RU2837560C1 - Method for laparoscopic treatment of recurrent inguinal hernias after previous endovidsurgical prosthetic repairs - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgery. Laparoscopic approach is performed. Hernial sac is separated. Parietal peritoneum of the inguinal region is mobilized in the caudal direction below the primary mesh prosthesis 3.0 below the pubic articulation medially and to the iliopsoas muscle laterally, creating a bed for the additional mesh prosthesis. Additional mesh prosthesis is installed so that it overlaps the hernia orifice more than 4.0 cm in each direction overlapping the primary mesh prosthesis. Additional mesh prosthesis is fixed to the musculo-aponeurotic structures along the perimeter, including the primary mesh prosthesis, avoiding the vascular and nerve passage areas. Prosthesis is re-toned with the formed parietal peritoneum flap.

EFFECT: method enables increasing the effectiveness of the laparoscopic treatment of recurrent inguinal hernias following the previous endovisional prosthetic repairs and reducing the negative postoperative effects.

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Description

The invention relates to medicine, namely to surgery, herniology, and can be used for surgical treatment of recurrent inguinal hernias.

The choice of hernioplasty method for recurrent inguinal hernias is one of the unsolved problems of modern herniology.

A method of hernioplasty of inguinal hernia of Lichtenstein is known (Timerbulatov V.M., Yamalov R.A., Fayazov R.R., Kunafin M.S., Timerbulatov Sh.V., Trukhanov O.G. Hernioplasty according to Lichtenstein for inguinal hernias // Medical Bulletin of Bashkortostan. 2010. No. 6. URL: https://cyberleninka.ru/article/n/gernioplastika-po-lihtenshteynu-pri-pahovyh-gryzhah (date of access: 19.02.2024), when the skin and subcutaneous fat are dissected to the aponeurosis, the inguinal canal is opened, the spermatic cord is taken on a holder, the hernial sac is isolated and processed. A polypropylene mesh is cut out in advance, placed on the back wall of the inguinal canal, fixed to the structures of the inguinal region: pubic tubercle, inguinal (Poupart's) ligament, edge of the internal oblique muscle in the area of the tendon. The spermatic cord is placed on the implant. The anterior wall of the inguinal canal is restored by suturing the aponeurosis sheets edge to edge with a continuous suture.

The disadvantages of this method are:

- high trauma of access to the posterior wall of the inguinal canal;

- the presence of access in the plastic surgery area causes complications from the wound (hematomas, seromas, suppuration);

- recurrence of the hernia, requiring reoperation.

A method of hernioplasty of recurrent inguinal hernia is known (method of treatment of recurrent inguinal hernias: patent RU 2473315, Russian Federation, application RU 2011100816, declared 12.01.2011, published 27.01.2013), when the skin, subcutaneous fat, aponeurosis of the external oblique muscle and implant in the area of the deep inguinal ring are alternately dissected, the hernial sac is processed, after which an additional implant is modeled, which is installed between the implant and the transverse fascia in the inguinal space with subsequent fixation.

The disadvantages of this method are:

- trauma: dissection of the primary implant from the transverse fascia is traumatic and not always safe due to the adhesion process, requiring long-term rehabilitation of the patient;

- high trauma of access to the posterior wall of the inguinal canal;

- the presence of access in the plastic surgery area causes complications from the wound (hematomas, seromas, suppuration);

- recurrence of the hernia, requiring reoperation.

The closest to the claimed method is a method of laparoscopic hernioplasty for recurrent inguinal hernias using a polypropylene structure (Polypropylene structure for laparoscopic hernioplasty for recurrent inguinal hernias: patent RU 2738161, Russian Federation, application RU 2020100830, filed on 01/09/2020, published on 12/09/2020), which is a three-dimensional herniosystem of two parts connected in the abdominal cavity without wide release of the hernial orifice from scar tissue. One of the elements of the structure is a hernial orifice obturator formed from a polypropylene tape that is twisted in the shape of a shuttlecock. The obturator is installed in the hernial orifice and fixed with a herniostapler. The second element is a polypropylene mesh covering the medial and lateral inguinal fossae. The net is fixed to the shuttlecock with herniostapler staples.

This technique is proposed for recurrent inguinal hernias not after endovideosurgical prosthetic plastic surgery of the inguinal canal. The disadvantages of this technique are chronic pain syndrome, postoperative neuralgia due to the obturator, which significantly reduces the patient's quality of life, the need for additional treatment, including physiotherapy. The described technique determines the intra-abdominal location of the polypropylene mesh prosthesis, which is dangerous due to the development of adhesive obstruction, since the prosthesis is not peritoneized. The polypropylene mesh prosthesis is a germinating material, in the area of its standing, an adhesive process develops.

The technical problem is the need to develop a method for laparoscopic treatment of recurrent inguinal hernias after previously undergone endovideosurgical prosthetic plastic surgery, devoid of the above-mentioned disadvantages.

The technical result consists in increasing the effectiveness of laparoscopic treatment of recurrent inguinal hernias after previously undergone endovideosurgical prosthetic plastic surgery and in reducing negative effects in the postoperative period.

The technical result is achieved in that in the method of laparoscopic treatment of patients with recurrent inguinal hernias after previously undergone endovideosurgical plastic surgery with the installation of a mesh prosthesis, including laparoscopic access, isolation of the hernial sac, installation of an additional mesh prosthesis, according to the invention, the peritoneum is cut along the upper edge of the hernial orifice, after isolation of the hernial sac, the peritoneum of the inguinal region is mobilized in the zone of unchanged tissues outside the previously installed mesh prosthesis by 3.0-4.0 cm below the pubic symphysis medially and to the iliopsoas muscle laterally, creating a bed for an additional mesh prosthesis, wherein the new mesh prosthesis is installed so that it covers the hernial orifice by more than 3.0-4.0 cm in each direction, overlapping the primarily installed mesh prosthesis, after which the new mesh prosthesis is fixed to the muscular-aponeurotic structures along the perimeter, including to the initially installed mesh prosthesis, avoiding the areas where blood vessels and nerves pass (Fig.), with subsequent peritonization of the prosthesis with the formed parietal peritoneum flap.

The figure illustrating the installation of an additional prosthesis shows the following positions:

1 – primarily installed mesh prosthesis;

2 – additional (new) mesh prosthesis;

3 – hernial orifice;

4 - iliopsoas muscle;

5 – elements of the spermatic cord;

6 – peritoneum;

7 - vas deferens;

8 - pubic symphysis;

9 – epigastric vessels.

The proposed technique increases the effectiveness of laparoscopic treatment of recurrent inguinal hernias after previously undergone endovideosurgical prosthetic plastic surgery and reduces negative effects in the postoperative period due to the fact that the peritoneum is cut atypically and an additional mesh polypropylene prosthesis is installed without removing the primarily installed prosthesis.

The method is carried out as follows.

At the beginning of the operation, the patient is in the supine position with the head end lowered. Three trocars are installed in typical points. Under the control of the laparoscope, the localization of the recurrent hernia and the supposed cause of the recurrence are determined. The parietal peritoneum is incised in the horizontal direction for at least 10.0 cm along the upper edge of the hernial orifice. The primarily installed polypropylene mesh prosthesis is not removed. Then the hernial sac is isolated, the parietal peritoneum of the inguinal region is mobilized in the caudal direction below the previously installed polypropylene mesh prosthesis by 3.0 cm below the pubic symphysis medially and to the iliopsoas muscle laterally, forming a bed for an additional prosthesis, which is cut out individually so as to cover the hernial orifice by more than 3.0-4.0 cm in each direction, overlapping the primarily installed mesh. An additional porous mesh polypropylene prosthesis is fixed around the perimeter with a hernial stapler, including to the initially installed prosthesis outside the areas of blood vessels and nerves (Fig.) and is peritonized with a cut flap of parietal peritoneum with a hernial sac.

The claimed invention is illustrated by examples.

Example 1

Patient A., 54 years old. The patient underwent surgery in 2020 using the proposed method.

Laparoscopy is performed under endotracheal anesthesia in the supine position; trocars are installed at typical points. The localization of the recurrent hernia is determined under laparoscopic control. The parietal peritoneum is incised in the horizontal direction for at least 10.0 cm along the upper edge of the hernial orifice. The primarily installed polypropylene mesh prosthesis is not removed. Then the hernial sac is isolated, the parietal peritoneum of the inguinal region is mobilized in the caudal direction below the previously installed polypropylene mesh prosthesis by 3.0 cm below the pubic symphysis medially and to the iliopsoas muscle laterally, forming a bed for an additional prosthesis, which is cut individually so as to cover the hernial orifice by more than 3.0 cm in each direction, overlapping the primarily installed mesh. An additional porous mesh polypropylene prosthesis is fixed around the perimeter with a herniostapler, including to the primarily installed prosthesis outside the areas of blood vessels and nerves, and is peritonized with a cut flap of parietal peritoneum with a hernial sac.

The patient used a bandage for 1 month in the postoperative period. On the 3rd day, the patient was discharged for outpatient treatment in a satisfactory condition. The patient was examined 3 months, 1 year and 3 years after the operation. No data on relapse of the disease or complications were found.

Example 2

Patient B., 65 years old. The patient underwent surgery in 2021 using the proposed method.

Laparoscopy is performed under endotracheal anesthesia in the supine position; trocars are installed at typical points. The localization of the recurrent hernia is determined under laparoscopic control. The parietal peritoneum is incised in the horizontal direction for at least 10.0 cm along the upper edge of the hernial orifice. The primarily installed polypropylene mesh prosthesis is not removed. Then the hernial sac is isolated, the parietal peritoneum of the inguinal region is mobilized in the caudal direction below the previously installed polypropylene mesh prosthesis by 3.0 cm below the pubic symphysis medially and to the iliopsoas muscle laterally, forming a bed for an additional prosthesis, which is cut individually so as to cover the hernial orifice by more than 4.0 cm in each direction, overlapping the primarily installed mesh. An additional porous mesh polypropylene prosthesis is fixed around the perimeter with a herniostapler, including to the primarily installed prosthesis outside the areas of blood vessels and nerves, and is peritonized with a cut flap of parietal peritoneum with a hernial sac.

The patient used a bandage for 1 month in the postoperative period. On the 4th day, the patient was discharged for outpatient treatment in a satisfactory condition. The patient was examined 1 month, 3 months, 1 year and 3 years after the operation. No data on relapse of the disease or complications were found.

Since 2015, 76 patients have been operated on using the stated method; no relapses or complications were detected in the late postoperative period.

Since 2020, 23 patients have been operated on using the prototype method. In the late postoperative period, 9 patients (39.13%) had postoperative neuralgia, chronic pain syndrome due to the obturator, which significantly reduces the patient's quality of life. In the postoperative period, conservative treatment by specialists (neurologist, physiotherapist) and additional costs associated with the purchase of medications were required.

Claims (1)

A method for laparoscopic treatment of patients with recurrent inguinal hernias after previously undergone endovideosurgical plastic surgery with installation of a primary mesh prosthesis, including laparoscopic access, isolation of the hernial sac, installation of an additional mesh prosthesis, characterized in that the peritoneum is cut along the upper edge of the hernial orifice, after isolation of the hernial sac, the parietal peritoneum of the inguinal region is mobilized caudally below the primarily installed mesh prosthesis by 3.0 below the pubic symphysis medially and to the iliopsoas muscle laterally, creating a bed for an additional mesh prosthesis, wherein the new mesh prosthesis is installed so that it covers the hernial orifice by more than 4.0 cm in each direction, overlapping the primarily installed mesh prosthesis, after which the new mesh prosthesis is fixed to the muscular-aponeurotic structures along the perimeter, including the primarily installed mesh prosthesis, avoiding areas where blood vessels and nerves pass, with subsequent peritonization of the prosthesis with the formed parietal peritoneum flap.