RU2580974C1 - Method minimally invasive hernia repair laparoscopic inguinal with trashernial fixing selectively adhesiveness allograft - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: at the location of the hernia sac in the inguinal canal is carried out through the introduction of laparoscope iliac region located on the side of the hernia. Spend a laparoscope during the hernia sac to the projection area on the hernial sac external inguinal ring. Under the supervision of transillumination of tissue in the projection of the external inguinal ring operate under the trocar incision. Allocate and opened the bottom of the hernia sac. Through the created opening into the peritoneal cavity the trocar is introduced at a predetermined allograft in its sleeve, and comprising a fixation tape having an adhesive on one side and, on the other hand non-adhesive coating. Place the adhesive side of the allograft in the parietal peritoneum, closing the hernial ring and fixing is carried out using the retaining belt. When the location of the hernia sac in the inguinal canal and scrotum carry introducing a laparoscope through the iliac region, located on the side of the hernia, and spend it in the course of the hernia sac to the projection area on the hernial sac external inguinal ring. Under the supervision of transillumination of tissue in the projection of the external inguinal ring is performed under the skin incision trocar is isolated and opened the front wall of the hernia sac. Through the created opening into the peritoneal cavity the trocar is introduced at a predetermined allograft in its sleeve, and comprising a fixation tape having an adhesive on one side and, on the other hand non-adhesive coating. Place the adhesive side of the allograft in the parietal peritoneum, closing the hernial ring and fixing is carried out using the retaining belt.

EFFECT: invention reduces the trauma of intervention, provide a low level of pain in the postoperative period.

10 cl, 14 dwg, 2 ex

Description

FIELD OF THE INVENTION

The invention relates to medicine, namely to herniology.

State of the art

Over the past few decades, surgical approaches to the treatment of inguinal hernias have undergone significant changes. First of all, this is due to the development and continuous improvement of endoscopic technology, mesh allografts, the possibility of a free exchange of experience at the international level. There is also a general trend in the development of minimally invasive surgery, which at this stage is one of the main factors determining the direction of development of surgical instruments, surgery and herniology, in particular. Now we see that modern methods of plastic inguinal canal are not perfect and the issues of developing new and improving old methods still remain relevant.

Currently, there are methods of plastic inguinal canal, functionally similar to the method developed by us - there are no similar methods. TAPP (transabdominal preperitoneal patch plasty), TEP (total extraperitoneal patch plasty).

In addition, in connection with the development of technologies, a large selection of allografts with selective adhesiveness (not causing adhesions in the abdominal cavity), that is, installed directly on the peritoneum, has appeared. The method for installing such allografts has received the general name IPOM (intraperitoneal onlay mesh). This method does not describe a specific type of plastic, but its name reflects the way the allograft is fixed relative to the peritoneum and aponeurosis.

I. TAPP (transabdominal preperitoneal patch plasty) consists of the following main steps (VV Zhebrovsky, Mohamed Tom Elbashir. “Surgery of abdominal hernias and eventrations”, Simferopol, “Business Inform”, 2002, p. 294 - prototype):

1. The introduction of trocars under the control of vision.

2. Videoscopic examination of the abdominal cavity.

3. The arcuate incision of the parietal peritoneum over the hernial portal.

4. Isolation of the hernial sac by invagination into the abdominal cavity.

5. Isolation of anatomical formations for fixation of the mesh prosthesis.

6. Cutting the mesh to the required shape and size.

7. The introduction of the sleeve with a protective mesh into the abdominal cavity.

8. Covering the net of all hernial gates.

9. Fixing the mesh with a hernial stapler.

10. Suturing of the incision of the peritoneum.

II. TEP (total extraperitoneal patch plasty) (Zhebrovsky V.V., Mohamed Tom Elbashir. “Surgery of hernias of the abdomen and eventings”, Simferopol, “Business Inform”, 2002, p. 305) includes the following steps:

1. A peritoneal trocar through a micro incision under the umbilicus under the umbilicus with a dissector balloon, by stretching of which the peritoneum is peeled off and the space required for manipulations is created, replacing it with a laparoscope trocar with a sealing sleeve. Carbon dioxide insufflation to maintain the formed preperitoneal cavity.

2. Carrying out working trocars.

3. Preparation with the release of the internal inguinal ring; A., v. epigastrica inferior; a., v. iliaca externa; lig. pectineale.

4. Removing the hernial sac from the internal inguinal ring and separating the vas deferens and testicular vessels from it.

5. With bilateral hernias, carrying out similar actions on the opposite side.

6. Conducting into the preperitoneal space of the mesh prosthesis and closing it hernia gate.

7. Fixing the mesh with a hernial stapler to the scallop ligament.

8. Checking the operating area for hemostasis and the correct location of the grid.

9. Installation of drainage through a puncture of the lateral trocar.

10. The removal of working trocars under visual control and the release of carbon dioxide from the preperitoneal region.

11. Suturing the fascia in the openings of the optical and working medial trocars.

12. Suturing of the skin in the area of trocar punctures.

III. IPOM (intraperitoneal onlay mesh)

The method involves the use of a multilayer mesh allograft with selective adhesiveness, the visceral surface of which has (depending on the model) various coating compositions that prevent the formation of adhesions between the graft and visceral peritoneum. In the variety of varieties of this type of nets, two main structures can be distinguished:

1 - Allograft in the form of a sheet, cut out in size and shape of the defect. Most often used for large ventral hernias and plastic inguinal canal. It does not have its own fixation device, it is fixed in various ways at the discretion of the surgeon and depending on the type of plastic. The installation method for an inguinal hernia is practically no different from TAPP, with the exception of the absence of stages 3 and 4. For fixation, in addition to the herniostapler, transmural immersion sutures with a Duchamp type needle are most often used;

2 - The allograft has the shape of a circle, between the layers of which a flexible frame is often sewn, which provides elasticity, memory and resistance to deformation. To the geometric center of the grid, on the parietal (not having a special non-adhesive coating) side, tapes are attached, which serve for fixing to tendon structures. Appointment - ventral hernias with narrow gates, previously not used for inguinal hernias.

The vast majority of models (regardless of manufacturer) of this type, without drastic changes in the design, are applicable for performing plastics according to our proposed method. The disadvantages of the TEP method are:

1. To perform the operation, specific tools are required, which are not available in all operating rooms - a balloon dissector, a hernial stapler.

2. A fairly invasive method. This is due to the fact that, firstly, three trocars are installed in the abdominal cavity, compared with our technique (two trocars), and secondly, the trauma of this operation is due to the need to separate the peritoneum from the muscle-aponeurotic layer, which is quite traumatic, and, thirdly, during this operation it is necessary to isolate the hernial sac and invaginate it into the abdominal cavity, which is associated with the risk of damage to the vessels of the spermatic cord, up to the injury of the vas deferens.

3. The development of preperitoneal, subcutaneous emphysema is an absolute minus.

4. The high cost of consumables - the cost of the herniostapler and mesh allograft.

5. Considering the relative complexity of the operation and the need to isolate the hernial sac from the surrounding tissues, isolate the above vessels and other stages, the duration of the operation is significantly extended, compared with our proposed technique.

6. Low reproducibility of the operation - TAPP can be performed by an experienced surgeon, with significant experience in performing endoscopic operations after several dozen assistants.

The same disadvantages relate to the TAPP and IPOM - methods (as a method of intra-abdominal plastic surgery for inguinal hernia). An additional disadvantage of TAPP is the possibility of damage to the intestine, since plastic is transabdominal and for some time in the abdominal cavity, work is performed using a manipulator using coagulation and an electric knife. The classic IPOM is less invasive, however, the advantage in time and less invasiveness is obscured by the need for transmural immersion joints.

Chronic pain syndrome is inherent in all of the above methods.

Disclosure of invention

The methods developed by us allow us to achieve the following technical results:

- reducing the invasiveness of the intervention, prevention of intraoperative complications (bleeding, damage to nerves and vas deferens),

- ensuring a low level of pain in the postoperative period,

- achieving a good aesthetic result while maintaining the reliability of hernioplasty,

- simplification of the intervention technique.

The achievement of the above results is due to the minimization of access to the abdominal cavity, one of which is located in the pubic pubis, as well as the exclusion of stages associated with the isolation of the hernial sac from the structures of the spermatic cord.

We have developed two options for laparoscopic inguinal hernia repair: for the case of the location of the hernial sac in the region of the inguinal canal and the location of the hernial sac in the region of the inguinal canal and scrotum.

When the hernial sac is located in the area of the inguinal canal, the laparoscope is inserted through the iliac region located on the side of the hernia and is carried out along the hernial sac to the projection onto the hernial sac of the external inguinal ring. Under the control of tissue transillumination in the projection of the external inguinal ring, a skin incision is performed under a 10 or 12 mm trocar, the bottom of the hernial sac is isolated and opened. Through the created hole, a trocar is introduced into the abdominal cavity with an allograft pre-installed in its sleeve containing fixation tapes and having adhesive and on the other hand non-adhesive coatings, and the allograft is placed with the adhesive side on the parietal peritoneum, closing the hernia gate. Fixation is carried out using fixation tapes.

Moreover, the implementation of this operation also includes the following features:

- before the allograft is inserted into the trocar, it is prepared for insertion into the abdominal cavity, for which fixation tapes are laid along the allograft plane, rolled up in the form of a tube coaxially with the direction of the fixation tapes, then the resulting blank is introduced into the trocar sleeve without the intracircuit, tapes towards the introducer, the individual ligature tapes are stitched at the ends, removed through the intraduser and taken to the holder, the intraduser is mounted on the trocar sleeve, and after the allograft is inserted into the abdominal cavity using a pusher, the straightened prosthesis is pulled to the trocar sleeve using ligatures, the allograft is oriented on the parietal peritoneum, pulling the ligatures and rotating the trocar sleeve along the axis;

- a laparoscope is introduced through the point of Mc Burney or symmetrical to it relative to the projection of the white line of the abdomen on the anterior abdominal wall;

- in the projection of the external inguinal ring, a skin incision is made under a 10- or 12-mm trocar;

- tapes are fixed to the pubic tubercle, Cooper ligament, inguinal ligament with separate interrupted sutures with non-absorbable monofilament thread.

When the hernial sac is located in the area of the inguinal canal and scrotum, the laparoscope is inserted through the iliac region located on the side of the hernia and the hernia sac is carried out along the projection onto the hernial sac of the external inguinal ring, under the control of tissue transillumination, a skin incision is performed under the projection of the external inguinal ring 10- or 12-mm trocar, isolate and open the front wall of the hernial sac, through the created hole into the abdominal cavity enter the trocar with a pre-installed allograft sleeve in its sleeve, with ERZHAN fixation belt and having an adhesive on one side and, on the other hand, non-adhesive coating is placed on allograft adhesive side of parietal peritoneum covering the hernial ring, and fixation was performed using the retaining tape.

Moreover, the implementation of this variant of the operation also includes the following features:

- before the allograft is inserted into the trocar, it is prepared for insertion into the abdominal cavity, for which fixation tapes are laid along the allograft plane, rolled up in the form of a tube coaxially with the direction of the fixation tapes, then the resulting blank is introduced into the trocar sleeve without the intracircuit, tapes towards the introducer, the individual ligature tapes are stitched at the ends, removed through the intraduser and taken to the holder, the intraduser is mounted on the trocar sleeve, and after the allograft is inserted into the abdominal cavity using a pusher, the straightened prosthesis is pulled to the trocar sleeve using ligatures, the allograft is oriented on the parietal peritoneum, pulling the ligatures and rotating the trocar sleeve along the axis;

- a laparoscope is introduced through the point of Mc Burney or symmetrical to it relative to the projection of the white line of the abdomen on the anterior abdominal wall;

- in the projection of the external inguinal ring, a skin incision is made under a 10- or 12-mm trocar;

- tapes are fixed to the pubic tubercle, Cooper ligament, inguinal ligament with separate interrupted sutures with non-absorbable monofilament thread.

Brief Description of the Illustrations

FIG. 1 shows an allograft: 1 - ligature holder, 2 - fixation tape, 3 - multilayer mesh allograft with a non-adhesive coating.

FIG. 2 - laying of fixation tapes along the allograft plane.

FIG. 3-4 shows the stages of laying an allograft in the sleeve of a trocar.

FIG. 5 shows the fixation on the holders of allograft tapes.

FIG. 6 shows the markings on the anterior abdominal wall from the hernia: 4 - hernial sac, 5 - long axis of the hernial sac, 6 - Mc Burney point, 7 - inner inguinal ring.

FIG. 7 shows the implementation of pneumoperitoneum.

FIG. 8 depicts a cut at the point of Mc Burney.

FIG. 9 shows the introduction of a laparoscope into the hernial sac: 8 - laparoscope, 9 - trocar, 10 - the bottom of the hernial sac.

FIG. 10 shows a skin incision under the control of tissue transillumination in a projection of the external inguinal ring.

FIG. 11 shows the opening of the hernial sac: on the clamps, the bottom of the hernial sac or the front wall of the hernial sac.

FIG. 12 shows the insertion of a trocar sleeve (11) into the hernial sac with an allograft located therein.

FIG. 13 shows ablation of an allograft into the abdominal cavity.

FIG. Figure 14 shows postoperative wounds (12): fixation of tapes to the pubic tubercle (or to other dense structures - Cooper's ligament, inguinal ligament) with separate interrupted sutures.

The implementation of the invention

The developed method is based on the use of multilayer mesh prostheses and is a type of IPOM (intraperitoneal onlay mesh). At this stage, the use of various currently existing allografts is considered acceptable.

General characteristics of the allograft design.

In our view, the allograft should have a round or oval shape, depending on the size of the defect in the anterior abdominal wall and the patient himself. The allograft must have physiological bends, allowing the prosthesis to be placed more congruently under the defect, i.e. have impressions matching the topography of the lateral and medial inguinal fossae, as well as protrusions corresponding to the plica lateralis of the pupartic ligament, iliac vessels and ductus deferents. Preferred diameters are 40, 60 and 80 mm for adults. In addition, the allograft must have a fixation device.

Allograft Requirements

In relation to existing branded dentures, the prosthesis for this method should have:

1) greater congruence;

2) higher shape memory;

3) less rigidity;

4) have greater resistance to deformation;

5) the fixation device should have greater elasticity (when using the existing design of the fixation device);

6) the parietal surface of the allograft should have sufficiently high adhesive properties.

Indications for minimally invasive alloplasty of the inguinal canal with inguinal hernias:

1) oblique inguinal hernia;

2) oblique inguinal-scrotal hernia;

3) oblique inguinal hernia with a straightened course;

4) direct inguinal hernia.

Contraindications to the implementation of minimally invasive alloplasty of the inguinal canal with inguinal hernias:

1) large inguinal-scrotal hernias, with a width of hernia gate comparable with the size of the mesh (in the ratio of the diameters along the length of 0.6: 1 at the mesh);

2) pronounced concomitant therapeutic pathology that does not allow laparoscopy;

3) purulent-inflammatory process of the hernial sac, its contents and / or skin in the area of hernial protrusion;

4) individual intolerance to allograft components;

5) irreversible inguinal hernia (relative contraindication);

6) a pronounced adhesion process of the abdominal cavity (surgery, history of injury), preventing laparoscopy.

Conditions for the operation:

1) the operation is performed in a sterile operating room equipped with standard laparoscopic equipment;

2) it is recommended to perform surgery under endotracheal anesthesia;

3) the presence of a proper allograft.

Description of the operation

The first step in sterile conditions is the preparation of an allograft for insertion into the abdominal cavity.

Fixation tapes are laid on the plane of the allograft. The allograft folds in the form of a tube coaxially with the direction of the fixation tapes (Fig. 2). The obtained blank is introduced into the sleeve of a 10- or 12-mm trocar without an intraduser, with ribbons towards the intraduser (Fig. 3, 4).

The tapes of the prosthesis fixation device with individual ligatures are stitched at the ends, removed through the intraducer and taken to the holder. The intraduser is mounted on the sleeve of the trocar (Fig. 5).

Markings are made on the anterior abdominal wall from the hernia: the point of Mc Burney, the area of projection of the internal inguinal ring on the anterior abdominal wall is noted (Fig. 6).

The anterior abdominal wall is treated with an antiseptic solution, the inguinal region is treated on the side of the hernial protrusion. The surgical field is lined with sterile surgical material. Pneumoperitoneum is performed at the discretion of the operating surgeon according to the most convenient method, depending on the available instruments (Fig. 7).

An incision is made at the point of Mc Burney under a 10- or 5-mm trocar on the side of an inguinal hernia, depending on the diameter of the existing optical system (Fig. 8). The patient is transferred to the Trendelenburg position and on the opposite side with respect to the hernia (on the left side with a right-handed hernia). A laparoscope is inserted into the abdominal cavity. Inspection of the hernial defect, inspection of the mouth of the hernial sac. If the contents of the hernial sac are present, the contents are manually reduced to the abdominal cavity. The camera is held along the hernia sac to its bottom or to the projection area on the hernia sac of the external inguinal ring (Fig. 9).

Under the control of tissue transillumination in the projection of the external inguinal ring, a skin incision is made under a 10- or 12-mm trocar (Fig. 10). The wall or bottom of the hernial sac stands out. At the Billroth clamps, the bottom of the hernial sac (or the front wall of the hernial sac) is opened.

The access to the bottom of the hernial sac is performed in layers (or to the front wall of the hernial sac - if the hernia is inguinal-scrotal). At the clamps, the bottom of the hernial sac (or the front wall of the hernial sac) is opened (Fig. 11).

Through an opening in the bottom of the hernial sac (or in the front wall of the hernial sac), a 10- or 12-mm trocar with an allograft pre-installed in the sleeve of the trocar is inserted into the abdominal cavity (Fig. 12).

With the help of a pusher, the allograft is reduced to the abdominal cavity (Fig. 13). The straightened prosthesis is pulled to the trocar sleeve using ligatures. By pulling the ligatures and rotating the trocar sleeve along the axis, the correct orientation of the allograft is achieved. By placing an allograft on the parietal peritoneum, the trocar is removed from the abdominal cavity.

The tapes are fixed to the pubic tubercle (or to other dense structures - Cooper’s ligament, inguinal ligament) with separate interrupted sutures of non-absorbable monofilament suture, then excess tapes are cut below the skin level, departing from the fixation point at least 0.5 cm (Fig. 14). Carbon dioxide is evacuated from the abdominal cavity, a trocar installed at the point of Mc Burney is removed. Wounds are sutured in layers. Intradermal sutures with absorbable suture are applied to the skin. The treatment of wounds and skin in the area of skin sutures with an antiseptic solution is performed. Adhesive dressing. The end of the operation.

Clinical examples

1. Patient I., 52 years old, was admitted for planned surgical treatment with a diagnosis of Right-sided acquired correctable inguinal hernia.

From the anamnesis, he considers himself to be sick during the last year, 1 year ago after physical activity he noted the appearance of hernial protrusion in the right inguinal region, during the last year the hernial protrusion gradually increased. Outpatient consulted by a surgeon - recommended planned surgical treatment, outpatient examination. Received for planned surgical treatment.

Objective inspection - local status. In the right inguinal region in a vertical position, a hernial protrusion of 4 × 3 × 1 cm is determined, painless on palpation, soft-elastic consistency, freely set into the abdominal cavity in a horizontal position. The symptom of a cough push is positive. The internal inguinal ring during palpation is not reliably determined.

The patient was operated on as planned. Alloplasty of the inguinal canal was performed according to our method described above.

1) The duration of the operation is 23 minutes.

2) In the postoperative period, the patient on a 10-point scale notes a pain level of 2 points at the 3rd hour after surgery (without the use of analgesics of any pharmacological group), 1 point 10 hours after surgery and 1 point 24 hours after surgery.

3) A short period of rehabilitation after surgery - the patient was discharged from the hospital the day after surgery in a satisfactory condition.

4) Uncomplicated postoperative period.

5) The wounds healed by first intention, postoperative scars without signs of inflammation. It was not necessary to remove the sutures, taking into account the peculiarities of applying an intradermal suture using absorbable material.

6) During the 6-month period after the plastic surgery, data for recurrence of inguinal hernia were not received.

2. Patient A., 63 years old, was admitted for routine surgical treatment with a diagnosis of Left-side acquired acquired inguinal hernia.

From the anamnesis, she considers herself ill for the past 4 years, 4 years ago after physical exertion, noted the appearance of hernial protrusion in the right inguinal region, over the past year hernial protrusion gradually increased. Outpatient consulted by a surgeon - recommended planned surgical treatment, outpatient examination. Received for planned surgical treatment.

Objective inspection - local status. In the left inguinal region in a vertical position, a hernial protrusion of 6 × 4 × 2 cm is determined, painless on palpation, soft-elastic consistency, freely set into the abdominal cavity in a horizontal position. The symptom of a cough push is positive. The internal inguinal ring during palpation is not reliably determined.

The patient was operated on as planned. Alloplasty of the inguinal canal was performed according to our method described above.

1) The duration of the operation is 20 minutes.

2) In the postoperative period, the patient on a 10-point scale notes a pain level of 3 points at the 3rd hour after surgery (without the use of analgesics of any pharmacological group), 1 point 10 hours after surgery and 1 point 24 hours after surgery.

3) A short period of rehabilitation after surgery - the patient was discharged from the hospital the day after surgery in a satisfactory condition.

4) Uncomplicated postoperative period.

5) The wounds healed by first intention, postoperative scars without signs of inflammation.

6) During the 6-month period after the plastic surgery, data for recurrence of inguinal hernia were not received.

Claims (10)

1. The method of laparoscopic hernia repair of an inguinal hernia, including the introduction of an allograft into the abdominal cavity, closing the hernia gate and fixing it to the connective tissue structures, characterized in that when the hernia is located in the inguinal canal, the laparoscope is inserted through the iliac region located on the side of the hernia, and carried out along the hernial sac to the projection area on the hernial sac of the external inguinal ring, under the control of tissue transillumination in the projection of the external inguinal ring the incision under a 10- or 12-mm trocar, the bottom of the hernial sac is isolated and opened, a trocar is introduced into the abdominal cavity with an allograft pre-installed in its sleeve containing fixation tapes and having adhesive and non-adhesive coating on one side , place the allograft with the adhesive side on the parietal peritoneum, closing the hernial gate, and the fixation is carried out using fixation tapes. 2. The method according to p. 1, characterized in that before the introduction of the allograft into the trocar, it is prepared for insertion into the abdominal cavity, for which the fixation tapes are laid along the plane of the allograft, they are rolled into a tube aligned with the direction of the fixation tapes, then into the sleeve of the trocar the resulting preform is introduced into the introducer, tapes towards the introducer, the individual ligature tapes are stitched at the ends, removed through the introducer and taken to the holder, the introducer is placed on the trocar sleeve, and after insertion llotransplantata into the peritoneal cavity by means of pusher straighten the prosthesis is pulled up to the trocar sleeve by means of ligatures to orient allograft parietal peritoneum, tightening the ligature and rotating the trocar sleeve axis. 3. The method according to p. 1, characterized in that the laparoscope is introduced through the point of Mc Burney or symmetrical to it relative to the projection of the white line of the abdomen on the anterior abdominal wall. 4. The method according to p. 1, characterized in that in the projection of the external inguinal ring, a skin incision is made under a 10- or 12-mm trocar. 5. The method according to p. 1, characterized in that the tape is fixed to the pubic tubercle, Cooper ligament, inguinal ligament with separate interrupted sutures with a non-absorbable monofilament thread. 6. The method of laparoscopic inguinal hernia repair, including the introduction of an allograft into the abdominal cavity, closing the hernia gate and fixing it to the connective tissue structures, characterized in that when the hernial sac is located in the inguinal canal and scrotum, the laparoscope is inserted through the iliac region located on the side of the hernia , and spend along the hernial sac to the projection area on the hernial sac of the external inguinal ring, under the control of tissue transillumination in the projection of the external inguinal ring they remove a skin incision under a 10- or 12-mm trocar, isolate and open the front wall of the hernial sac, introduce a trocar into the abdominal cavity with an allograft pre-installed in its sleeve, containing fixation tapes and having adhesive on one side and on the other hand non-adhesive coating, place the allograft with the adhesive side on the parietal peritoneum, closing the hernia gate, and the fixation is carried out using fixation tapes. 7. The method according to p. 6, characterized in that before the introduction of the allograft into the trocar, it is prepared for insertion into the abdominal cavity, for which the fixation tapes are laid along the plane of the allograft, fold it in the form of a tube coaxially with the direction of the fixation tapes, then into the trocar sleeve without the resulting preform is introduced into the introducer, tapes towards the introducer, the individual ligature tapes are stitched at the ends, removed through the introducer and taken to the holder, the introducer is placed on the trocar sleeve, and after insertion llotransplantata into the peritoneal cavity by means of pusher straighten the prosthesis is pulled up to the trocar sleeve by means of ligatures to orient allograft parietal peritoneum, tightening the ligature and rotating the trocar sleeve axis. 8. The method according to p. 6, characterized in that the laparoscope is introduced through the point of Mc Burney or symmetrical to it relative to the projection of the white line of the abdomen on the anterior abdominal wall. 9. The method according to p. 6, characterized in that in the projection of the external inguinal ring, a skin incision is made under a 10- or 12-mm trocar. 10. The method according to p. 6, characterized in that the tape is fixed to the pubic tubercle, Cooper ligament, inguinal ligament with separate interrupted sutures with a non-absorbable monofilament thread.

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