CAUSES OF INGUINAL HERNIAS RECURRENCE DURING THE LIECHTENSTEIN OPERATION
Numerous methods of plastic surgery of inguinal hernias with own tissues, which were developed by surgeons, gave relapses up to 35%. A large number of relapses in the treatment of inguinal hernias with tension methods forced surgeons to look for new ways to solve this problem.
Without pathological changes in the deep inguinal ring, a hernia cannot occur, and this leads to the conclusion that all existing methods, which are aimed at strengthening only the front wall of the inguinal canal, are pathogenetically unfounded and often a recurrence of the hernia can be expected.
Therefore, a justified operation for various types of inguinal hernia is the strengthening of the deep ring and the back wall of the inguinal canal.
Changing the concept of the approach to the treatment of inguinal hernias should be aimed at minimizing trauma and take into account the pathogenetic features of the development of hernias.
The reason for the development of inguinal hernias is expansion, destruction, functional insufficiency of deep inguinal openings: medial and lateral.
The back wall of the inguinal canal does not have a protective function when intraperitoneal pressure increases and cannot resist hernia formation. At the same time, its weakening, destruction can contribute to the increase of the internal inguinal opening. Although we did not come across any publication that gave an example of a hernia exiting directly through the back wall of the inguinal canal.
Based on our own clinical experience, as well as the processing of a large number of literary sources, we offer a modified type of Lichtenstein's operation in the following interpretation: a typical incision of the skin and subcutaneous tissue with the opening of the aponeurosis of the external oblique abdominal muscle; mobilization of the spermatic cord; mobilization of the hernia sac, its opening, stitching at the base and removal. With a direct inguinal hernia, if the bag is small, there is no need to remove it. Revision of the internal inguinal ring in case of an oblique hernia and, if necessary, sewing it to the required size (the tip of the little finger should pass between the cord and the ring).
Revision of the medial deep ring in direct inguinal hernia and its suturing "tightly" over the hernial protrusion.
Prepare a mesh implant so that its dimensions cover both deep holes, dissect it according to our proposed method. Fix the net to the deep ring using the described method. Sew the lower part of the mesh with an overlap of 1-1.5 cm to the pubic bone, fix the lateral edge of the implant to the pubic ligament with a wrapping suture or knotted single sutures.
Above the spermatic cord, the legs of the dissected implant are sewn together and sewn to the aponeurosis of the external oblique muscle of the abdomen from below.
The medial edge of the mesh is sewn to the internal oblique muscle and to the aponeurosis of the external oblique muscle in the manner described above.
The middle part of the mesh is fixed to the sewn medial deep inguinal ring and to the middle of the inguinal canal with separate knotted stitches. We lay the spermatic cord on the mesh, over which we sew the aponeurosis of the external oblique muscle of the abdomen, subcutaneous tissue and skin.
In our opinion, the method of surgery proposed by us for direct and oblique inguinal hernias is the most optimal, minimally traumatic, which best meets the modern requirements of the pathogenesis of the disease. But even this method of plastic inguinal hernias is not ideal and needs constant improvement.
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