RU2563956C1 - Tension-free fascial-aponeurotic inguinal wall plate in herniotomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: transverse fascia is closed with interrupted sutures by corrugation or duplication. That is followed by making 2 interrupted stitches to join a medial crus of an external inguinal ring and a superior pubic ligament; a lateral portion of the medial crus of the external inguinal ring with Colles ligament and an attachment point of an inguinal ligament. Medial and lateral leaves of dissected aponeurosis of an abdominal external oblique muscle are sutured with nonabsorbable uninterrupted stitches up to a spermatic cord, which is retracted 1-1.5 cm in the lateral direction. One or two interrupted stitches are made to close the aponeurosis behind an exit point of the spermatic cord so that an outlet of the spermatic cord in the aponeurosis makes 0.8-1 cm.

EFFECT: method prevents recurrent inguinal hernias and postoperative pain syndrome.

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Description

Application area

The invention relates to surgery, namely to abdominal surgery.

Analogs of the Invention

Known methods of plasty of the inguinal wall during herniotomy (Kuhn L.V. Surgical treatment of inguinal hernias. GOUVPO St. Petersburg State Medical Academy named after Mechnikov, 2006).

A known method is as follows. After opening the inguinal canal and removing the hernial sac, the combined tendon of the lateral abdominal muscles and transverse fascia are sutured in the medial region to the Cooper ligament. Sutured in the lateral region of the tendon of the transverse muscle to the inguinal ligament.

By the method described by S.A. Gushchin, plastic surgery of the transverse fascia with modeling of the internal inguinal ring and plastic surgery of the posterior wall of the inguinal canal are performed. To close, use the lower inner flap of the aponeurosis of the external oblique muscle of the abdomen, which is dissected in the transverse direction and fixed to the transverse fascia with interrupted sutures in the region of the inguinal space. The inferior aponeurosis flap of the external oblique muscle is fixed to the internal oblique muscle. The upper flap of the aponeurosis of the external oblique muscle of the abdomen is fixed with a suture to the pubic tubercle through the lower flap of the aponeurosis of the external oblique muscle of the abdomen. It is possible to suture the upper, lower inner and lower outer flaps of the aponeurosis of the external oblique muscle of the stomach after a laxative dissection of the upper flap of the aponeurosis of the external oblique muscle of the abdomen immediately above the pubic tubercle transversely to the passage of fibers over the spermatic cord with the formation of a new inguinal canal and external inguinal ring A. A method of surgical treatment of medium-sized oblique and direct inguinal hernias, Ulyanovsk) - analogue.

The disadvantages of the above methods include the following:

1. Stitching of dissimilar tissues during inguinal canal plasty - fixation of aponeurosis to muscles, and vice versa, which is highly undesirable.

2. Additional trauma of the aponeurosis of the external oblique muscle of the abdomen with its transverse dissection during plastic surgery.

3. Tension nature of the plastic of the inguinal canal during hernia repair.

4. The use of the inguinal ligament in plastic surgery with possible razvorennosti and weakening, creating the prerequisites for recurrence of hernias.

As a prototype, we took a method of hernia repair with plastic of the posterior inguinal wall according to Postempsky (Nesterenko Yu.A., Gaziev R.M. Inguinal hernias. Reconstruction of the posterior wall of the inguinal canal. - M .: BINOM, 2005). The aponeurosis of the external oblique muscle of the abdomen is dissected along the lateral edge of the external inguinal ring. After mobilization of the spermatic cord and processing of the hernial sac, the internal oblique and transverse muscles are dissected laterally from the internal inguinal ring to move the spermatic cord to the upper lateral angle of the incision, after which the muscles are sutured. Plastic surgery of the posterior wall of the inguinal canal is performed. The upper flap of the aponeurosis of the external oblique muscle of the abdomen with the edges of the internal oblique and transverse muscles of the abdomen with the transverse fascia is captured into the suture from the top, and hemmed under the spermatic cord to the inguinal ligament. The lateral leaf of the aponeurosis of the external oblique muscle is fixed with sutures on top of the medial flap. The spermatic cord is laid on the aponeurosis and above it fascia and skin are sutured in layers.

The disadvantages of the prototype

1. Tension nature of autoplasty for hernia repair.

2. Ischemic-dystrophic changes in soft tissues used in plastic surgery.

3. The elimination of the valve mechanism of functioning of the internal oblique and transverse muscles of the anterior abdominal wall in the groin.

4. Damage to the ileo-inguinal, femoral-inguinal nerves.

5. The release of tendon tissues during surgery with the risk of complete destruction of the inguinal ligament in the future.

6. The complexity of surgical techniques with soft tissue trauma.

7. Increased risk of femoral hernia formation due to enlargement of the femoral canal.

8. The use of invoiced connective and muscle tissue in elderly patients.

9. Relapse of inguinal hernia up to 10-15%.

The aim of the invention is to eliminate the possible negative aspects of autoplastic herniotomy, which are the cause of the formation of recurrent inguinal hernias and postoperative pain.

The essence of the proposed method

The proposed method is illustrated in FIG. 1, where it is indicated: inguinal ligament - FIG. 1, pos. one; spermatic cord - FIG. 1, pos. 2; superior pubic ligament - FIG. 1, pos. 3; a suture on the aponeurosis - Fig. 1, pos. four.

The proposed method of surgical treatment is as follows.

After a standard hernia repair with stitching, crossing and removal of the hernial sac under local anesthesia, the transverse fascia is sutured with interrupted sutures by corrugation or duplicate. M. cremaster is excised. Careful hemostasis. The spermatic cord (Fig. 1, pos. 2) is removed from the inguinal canal, taken to the holder. Plastic inguinal wall is performed behind the spermatic cord.

Two interrupted sutures are applied:

1) on the medial leg of the external inguinal ring and the superior pubic ligament (Fig. 1, item 3);

2) the lateral part of the medial pedicle of the external inguinal ring with the Koles ligament and the site of attachment of the pupartic ligament.

On the medial and lateral sheets of the dissected aponeurosis of the external oblique muscle of the abdomen, a continuous suture is made with a non-absorbable thread to the spermatic cord (Fig. 1, pos. 2), which is laterally withdrawn by 1-1.5 cm. Behind the exit of the spermatic cord (Fig. 1, pos. . 2) impose one or two interrupted sutures on the dissected aponeurosis (Fig. 1, item 4.). The outlet of the spermatic cord (Fig. 1, Pos. 2), in the aponeurosis (Fig. 1, Pos. 4. Delivers 0.8-1 cm. If there is a tendency to aponeurosis of the external oblique muscle, nodal sutures with a thin thread are applied. in subcutaneous tissue for sutured aponeurosis Nodal sutures on the skin with the obligatory introduction of a rubber graduate into the wound for one day.

Examples of specific performance of the method

1. Patient M. was operated on with a diagnosis of Right-sided direct inguinal hernia with fascial-aponeurotic autoplasty of the inguinal wall. Relapse of inguinal hernia did not occur.

2. Patient M. was operated on with a diagnosis of Right-sided inguinal hernia. Concomitant COPD disease. A hernia repair operation was performed with fascial aponeurotic autoplasty according to the proposed method. The postoperative course is smooth. Discharged on the 10th day after surgery. Examination of the patient in May 2014. No complaints. Relapse of inguinal hernia is not available.

3. Patient T., operated on 07.03.2013, with a diagnosis of Left-sided inguinal hernia. A hernia repair was performed with fascial aponeurotic plastic of the inguinal wall according to the proposed method. There were no complications. Discharged on the 10th day. Examination in May 2014. No complaints, recurrence of inguinal hernia is not available.

In all cases, such a complication as dropsy of the testicle was not noted. There was one complication after the operation - the imbibition of blood of the soft tissues of the surgical wound. Conducted conservative treatment. Recovery. Average stay in a bed is 8-10 days.

This method of surgical treatment was used for oblique, direct, recurrent, restrained inguinal hernias, does not depend on the size of the internal inguinal ring, inguinal gap, the degree of destruction of the transverse fascia of the posterior wall of the inguinal canal. Surgery is performed without involvement of the inguinal ligament, internal oblique and transverse muscles, without damage to the underlying nerves.

The positive effect of the application of the method

32 patients with inguinal hernias were operated on in the surgical department. Women - 7, men - 25. Age structure: up to 40 years old 4 - 12.5%, up to 60 years old 8 - 25%, up to 84 years old 20 - 62.5%. Operated in 2012 - 4, in 2013 - 13, in 2014 - 15.

Relapse of hernias in the operated patients was not observed even when engaged in heavy physical labor. This method of surgical treatment is recommended for patients older than 35 years.

According to Yu.B. Salova, recurrence of inguinal hernias with autoplasty after 35 years is 12-13%. The recurrence rate when using explants according to I. Lichtenstein is 1.6% (1993), E. Shouldice 1%, V. Zhebrovsky is 2.4% (2000).

Claims (1)

Tension-free fascial-aponeurotic plastic of the inguinal wall during herniotomy, including herniation with plastic of the posterior wall of the inguinal canal, characterized in that the transverse fascia is sutured with interrupted sutures by corrugation or duplicate, two nodular sutures are sutured, suturing the medial leg of the external inguinal ring and the upper forehead as well as on the lateral part of the medial leg of the external inguinal ring with the Koles ligament and the place of attachment of the pupartic ligament, on the medial and lateral sheets dissected aponeurosis of the external oblique muscle of the abdomen imposes a continuous suture with non-absorbable thread to the spermatic cord, which is laterally 1-1.5 cm laterally, one or two nodal sutures are placed behind the exit of the spermatic cord on the dissected aponeurosis, so that the outlet of the spermatic cord in the aponeurosis is 0. 8-1 cm, the spermatic cord is laid in the subcutaneous tissue for sutured aponeurosis.

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