JOURNAL OF HEPATO-GASTROENTEROLOGY RESEARCH | ЖУРНАЛ ГЕПАТО-ГАСТРОЭНТЕРОЛОГИЧЕСКИХ ИССЛЕДОВАНИЙ
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УДК: 616.34-007.43-031:611.957
Усаров Шерали Насретдинович
ассистент кафедры хирургических болезней №1,
Самаркандского государственного медицинского института.
Самарканд, Узбекистан.
Давлатов Салим Сулаймонович
к.м.н., доцент кафедры факультетской и госпитальной хирургии,
Бухарского государственного медицинского института.
Самарканд, Узбекистан.
Рахманов Косим Эрданович
к.м.н., доцент кафедры хирургических болезней №1,
Самаркандского государственного медицинского института.
Самарканд, Узбекистан.
МОДИФИЦИРОВАННЫЙ СПОСОБ ПЛАСТИКИ ПАХОВОЙ ГРЫЖИ
For citation:
Usarov Sherali Nasritdinovich, Davlatov Salim Sulaymonovich, Rakhmanov Kosim Erdanovich. Modified method
of inguinal hernia repair. Journal of hepato-gastroenterology research. 2020, vol. 3, issue 1, pp. 49-53
http://dx.doi.org/10.26739/
2181-1008-2020-3-12
АННОТАЦИЯ
Паховые грыжи - один из самых распространенных грыж в мире. Их диагностируют чаще у мужчин, в 10 и более
раз чаще, чем у женщин. Цель исследования: повысить эффективность хирургического лечения паховых грыж за счет
совершенствования технологии укрепления обеих стенок пахового канала. Материалы и методы исследования.
Исследование основано на результатах хирургического лечения 47 пациентов, перенесших герниоаллопластику по
поводу паховой грыжи в хирургическом отделении клиники Самаркандского государственного медицинского
института. Результаты исследований. Из 47 выполненных герниоаллопластик в 14 (29,8%) случаях (основная группа)
мы применили модифицированный метод герниоаллопластики паховых грыж. У этих пациентов после обычного
кожного разреза рассекали апоневроз наружной косой мышцы живота. Высоко изолировали и удалили грыжевой
мешок. Затем последовала изоляция семенного канатика по всей его длине. Поперечная фасция обнажалась во
внутреннем отверстии пахового канала. Сетчатый трансплантат 10 × 15 см вскрыт интраоперационно с учетом
индивидуальных особенностей. Выводы. Представленная методика реконструкции пахового канала, направленная на
уменьшение травматизма и сокращение сроков вмешательства, может найти широкое применение.
Ключевые слова:
паховая грыжа, паховый канал, трансплантат, рецидив, осложнение.
Usarov Sherali Nasritdinovich
1-sonli jarrohlik kasalliklari kafedrasi assistenti,
Samarqand davlat tibbiyot instituti.
Samarqand, O'zbekiston.
Davlatov Salim Sulaymonovich
Tibbiyot fanlari nomzodi, fakultet va gospital xirurgiya
kafedrasi dotsenti, Buxoro davlat tibbiyot instituti.
Samarqand, O'zbekiston.
Rakhmanov Kosim Erdanovich
Tibbiyot fanlari nomzodi, 1-sonli jarrohlik kasalliklari
kafedrasi dotsenti, Samarqand davlat tibbiyot instituti.
Samarqand, O'zbekiston.
JOURNAL OF HEPATO-GASTROENTEROLOGY RESEARCH | ЖУРНАЛ ГЕПАТО-ГАСТРОЭНТЕРОЛОГИЧЕСКИХ ИССЛЕДОВАНИЙ
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CHOV CHURRALARINI MODIFITSIRLANGAN USULDA PLASTIKA QILISH
ANNOTATSIYA
Chov churralari dunyodagi eng keng tarqalgan churralar qatoriga kiradi. Ular erkaklar orasida ayollarga qaraganda 10
yoki undan ko'p marta ko`proq aniqlanadi,. Tadqiqotning maqsadi: chov kanalning ikkala devorini mustahkamlash
texnologiyasini takomillashtirish orqali chov churralarni jarrohlik davolash samaradorligini oshirish. Materiallar va tadqiqot
usullari. Tadqiqot Samarqand davlat tibbiyot instituti klinikasining jarrohlik bo'limida chov churra uchun hernioalloplastika
qilingan 47 nafar bemorni jarrohlik davolash natijalariga asoslangan. Tadqiqot natijalari. 14 nafar (29,8%) holatda o'tkazilgan
47 ta hernioalloplastika (asosiy guruh), biz chov churralar modifikatsiyalangan hernioalloplastika usulidan foydalandik. Ushbu
bemorlarda an'anaviy teri kesimidan so'ng tashqi qiyshiq qorin mushaklari aponevrozi kesilgan. Yuqori darajada ajratilgan va
churra sumkasini olib tashlagan. Keyin spermatik simni butun uzunligi bo'ylab ajratib turing. Chov kanalning ichki ochilish
qismida ko'ndalang fastsiya paydo bo'ldi. 10 × 15 santimetrli payvandlash individual xususiyatlarni hisobga olgan holda
operatsiya davomida ochildi. Xulosa. Travmani kamaytirish va aralashish vaqtini qisqartirishga qaratilgan chov kanalni
rekonstruksiya qilishning taqdim etilgan texnikasi keng amaliyotda qo'llanilishi mumkin.
Kalit so'zlar:
chov churra, chov kanali, transplantat, qaytalanish, asorat.
Usarov Sherali Nasredinovich
Assistant of the Department of Surgical Diseases No. 1,
Samarkand State Medical Institute.
Samarkand, Uzbekistan.
Davlatov Salim Sulaymonovich
Candidate of Medical Sciences, Associate Professor
of the Department of Surgical Diseases No. 1,
Samarkand State Medical Institute.
Samarkand, Uzbekistan.
Rakhmanov Kosim Erdanovich
Candidate of Medical Sciences, Associate Professor
of the Department of Surgical Diseases No. 1,
Samarkand State Medical Institute.
Samarkand, Uzbekistan.
MODIFIED METHOD OF INGUINAL HERNIA REPAIR
ANNOTATION
Inguinal hernias are among the most common hernias in the world. They are diagnosed more often among men, 10 or
more times higher than among women. Objective of the study: to increase the efficiency of surgical treatment of inguinal hernias
by improving the technology of strengthening both walls of the inguinal canal. Materials and research methods. The study is
based on the results of surgical treatment of 47 patients who underwent hernioalloplasty for inguinal hernia in the surgical
department of the clinic of the Samarkand State Medical Institute. Research results. Of the 47 performed hernioalloplasty in 14
(29.8%) cases (the main group), we used the modified method of hernioalloplasty of inguinal hernias. In these patients, after a
conventional skin incision, the aponeurosis of the external oblique abdominal muscle was dissected. Highly isolated and removed
the hernial sac. Then followed the isolation of the spermatic cord along its entire length. The transverse fascia was exposed at
the inner opening of the inguinal canal. The mesh graft 10 × 15 cm was opened intraoperatively, considering individual
characteristics. Conclusions. The presented technique of reconstruction of the inguinal canal, aimed at reducing trauma and
reducing the time of intervention, can be used in wide practice.
Key words:
inguinal hernia, inguinal canal, graft, recurrence, complication.
Introduction.
Surgery for inguinal hernias is the most
frequent among elective surgical interventions [1]. At the end
of the 19th century, the basic principles of the surgical
treatment of inguinal hernias were determined. The classic
Bassini method of inguinal hernioplasty served as the basis for
various options for inguinal autogernioplasty. Some of them
are
widely
used
in
surgical
practice.
However,
autogernioplasty performed using the patient's own tissues
does not lead to sufficient strength of the restored structures of
the groin region and is often accompanied by relapses (10% in
primary and up to 30% in repeated hernioplasty) [1, 2].
Surgical treatment of inguinal hernias using traditional
methods involves plastic surgery aimed at strengthening the
anterior or posterior wall of the inguinal canal. The operation
is performed without the use of foreign materials.
The Marcy repair was developed in 1892 and is used
only for oblique inguinal hernias. This technique involves the
reduction of the hernial sac and the closure of the internal
inguinal canal by applying one to three sutures. This leads to
tension in the tissues of the inner inguinal ring, which in turn
causes the formation of recurrent oblique inguinal hernias, and
to a change in the direction of efforts in the area of the bottom
of the inguinal canal, which can lead to the formation of direct
recurrent inguinal hernias.
The Bobrov- Girard method strengthens the anterior
wall of the inguinal canal. Above the spermatic cord, first the
edges of the internal oblique and transverse abdominal
muscles are sewn to the inguinal ligament, and then with
separate sutures - the upper flap of the aponeurosis of the
external oblique abdominal muscle. The lower aponeurosis
flap is fixed with sutures on the upper aponeurosis flap, thus
forming a duplicate.
Method S.I. Spasokukotsky is that the inner
aponeurosis flap of the external oblique abdominal muscle
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together with the edges of the internal oblique and transverse
abdominal muscles is sutured to the inguinal ligament with one
row of interrupted silk sutures. Then the outer flap of the
aponeurosis is sutured over the inner one.
With Cooper's ligament or McVay plastic surgery, the
bottom of the inguinal canal is pulled laterally and fixed to the
Cooper's ligament under the inguinal ligament. This leads to
tissue tension in the area of the bottom of the inguinal canal.
To relieve the tension in the tissues of the bottom of the
inguinal canal resulting from this method, incisions are often
made in the anterior rectus abdominis muscle.
Method M.A. Kimbarovsky. After processing and
cutting off the hernial sac, the inner flap of the dissected
aponeurosis and the underlying muscles are stitched from
outside to inside, retreating 1 cm from the edge of the incision.
The needle is passed again only through the edge of the
internal flap of the aponeurosis, going from the inside out, then
the edge of the inguinal ligament is stitched with the same
thread. Having applied four or five such stitches, they are tied
in turn; while the edge of the internal flap of the aponeurosis
is tucked under the edge of the muscles and brought into close
contact with the inguinal ligament.
The Bassini method is aimed at strengthening the
posterior wall of the inguinal canal. After removing the hernial
sac, the spermatic cord is pushed aside and under it the lower
edge of the internal oblique and transverse muscles is sutured
together with the transverse fascia of the abdomen to the
inguinal ligament. The spermatic cord is placed on the formed
muscle wall. Deep suturing helps to restore the weakened
posterior wall of the inguinal canal. The edges of the
aponeurosis of the external oblique muscle are sutured edge to
edge above the spermatic cord.
Plastic on Shouldice is a modification of plastics
Bassini, assumes a four-bottom closure of the inguinal canal.
After dissection of the oblique hernial sac (if any), the bottom
of the inguinal canal is opened from the inner inguinal ring to
the pubis. The bottom of the inguinal canal is then closed using
four layers of continuous sutures so that the medial edge of the
bottom of the inguinal canal overlaps its lateral edge. The next
two layers overlap the first two layers, while the edge of the
rectus abdominis muscle is pulled closer to the inguinal
ligament. When using this technique, the main tissue tension
occurs in the area of the bottom of the inguinal canal.
The Kukudzhanov method is proposed for straight and
complex forms of inguinal hernias. It consists in suturing
between the outer edge of the vagina of the rectus abdominis
muscle and the superior pubic ligament (Cooper's) from the
pubic tubercle to the fascial sheaths of the iliac vessels. Then
the connected tendon of the internal oblique and transverse
muscles together with the upper and lower edges of the
dissected transverse fascia is sutured to the inguinal ligament
[2, 4, 6]. I. Lichtenstein et al. in search of ways to reduce the
number of relapses (1987, 1991) created the concept of a
tension-free technique. According to the authors, tension
stitching of dissimilar tissues is the main cause of recurrent
hernias, as it does not correspond to the biological laws of
wound healing. The use of various implants for hernia repair
has led to a significant decrease in the number of relapses. The
results of using Lichtenstein plastic surgery in non-specialized
surgical centers are close to the results of treatment in
specialized clinics, which proves the simplicity, safety and
effectiveness of the technique. Over the past decades,
Liechtenstein plastic has become widespread throughout the
world [4, 10].
For radical treatment, only surgical methods of
treatment are used, since defects in the abdominal wall are not
capable of recovery and regeneration. Surgical methods of
treatment are numerous, and long-term results are not always
successful, since for a long-time due attention was not paid to
the posterior wall of the inguinal canal as the main supporting
anatomical structure [2, 3].
Modern herniologists L. Nyhus, RE Condon, et al.
Argue that any inguinal hernia is the result of a stretching or
defect in the transverse fascia. According to the literature, in
Russia in 1 year more than 200,000 hernioplasty for inguinal
hernias are performed, of which more than 70% are performed
by traditional methods. In the United States, out of 700,000
hernia repairs, relapses occur in 10-15%, and the cost of
retreatment is more than $ 28 million [4, 12].
The problem of choosing a relapse-free method of
surgical treatment of patients with inguinal hernias has been
and remains relevant, due to the wide spread of the disease and
the predominant lesion of people of working age (3-7% of the
male working population) [2].
To date, a large amount of material has been
accumulated on the study of the pathogenesis and etiology of
inguinal hernias, numerous methods of surgical treatment have
been described, and the results do not fully satisfy either
patients or surgeons. According to literature data, recurrent
hernias occur in 10% of cases with simple forms, and in 30%
- with complex ones (recurrent, giant, restrained, sliding).
Relapses after traditional methods of hernioplasty are in 20%,
and recurrences are in 35-40% of patients. Over the past 40
years, about 50 new methods of hernia repair have been
proposed, and the total number of methods and modifications
for eliminating inguinal hernias has approached 300 [2]. This
testifies to the ongoing search for new, more effective methods
of surgery and treatment.
Today, the variety of methods for eliminating inguinal
hernias can be grouped into two fundamentally different
methods: plasty with local tissues and "tension-free" with the
use of mesh endoprostheses. Each method has its own
advantages and disadvantages. At the present stage,
endolaparoscopic hernioplasty is widely introduced into
practice. The disadvantages of this method are the complexity
of the technique, the high cost of equipment and consumables,
a large number of contraindications, the possibility of rare but
very dangerous complications [2, 11].
The number of relapses after endoscopy reaches 15-
20%. Despite the enthusiasm for endovideosurgery, the bulk
of the interventions will be performed extraperitoneally for a
long time, therefore, the issue of widespread use of
laparoscopic hernioplasty for inguinal hernias requires further
analysis of the effectiveness and viability of this technique [9].
The increased claims to the assessment of the
postoperative rehabilitation of patients from the standpoint of
the quality of life force to reconsider the requirements for the
proposed methods. The success of surgical treatment of
patients with inguinal hernias, especially in recurrent and
complex forms with altered ratios of the layers of the
abdominal wall and inguinal canal, can be ensured by reliable
strengthening of the posterior wall. The development and
introduction into surgical practice of more effective methods
of treatment and prevention of the development of recurrent
JOURNAL OF HEPATO-GASTROENTEROLOGY RESEARCH | ЖУРНАЛ ГЕПАТО-ГАСТРОЭНТЕРОЛОГИЧЕСКИХ ИССЛЕДОВАНИЙ
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forms of inguinal hernias determines the relevance of the
chosen topic.
Objective of the study:
to increase the efficiency of
surgical treatment of inguinal hernias by improving the
technology of strengthening both walls of the inguinal canal.
Materials and research methods.
The study is based
on the results of surgical treatment of 47 patients who
underwent hernioalloplasty for an inguinal hernia in the
surgical department of the clinic of the Samarkand State
Medical Institute in the period from 2015 to 2019. To study
the effectiveness of the proposed method of inguinal hernia
repair, we compared the results of treatment in both groups.
The first group of control comparison included 33
(70.2%) hernioalloplasty, produced by the conventional
Liechtenstein method. In 14 (29.8%) cases, we used the
technique we developed for alloplasty of inguinal hernias and
combined these observations into the second main group.
In both groups of patients, men were predominant
(control group - 94.6%, main group - 91.2%) over fifty years
(control group - 76.7%, main group - 80.4%).
Table 1 shows the characteristics of patients depending
on the type of hernia according to the classification of LM
Nyhus (1993). Oblique hernias with a widened displaced inner
inguinal ring without protrusion of the posterior wall of the
inguinal canal (type II) were observed in 4 (7.02%) patients in
the control group. Direct hernias (type IIIA) were detected in
5 (8.8%) patients. Oblique hernias with a large dilated internal
inguinal ring (type IIIB) were observed in 25 (43.8%) patients.
In 13 (22.8%) cases, recurrent inguinal hernias were detected
(type IVA - straight, type IVB - oblique) [1].
Table 1.
Distribution of patients by type of hernia.
Comparison
groups
Hernia type
Control
comparison
group
Main group
Total
Quantity
%
Quantity
%
Quantity
%
II
4
12.1
-
4
7.02
IIIA
3
9.1
2
14.3
5
8.8
IIIB
18
54.5
7
50
25
43.8
VAT
-
-
1
7.1
1
1.7
IVB
8
24.2
4
28.6
12
21.05
Total
33
14
47
Research
results.
Of
the
47
performed
hernioalloplasty in 14 (29.8%) cases (the main group), we used
the modified method of hernioalloplasty of inguinal hernias. In
these patients, after a conventional skin incision, the
aponeurosis of the external oblique abdominal muscle was
dissected. Highly isolated and removed the hernial sac. Then
followed the isolation of the spermatic cord along its entire
length. The transverse fascia was exposed at the inner opening
of the inguinal canal. The mesh graft 10 × 15 cm was opened
intraoperatively, taking into account individual characteristics.
The lower edge of the transverse abdominal muscles was
sutured without tension with a 3.0 prolene suture with the
upper inner part of the graft to the transverse fascia. Then the
lower edge of the graft was sewn to the pipartligament with
interrupted sutures to a point located 2 cm lateral to the inner
inguinal ring. Further, in the projection of the center of the
inner inguinal ring, a graft was taken into the fold with a clamp
and a hole 7-8 mm in diameter was cut out with scissors. The
graft was dissected from it vertically upwards. The spermatic
cord was placed through the incision into the prepared hole.
This achieved an extremely accurate comparison of the exit
site of the spermatic cord and the window in the graft. The
medial edge of the graft was fixed with a continuous suture to
the aponeurosis of the rectus abdominis muscle. Then, with the
same thread, the upper edge of the mesh was fixed from the
inside with a U-shaped suture to the aponeurosis of the
external oblique abdominal muscle. After the final
straightening of the mesh, the excess lateral flap was excised.
The aponeurosis of the external oblique muscle of the
abdomen was sutured edge to edge. The operation was
completed by suturing the subcutaneous tissue and continuous
intradermal suture. Sutures were applied to the skin.
When
performing
hernioplasty
according
to
Liechtenstein (control group), the average duration of the
operation was 56.5 ± 12.4 minutes. When using the method of
operation developed by us (in the main group), the duration of
the operation was 39.7 ± 13.6 minutes. Thus, in the main
group, the duration of the operation was shorter than in the
control group.
Pain syndrome after surgery was mild or moderate in
all patients. In no case was the administration of narcotic
analgesics required. With any method of alloplasty, despite the
inertness of the synthetic material, a tissue reaction develops
around it, accompanied by the release of a large amount of
serous exudate, and long-term persistent seromas are formed
[4, 6]. In 8 (24.2%) patients in the control group in the early
postoperative period, long-term persistent seroma with skin
maceration around the wound was observed. No such
complications were observed in the main group. Wound
suppuration was not noted either in the main group or in the
control comparison group.
In terms from 12 months to 3 years, the results of
surgical treatment were traced in 25 patients of the control
group and in all patients of the main group. No relapse of the
disease was observed in the long-term period. In the control
group, 1 patient with benign prostatic hyperplasia had a relapse
of the disease. After elimination of the etiological factor, the
patient underwent a second operation using a modified method
developed by us.
Conclusions.
Thus, the presented technique of
reconstruction of the inguinal canal, aimed at reducing trauma
and shortening the time of intervention, can be used in wide
practice.
This method is more reliable due to the following
circumstances:
1. The implant is located under the muscles, but
adjacent to the aponeurosis. With this option, firstly, intra -
abdominal pressure is evenly distributed over all fixation
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points and there is less likelihood of tearing the mesh from the
tissue, and secondly, when the mesh is fixed to the
aponeurosis, the tissue reaction develops less, with the
formation of a long-term persistent seroma.
2. The method is universal, i.e. can be used for both
oblique and direct inguinal hernias.
3. Here, to a much lesser extent, the topographic and
anatomical relationships in the groin area are disturbed, and in
conditions of hernia repair with recurrent and multiple
recurrent hernias, these relationships are restored.
4. The method is less traumatic, simple and, most
importantly, pathogenetically justified.
Conflict of interest.
The authors declare no conflicts
of interest or special funding for the current study.
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