RU2850625C1 - Method of laparoscopic gernioplasty of direct inguinal hernia - Google Patents

Abstract

FIELD: medicine; surgery.

SUBSTANCE: L-shaped incision is made in the peritoneum of the inguinal region. The lower flap of the peritoneum is mobilised. The hernial sac is isolated. The transverse fascia is grasped with a laparoscopic clamp in the central part of the medial fossa. The transverse fascia is pulled into the preperitoneal space and dissected with laparoscopic scissors above the clamp. A laparoscopic needle holder with a piercing needle and absorbable thread is inserted into the abdominal cavity. The dissected transverse fascia is pulled up to the hernial orifice. Pierce the lateral edge of the hernial orifice, the lateral and medial edges of the fascia in the incision area, and the medial edge of the hernial orifice with a needle. Use a laparoscopic clamp and needle holder to form an intracorporeal knot, thereby performing the first stitch. One stitch is made along the lateral and medial edges of the hernial orifice. A mesh endoprosthesis is placed in the inguinal region on the abdominal side, covering the edges of the hernial orifice. The peritoneal incision is sutured.

EFFECT: laparoscopic hernioplasty of a direct inguinal hernia and prevention of the development of postoperative complications in patients with a direct inguinal hernia, such as seroma and hernia recurrence.

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Description

The invention relates to the field of medicine, namely to hernioplasty, and can be used in laparoscopic hernioplasty of a direct inguinal hernia.

The surgical treatment of inguinal hernias remains a pressing issue due to the widespread prevalence of this condition and its predominant prevalence in individuals of working age. Inguinal hernia surgery is the most frequently performed elective surgical procedure. In Russia, over 150,000 elective inguinal hernia surgeries are performed annually (Clinical Guidelines - Inguinal Hernia - 2021, p. 3).

In recent years, the popularity of laparoscopic surgery for inguinal hernias has been rapidly growing, namely, laparoscopic transabdominal preperitoneal repair (TAPP) and total extraperitoneal repair (TEP) (Lutsevich O.E., Galliamov E.A., Gordeev S.A. et al. Laparoscopic hernioplasty: technology of the future // Clinical and experimental surgery. Journal named after Academician B.V. Petrovsky - 2014, No. 3, pp. 66-67; Galliamov E.A., Agapov M.A., Busyrev Yu.B., et al. Results of various methods of fixing the mesh prosthesis in laparoscopic hernioplasty (TAPP) - Surgery. Journal named after N.I. Pirogov. - 2021, No. 1, p. 3).

It is known that direct inguinal hernias are among the most complex hernias of the inguinal space (Patent of the Russian Federation No. 2498778 "Method for strengthening the inguinal canal in case of direct inguinal hernia by plastic surgery of the transverse fascia with endoloupons", published on 20.11.2013).

There are various methods of laparoscopic hernioplasty of direct inguinal hernia (Egiev V.N. and Voskresensky P.K. Hernias. - M.: Publishing House. MEDPRAKTIKA-M. - 2015, p. 193; Li J, Zhang W. Closure of a direct inguinal hernia defect in laparoscopic repair with barbed suture: a simple method to prevent seroma formation? // Surgical Endoscopy. 2018, No. 32, p. 1082-1086; Ng A.Y., Lin, J., Ching S.S. et al. Does primary closure of direct inguinal hernia defect during laparoscopic mesh repair reduce the risk of early recurrence? // Hernia. 2020, No. 5, p. 1093-1098).

However, all these methods have a number of disadvantages, such as the possibility of seroma, hematoma, hernia recurrence, and chronic pain (Ferrarese A., Marola S., Surace A., Borello A., Bindi M., Cumbo J., Solej M., Enrico S., Nano M., Martino V. Fibringlue versus stapler fixation in laparoscopic transabdominalinguinal hernia repair: a single center 5-year experience and analysis of the results in the elderly // Int. J. Surg. -2014, N 12, p.94-98; Ng A.Y., Lin J., Ching S.S., Lee J., Wong A.S.Y. Does primary closure of direct inguinal hernia defect during laparoscopic mesh repair reduce the risk of early recurrence? // Hernia. 2020, N 5, p.1093-1098).

The problem of development of such postoperative complications as recurrence of the disease after surgery (up to 2.0% or more), formation of seroma (from 0.5 to 12.2%), hematoma (4.2% to 13.1%) in direct inguinal hernia remains not fully resolved and depends to a large extent on the chosen technique of laparoscopic hernioplasty of direct inguinal hernia (Kockerling F, Bittner R, Adolf D, Fortelny R, Niebuhr H, Mayer F, Schug-Pass C. Seroma following transabdominal preperitoneal patch plasty (TAPP): incidence, risk factors, and preventive measures // Surgical Endoscopy. 2018, N 32, p. 2222-2231; Wong W., Lo O.S., Law W.L., Topic: Inguinal Hernia - Fixation, 2015, N 19, (p. 358-359; Clinical guidelines - Inguinal hernia - 2021, pp. 22-25). Therefore, the development of new, highly effective methods for laparoscopic hernioplasty of direct inguinal hernia is a pressing issue in modern surgery.

A search of scientific medical and patent literature revealed various methods of laparoscopic hernioplasty for direct inguinal hernia.

Russian Federation Patent No. 2295930 “Method of Preperitoneal Hernioplasty” (published March 27, 2007) describes a method for laparoscopic hernioplasty of a direct inguinal hernia.

The preperitoneal space in the periumbilical region is entered by opening the anterior leaflet of the rectus abdominis sheath and then inserting a trocar sheath without a stylet into the sheath. Carbon dioxide is injected at a pressure of 12 mmHg. The laparoscope is inserted along the posterior surface of the rectus abdominis muscle into the preperitoneal space of the inguinal region. Using the laparoscope sheath, a primary cavity is created in the preperitoneal space in the projection of the medial and lateral inguinal fossae. The peritoneum is separated. Additional 5 mm ports are placed midway between the umbilicus and the symphysis, 5 cm lateral to the midline. The hernial sac is exposed. The inguinal ligament, the arch of the internal oblique and transverse abdominal muscles, the inferior epigastric vessels, and the Kupffer's ligament are dissected. The hernial orifice is exposed. A non-absorbable multifilament suture is inserted through the trocar and a continuous intracorporeal suture is placed between the iliopubic tract, the vault of the internal oblique muscle of the abdomen and the transversalis fascia.

A disadvantage of this method is the "blind" placement of the trocar without visual control, which is usually associated with a high rate of peritoneal perforation and the resulting technical difficulties in continuing the surgery. Furthermore, the method described above is tension-based, requiring tissue alignment using suture material. Numerous comparative studies have shown that tension-based repair methods are characterized by a higher rate of recurrence, postoperative complications, and a relatively high level of pain (Russian Federation Patent No. 2653797 "Method of Laparoscopic Preperitoneal Hernioplasty," published May 14, 2018).

Russian Federation Patent No. 2303408 “Method for treating inguinoscrotal hernia with laparoscopic transabdominal preperitoneal hernioplasty” (published July 27, 2007) describes a method for laparoscopic hernioplasty of a direct inguinal hernia.

The hernial sac is isolated, and the peritoneum is circularly incised at the neck. It is invaginated into the abdominal cavity, secured with soft clamps, and the peritoneum of the hernial sac is demucosed using electrocoagulation with a ball electrode.

The disadvantage of this method is its traumatic nature, since it requires open dissection of skin and subcutaneous tissue, which can lead to the development of infectious and inflammatory complications (Patent of the Russian Federation No. 2653797 "Method of laparoscopic preperitoneal hernioplasty", published on May 14, 2018).

Russian Federation Patent No. 2498778 "Method for Strengthening the Inguinal Canal in Direct Inguinal Hernia by Endoloop Plastic Surgery of the Transverse Fascia" (published November 20, 2013) describes a method for laparoscopic hernioplasty of direct inguinal hernia.

Tissue dissection is performed in the preperitoneal space. All elements of the inguinal space are isolated. An endoloop is placed on the base of the transversalis fascia extended into the preperitoneal space. A mesh endoprosthesis is inserted and secured.

The disadvantage of this method is the possibility of developing aseptic necrosis of the transverse fascia and slippage of the ligature with subsequent development of seroma (Sheptunov Yu.M., Vnukov P.V. Method of preventing seroma during transabdominal preperitoneal plastic surgery for direct inguinal hernia // Endoscopic surgery. - 2018, No. 24, pp. 3-6).

Russian Federation Patent No. 2512761 “Method of Laparoscopic Hernioplasty” (published April 10, 2014) describes a method for laparoscopic hernioplasty of a direct inguinal hernia.

Pneumoperitoneum is established and the abdominal cavity is inspected. The abdominal cavity is punctured with an injection needle from the left or right iliac fossa. The tip of the needle is inserted into the peritoneum at the internal inguinal ring, and a volume of DefTux is injected sufficient to obstruct the internal inguinal ring.

The disadvantage of this method is its traumatic nature, associated with the need to place instruments and a laparoscope into the abdominal cavity, poorly studied complications and adverse reactions in the late postoperative period associated with the introduction of the drug into the inguinal ring (Patent of the Russian Federation No. 2653797 "Method of laparoscopic preperitoneal hernioplasty", published on 14.05.2018).

The work (Egiev V.N. and Voskresensky P.K. Hernias. - M.: Publishing House. MEDPRAKTIKA-M. - 2015, p. 450) describes a method of laparoscopic hernioplasty of a direct inguinal hernia.

A 10 mm trocar with a laparoscope is inserted into the periumbilical region. Two additional manipulation trocars, 5 mm and 12 mm in diameter, are inserted to the right and left of the trocar as standard. Carbon dioxide is injected into the abdominal cavity at a pressure of 14-16 mmHg. An L-shaped incision is made in the inguinal peritoneum, the lower peritoneal flap is mobilized, and the hernial sac is isolated. The transversalis fascia is grasped with a laparoscopic instrument and secured to Cooper's ligament with one or two clips using a hernia stapler. A mesh endoprosthesis is then placed, covering all weak points in the inguinal region, secured, and the peritoneum is sutured over it.

The disadvantage of this method is the likelihood of developing seroma, since it is possible for the transverse fascia to cut through with the clip during its fixation (Bittner R, Montgomery MA, eds. Update of guidelines on laparoscopic (TAPP) and endoscopic (TER) treatment of inguinal hernia (International Endohernia Society) // Surgical Endoscopy. 2015, N 2, p. 289-321; Emelianov SI, Protasov AV, Rutenburg GM Endosurgery of inguinal and femoral hernias. - St. Petersburg: Foliant, 2000, p. 176), as well as the possibility of developing pain syndrome in the postoperative period (Sheptunov Yu.M., Vnukov PV Method of preventing seroma during transabdominal preperitoneal plastic surgery for direct inguinal hernia // Endoscopic surgery. - 2018, No. 24, pp. 3-6).

In the Russian Federation patent application No. 2014121782 “Method for preventing seromas and hematomas during laparoscopic hernioplasty of direct inguinal hernias” (published 12/10/2015), a method for laparoscopic hernioplasty of a direct inguinal hernia is described.

The hernial sac is exposed. The stretched transversalis fascia is partially excised by grasping the transversalis fascia in the central part of the medial fossa with a laparoscopic clamp and pulling it toward the body. In this position, a window no larger than 1.5 x 1.5 cm is cut around the clamp with scissors. The internal and external inguinal fossae are closed with a composite vicrylpropylene mesh and secured with a hernia stapler. The integrity of the parietal peritoneum is then restored, securing its edges with a hernia stapler or hand suture.

The disadvantage of this method is its traumatic nature, since excision of the transverse fascia can lead to injury of the ilioinguinal nerve located next to it, followed by the development of chronic pain syndrome (S.V. Tarasenko, O.V. Zaitsev, A.A. Kopeikin, Sh.I. Akhmedov, T.S. Rakhmaev. Method of strengthening the posterior wall of the inguinal canal in direct inguinal hernia by plastic surgery of the transverse fascia with endoloops // Bulletin of Experimental and Clinical Surgery. - 2015, No. 8, pp. 310-312).

The closest technical solution adopted as a prototype is described in Russian Patent No. 2625445 (published July 13, 2017) "Method for Preventing Seroma during Laparoscopic Inguinal Hernioplasty of a Direct Inguinal Hernia." This method involves making an L-shaped incision in the inguinal peritoneum, mobilizing the inferior peritoneal flap, isolating the hernial sac, placing a mesh endoprosthesis in the inguinal region, and suturing the peritoneal incision. The mesh endoprosthesis is used to cover all weak points in the inguinal region and is secured to Cooper's ligament at the medial edge with a spiral clip. The transversalis fascia is manually repositioned into the external opening of the inguinal canal until it contacts the mesh endoprosthesis. The transverse fascia is fixed to the endoprosthesis in the center of the medial inguinal fossa with an interrupted intracorporeal suture, after which the peritoneal incision is sutured.

A disadvantage of the prototype is the likelihood of hernia recurrence, since manual reduction may result in displacement of the endoprosthesis (Sheptunov Yu.M., Vnukov P.V. Method for preventing seroma during transabdominal preperitoneal plastic surgery for direct inguinal hernia // Endoscopic surgery. - 2018, No. 24, pp. 3-6). Also, due to excessive tension that occurs during fixation of the transverse fascia to the endoprosthesis, cutting through the transverse facies and developing seroma are possible (Li J., Gong W. & Liu Q. Intraoperative adjunctive techniques to reduce seroma formation in laparoscopic inguinal hernioplasty: a systematic review // Hernia, 2019, N 23, pp. 723-731). Moreover, the recurrence rate is 2% or more, the incidence of seroma formation varies from 0.5% to 12.2%.

The objective of the proposed invention is to develop a highly effective method for laparoscopic hernioplasty of a direct inguinal hernia.

The technical result of implementing this method is the prevention of complications: seroma and hernia recurrence in the postoperative period.

The technical result is achieved by making an L-shaped incision in the inguinal peritoneum, mobilizing the lower peritoneal flap, and isolating the hernial sac. After isolating the hernial sac, the transversalis fascia is grasped with a laparoscopic clamp in the central part of the medial fossa, pulled into the preperitoneal space, and incised with laparoscopic scissors above the clamp. A laparoscopic needle holder with a piercing needle and absorbable suture is inserted into the abdominal cavity. The incised transversalis fascia is pulled toward the hernial orifice, and the lateral edge of the hernial orifice, the lateral and medial edges of the fascia in the incision area, and the medial edge of the hernial orifice are punctured with the piercing needle. An intracorporeal knot is formed with the laparoscopic clamp and needle holder, thereby performing the first stitch. Then, one stitch is placed along the lateral and medial edges of the hernial orifice. A mesh endoprosthesis is placed in the groin area on the abdominal side, covering the edges of the hernial orifice, and the peritoneal incision is sutured.

A detailed description of the method of laparoscopic hernioplasty of direct inguinal hernia.

The patient is placed on the operating table in a supine position. Under endotracheal anesthesia, the surgical site is cleaned with antiseptic solutions.

A 12 mm skin incision is made above the umbilicus with a scalpel. A first modular laparoscopic trocar, such as one manufactured by MNPO Endomedium (Russia), is inserted into the abdominal cavity. It is 11 mm in diameter, 100 mm long, and has a universal valve and stopcock. A pneumoperitoneum is established through the stopcock of the first trocar using carbon dioxide at a pressure of 12 mmHg. A laparoscope, such as one manufactured by MNPO Endomedium (Russia), is inserted into the first trocar. It is 10 mm in diameter, has a 30-degree scope, and is 320 mm long.

A 12-mm skin incision is made in the right iliac fossa with a scalpel. A second modular laparoscopic trocar, such as one manufactured by MNPO Endomedium (Russia), is inserted into the abdominal cavity. It is 11 mm in diameter, 100 mm long, and has a universal valve. A trocar adapter, such as one manufactured by MNPO Endomedium (Russia), is inserted through the second 11-mm trocar to allow use of a 5-mm diameter instrument.

In the left iliac region, a 7 mm skin incision is made with a scalpel, and a third modular laparoscopic trocar is inserted into the abdominal cavity, for example, one manufactured by MNPO Endomedium (Russia), with a diameter of 6 mm, a length of 100 mm, and a universal valve.

Through the third trocar with a diameter of 6 mm, a laparoscopic clamp is inserted, for example, with elongated jaws, single-branch, monopolar, modular, with a diameter of 5 mm, length of 348 mm, manufactured by the company MNPO Endomedium (Russia).

Through the second 11 mm diameter trocar, laparoscopic monopolar modular Metzenbaum scissors, such as those manufactured by MNPO Endomedium (Russia), are inserted. From the abdominal cavity, the inguinal peritoneum is grasped with a clamp, and a 10 x 5 mm L-shaped incision is made in the inguinal peritoneum using laparoscopic scissors.

The laparoscopic scissors are removed, and monopolar grasping dissector forceps, such as the Maryland type, manufactured by MNPO Endomedium (Russia), with a branch length of 23 mm and a diameter of 5 mm, are inserted into the abdominal cavity through the second trocar with a diameter of 11 mm. The lower peritoneal flap is mobilized and the hernial sac is isolated.

The dissector forceps are removed, and laparoscopic scissors are reinserted through the second trocar with a diameter of 11 mm, for example, Metzenbaum monopolar modular scissors manufactured by the company MNPO Endomedium (Russia).

The transversalis fascia is grasped in the central part of the medial fossa with a laparoscopic clamp, pulled into the preperitoneal space and dissected with laparoscopic scissors above the clamp.

The laparoscopic scissors are removed, and a laparoscopic needle holder with straight branches, for example, manufactured by MNPO Endomedium (Russia), with a diameter of 5 mm with an installed atraumatic piercing needle, 26 mm long with a surgical absorbable thread, for example, Armacryl thread with a thickness of 0.2 mm and a length of 75 cm manufactured by Armline LLC (Russia), is inserted into the abdominal cavity through a second trocar with a diameter of 11 mm.

The dissected transverse fascia is pulled towards the hernial orifice using a laparoscopic clamp, the lateral edge of the hernial orifice, the lateral and medial edges of the fascia in the area of dissection, and the medial edge of the hernial orifice are pierced with a piercing needle.

Using a laparoscopic clamp and needle holder, an intracorporeal knot is formed, thereby performing the first stitch. Then, one stitch is placed along each lateral and medial margin of the hernial orifice.

The laparoscopic needle holder with the installed atraumatic piercing needle is removed, and a twisted mesh endoprosthesis, such as the Esfil mesh endoprosthesis, manufactured by Lintex LLC (Russia), white and blue, measuring 10x15 cm, is inserted into the abdominal cavity through the second trocar. The mesh endoprosthesis is placed in the groin area on the abdominal side, covering the edges of the hernial orifice, using a laparoscopic clamp.

The peritoneal incision is sutured with a continuous suture using an atraumatic piercing needle 26 mm long with a surgical absorbable thread, for example, the Armacryl thread, manufactured by Armline LLC (Russia), 0.2 mm thick.

The practical feasibility of the claimed method of laparoscopic hernioplasty of direct inguinal hernia is illustrated by examples from clinical practice.

Case 1: Patient V., 35, employed. He was admitted to the surgical department of the Kaniv Central District Hospital for planned surgery. For three years, he had a bulge in his right iliac region. The bulge gradually increased in size. He complained of intermittent, nagging pain in this area that occurred after physical activity. Upon examination, the bulge was up to 5 cm in diameter upon straining, easily retracted into the abdominal cavity, and did not descend into the scrotum. Diagnosis: direct inguinal hernia on the right.

Patient V. underwent laparoscopic hernioplasty of a direct inguinal hernia according to the claimed method.

Patient V. was placed on the operating table in a supine position. Under endotracheal anesthesia, the surgical site was treated with antiseptic solutions.

A 12-mm skin incision was made above the umbilicus with a scalpel. The first modular laparoscopic trocar, manufactured by MNPO Endomedium (Russia), was inserted into the abdominal cavity. It was 11 mm in diameter, 100 mm long, and had a universal valve and stopcock. A pneumoperitoneum was established using carbon dioxide at a pressure of 12 mmHg through the stopcock of the first trocar. A laparoscope, manufactured by MNPO Endomedium (Russia), was inserted into the first trocar. It was 10 mm in diameter, had a 30-degree optic, and was 320 mm long.

During examination of the abdominal organs on the right, medial to the spermatic cord, a hernial defect with a diameter of 2 cm was visualized.

A 12-mm skin incision was made in the right iliac region with a scalpel. A second modular laparoscopic trocar (manufactured by MNPO Endomedium, Russia) with a universal valve, 11 mm in diameter and 100 mm in length, was inserted into the abdominal cavity. An adapter for trocars manufactured by MNPO Endomedium, Russia, was inserted through the second 11-mm trocar to accommodate 5-mm diameter instruments.

A 7 mm skin incision was made in the left iliac region with a scalpel, through which a third modular laparoscopic trocar manufactured by MNPO Endomedium (Russia) with a diameter of 6 mm, a length of 100 mm, and a universal valve was inserted into the abdominal cavity.

Through the third trocar with a diameter of 6 mm, a laparoscopic single-branch, monopolar modular clamp with extended jaws manufactured by the company MNPO Endomedium (Russia) with a diameter of 5 mm and a length of 348 mm was inserted.

Through the second 11 mm diameter trocar, laparoscopic monopolar modular Metzenbaum scissors (manufactured by MNPO Endomedium, Russia) were inserted. From the abdominal cavity, the inguinal peritoneum was grasped with a clamp, and a 10 x 5 mm L-shaped incision was made in the inguinal peritoneum using laparoscopic scissors.

The laparoscopic scissors were removed, and monopolar Maryland-type dissector forceps manufactured by MNPO Endomedium (Russia) with a branch length of 23 mm and a diameter of 5 mm were inserted into the abdominal cavity through a second trocar with a diameter of 11 mm. The lower peritoneal flap was mobilized and the hernial sac was isolated.

The dissector forceps were removed, and the laparoscopic Metzenbaum monopolar modular scissors manufactured by MNPO Endomedium (Russia) were reinserted through the second trocar with a diameter of 11 mm.

The transversalis fascia was grasped in the central part of the medial fossa with a laparoscopic clamp, pulled into the preperitoneal space and dissected with laparoscopic scissors above the clamp.

The laparoscopic scissors were removed, and a laparoscopic needle holder with straight branches manufactured by MNPO Endomedium (Russia) with a diameter of 5 mm was inserted into the abdominal cavity through a second trocar with a diameter of 11 mm. The needle holder had an installed atraumatic piercing needle, 26 mm long, with an absorbable surgical thread "Armacryl" with a thickness of 0.2 mm and a length of 75 cm manufactured by Armline LLC (Russia).

The dissected transverse fascia was pulled to the hernial orifice using a laparoscopic clamp, the lateral edge of the hernial orifice, the lateral and medial edges of the fascia in the area of dissection, and the medial edge of the hernial orifice were punctured with a piercing needle.

Using a laparoscopic clamp and needle holder, we created an intracorporeal knot, thereby completing the first stitch. Then, we performed one stitch each along the lateral and medial edges of the hernial orifice.

The laparoscopic needle holder with the atraumatic piercing needle was removed, and a twisted mesh endoprosthesis—the Esfil mesh endoprosthesis manufactured by Lintex LLC (Russia), white and blue, measuring 10×15 cm—was inserted into the abdominal cavity through the second trocar. The mesh endoprosthesis was placed in the groin area on the abdominal side, covering the edges of the hernial orifice, using a laparoscopic clamp.

The peritoneal incision was sutured with a continuous suture using an atraumatic piercing needle 26 mm long with surgical absorbable thread "Armacryl", manufactured by Armline LLC (Russia), 0.2 mm thick.

On the 4th day, patient V. was discharged from the hospital in satisfactory condition.

Development of complications: seroma and recurrence of hernia in the postoperative period in patient V. were not recorded.

Case 2: Patient S., 65, unemployed. He was admitted to the surgical department of the Kanev Central District Hospital for planned surgery. For six years, he had a hernia in his right iliac region. The hernia gradually increased in size. He complained of intermittent, nagging pain in this area that occurred after physical exertion. Upon examination, the hernia was up to 6 cm in diameter upon straining, easily retracted into the abdominal cavity, and did not descend into the scrotum. Diagnosis: direct inguinal hernia on the right.

Patient S. underwent laparoscopic hernioplasty of a direct inguinal hernia according to the claimed method.

Patient S. was placed on the operating table in a supine position. Under endotracheal anesthesia, the surgical site was treated with antiseptic solutions.

A 12-mm skin incision was made above the umbilicus with a scalpel. The first modular laparoscopic trocar, manufactured by MNPO Endomedium (Russia), was inserted into the abdominal cavity. It was 11 mm in diameter, 100 mm long, and had a universal valve and stopcock. A pneumoperitoneum was established using carbon dioxide at a pressure of 12 mmHg through the stopcock of the first trocar. A laparoscope, manufactured by MNPO Endomedium (Russia), was inserted into the first trocar. It was 10 mm in diameter, had a 30-degree optic, and was 320 mm long.

During examination of the abdominal organs on the right, medial to the spermatic cord, a hernial defect with a diameter of 3 cm was visualized.

A 12-mm skin incision was made in the right iliac region with a scalpel. A second modular laparoscopic trocar (manufactured by MNPO Endomedium, Russia) with a universal valve, 11 mm in diameter and 100 mm in length, was inserted into the abdominal cavity. An adapter for trocars manufactured by MNPO Endomedium, Russia, was inserted through the second 11-mm trocar to accommodate 5-mm diameter instruments.

A 7 mm skin incision was made in the left iliac region with a scalpel, through which a third modular laparoscopic trocar manufactured by MNPO Endomedium (Russia) with a diameter of 6 mm, a length of 100 mm, and a universal valve was inserted into the abdominal cavity.

Through the third trocar with a diameter of 6 mm, a laparoscopic single-branch, monopolar modular clamp with extended jaws manufactured by the company MNPO Endomedium (Russia) with a diameter of 5 mm and a length of 348 mm was inserted.

Through the second 11 mm diameter trocar, laparoscopic monopolar modular Metzenbaum scissors (manufactured by MNPO Endomedium, Russia) were inserted. From the abdominal cavity, the inguinal peritoneum was grasped with a clamp, and a 10 x 5 mm L-shaped incision was made in the inguinal peritoneum using laparoscopic scissors.

The laparoscopic scissors were removed, and monopolar Maryland-type dissector forceps manufactured by MNPO Endomedium (Russia) with a branch length of 23 mm and a diameter of 5 mm were inserted into the abdominal cavity through a second trocar with a diameter of 11 mm. The lower peritoneal flap was mobilized and the hernial sac was isolated.

The dissector forceps were removed, and the laparoscopic Metzenbaum monopolar modular scissors manufactured by MNPO Endomedium (Russia) were reinserted through the second trocar with a diameter of 11 mm.

The transversalis fascia was grasped in the central part of the medial fossa with a laparoscopic clamp, pulled into the preperitoneal space and dissected with laparoscopic scissors above the clamp.

The laparoscopic scissors were removed, and a laparoscopic needle holder with straight branches manufactured by MNPO Endomedium (Russia) with a diameter of 5 mm was inserted into the abdominal cavity through a second trocar with a diameter of 11 mm. The needle holder had a 26 mm long atraumatic piercing needle with an absorbable surgical thread "Armacryl" with a thickness of 0.2 mm and a length of 75 cm manufactured by Armline LLC (Russia).

The dissected transverse fascia was pulled to the hernial orifice using a laparoscopic clamp, the lateral edge of the hernial orifice, the lateral and medial edges of the fascia in the area of dissection, and the medial edge of the hernial orifice were punctured with a piercing needle.

Using a laparoscopic clamp and needle holder, we created an intracorporeal knot, thereby completing the first stitch. Then, we performed one stitch each along the lateral and medial edges of the hernial orifice.

The laparoscopic needle holder with the installed atraumatic piercing needle was removed, and a twisted mesh endoprosthesis was inserted into the abdominal cavity through the second trocar - the Esfil mesh endoprosthesis manufactured by Lintex LLC (Russia), white and blue, measuring 10x15 cm. The mesh endoprosthesis was placed in the groin area on the abdominal side, covering the edges of the hernial orifice, using a laparoscopic clamp.

The peritoneal incision was sutured with a continuous suture using an atraumatic piercing needle 26 mm long with surgical absorbable thread "Armacryl", manufactured by Arm-Line LLC (Russia), 0.2 mm thick.

On the 4th day, patient S. was discharged from the hospital in satisfactory condition.

Development of complications: seroma and recurrence of hernia in the postoperative period in patient S. were not recorded.

Using the proposed method, direct inguinal hernia repair was performed in 23 patients (18 men and 5 women, aged 18 to 75 years) in the surgical department of the Kanevskaya Central Regional Hospital. No late postoperative complications, such as seroma or hernia recurrence, were observed in any of the patients.

Thus, the claimed method is effective and allows for the virtual elimination of disease recurrence and the development of seroma in the postoperative period in patients with direct inguinal hernia.

Claims (1)

A method of laparoscopic hernioplasty of a direct inguinal hernia, including making an L-shaped incision of the peritoneum of the inguinal region, mobilizing the lower peritoneal flap, isolating the hernial sac, placing a mesh endoprosthesis in the inguinal region and suturing the peritoneal incision, characterized in that after isolating the hernial sac, the transverse fascia is grasped with a laparoscopic clamp in the central part of the medial fossa, pulled up into the preperitoneal space and dissected with laparoscopic scissors above the clamp; a laparoscopic needle holder with a piercing needle and absorbable thread is inserted into the abdominal cavity, the dissected transverse fascia is pulled to the hernial orifice, the lateral edge of the hernial orifice, the lateral and medial edges of the fascia in the area of the dissection, as well as the medial edge of the hernial orifice are pierced with a needle; Using a laparoscopic clamp and needle holder, an intracorporeal knot is formed, thereby performing the first stitch, then one stitch is performed along the lateral and medial edges of the hernial orifice, after which a mesh endoprosthesis is placed in the groin area from the abdominal side, covering the edges of the hernial orifice, and the peritoneal incision is sutured.