RU2426501C1 - Method of surgical treatment of hip hernia - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to herniology. Essence of method lies in the following: through inguinal access aponeurosis of external oblique abdominal muscle is cut. Inguinal canal is opened, on upper medial edge of inguinal segment from pubic tubercle to deep inguinal ring transverse fascia is cut, flap with base on ilio-pubic bundle. It is turned up with exposure of preperitoneal space. Hernial sac is exposed and dissected. Autoplasty of femoral canal is carried out by sewing flap to pectineal ligament. By means of the second series of sutures external edge of rectus muscle aponeurosis is sewn with pubic tubercle. After that connected tendon and transverse muscle aponeurosis with seized flap of transverse fascia is sutured with ilio-pubic bundle, with formation of external inguinal ring.

EFFECT: method creates optimal conditions for tissue adhesion and eliminates possibility of hernia recurrence.

1 ex, 7 dwg

Description

The invention relates to medicine, namely to surgery.

A known method of surgical treatment of a femoral hernia (V.V. Zhebrovsky, "Surgery of abdominal hernias", M .: MIA, 2005, pp. 243-244), including surgical access by performing a vertical or oblique incision of the skin and subcutaneous tissue in the region oval fossa on the thigh. After dissection of the transverse fascia, the preperitoneal space is exposed, the femoral canal is opened, the hernial sac is exposed. Protecting the femoral vein located laterally to the hernial sac with a blunt hook, carefully secrete the sac as high as possible. The neck of the hernial sac is exposed and opened. The insides inside it are set into the abdominal cavity. The hernial sac is stitched at the neck, bandaged and cut off. After that, the femoral canal is performed. From the scallop fascia, a flap is cut out with a base on the scallop ligament, the free edge of which is sutured to the inguinal ligament without tension.

However, the known method has several significant disadvantages. Surgical access in the area of the oval fossa complicates the high processing of the hernial sac. The femoral canal is not completely eliminated; its inner opening remains open.

Thin scalloped fascia cannot fully close the femoral ring, which creates a high risk of femoral hernia recurrence.

With a restrained femoral hernia, the intersection of the inguinal ligament in order to release the restrained organs is fraught with damage to the obstructive artery, which quite often departs from the lower epigastric artery.

As the closest analogue, a method of surgical treatment of a femoral hernia was adopted (N.V. Voskresensky, S.L. Gorelik, “Surgery of the hernias of the abdominal wall”, M .: Medicine, 1965, pp. 252-253), including surgical access by incision skin and subcutaneous tissue parallel to and above the inguinal ligament, dissection of the aponeurosis of the external oblique muscle of the abdomen and transverse fascia, exposure of the preperitoneal space, opening of the femoral canal, isolation of the hernial sac and its excision. Subsequent plasty of the femoral canal is performed as follows: the inguinal and scallop ligaments are sutured, the posterior wall of the inguinal canal is restored with the second row of sutures, stitching the internal oblique and transverse muscles together with the upper edge of the transverse fascia with the inguinal ligament to the deep inguinal ring. Above the spermatic cord (or the round ligament of the uterus), the leaves of the aponeurosis of the external oblique muscle of the abdomen are sutured with duplication.

The disadvantage of this method is the high probability of relapse. Stitching of the rigid inguinal ligament with the immovable scallop ligament occurs with great tension, while the inguinal ligament is pulled with sutures to the scallop ligament, as a result of which the height of the inguinal gap increases by the distance between these ligaments, and when the posterior wall of the inguinal canal is restored, the internal oblique and transverse muscles are stitched. with the inguinal ligament is carried out with great tension. As a result, the stitched muscles atrophy, the sutures are cut, an inguinal hernia is formed.

Suturing the inguinal and scallop ligaments to the wall of the femoral vein reduces the area of the vascular lacuna and there is a danger of compression of the femoral vein.

The objective of the invention is the creation of a highly effective method of surgical treatment of femoral hernia, which allows to prevent possible intra- and postoperative complications, to reduce the likelihood of relapse.

The essence of the invention lies in the fact that in a method of surgical treatment of a femoral hernia, including surgical access, performed by cutting the skin and subcutaneous fat parallel and above the inguinal ligament, dissecting the aponeurosis of the external oblique muscle of the abdomen, opening the femoral canal, isolating and excising the hernial sac and subsequent autoplasty of the femoral canal, after opening the femoral canal, the cranially internal oblique muscle of the abdomen is removed, exposing the aponeurosis of the transverse muscle, which is dissected from the left lateral tubercle to the deep inguinal ring along the upper medial edge of the inguinal gap, 5 mm from the connected tendon and aponeurosis of the transverse muscle, cross the deep inguinal ring, continue the incision down to the ilio-pubic cord, receive a flap from the entire transverse fascia with the base on the ileum - pulmonary traction, turn it laterally, exposing the preperitoneal space, allocate and excise the hernial sac, autoplasty of the femoral canal is performed by suturing the cut flap to the scallop suture without tension, the second row of sutures restores the posterior wall of the inguinal canal, suturing the outer edge of the aponeurosis of the rectus abdominis muscle to the pubic tubercle, then the connected tendon and the aponeurosis of the transverse muscle with the grasped transverse fascia flap are sutured to the iliac-pubic strand, thus forming a deep groove ring, after that, over the laid spermatic cord or round ligament of the uterus, the aponeurosis leaves of the external oblique muscle are sutured, forming a superficial inguinal ring.

Using the invention allows to obtain the following technical result.

The method is highly effective. Inguinal access provides a wide exposure of the preperitoneal space, due to which all subsequent manipulations and suturing are performed under visual control, which helps to prevent possible intraoperative complications associated with direct surgical intervention: damage to internal organs, blood vessels, nerve trunks.

Through the inguinal access, the hernia gate is closed with a flap of strong transverse fascia, hemming it to the scallop ligament without tension, which creates the most optimal conditions for fusion of stitched tissues and excludes the possibility of compression of the femoral vein. Thus, the probability of postoperative complications is minimized - muscle atrophy, teething and subsequent formation of inguinal hernia.

The duration of the operation is 45-50 minutes.

The technical result is achieved due to the new technology of the operation, including a certain sequence of surgical techniques developed by the author: performing inguinal surgical access, opening the femoral canal, forming a flap, sequential exposure of the preperitoneal space, processing and excision of the hernial sac, performing autoplasty of the hernial portal, restoration of the back wall of the inguinal channel, the formation of a deep inguinal ring.

The novelty of the method lies in the fact that for the first time a tensionless autoplasty of the hernia gate of the femoral hernia was proposed through the inguinal access with a flap formed from the entire transverse fascia of the inguinal gap using an existing incision and making an incision along its upper medial edge, while conditions are created for closing the hernia gate with a cut flap without tension. The likelihood of relapse is minimized also due to the fact that the posterior wall of the inguinal canal is restored by stitching strong fascial-aponeurotic tissues with the formation of a deep inguinal neo-ring.

The method is as follows (Fig.1-7).

The operation is performed under local anesthesia.

Perform surgical access: make an incision in the skin and subcutaneous tissue parallel to and above the inguinal ligament. The aponeurosis of the external oblique muscle is exposed and dissected, the inguinal canal is opened. The iliac-inguinal nerve is medially pushed back, the spermatic cord (or the uterine round ligament) is taken to the holder and retracted laterally. Under the transverse fascia, 20 ml of a 0.25% novocaine solution is injected, the cranial internal oblique muscle is crocheted and the transverse muscle aponeurosis is exposed underneath. A flap is formed from the transverse fascia, which is dissected from the pubic tubercle to the deep inguinal ring along the upper medial edge of the inguinal gap, departing from the connected tendon and aponeurosis of the transverse muscle by 5 mm. After crossing the deep inguinal ring, the incision is continued down to the ilio-pubic cord (Fig. 1). The resulting flap with the base on the iliac-pubic striae is turned laterally, exposing the preperitoneal space (figure 2). With a gauze ball, the preperitoneal tissue and lower epigastric vessels are removed from the internal surface of the ilio-pubic cord, the peritoneal space is inspected to detect a hernial sac and to identify options for the location of the vessels. The neck of the hernial sac is isolated, it is taken on the provisional holder - a thin polyvinyl chloride tube (Fig. 3). Pulling the neck of the bag and crossing the existing adhesions between the hernial sac and the walls of the femoral canal, the bag is transferred to the inguinal region, opened, the contents are put into the abdominal cavity. The hernial sac is stitched at the neck, bandaged and cut off (Fig. 4).

After this, the femoral canal is plasticized as follows. The cut flap of the transverse fascia is sutured to the scallop ligament with a non-absorbable thread with interrupted sutures (Fig. 5). The second row of sutures restore the posterior wall of the inguinal canal. The outer edge of the aponeurosis of the rectus abdominis is sutured with one suture to the pubic tubercle. The connected tendon and aponeurosis of the transverse muscle with a captured narrow medial flap of the transverse fascia is sutured to the ilio-pubic strand, thereby forming a deep inguinal ring that passes the tip of the finger (Fig.6). The spermatic cord (or the round ligament of the uterus) is placed in place and above it, the aponeurosis leaves of the external oblique muscle are sutured, a superficial inguinal ring is formed (Fig. 7). Suture the subcutaneous tissue and skin. In the course of the operation, thorough hemostasis is performed, rude manipulations are unacceptable.

The proposed method operated on 14 patients (volunteers) with a femoral hernia. All patients are women aged 47 to 72 years. There were no complications during the operation and in the immediate postoperative period. In the period from one year to 2 years, 8 patients were examined. There are no complaints, no relapses.

Example. Patient S., 68 years old, a pensioner, was admitted to the surgical department with a right femoral hernia. When viewed on the anteroposterior surface of the right thigh, below the inguinal ligament, a protrusion of 4 × 3 cm is determined, when pressed, the contents freely go into the abdominal cavity.

The operation of the proposed method under local anesthesia. An incision was made in the skin and subcutaneous tissue parallel to and above the right inguinal ligament, the aponeurosis of the external oblique muscle of the abdomen was dissected, the iliac-inguinal nerve was moved medially, the round ligament of the uterus was taken to the holder and moved laterally. Under the transverse fascia, 20 ml of 0.25% novocaine was injected, the internal oblique muscle was hooked cranially. The transverse fascia is dissected from the pubic tubercle to the deep inguinal ring, retreating from the edge of the connected tendon and aponeurosis of the transverse muscle by 5 mm. After crossing the deep inguinal ring, the incision is continued down to the ilio-pubic cord. The resulting flap of the transverse fascia is turned laterally. The peritoneal fiber and lower epigastric vessels are shifted with a gauze ball from the inner surface of the ilio-pubic cord. The neck of the hernial sac, extending under the ileo-pubic cord and inguinal ligament, was taken, taken to the provisional holder. By pulling on the holder and bluntly separating the fusion of the hernial sac with surrounding tissues, the sac is transferred to the inguinal region, opened. A lock of the omentum is fixed to the inner surface of the hernial sac, resected, the hernial sac is stitched at the neck, bandaged, cut off. A deep femoral ring 2.5 × 2.0 cm in size has been formed. A previously prepared transverse fascia flap is sutured to the scallop ligament from the pubic tubercle to the femoral vein with nodular nylon sutures. The edge of the vagina of the rectus muscle is sutured with one suture to the pubic tubercle, the connected tendon and the aponeurosis of the transverse muscle with the medial flap of the transverse fascia are sutured to the iliac-pubic cord. A round ligament of the uterus is laid in place and above it are sewn sheets of aponeurosis of the external oblique muscle. Sutures on the subcutaneous tissue and skin. The duration of the operation was 45 minutes. After surgery, drugs were not prescribed. The patient was discharged on the fourth day after the operation, the sutures were removed at the clinic, wound healing by primary intention. The patient was examined after 2 years. No complaints, no relapse.

Claims (1)

A method for surgical treatment of a femoral hernia, including surgical access by cutting the skin and subcutaneous fat parallel and above the inguinal ligament, dissecting the aponeurosis of the external oblique muscle of the abdomen, opening the femoral canal, isolating and excising the hernial sac and subsequent autoplasty of the femoral canal, characterized in that after opening the femoral canal, the cranially internal oblique muscle of the abdomen is pushed back, exposing the aponeurosis of the transverse muscle, which is dissected from the pubic tubercle to the deep groin ring along the upper medial edge of the inguinal gap, retreating 5 mm from the connected tendon and aponeurosis of the transverse muscle, cross the deep inguinal ring, the incision continues down to the ilio-pubic cord, a flap is obtained from the entire transverse fascia with the base on the iliac-pubic traction, turn it laterally, exposing the preperitoneal space, allocate and dissect the hernial sac, autoplasty of the femoral canal is performed by suturing the cut flap to the scallop ligament without tension, the second row of sutures s restore the posterior wall of the inguinal canal, suturing the outer edge of the aponeurosis of the rectus abdominis muscle to the pubic tubercle, then the connected tendon and the transverse muscle aponeurosis with the graft of the transverse fascia is sutured to the iliac-pubic strand, thus forming a deep inguinal ring, after which in place of the spermatic cord or round ligament of the uterus, the aponeurosis leaves of the external oblique muscle are sutured, forming a superficial inguinal ring.

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