, optimal surgical approach and valid abdominoscopy and hernia sac inspection, reduced injuries, elimination of postoperative complications.

2 dwg, 1 ex

Description

The invention relates to medicine, namely to surgery for inguinal hernias, and can be used for hernia repair and plastic surgery of hernial glands with giant strangulated and irreparable inguinal hernias.

It is known that prosthesis of the anterior abdominal wall from preperitoneal access using a prolene implant is a reliable method of treatment in elective surgery of inguinal hernias. However, in cases of gigantic, irreducible, multi-chamber hernias, there are difficulties in isolating the hernial sac, removing and repositioning the restrained organs in the abdominal cavity, which is sometimes dangerous with vital complications.

The purpose of the invention: to improve the results of surgical treatment of giant strangulated and irreparable inguinal hernias. The goal is achieved by hernia repair from preperitoneal access using a T-shaped incision followed by prosthesis of the anterior abdominal wall in the groin-femoral fold with a prolene implant.

The method is as follows: 3.0 cm above the womb oblique section 12.0 cm long from the outer edge of the rectus abdominis muscle in the direction of the superior anterior iliac spine dissect the skin, subcutaneous fat, aponeurosis. Visualize the preperitoneal space and the restraining ring. In any convenient place, the peritoneum is opened and the restrained organ is visualized. Then the incision is continued in the form of a T-shaped (if necessary, switching to the scrotum), dissecting “at 12 o’clock” the skin, subcutaneous fat, aponeurotic-fascial complex, muscles through the pinching ring, thereby releasing the contents of the hernial sac (Fig. 1) Next, assess the viability of the impaired organ, if necessary, perform its resection.

After isolation of the hernial sac and the end of manipulation of the restrained organs (resection of the intestine, dissection of adhesions, etc.), they proceed directly to prosthetics of the posterior surface of the anterior abdominal wall. In this case, the mesh is fixed along its lower edge to the pubic tubercle, Cooper ligament and m. psoas. The upper edge of the mesh is fixed to the transverse fascia. Since the T-shaped incision in this case is laxative, its edges are not stitched together to avoid tension, but are fixed to the prolene implant (Fig. 2).

Thus, with the help of a mesh implant, which in this case plays a skeleton role, the volume of the abdominal cavity is increased, which, in turn, with giant hernias simplifies the movement of organs into the abdominal cavity and prevents the development of small abdominal syndrome (comp-syndrome).

This presented method allows you to:

1) it is quite easy and safe to manipulate in the area of the infringing ring with good visualization of the vascular bundle (iliac artery and vein) and impaired organs;

2) to perform a full audit of the abdominal organs and the contents of the hernial sac;

3) if necessary, perform a bowel resection for its necrosis without additional laparotomy incision. (With known classical methods of hernia repair in cases where it is necessary to perform a resection of the strangulated intestine, an additional extensive laparotomy is required.)

4) this method by fixing the mesh to the edges of the T-shaped section allows you to prevent the development of the comp-syndrome.

Example. Patient S., 50 years old, was admitted to 1 x / o BSMP after 1 day from the onset of the disease with a diagnosis of Cramped recurrent right-sided inguinal hernia. Small bowel obstruction. Necrosis of the small intestine.

Upon receipt of a complaint of severe pain in the abdomen, mainly in the inguinal region on the right, the irreducibility of hernial protrusion in this area, bloating, repeated vomiting, and stool and gas retention.

From the anamnesis: 10 years ago, was operated on for a right-sided oblique inguinal hernia with plastic by local tissues, hernia recurrence for 5 years. Over the past year, he repeatedly noted periodic pains in the protrusion, stopped by antispasmodics. In the last 3 months, the hernia has ceased to set. Deterioration of well-being associated with symptoms of intestinal obstruction and the presence of severe pains in the area of hernial protrusion, not stopped by antispasmodics, within 1 day. On examination: The abdomen is swollen, painful on palpation, in the right inguinal region, where an intense painful tumor formation of 120 × 10.0 × 6.0 cm in size is determined, of a dense-elastic consistency, irreducible into the abdominal cavity; the skin above it is not changed. There is no transfer cough.

An emergency procedure was performed for laparotomy with the access described above. The constricting ring is dissected. During the audit, 30 cm from the ileocecal angle, a restrained part of the small intestine with necrosis of its wall and chronic intestinal obstruction due to repeated infringement was revealed. The loops of the small intestine located in the hernial sac are a conglomerate, which is not possible to separate because of the pronounced adhesion process. In the wall of the strangulated part of the small intestine there are whitish scars and there is a 6.0 cm long section of black-green color. Resection of the small intestine within healthy tissues and intestinal intestinal intubation below the anastomosis were performed. A hernial sac was isolated, cut off at the neck. The abdominal cavity is washed with an antiseptic solution. The peritoneal defect is sutured. Prosthetics of the anterior abdominal wall were performed with a prolene implant according to the method described above. The course of the postoperative period without features. Antibacterial, symptomatic therapy was carried out. The postoperative wound healed by primary intention. Sutures were removed on the 8th day. The patient was discharged in satisfactory condition. At the control examination after 6, 12 months, no relapse was detected.

A clinical example demonstrates the effectiveness of the described method from a T-shaped laparotomy incision. In total, according to this technique, 18 patients with inguinal hernias were operated on: of them 16 giant strangulated and 2 irreparable. During follow-up examinations, no relapses were detected.

Information sources

1. Toskin K.D., Zhebrovsky V.V. Hernia of the abdominal wall. M .: Medicine, 1990

2. Egiev V.I. Atlas of operative hernia surgery. M .: Medical practice - M, 2003.

3. Teaching aid of the Department of Faculty Surgery of the St. Petersburg State Medical University named after Academician I.P. Pavlov / Edited by V. Sedov /, 1998 - prototype.

Claims (1)

A method for surgical treatment of gigantic strangulated and irreducible inguinal hernias with prosthetic anterior abdominal wall prosthetics with a properitoneal access implant, characterized in that herniation is performed from a T-shaped incision.

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