RU2519365C2 - Method for surgical management of inguinal hernia in children - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, particularly herniology. A method involves a transection of skin, subcutaneous fat and aponeurosis of the abdominal external oblique muscle 1-1.5 cm above the sonographic projection of the deep inguinal ring. The abdominal internal oblique and transverse muscles are dissected along the muscle fibres to a transverse fascia. The transverse fascia is exposed, and a peritoneum is stripped therefrom within a lateral inguinal fossa below a proximal edge of the incision wound. A hernia sac and partially adjoining testicular neurovascular bundle and deferent duct are exposed. The hernia sac is separated from the above components of the spermatic cord in front of an opening of the deep inguinal ring. If necessary, hydraulic preparation of the vessels, deferent duct and hernia sac with 0.25% novocaine follows.

EFFECT: method enables avoiding the vessel and deferent duct injuries.

2 cl, 4 dwg, 2 ex

Description

The invention relates to medicine, namely to surgery of childhood, and can be used in herniology.

A known method of endovascular surgical extraperitoneal prosthetic hernioplasty (Ferzli GS, Massad A., Albert P. // J. Laparoendosc. Surg. - 1992. - Vol.2, N 6. - p. 281-286), which is carried out without entering into the abdominal cavity. In this case, a micro incision of the skin, fiber, aponeurosis to the peritoneal space is performed. Then the primary space is bluntly created in the preperitoneal tissue to the fold, into which it is injected for 3-4 minutes and inflated with carbon dioxide or with the introduction of physiological solution, a balloon dilatator (spacemaker). After removing the balloon, a trocar with a special obturator is introduced into the working cavity, which allows maintaining the pressure of carbon dioxide in the preperitoneal space. Then, along the midline, two working trocars with a diameter of 12 mm and 5 mm are introduced into the cavity formed, with the help of which the loose adhesions are separated, a hernial sac and elements of the spermatic cord are isolated from the surrounding tissues. The hernial sac is clipped and crossed at the neck, after which the implant is inserted and, as with laparoscopic transabdominal hernioplasty, it is fixed with a herniostapler. The disadvantage of this method is excessive trauma to the soft tissues of the abdominal wall, due to exposure of the inner surface of the transverse fascia over a large area to the fold, as well as the introduction of two trocars into the lumen of the created space through separate skin incisions. In addition, the method involves the use and placement in the created space of the implant.

There is a method of surgical treatment of inguinal and femoral hernias with oblique inguinal preperitoneal mini-access (Starchenkov SB Preperitoneal hernioplasty with inguinal hernias from supra-inguinal oblique mini-access: dissertation of Candidate of Medical Sciences. Starchenkov SB - Kemerovo, 2007 . - 137 p.), In which, departing cephalically 1 cm from the projection of the deep inguinal ring, determined sonographically, an incision is made in the skin, subcutaneous tissue, and aponeurosis of the external oblique muscle of the abdomen towards the middle of the inguinal ligament. The internal oblique and transverse muscles of the abdomen are stupidly diluted, the transverse fascia is dissected, with the help of a preperitoneoscope, the parietal peritoneum is peeled off, forming a pocket in the preperitoneal space. After the stage of herniotomy, the inguinal region is strengthened by placing a mesh polypropylene explant in the preperitoneal space. The disadvantages of this method are: the use of a special device - preperitoneoscope to create a working space, excessive trauma to the soft tissues of the preperitoneal space with the risk of trauma to the vessels, vas deferens and peritoneum when creating a pocket, the need to use a polypropylene explant to strengthen the inguinal region.

Closest to the proposed solution (prototype) is the method of preperitoneal plasty of the inguinal canal according to Nyhus (Nyhus LM. The preperitoneal approach and iliopubic tract repair of inguinal hernia. In Nyhus LM, Condon RE, eds. Hernia, 3rd ed. Philadelphia: JB Lippincott Company , 1989; 154-177). The method is most indicated for the treatment of recurrent hernias. The operation is performed from the posterior extraperitoneal access, providing access to the posterior wall of the inguinal canal. A skin incision is made in the transverse direction 2 transverse fingers above the symphysis. Cut the skin, subcutaneous tissue, the anterior wall of the aponeurotic vagina of the rectus abdominis muscle. In the transverse direction, the aponeurosis of the external oblique abdominal muscle, the internal oblique, transverse abdominal muscles are dissected throughout the entire thickness. The internal inguinal ring is identified with the help of a finger inserted into the external inguinal ring, after which the muscle-aponeurotic layers are dissected immediately above it, the rectus muscle is crocheted and the lower epigastric vessels are crossed if necessary. Then open the transverse fascia throughout the whole slightly higher or lower skin incision lateral from the incision of the aponeurosis of the vagina of the rectus abdominis muscle. The hernial sac is secreted in a blunt and sharp way from the retroperitoneal space, then with small inguinal hernias, it is immersed in the abdominal cavity after a purse string suture is placed on its neck. If difficulties arise at the time of bag isolation with large hernias, they cross it at the neck, leaving the distal part in the inguinal canal. In case of a small hernial defect, the inner inguinal ring is sutured with 1-2 sutures laterally from the spermatic cord so as not to damage it. Plastic inguinal canal is produced with 5-6 sutures, which are applied between the transverse fascia and the iliac-pubic tract.

The disadvantages of this method are the complexity of its implementation and trauma to the soft tissues of the anterior abdominal wall, due to the need to expose the external and internal walls of the inguinal canal and the intersection of the anterior wall of the vagina of the rectus abdominis muscle, sometimes with the lower iliac vessels; determination of the projection of the internal inguinal ring through the external - with a finger inserted into it; and also the need to perform plastic inguinal canal medially from the internal inguinal ring.

The aim of the proposed method for the surgical treatment of inguinal hernias in children is to reduce trauma to the soft tissues of the abdominal wall, preventing damage to blood vessels and the vas deferens.

The technical result is achieved by hernia repair in the preperitoneal space with exposure of the peritoneum, the inner surface of the transverse fascia and the neck of the hernial sac within the lateral inguinal fossa below the distal edge of the surgical wound, which eliminates damage to the vagina of the rectus muscle, lower epigastric, testicular vessels and vas deferens. The introduction of a 0.25% solution of novocaine into the preperitoneal fiber provides hydraulic preparation of the peritoneum, blood vessels and vas deferens from the neck of the hernial sac and thereby facilitates their separation from each other. In addition, reducing, if necessary, the lumen of the inner inguinal ring from the lateral side with 1-3 sutures eliminates damage to its ligamentous apparatus, lower epigastric vessels, testicular vessels and vas deferens. Plastic inguinal canal is excluded, which reduces the risk of damage to the elements of the spermatic cord and lower epigastric vessels.

The novelty of the proposed method lies in the fact that the isolation and processing of the hernial sac, exposure of the peritoneum, the inner surface of the transverse fascia is carried out in the preperitoneal space within the lateral inguinal fossa below the distal edge of the surgical wound, if necessary, hydraulic preparation of the vessels, vas deferens, and hernial sac 0 is performed. 25% solution of novocaine, and a decrease in the enlarged internal inguinal ring is performed from the lateral side without plastic inguinal canal.

Technical solutions that have features that match the distinguishing features of our proposed method are not identified, which allows us to conclude that the proposed method meets the criterion of "inventive step".

The proposed method for the treatment of correctable inguinal hernias in children is as follows:

Before performing surgical treatment, an ultrasound scan is performed to confirm the diagnosis of inguinal hernia, to determine the projection of the deep opening of the inguinal canal on the anterior abdominal wall. During the operation, a transverse incision is made of the skin, subcutaneous tissue and aponeurosis of the external oblique muscle of the abdomen 3-5 cm long from the hernia (1 in Fig. 1) 1-1.5 cm above the projection of the deep inguinal ring (2 in Fig. 1) . Then, muscle-aponeurotic tissues are opened in layers to the transverse fascia by splitting the internal oblique and transverse muscles along the muscle fibers. The transverse fascia is opened (1 in Fig. 2) and the peritoneum (2 in Fig. 2) is bluntly exfoliated from it within the lateral inguinal fossa below the distal edge of the surgical wound, the hernial sac (1 in Fig. 3) is exposed and partially adjacent to it neurovascular bundle of the testis and vas deferens (2 in figure 3). A hernial sac is separated from the specified components of the spermatic cord before they enter the deep inguinal ring for 1.5-2 cm (3 in FIG. 3). If it is difficult to separate the peritoneum from the transverse fascia, and the vessels and vas deferens from the neck of the hernial sac, 10-15 ml of a 0.25% solution of novocaine is injected into the peritoneal space for the hydraulic preparation of tissues. Sew, bandage and cross the hernial sac at the neck (1 in figure 4), leaving the distal part of the sac open. Plastic inguinal canal is not performed. When revealing the expansion of the deep inguinal ring (2 in Fig. 4), it is sutured from the lateral side by 1-3 sutures superimposed on the edges of the opening (3 in Fig. 4).

Example 1

Patient P.V., 10 years old, medical history No. 1072. The diagnosis is right-sided inguinal hernia. The term hernias is 2 years. Operation: hernia repair from preperitoneal access on the right. Anesthesia is a combined apparatus-mask anesthesia.

An incision was made in the skin and subcutaneous tissue along the skin fold 4.5 cm long 1.5 cm higher than the ultrasound projection of the deep inguinal ring. The aponeurosis of the external oblique muscle is dissected, the fibers of the internal oblique and transverse muscles of the abdomen are stratified and separated by hooks. The transverse fascia is thinned - dissected. Dull way (Buyalsky's spatula and finger) sequentially detached the parietal peritoneum, distinguished the neck of the hernial sac and adjacent to it, before entering the deep inguinal ring, neurovascular bundle and vas deferens, which are easily separated. The hernial sac is stitched, bandaged at the neck, crossed. The distal sac migrated independently to the inguinal canal. The expanded deep inguinal ring is sutured with 2 sutures from the lateral side without compression of the anatomical elements of the cord. Hemostasis is dry. The surgical wound is stitched tightly in layers. Aseptic dressing. The duration of the operation is 20 minutes.

The early postoperative period was uneventful. Pain during movement persisted during the first day after surgery, pain in the postoperative wound during palpation for 3 days. Swelling of the scrotum and inguinal region was not noted. No decrease in the cremasteric reflex was detected. Sutures were removed on the 6th day after the operation, wound healing - by primary intention. The length of stay in the hospital is 7 days. The patient was examined 6 months after surgery. Complications associated with the operation, recurrence of the disease was not detected.

 Example 2

Patient B.A., 15 years old, medical history No. 1182. The diagnosis is left-sided, irreducible inguinal hernia. The period of hernias is 1 year. Operation: hernia repair from preperitoneal access on the left. Anesthesia is a combined apparatus-mask anesthesia.

An incision was made in the skin and subcutaneous tissue along the skin fold 5 cm long 1.5 cm higher than the established ultrasound projection of the deep inguinal ring. The aponeurosis of the external oblique muscle is dissected, the fibers of the internal oblique and transverse muscles of the abdomen are stratified and separated by hooks. The transverse fascia is thinned - dissected. The blunt path (Buyalsky’s spatula and finger) sequentially detached the parietal peritoneum, distinguished the neck of the hernial sac and the neurovascular bundle and spermatic cord adjacent to it before entering the deep inguinal ring, which are easily separated. The hernial sac is opened, an omentum welded to the wall of the sac is found in the lumen. The omentum is bluntly isolated and after hemostasis is immersed in the abdominal cavity. The neck of the hernial sac is stitched, bandaged, the sac is crossed. The distal sac migrated independently to the inguinal canal. The expanded deep inguinal ring is sutured with 2 sutures from the lateral side without compression of the anatomical elements of the cord. Hemostasis is dry. The surgical wound is stitched tightly in layers. Aseptic dressing. The duration of the operation is 20 minutes.

The early postoperative period was uneventful. Pain during movement persisted during the first day after surgery, pain in the postoperative wound during palpation for 3 days. Swelling of the scrotum and inguinal region was not noted. No decrease in the cremasteric reflex was detected. Sutures were removed on the 6th day after the operation, wound healing - by primary intention. The length of stay in the hospital is 7 days. The patient was examined 5 months after surgery. Complications associated with the operation, recurrence of the disease was not detected.

The proposed method performed 25 operations for patients aged 3 to 10 years. The method is applicable in herniology and can be performed in stationary conditions.

Claims (2)

1. A method of surgical treatment of inguinal hernias in children, including a transverse incision of the skin, subcutaneous tissue and aponeurosis of the external oblique muscle of the abdomen 1-1.5 cm above the projection of the deep inguinal ring, determined sonographically, the separation of the internal oblique and transverse muscles along the muscle fibers up to transverse fascia, dissection of the transverse fascia, isolation of the hernial sac in the preperitoneal tissue, separation of the vessels and the vas deferens from its neck for 1.5-2 cm, stitching and crossing it, stitching operation of a wound, characterized in that the transverse fascia is opened and the peritoneum is exfoliated from it within the lateral inguinal fossa below the proximal edge of the surgical wound, the hernial sac is exposed and the neurovascular bundle of the testicle and the vas deferens are partially adjacent to it, and the hernial sac is separated from these seed components the cord before they enter the deep inguinal ring. 2. The method according to claim 1. characterized in that, if necessary, hydraulic preparation of the vessels, vas deferens and hernial sac is performed with a 0.25% solution of novocaine.

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