Method for laparoscopic treatment of inguinoscrotal hernia

Abstract

FIELD: medicine; surgery; herniology.SUBSTANCE: during laparoscopic treatment of inguinoscrotal hernia, the peritoneum is cut along the diameter of the hernial orifice, which is at the level of the horizontal line from the pubic symphysis to the iliac crest. Resection of the hernial sac is performed at the level of the neck, avoiding damage to the inferior epigastric vessels and elements of the spermatic cord. The lower peritoneal flap is mobilized 4.0 cm below the pubic symphysis medially and to the iliopsoas muscle laterally, and the upper flap is mobilized 4 cm above the edge of the hernial orifice, creating a platform for the polypropylene mesh. A polypropylene mesh is installed, followed by peritoneal grafting using the formed parietal peritoneum flaps.EFFECT: reducing trauma and risk of postoperative complications during laparoscopic treatment of inguinoscrotal hernia.1 cl, 1 dwg, 2 ex

Description

[0001] The invention relates to medicine, namely to surgery, herniology, and can be used for the surgical treatment of inguinal-scrotal hernias.

[0002] There are many surgical treatment options for inguinoscrotal hernias, varying in access to the hernial sac, the method of reducing the contents of the hernia, and the repair technique, depending on the specific clinical case. Choosing the right hernioplasty method for inguinoscrotal hernias is one of the unresolved issues in modern herniology.

[0003] 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: 02 / 19 / 2024), in which, through traditional access, the skin and subcutaneous fat are dissected to the aponeurosis, the inguinal canal is opened, the spermatic cord is taken on a holder, isolated and processed by the hernial A polypropylene mesh is pre-cut and placed on the posterior wall of the inguinal canal, fixed to the inguinal structures: the pubic tubercle, the inguinal (Pupart's) ligament, and the edge of the internal oblique muscle in the tendon area. The spermatic cord is placed on the mesh. The anterior wall of the inguinal canal is reconstructed by suturing the aponeurosis layers edge to edge with a continuous suture.

[0004] The disadvantages of this method are:

[0005] - high trauma of access to the posterior wall of the inguinal canal;

[0006] - the presence of access in the plastic surgery area causes complications from the wound (hematomas, seromas, suppuration);

[0007] - a large area of ​​the wound surface in the scrotum after the isolation of the hernial sac, its mobilization from the spermatic cord can cause the formation of seromas and hematomas of the scrotum, complications from the testicle and epididymis (orchitis, epididymitis);

[0008] - recurrence of hernia in case of development of infection in the wound of the groin area, requiring reoperation.

[0009] Well-known endovideosurgical methods of inguinal hernioplasty (transabdominal preperitoneal plastic surgery and total extraperitoneal plastic surgery) involve wide dissection of the parietal peritoneum and mobilization of the hernial sac from the inguinal canal, followed by prosthetics of the posterior wall of the inguinal space with a polypropylene mesh. (Claus C, Furtado M, Malcher F, Cavazzola LT, Felix E. Ten golden rules for a safe MIS inguinal hernia repair using a new anatomical concept as a guide. Surg Endosc. 2020 Apr; 34(4):1458-1464. doi: 10.1007 / s00464-020-07449-z. Epub 2020 Feb 19. PMID: 32076858).

[0010] The disadvantages of these methods are:

[0011] - trauma: mobilization of the hernial sac from the inguinal canal and scrotum determines the presence of a large wound surface, which is fraught with the formation of seromas and hematomas of the scrotum;

[0012] - dissection of the spermatic cord over a significant length is dangerous due to damage to its elements with subsequent development of ischemic and inflammatory complications of the testicle and its appendages.

[0013] The closest to the claimed method is the method of O.E. Lutsevich (patent RU 2549478, published April 27, 2015), in which the inguinal canal is opened through an incision in the groin area, the hernial sac is isolated, sutured at the neck, and resected. The inguinal access is sutured. The second stage involves laparoscopic inguinal hernioplasty with a preperitoneal polypropylene mesh.

[0014] The disadvantages of this technique are:

[0015] - the presence of traditional inguinal access increases the trauma of the intervention and the risk of developing complications from the wound;

[0016] - traumatic operation due to two approaches;

[0017] - the release of the hernial sac from the scrotum causes a large wound surface and injury to the elements of the spermatic cord.

[0018] The technical problem is to develop an effective, minimally invasive method of laparoscopic treatment of inguinal-scrotal hernia, free from the above-mentioned disadvantages and eliminating the risk of negative effects in the postoperative period.

[0019] The technical result is achieved by using a laparoscopic approach for laparoscopic treatment of inguinoscrotal hernias. The peritoneum is incised at the level of the horizontal diameter of the hernial orifice (medially from the pubic symphysis, laterally to the iliac crest). The hernial sac is resected at the neck level along the superior and inferior hemispheres. When performing resection of the hernial sac along the superior hemisphere, damage to the inferior epigastric vessels is avoided, and when performing resection of the hernial sac along the inferior hemisphere, damage to the spermatic cord elements is avoided. The resulting upper flap of the parietal peritoneum is mobilized 4 cm above the hernial orifice from the midline to the iliac crest, the lower flap of the parietal peritoneum is mobilized downwards 4 cm below the pubic symphysis, to the intersection of the vas deferens with the iliac vein and to the iliopsoas muscle.This creates a platform for a 10x15 cm polypropylene mesh, leaving the hernial sac within the inguinal canal and scrotum. After the posterior inguinal wall is replaced, the mesh is peritonized.

[0020] The proposed technique increases the effectiveness of laparoscopic treatment of inguinal-scrotal hernias and reduces negative effects in the postoperative period due to the fact that the peritoneum is cut in an atypical manner, the hernial sac is resected at the level of the neck without isolating it, a polypropylene mesh is installed, followed by peritonealization.

[0021] The claimed invention is illustrated by a drawing, which shows a fragment of the operating area with a resected hernial sac extending into the scrotum.

[0022] The following symbols are shown in the drawing:

[0023] 1 - inferior epigastric vessels;

[0024] 2 - vas deferens;

[0025] 3 - testicular vessels and muscle supporting the testicle;

[0026] 4 - resected hernial sac extending into the scrotum;

[0027] 5 - upper parietal peritoneum flap;

[0028] 6 - ​​lower flap of the parietal peritoneum;

[0029] 7 - cutting line.

[0030] The method is carried out as follows.

[0031] At the beginning of the operation, the patient is in a supine position with the head down. Trocars (3 pcs.) are placed at typical points. The inguinoscrotal hernia is assessed under laparoscope control. The peritoneum is incised at the level of the horizontal diameter of the hernial orifice (medially: from the pubic symphysis, laterally: to the iliac crest); the hernial sac is resected at the level of the neck along the upper and lower semicircles. When performing resection of the hernial sac along the upper semicircle, damage to the inferior epigastric vessels is avoided, and when resecting the hernial sac along the lower semicircle, damage to the spermatic cord is avoided. The hernial contents (if any) are brought down into the abdominal cavity.The resulting upper flap of parietal peritoneum is mobilized 4 cm above the hernial orifice, extending from the midline to the iliac crest. The lower flap is mobilized downward 4 cm below the pubic symphysis, to the intersection of the vas deferens with the iliac vein and to the iliopsoas muscle. This creates a platform for the polypropylene mesh, while the hernial sac remains in the inguinal canal and scrotum. A mesh measuring 10 x 15 cm or larger is used, providing long-term support and strengthening the weakened abdominal wall, preventing hernia recurrence. After the posterior inguinal wall is replaced, the mesh is peritonized.

[0032] The claimed invention is explained by examples.

[0033] Example 1

[0034] Patient A., 54 years old, diagnosed with right inguinoscrotal hernia. The patient underwent surgery using the proposed method in 2019.

[0035] Laparoscopy is performed under endotracheal anesthesia in the supine position, with trocars placed at typical locations. A right inguinoscrotal hernia was identified under laparoscopic guidance. The peritoneum was incised at the level of the horizontal diameter of the hernial orifice (medially from the pubic symphysis, laterally to the iliac crest). The hernial sac was resected at the neck level along the superior and inferior hemispheres. When performing the resection of the hernial sac along the superior hemisphere, damage to the inferior epigastric vessels was avoided, and when performing the resection of the hernial sac along the inferior hemisphere, damage to the spermatic cord was avoided. The resulting upper flap of the parietal peritoneum was mobilized 4 cm above the hernial orifice from the midline to the iliac crest, the lower flap of the parietal peritoneum was mobilized downwards 4 cm below the pubic symphysis, to the intersection of the vas deferens with the iliac vein and to the iliopsoas muscle.Thus, a platform was created for the 10x15 cm polypropylene mesh, leaving the hernial sac within the inguinal canal and scrotum. After the posterior inguinal wall was replaced, the mesh was peritonized.

[0036] The patient wore a support bandage for one month postoperatively. On the third day, the patient was discharged for outpatient treatment in satisfactory condition. He was examined at three months, one year, and three years postoperatively. No evidence of recurrence or complications involving the scrotum or testicle was found.

[0037] Example 2

[0038] Patient B., 65 years old, diagnosed with left inguinoscrotal hernia. The patient underwent surgery using the proposed method in 2021.

[0039] Laparoscopy is performed under endotracheal anesthesia in the supine position, with trocars placed at typical locations. A left inguinal scrotal hernia was identified under laparoscopic guidance. The peritoneum was incised at the level of the horizontal diameter of the hernial orifice (medially from the pubic symphysis, laterally to the iliac crest). The hernial sac was resected at the neck level along the superior and inferior hemispheres. When performing the resection of the hernial sac along the superior hemisphere, damage to the inferior epigastric vessels was avoided, and when performing the resection of the hernial sac along the inferior hemisphere, damage to the spermatic cord was avoided. The resulting upper flap of the parietal peritoneum was mobilized 4 cm above the hernial orifice from the midline to the iliac crest, the lower flap of the parietal peritoneum was mobilized downwards 4 cm below the pubic symphysis, to the intersection of the vas deferens with the iliac vein and to the iliopsoas muscle.Thus, a platform was created for the 10x15 cm polypropylene mesh, leaving the hernial sac within the inguinal canal and scrotum. After the posterior inguinal wall was replaced, the mesh was peritoneized.

[0040] The patient wore a support bandage for one month postoperatively. On the fourth day, the patient was discharged for outpatient treatment in satisfactory condition. The patient was examined at one month, three months, one year, and three years postoperatively. No evidence of recurrence or complications involving the scrotum or testicle was found.

[0041] A total of 213 patients underwent surgery at the I.I. Mechnikov North-Western State Medical University between 2016 and 2024, including 134 patients who underwent surgery using the proposed method (laparoscopic approach) and 39 patients who underwent surgery using the prototype method (inguinal approach + laparoscopic approach). In the late postoperative period (2-12 months), no recurrences or complications associated with the hernial sac remaining in the scrotum were observed in patients in the first group (those who underwent surgery using the proposed method). However, in the second group (those who underwent surgery using the prototype method), 13.4% of patients developed complications from the inguinal wound, significantly increasing the treatment time and reducing the patients' quality of life. In the postoperative period, patients in the second group required conservative treatment and additional costs associated with the purchase of medications.

[0042] Thus, the use of the claimed method of laparoscopic treatment of inguinal-scrotal hernia in surgical practice significantly increases the effectiveness of treatment, reduces trauma and the risk of postoperative complications.

Claims

A method for laparoscopic treatment of inguinoscrotal hernia, which involves laparoscopic access, peritoneal opening, resection of the hernial sac, and installation of a polypropylene mesh, characterized in that the peritoneum is opened along the diameter of the hernial orifice, which is at the level of the horizontal line from the pubic symphysis to the iliac crest, resection of the hernial sac is performed at the level of the neck, avoiding damage to the inferior epigastric vessels and elements of the spermatic cord, the lower peritoneal flap is mobilized 4.0 cm below the pubic symphysis medially and to the iliopsoas muscle laterally, and the upper flap is mobilized 4 cm above the edge of the hernial orifice, creating a platform for the polypropylene mesh, after which the polypropylene mesh is installed with subsequent peritonealization with the formed flaps of the parietal peritoneum.

Images