Inguinal hernia in men operation according to Liechtenstein. Treatment of inguinal hernia is Lichtenstein operation. Hernia repair according to Sapezhko

The Lichtenstein operation is a variant of plastic surgery for inguinal hernia with strengthening of the hernial orifice with a mesh implant. This hernia repair technique is performed on children and adult patients more often than others, but has both advantages and disadvantages.

The Lichtenstein operation for inguinal hernia is the “gold standard” of surgery for removing a defect in the groin without tension on the natural tissues surrounding the hernial sac. During the operation, polymer or composite meshes are used, which have the ability to dissolve over time and promote the healing of injured tissue.

How is hernioplasty performed?

The operation has a small number of contraindications and risks; special preparation for surgery is not required. Inguinal hernia repair according to Lichtenstein is performed under spinal anesthesia; less commonly, general anesthesia is used.

Operation stages:

Creating access to the hernial sac - an incision of about 5 cm is made.
Dissection of the aponeurosis of the oblique muscle to the inguinal ring.
Fixation of the aponeurosis with a holder.
Isolation of the hernia, return of organs to their anatomical place.
Installation of surgical mesh.
Suturing the aponeurosis, applying absorbable sutures.

The Lichtenstein method is suitable for any type of groin hernia. This is one of the main options for getting rid of a hernia with minimal risk of recurrence. When other techniques involve suturing the defect with surrounding tissue, Lichtenstein hernioplasty uses a mesh that prevents re-protrusion, which is the main advantage of the method.

The criterion for the quality of the operation will be the wrinkling of the mesh implant, this indicates that the plastic surgery was performed without tissue tension, which guarantees good support of the hernial orifice.

Contraindications for surgery

Limitations and contraindications for plastic surgery according to Liechtenstein:

intolerance to anesthesia may become an obstacle to the operation, pain relief in this case will result in complications;
with a strangulated hernia emergency open surgery is performed, plastic surgery is postponed or completely cancelled;
when there are symptoms of acute abdomen the operation is not performed until the exact clinic and cause of the serious condition are clarified;
with a large hernia size some surgeons refuse to perform Lichtenstein surgery, predicting relapse after plastic surgery;
previous abdominal surgery is a contraindication to plastic surgery with mesh implant fixation;
chronic heart disease, bleeding disorders will also limit the choice of surgical treatment;
an absolute contraindication would be intestinal obstruction.

Advantages of plastic surgery according to Liechtenstein

The operation has become widespread due to the absence of a tension factor in the tissues surrounding the hernia, which has reduced the number of patients with relapse after surgical treatment. This technique also eliminates many postoperative complications associated with the cardiovascular system.

What other advantages does inguinal canal plastic surgery according to Lichtenstein have:

reduction in cases of postoperative complications by 10 times;
relatively short rehabilitation period;
absence of severe pain after surgery;
the possibility of performing plastic surgery under anesthesia without anesthesia;
simple technique, which reduces the risk of surgeon error.

Disadvantages of the method

Among the disadvantages of Lichtenstein plastic surgery, surgeons identify the following factors:

risk of injury and nerve damage in the groin which may result in loss of tissue sensitivity in the operated area;
risk of infection there is always, but after surgery doctors do everything possible to prevent purulent inflammation, and much depends on the patient himself;
Women are at risk of damage to the uterine ligament, which will lead to its descent; this complication is characterized by bleeding and severe pain;
scar changes can cause ischemia, testicular atrophy and dysfunction of the glands.

The likelihood of complications and recurrence of the hernia will depend on the accuracy of the diagnosis and the professionalism of the doctor, especially when it comes to operating on young children.

The cause of re-development of the disease can be the fixation of an implant that is not suitable in size and poor-quality treatment of the hernial sac. In addition to the recurrence of the inguinal hernia, there are other equally alarming consequences of the operation.

Possible complications

Before surgery, the surgeon always warns about the risk of complications:

wound infection and suppuration of sutures;
damage to organs in the hernial sac and trauma to surrounding tissues;
inaccurate fixation of the implant with its subsequent migration;
recurrence of the disease, development of a postoperative hernia;
complications after administration of an anesthetic drug;
hemorrhage with the formation of a hematoma.

Rehabilitation

Most complications can be prevented by following the rules of prevention in the early postoperative period. After plastic surgery performed under general anesthesia, the initial recovery lasts 2 days, then the patient is discharged home, but is observed by the surgeon for 2 weeks. In the first 14 days after plastic surgery, a gentle diet is prescribed, eliminating constipation and bloating. The patient should refrain from physical activity and wear a groin bandage regularly while performing daily activities.

In the early period after surgery, changes in the groin area can be observed:

swelling of the skin in the perineum;
darkening in the area of the surgical suture;
numbness or sensitivity;
minor bruising.

These symptoms are a normal reaction of the operated area to hernia repair. To ensure that the condition remains within normal limits, it is important to take precautions.

It is recommended not to drive for the first week, and it is also important to rule out conditions that would cause severe coughing or sneezing. For several days after plastic surgery, the scar should be protected from water. In the late period after surgery, the doctor may prescribe physical therapy and physiotherapy.

The disadvantage of this technique is the severe pain syndrome that occurs due to suturing of deep fascia and muscles and compression of nerve trunks. After hernia repair according to C.B. McVay patients can start working no earlier than 3–4 weeks.

The introduction of multilayer plastic methods has reduced the number of relapses, especially when operating on complex and recurrent hernias. The disadvantage of these methods is the complexity of the surgical technique and its traumatic nature, which prevents their widespread use.

A common disadvantage of all autoplastic methods of treating inguinal hernias is the tension of the tissues used to close the defect, which leads to disruption of microcirculation and the development of trophic disorders in them. This becomes the main reason for relapse.

Repair of inguinal hernias using mesh allografts (Lichtenstein method, insertion method, Stopp method)

As noted, in the 60s of the XX century. Polymer materials began to be used in hernia surgery. However, due to the large number of complications when using nylon, nylon, and dacron allografts (wound suppuration, formation of seromas, inflammatory infiltrates, hematomas, fistulas), these techniques were not used for some time. F.C. Usher (1959) was one of the first to develop a fundamentally new plastic material based on polypropylene mesh. These meshes (Marlex mesh, Bard, USA), when used as a plastic material, unlike nylon and nylon, were not rejected and did not cause serious complications. American surgeon I.L. Lichtenstein (1986) developed and tested a method for the treatment of inguinal hernias based on the use of mesh allografts made of polypropylene. Unlike

methods E. Bassini, E.E. Shouldice, C.B. McVay, plastic surgery of inguinal hernias using the Lichtenstein method is performed without tension on tissues (aponeurosis, muscles, ligaments) by suturing a mesh graft into the hernia defect. It has been proven experimentally and clinically that in the absence of tissue tension, ischemic and degenerative changes do not occur in them, which prevents the occurrence of recurrent hernias. Polypropylene meshes were usually fixed in such a way as to strengthen the posterior wall of the inguinal canal. Quickly growing granulation tissue, the polypropylene mesh becomes an integral part of the abdominal wall and reliably prevents the development of hernias. Currently, plastics with polymer materials are experiencing a rebirth (I.L. Lichtenstein, 1989; L.M. Nyhus, 1995; R. Stoppa, 1995; P. Amid, 2000).

An important aspect of inguinal hernia surgery is the economic aspect: the time the patient loses ability to work after the operation, the time he spends in the hospital, the cost of the operation and anesthesia. Thus, the period of complete social and labor rehabilitation after autoplasty of an inguinal hernia is 4–6 months. In 1966, the American surgeon Lichtenstein first drew attention to the importance of the period of postoperative disability. Gradually, new criteria for assessing the effectiveness of inguinal hernia repair were introduced and legalized not only by the absence of recurrence for a certain time, but also by the time of postoperative disability, the severity of postoperative pain syndrome, and swelling of the spermatic cord.

Since 1984, the Lichtenstein Clinic began to perform surgical interventions using a new technique called “free tension”. The key point of this method was the use of alloplasty. In the mid-90s, this technique began to be introduced in various clinics around the world (A.I. Gilbert,

1992; A.G. Shulman, 1992; R.E. Stoppa, 1993; G.E. Wantz, 1993; Kingsnorth, 1994). Currently, data from more than 70 surgeons who performed 22,300 operations using the Lichtenstein method have been published.

According to the literature and our experience, it can be argued that the Lichtenstein method has become one of the modern optimal methods for treating inguinal hernias (P.K. Amid, 1999; I.M. Rutkov, 1999; G.E. Wantz et al., 1999; V.V. Grubnik et al., 1999). Its main advantages: simplicity, low cost, good immediate and long-term results.

Technique of inguinal hernia repair according to Lichtenstein.

Surgery is usually performed under local anesthesia. A skin incision is made from the pubic tubercle laterally, parallel to the inguinal ligament. Due to the fact that when performing an operation according to the Lichtenstein technique, there is no need for a wide dissection of the muscles and transverse fascia, the skin incision does not exceed 5–6 cm. After the skin incision and dissection of the subcutaneous fatty tissue, the aponeurosis of the external oblique abdominal muscle and the outer ring of the inguinal canal are opened . The upper layer of the aponeurosis of the external oblique abdominal muscle is mobilized from the underlying internal oblique abdominal muscle by 3–4 cm (Fig. 81). Sufficient mobilization of the external oblique aponeurosis is dually important because it allows visual identification of the iliohypogastric nerve and creates a large space for implantation of the mesh allograft. The spermatic cord is then mobilized, while avoiding possible damage to blood vessels and nerves. If the hernia is oblique, then a hernial sac is found among the elements of the spermatic cord. If the hernial sac is small, after isolation it is immersed in the abdominal cavity. For inguinal-scrotal hernias, the hernial sac is sutured

bases, bandaged and excised. In case of direct hernias, it is invaginated into the abdominal cavity. With large inguinoscrotal hernias, complete separation of the hernial sac from the elements of the spermatic cord is quite traumatic, in some cases requiring removal of the testicle into the wound, accompanied by damage to the vessels of the spermatic cord, which leads to ischemic orchitis and testicular atrophy in the future. Therefore, in such cases, a number of authors (G.E. Wantz, 1992, 1999; P.K. Amid, 1999) suggest not completely isolating the hernial sac, but crossing and ligating it at the level of the internal ring of the inguinal canal. To prevent testicular hydrocele from occurring, the anterior wall of the hernial sac is partially excised, and the distal part of the hernial sac is left in situ. After isolating the hernial sac, the inguinal canal is carefully examined, and through the Borgos space, the femoral canal is examined for the presence of femoral hernias.

For hernial orifice repair, most authors use polypropylene mesh. A patch of a certain shape (Fig. 82) measuring 6 x 12 cm is cut out of the mesh. Some authors (P.K. Amid, 1999; Kark, Kurzer, 1999) believe that the allograft should not be less than 8–10 x 16 cm.

Taking the cord upward, the rounded end of the mesh is fixed with a monofilament thread to the pubic tubercle (to the superior pubic ligament) (see Fig. 82). This is a decisive moment that ensures the reliability of all plastic. We consider it mandatory to capture the superior pubic ligament with the first 2–3 sutures in order to prevent the development of a femoral hernia. The mesh is fixed to the inguinal ligament with 4–5 interrupted sutures or a continuous suture. The last suture on the inguinal ligament should be located lateral to the internal inguinal ring.

Along the outer edge of the mesh, an incision is made parallel to the inguinal ligament, forming two ends: wide (2/3) at the top and

narrower (1/3) at the bottom (Fig. 83). The upper, wide end is passed over the spermatic cord, it crosses and is located on top of the narrow one (Fig. 84). Thus, the spermatic cord passes through the window in the mesh (Fig. 85). Both ends of the mesh are sewn together with interrupted sutures. The “window” in the mesh should have a diameter of about 1 cm. Then the superomedial edge of the mesh is fixed with 4–5 interrupted sutures to the internal oblique and transverse abdominal muscles and to the rectus sheath (see Fig. 84, 85). An important criterion for the quality of plastic surgery is the wrinkling of the mesh after the end of its fixation stage, which ensures tension-free plastic surgery. Crossing the two ends of the mesh to form a “window” creates a configuration similar to the natural one formed by the transversalis fascia, which is considered responsible for the integrity of the internal ring normally. Excess mesh along the lateral edge is trimmed, leaving at least 5–7 cm of mesh behind the inner ring. The remainder is brought under the aponeurosis of the external oblique muscle, which is then sutured over the cord with a non-absorbable end-to-end suture without tension. After the mesh has grown into granulation tissue, intra-abdominal pressure is evenly distributed over the entire area of the mesh. The aponeurosis of the external oblique muscle firmly holds the mesh in place, acting as an external support when intra-abdominal pressure increases.

Bard has proposed a special mesh graft design that greatly simplifies the operation using the Lichtenstein technique. The graft is made of a monofilament polypropylene mesh and consists of an inner round shape of small diameter and an outer ellipsoidal layer of large dimensions welded to it (Fig. 86). Plastic surgery using such a graft is carried out as follows: the lower mesh plate of the graft

inserted into the inner ring of the inguinal canal and straightened in the preperitoneal tissue. The outer plate is fixed to the superior pubic and inguinal ligaments and muscles. Performing hernioplasty using this mesh allograft is significantly simplified and takes no more than 15–20 minutes.

For small oblique inguinal hernias, Lichtenstein proposed strengthening the internal ring of the inguinal canal by introducing a mesh rolled into a “roller” (Fig. 87). This technique was first proposed for the repair of femoral hernias, and then it began to be used for inguinal hernias. A rolled mesh graft (in American literature this technique is called “plug”) is fixed with several sutures in the inguinal canal, preventing the hernia from coming out (Fig. 88). Studies have shown that in the human body, the size of a rolled mesh graft can be reduced by up to 75%. The latter can cause migration of the graft with the formation of a recurrent hernia. Such serious complications as perforation of the bladder or intestines as a result of transplant migration have also been described (P.K. Amid, 1997). Therefore, Bard currently produces special mesh grafts in the form of a pyramid or shuttlecock (Fig. 89). The top of such a graft is inserted into the hernial canal, and the petals of the base are fixed to the walls of the inguinal canal with several sutures. From above, the area of the inguinal canal is additionally covered with a sheet of mesh graft. A similar operation is widely used and promoted by American surgeons: Ira M. Rutkov and Alan W. Robbins (1993, 1999), who performed more than 2000 hernia repairs using the “plug” technique. Despite the fact that the authors report excellent immediate and long-term results of such operations, a number of surgeons (P.K. Amid, 1999; S.E. Stock,

1995, 1999; G.E. Wantz, 1999) believe that the “plug” technique is advisable to use for small femoral and oblique inguinal hernias. Even the latest design of branded mesh grafts in the form of shuttlecocks is not without drawbacks: when the connective tissue grows, the shuttlecock shrinks

And its diameter decreases by 10–15% (P.K. Amid et al., 1997), which may be the reason for the migration of the latter and the development of recurrent hernia. Therefore, the technique of inguinal hernia repair using mesh grafts in the form of shuttlecocks (“plugs”) is not widely used at present.

After surgery, patients are placed on the operated area with an ice pack for 1–2 hours and given analgesics, and after 6–8 hours they are allowed to get up and walk. As a rule, patients are discharged 6–12 hours after surgery. In the first 4 days after surgery, patients are prescribed non-narcotic analgesics (analgin, baralgin, tramadol, paracetamol). It should be noted that after hernioplasty according to Lichtenstein, the pain syndrome is significantly less pronounced than after classical herniotomy according to the method of Bassini, Shouldice, McVey, Girard. This is due to the fact that there is no tissue tension, constant tension of the muscles and ligaments in the groin area. The mesh graft quickly grows into granulation tissue; its complete ingrowth occurs within 3–6 weeks. after operation. Therefore, patients should be advised to limit physical activity in the first 2 weeks. Starting from the 3rd week, patients can begin active physical work and sports.

Observation by a surgeon is required in the first 10–14 days after surgery for early detection of postoperative complications (hematomas, seromas in the operation area, suppuration of the postoperative wound). During this period, special attention should be paid to

condition of the testicle, the presence of scrotal edema, detection of ischemic orchitis and, as a consequence, testicular atrophy. To study the long-term results of surgical interventions, patients should be examined by a surgeon after 3, 6, 12 months. after surgery, as well as in the long term (3 years, 5 years or more). When examining in the long term, special attention is paid to the presence of relapse, the severity of pain syndrome (chronic pain in the groin area, pain during exercise, urination, radiating pain along the nerves, pain during urination), as well as the appearance of hernias (inguinal, femoral) on the opposite side. side. A thorough study of the immediate and long-term results allows us to objectively assess the effectiveness of various types of hernioplasty.

Results of hernioplasty using the Lichtenstein method.

The Lichtenstein technique is currently widely used in clinics in the USA and Western Europe. The results of this method were most thoroughly studied at the Institute of Herniology, created by Liechtenstein himself. Liechtenstein's student P.K. Amid, at the first international congress on ambulatory surgery (Venice, 1999), reported the results of 5,000 hernioplasties using the Lichtenstein method performed over the past 10 years. The age of the operated patients ranged from 19 to 86 years. 44% of patients had oblique inguinal hernias, 43.1% had direct inguinal hernias, 12.5% had both direct and oblique inguinal hernias, and a combination of inguinal and femoral hernias – 5.8%. 27% of patients were operated on for bilateral inguinal hernias. 22% were overweight. Almost all patients (98.7%) were operated on under local anesthesia. The average duration of the operation is 30–45 minutes; 99% of patients were operated on as an outpatient basis and were discharged 3–6 hours after surgery.

Having studied the immediate and long-term results of Lichtenstein operations in 5000 patients, P.K. Amid (1999) noted a very low percentage of postoperative complications - not exceeding 1-2%. Recurrent hernias were observed in only 4 (0.08%) patients. Analysis of these cases showed that in 3 patients relapse occurred due to the use of small-sized meshes, in 1 – as a result of poor graft fixation. P.K. Amid indicates the need to use meshes of sufficient size (should overlap the Hesselbach triangle by 3–4 cm). It must be remembered that according to recent studies (A.G. Shulman, 1995; P.K. Amid, 1997), when a mesh graft grows with connective tissue, the size of the graft decreases by approximately 20%. The second important factor in the success of the operation is the careful fixation of the mesh to the superior pubic and inguinal ligaments, as well as to the muscles in the area of the internal inguinal ring. When the mesh graft is installed correctly, intra-abdominal pressure presses it against the anterior abdominal wall and thus provides additional fixation. If the size of the mesh is not large enough and it is poorly fixed, then in the early postoperative period it may become displaced, it may curl into a “roller,” which will inevitably lead to the development of a relapse. With proper technical performance of hernioplasty using the Lichtenstein method, as a rule, no relapses are observed.

From 1994 to 2000, 282 patients (263 men and 19 women) were operated on for inguinal hernias in our clinic. In 74 patients, hernioplasty was performed on both sides. 74 patients underwent surgery for recurrent hernias (Table 4). The patients' ages ranged from 16 to 86 years; the average age is 42.2 years.

Table 4. Nature of surgical interventions performed

Patients with	According to the Lichtenstein method		Autoplastic methods

	Unilateral	Double sided	Unilateral	Double sided

Primary

Recurrent

A total of 356 hernia repairs were performed, of which 209 were performed using the Lichtenstein method, 147 using autoplastic methods (according to Bassini, Girard-Kimbarovsky, Postemski, McVay). 175 patients (62%) had concomitant pathologies: coronary heart disease with varying degrees of circulatory failure, hypertension, varicose veins of the lower extremities, chronic nonspecific lung diseases, obesity, and urinary tract diseases.

Patients with hernias did not undergo special preoperative preparation. Most patients arrived at the clinic on the day of surgery. The method of anesthesia was chosen depending on the size of the hernial protrusion, the general condition of the patient, the presence of concomitant pathology and the need to perform simultaneous surgical interventions. The operation was performed under local anesthesia in 220,220 patients (78%), under spinal anesthesia - 14, under general anesthesia - 48.

According to the Lichtenstein method given above, 163 patients were operated on. During 43 surgical interventions, the plastic “patch” was supplemented by the use of an “insert” - “plug” (see Fig. 89), which was a shuttlecock made of mesh, 5 x 2 cm in size. The “insert” was inserted into the expanded internal inguinal ring and fixed to the transverse fascia with 4–5 interrupted sutures. Then plastic surgery was performed according to the method described above.

Yu. P. SAVCHENKO, I. Y. LAKOMSKY, M. D. ZEZARAHOVA, A. P. PUZANOV

INGUINAL HERNIA REPAIR ACCORDING TO LIECHTENSTEIN

Department of General Surgery, Kuban State Medical University of the Ministry of Health of Russia, Russia, 350063, Krasnodar, st. Sedina, 4, tel. 89186293333. E-mail: [email protected]

The variety of existing methods of hernioplasty is explained by unsatisfactory treatment results. Laparoscopic methods of inguinal canal plastic surgery that have appeared in recent years are accompanied by a significantly lower percentage of complications and relapses. A modified technique of “tension-free” hernioplasty according to Lichtenstein using a polypropylene mesh is presented.

Key words: hernioplasty, inguinal hernia.

Yu. P. SAVCHENKO, I. Y. LAKOMSKIY, M. D. ZEZARACHOVA, A. P. PUZANOV PLASTIC INGUINAL HERNIA ON LIECHTENSTEIN

Department of general surgery Kuban state medical university, Russia, 350063, Krasnodar, Sedina str., 4, tel. 89186293333. E-mail: [email protected]

The variety of existing methods of hernia repair due to poor treatment outcomes. Emerged in recent years, laparoscopic techniques Shoulder repair is accompanied by a significantly lower rate of complications and relapses. The technique not pull Lichtenstein hernia repair by using a polypropylene mesh.

Key words: hernia repair, inguinal hernia.

Introduction

According to the literature, about 4% of the world's inhabitants suffer from abdominal wall hernias, of which 70% are inguinal. Among every million inhabitants of the globe, 40,000 people are diagnosed with abdominal hernias. Treatment of such patients is not only a medical problem, but also a socio-economic one, which has not yet been fully resolved. There is still no consensus on a number of issues regarding the tactics of treating inguinal hernias and the surgical technique: which wall of the inguinal canal needs strengthening to a greater extent, what is the most rational way to carry out this strengthening, which ligament formations are more appropriate to use for fixing the reinforcing layers, which plastic material should be given preference. The recurrence rate of inguinal hernias ranges from 3.5% to 45%. Over 300 methods and variants of inguinal hernioplasty are known, which indicates surgeons' dissatisfaction with the results of treatment and the ongoing search for new, more effective methods of surgery. Traditional methods of plastic surgery of the inguinal canal are sometimes accompanied by damage to the n. ilioinguinalis, iliohypogastricus and genitofemoralis. It is not uncommon for a violation of the blood supply to the testicle as a consequence of injury to the arterial and venous vessels of the spermatic cord. An attempt to avoid these complications was the use of the principle of “tension-free” hernioplasty, in which there is no tension on the structures of the inguinal canal. The idea was promoted by French surgeons J. Rives, R. Stoppa. The authors used subumbilical and inguinal approaches for hernia repair and placed a polymer mesh between the peritoneum and the transversalis fascia. When using tension-free hernioplasty, J. Rives noted 8 wound suppurations (2.6%) and 2 hernia recurrences (0.7%) after 302 hernioplasties. R. Stoppa et al. in 8% of cases, hematoma of the postoperative wound was noted, in 5.8% - wound suppuration

and observed a 2.5% hernia recurrence rate after 255 operations. The principle of “tension-free” hernioplasty has been developed in laparoscopic methods of inguinal canal plastic surgery. Currently, the percentage of relapse with endoscopic hernioplasty varies depending on its type and the experience of the operating surgeon: from 0.8% with transabdominal preperitoneal hernioplasty to 3.2% with intraperitoneal hernioplasty.

I. Lichtenstein used a polypropylene mesh as a plastic material, placing it anterior to the transverse fascia. In 1993, he published the results of 3125 hernioplasties, in which only 4 cases relapsed. After using the Lichtenstein procedure in 3 different surgical centers, J. Bames, J. Cappozzi et al. , L. Tincler noted 1 postoperative wound suppuration and 7 cases of relapse (0.36%) per 2000 operations.

Materials and methods

We have been using Lichtenstein plastic surgery since 2006. During this period, 76 operations were performed on 68 patients (in 8 cases, plastic surgery was performed on both sides). In 16 operations, general anesthesia was used, in 40 - epidural anesthesia, in 12 - local infiltration.

A skin incision 5-6 cm long was made 2 cm above the Pupart's ligament. The aponeurosis of the external oblique abdominal muscle was opened to the external inguinal ring. The spermatic cord was isolated and placed on a holder. Among the elements of the spermatic cord (in oblique hernias), the hernial sac was isolated, trying not to open it. A purse-string suture was placed on the neck of the hernial sac, after which the sac was immersed in the abdominal cavity. For direct inguinal hernias, the hernial sac was invaginated after applying a continuous suture to the transverse fascia. A polypropylene mesh (we used the “Surgimesh” mesh from Auto Suture) was modeled according to the dimensions of the posterior wall of the inguinal

channel. When fixing it, a hernia stapler was not used; in all cases, separate sutures of polypropylene monofilament suture material were applied<^ифрго» № 2/0.

The first suture was used to fix the mesh to the periosteum of the pubic bone. Then it was placed so that it completely covered the posterior wall of the inguinal canal and overlapped the internal oblique and transverse abdominal muscles by 1-2 cm, extended lateral to the internal opening of the inguinal canal and was tucked along the inguinal ligament. The mesh was fixed to the Poupart ligament, internal oblique abdominal muscle, the spermatic cord was placed in the mesh window, and behind it the edges of the mesh were sutured again. We consider it sufficient to fix the mesh with 6-8 separate sutures. At this point, the stage of reconstruction of the inguinal canal was completed. The aponeurosis of the external oblique abdominal muscle was sutured with interrupted (49) or continuous (19) suture with polypropylene thread No. 2/0. A cosmetic or interrupted suture was placed on the skin.

Results and discussions

All patients underwent the operation easily; in the first hours after it they began to get up and walk. The almost complete absence of pain in the surgical area was noteworthy. After the operations, three complications were noted: postoperative wound infiltration (2) and subcutaneous tissue hematoma (1). No re-intervention was required. The use of Lichtenstein plastic surgery has significantly reduced the length of stay of patients in the hospital. Its average duration was 3.2 days. It is possible to discharge the patient for outpatient observation the day after the operation. We recommend that patients begin normal physical labor 1 month after surgery.

Discussion and conclusion

Our experience has shown the high efficiency and simplicity of inguinal canal plastic surgery according to Lichtenstein. The course of the immediate postoperative period is incomparable with that of the Bassini or Shouldice plastic surgery we previously used and can only be compared with the course of the postoperative period after the use of laparoscopic types of plastic surgery. The advantages of Lichtenstein plastic surgery are as follows: 1) it is much simpler to perform than laparoscopic surgery and does not require complex equipment;

vaniya and therefore cheaper; 2) when analyzing the results of a large number of operations performed by different authors, it was found that the relapse rate with Lichtenstein plastic surgery is lower than with laparoscopic hernioplasty, which is apparently due to the complexity of the reconstructive stage of the operation; 3) when using this method, the period after surgery proceeds practically without pain, which results in early rehabilitation of patients and an early return of patients to normal physical activity.

It seems to us that Lichtenstein plastic surgery is currently the method of choice for the treatment of most patients with inguinal hernias.

Literature

1. Bychenkov V. P. Planned hernia repairs in elderly and senile patients II Surgery. - 1991. - No. b. - S. B7-B9.

2. Veronsky G.I., Komarovskikh K.F. Deep hernioplasty from the preperitoneal approach II Surgery. - 1991. - No. b. -WITH. 79-B1.

3. Kanshin N.N., Volenko A.V., Pometun V.V. Hernioplasty for direct inguinal hernia without opening and excision of the hernial sac II Bulletin of Surgery. - 1993. - No. 1-2. - pp. 126-129.

4. Korovin A. Ya., Kulish V. A., Vystupets B. V. Turkin D. V. Possibilities of laparoscopic simultaneous treatment of bilateral inguinal hernias II Kuban Scientific Medical Bulletin. - 2010. - No. 9 (123). - P. 115-11B.

b. Fedorov V. D., Andreev S. D., Adamyan A. A. Principles of surgical treatment of inguinal hernias II Surgery. - 1991. - No. 1. -S. 59-64.

6. Yanov V. N. Thermal treatment of autodermal implants II Bulletin of Surgery. - 1975. - No. 9. - P. 90-91.

7. Amid P. K., Shulman A. G., Lichtenstein I. L. II Am. j. surg. -1993. - No. 165. - R. 369-371.

B. Barnes J. R. II Surg. gynec. obstet. - 19B7. - No. 165. - R. 33-37.

9. Capozzi J. A., Berkenfield J. A., Cherry J. K. II Surg. gynec. obstet. - 19BB. - No. 167. - R. 124-12B.

10. Lichtenstein I. L., Shulman A. G., Amid P. K., Montllor M. M. II Am. j. surg. - 19B9. - No. 157. - R. 1BB-193.

11. Mac Fedyen B. V., Spaw A. T., Corbitt J. et al. II Surg. endose. -1993. - No. 7. - R. 155-15B.

12. Stoppa R. E., Rives J. L., Worlaumont C. Il Surg. clin. north. am. - 19B4. - No. 64. - R. 269-2B6.

13. Tinckler L. F. Ann R. Il Col. surg. engl. - 19B5. - Vol. 67. No. 4. - R. 26B.

Received 06/30/2013

D. V. TURKIN, B. V. PRESENTER

ATENSIONAL ALLOHERNIOPLASTY IN THE TREATMENT OF COMBINED INGUINAL HERNIA

Department of Faculty Surgery with a course of anesthesiology and resuscitation of the Kuban State Medical University of the Ministry of Health of Russia, Russia, 350063, Krasnodar, st. Sedina, 4, tel. +7-918-451 95 30. E-mail: [email protected]

A new method of surgical treatment of combined inguinal hernias is proposed, based on the anatomical restoration of the posterior wall of the inguinal canal. The method involves the prevention of formation and femoral hernias, which helps to avoid relapses of the disease. 95 patients were operated on. No immediate or distant recurrences of the hernia were detected.

Key words: inguinal hernia, inguinal canal, hernioplasty.

Ministry of Health of Ukraine

Zaporozhye State Medical University

Department of Operative Surgery and Topographic Anatomy

on the topic: Hernioplasty according to Liechtenstein

Completed by: 2nd year student, 2nd group

Faculty of Medicine

Kalashnik Kirill Vadimovich

Checked by: Lyubomirskaya Victoria Anatolyevna

Zaporozhye

The most significant event in surgery in the 80s of the twentieth century was the birth of operative endoscopy. At the dawn of its development, it seemed that within a few years any surgical intervention could be successfully performed using a video system under monitor control. Over time, the stage of euphoria gave way to a period of common sense, understanding of the limitations and possibilities of endoscopic surgery.

One of the operations proposed for laparoscopic access was inguinal hernioplasty using an endoprosthesis (polypropylene mesh). As experience accumulated, the attitude towards this intervention became more restrained, but the mesh endoprosthesis began to be successfully used in “open” surgery. The head of the Training Center for Endoscopic, Molinoinvasive and Aesthetic Surgery, Associate Professor of the Department of Endoscopic and General Surgery of KSMA, Dr. med., talks about the method of hernioplasty according to Lichtenstein - an operation that has reduced the likelihood of relapses and has become a kind of revolution in the treatment of inguinal hernias. Sciences Igor Vladimirovich Fedorov.

Do you know that:

In 1892, E. Bassini reported on radical three-layer hernioplasty with a brilliant result for those times: only 8 relapses in 206 operations three years after surgical treatment. The results of his predecessors differed significantly: 30-40% of relapses during the first year and 100% 4 years after surgery.

Just a few years ago it seemed that the problem of surgical treatment of abdominal wall hernias had been finally and irrevocably solved. Plastic surgery with one's own tissues, performed under local or regional anesthesia, gave good results with zero mortality and a low rate of complications. However, according to WHO, this is only true for simple hernias. In complex cases, which include direct and bilateral inguinal, postoperative ventral and any recurrent hernias, the results are much worse. So, with direct inguinal hernias, the percentage of relapse reaches 10, and the probability of a second recurrence is 40% (for postoperative ones - up to 50%)! The likelihood of developing hernias after primary laparotomy ranges from 1 to 10% over a three-year period. These statistics have become a serious challenge for surgeons operating on abdominal wall hernias.

For many years, the reason for failures in the treatment of complex hernias was considered to be the surgeon’s technical miscalculations, incorrect choice of surgical option, comparison of heterogeneous tissues, etc. However, the hernia repair technique was worked out in detail throughout the twentieth century and all surgical schools promote essentially the same principles. Unfortunately, this does not lead to a reduction in the incidence of relapses.

The natural conclusion from the accumulated experience is that the cause of relapse of the disease lies elsewhere. Namely, in the failure of the tissues of the anterior abdominal wall used for hernioplasty. Due to tissue mobilization, the latter experience tension and ischemia. The hernia defect can be closed without tension using a synthetic endoprosthesis.

Do you know that:

The need to use a prosthesis for repair of inguinal hernias was recognized back in the 19th century. Various materials were tested, including the patient's own tissue. Thus, the fascia lata of the back was considered optimal for use for this purpose, which was used as a suture material, with plastic surgery “on a pedicle” or as a free graft. Unfortunately, it turned out that over time, the fascial tissue weakens, and when infected, it is rejected.

In 1975, Stoppe was the first to report on inguinal hernioplasty using a preperitoneal mesh prosthesis. The main point of the technique was to combine tissues without tension. Subsequent years were spent searching for material that would not cause rejection, suppuration, or other complications.

Requirements that a material for an ideal endoprosthesis must meet:

1. chemical inertness;

2. mechanical strength;

3. easy sterilization;

4. water permeability and germination by body tissues;

5. sufficient resistance to intra-abdominal pressure or external influences;

6. stimulation of germination by fibroblasts (as opposed to rejection or sequestration);

7. do not cause inflammation or rejection reactions;

8. transformation into the desired form;

9. the ability of fibers not to get tangled or separated;

10. do not cause allergies or hypersensitization;

11. lack of carcinogenic properties;

12. not be felt by the patient as a foreign body (be sufficiently rigid and hard);

13. do not change physical properties under the influence of tissue fluid.

It has been proven that polypropylene corresponds to these qualities to the greatest extent (Fig. 1). It is hypoallergenic and non-carcinogenic. An endoprosthesis made from this material quickly takes root (due to the ingrowth of fibroblasts into it), and the probability of relapse when using it ranges from 0 to 0.5%.

Fixation of the mesh can be carried out either using a thread of a similar chemical composition, or special automatic devices (staplers). Mechanization of implant fixation can significantly simplify and speed up the stage of reconstruction of the inguinal canal. In addition, when performing plastic surgery of the inguinal canal, it is possible to use polymer meshes that do not require their direct fixation. This effect is achieved by increasing the thickness and weight of the implant (Herniamesh) or introducing chemicals into the mesh that form physical and chemical adhesion to tissues (Sofradim).

General principles of implantation of prostheses have also been developed, which include the following points:

1. To prevent the formation of seromas during implantation, it is necessary to avoid direct contact of the prosthesis with subcutaneous fat.

2. The prosthesis should be located between the muscular aponeurotic tissues to prevent its displacement when intra-abdominal pressure increases.

3. The prosthesis must be of sufficient size to overlap the edges of the hernial orifice by 2-4 cm in the case of inguinal hernia repair and by 6-8 cm in the case of postoperative hernias. This is necessary for uniform distribution of intra-abdominal pressure over the entire area of the implant. Otherwise, when using a prosthesis of insufficient size that covers only the hernial orifice, intra-abdominal pressure will affect a much smaller area, which will lead to increased load along the suture line.

4. It is always necessary to fix the prosthesis along the periphery to prevent its wrinkling and displacement. After fixation to the tissues, the prosthesis should lie relatively freely, with folds and without tension, which in turn will compensate for the increase in intra-abdominal pressure during the patient’s physical activity and the decrease in the size of the implant as a result of scar formation.

5. It is necessary to avoid direct contact of prostheses made from non-absorbable materials with the visceral peritoneum to prevent the development of adhesions in the abdominal cavity, adhesive intestinal obstruction, ingrowth of mesh into organs and the formation of intestinal fistulas.

6. Broad-spectrum antibiotics should be used for prophylactic purposes during operations for recurrent and postoperative hernias, when using large prostheses, as well as when draining a postoperative wound.

7. Do not use implants made of non-absorbable materials during contaminated operations.

8. Avoid the use of multifilament suture materials for fixation of macroporous prostheses, which is associated with a high risk of infection.

Depending on the pore size and structure, all modern synthetic non-absorbable prostheses can be divided into 5 types.

Type I: fully macroporous monofilament polypropylene prostheses (Lintex, Prolene, Atrium, Marlex, Surgipro and Trelex). These meshes have pores larger than 75 microns, which is a prerequisite for macrophages, fibroblasts, blood vessels and collagen fibers to penetrate the pores and resist infection. This type of material causes active angiogenesis and a pronounced reaction of fibroblasts and serves as a framework for the growth of connective tissue, with the formation of a reliable “prosthetic” aponeurosis. Sufficient molecular permeability allows protein-like substances of the recipient to penetrate into the pores, resulting in rapid fibrinous fixation of the mesh to the tissues, which reduces the risk of seroma formation, since the “dead space” between the mesh and tissues quickly disappears. If the postoperative wound becomes suppurated, there is no need to remove such a prosthesis.

Type II: Fully microporous prostheses (expanded polytetrafluoroethylene Gore-Tex) with a pore size of less than 10 microns. Microporous materials allow bacteria to enter the pores and prevent the penetration of macrophages, so their use increases the risk of infection. This type of prosthesis does not cause a sufficiently intense proliferative reaction and vascularization, which leads not to the ingrowth of the mesh with connective tissue, but to encapsulation. In this case, a less dense scar is formed compared to the first type of materials.

III type: macroporous prostheses with multifilament or microporous components (polytetrafluoroethylene Teflon, Surgipro multifilament, Mersilene and Musgo-Mesh). The disadvantage of this group of materials is their relatively easy susceptibility to infection, which is associated with the presence of multifilament and microporous components that harbor bacteria. A more pronounced reaction to a foreign body was also noted in comparison with type 1 materials.

IV type: composite dentures with surfaces of different properties (Parietex Composite, Gore-Tex DualMesh, Europlak). They are intended for intraperitoneal implantation, as they do not cause adhesions in the abdominal cavity.

V type: rigid macroporous monofilament mesh polypropylene prostheses “Herniamesh”. As a result of special thermal and mechanical treatment, this type of mesh has the properties necessary for seamless implantation.

Operation technique

prosthesis hernioplasty Liechtenstein hernia

An 8-10 cm long incision of the skin and subcutaneous tissue fully corresponds to that of traditional hernioplasty with local tissues. The aponeurosis of the external oblique muscle is freed from fatty tissue only along the line of dissection. There is no need to highlight it widely as when creating a duplication. After opening the aponeurosis with scissors and a dissecting tupper, the inguinal ligament, the edge of the internal oblique and transverse muscles by 2 - 3 cm, the edge of the sheath of the rectus muscles and the pubic tubercle are isolated. Using your finger, you select a space under the aponeurosis up along the incision for subsequent placement of a mesh prosthesis.

With a direct inguinal hernia, the hernial sac does not open after release, but sinks into the abdominal cavity. The transversalis fascia over it is sutured with one or two absorbable sutures.

With an indirect hernia, the vaginal membrane of the spermatic cord is opened. A small hernial sac is isolated up to the cervix, opened and stitched in the cervical area. For large oblique and inguinal-scrotal hernias, it is sometimes more advisable to first isolate the neck of the hernial sac, stitch it and bandage it, and then completely remove the sac. In our opinion, isolation of the hernial sac should not be done with a tupper, which injures the tissue, but exclusively with scissors and tweezers with coagulation of small vessels. This allows you to atraumatically remove a bag of any size. We consider it inappropriate to leave part of the sac in the scrotum, especially in young and mature patients. After removing the sac, we restore the vaginal membrane of the spermatic cord.

Only after processing the hernial sac, we go around the spermatic cord with a dissector and take it on a holder. We do not see the need to perform this stage before isolating the sac, as the author of the technique does, and consider it more traumatic. Then the spermatic cord is sharply released from its connection with the underlying tissues along the entire length of the wound. We also consider it unnecessary to partially cross the levator testis muscle.

For oblique inguinal hernias, when the internal inguinal ring is significantly expanded or there is a hernia with a straightened canal, we narrow the internal inguinal ring with several sutures on the transverse fascia.

For plastic surgery, we use a polypropylene mesh produced by Ethicon (UK) [Ethicon (Great Britain)] measuring 8-13 cm or slightly narrower for a small inguinal space. At the medial end of the mesh, the corners are rounded, from the lateral end a longitudinal incision is made approximately 2/3 of the length of the prosthesis so that there is a wide branch on top (2/3) and a narrow branch on the bottom (1/3). At the end of the incision, a round hole up to 1 cm in diameter is made for the spermatic cord.

The prepared prosthesis is placed under the spermatic cord and fixed with a continuous suture of prolene, first to the pyramidal muscle sheath down to the pubic tubercle, then to the pubic tubercle, without capturing the periosteum. To prevent relapses, it is important that the prosthesis is fixed to these formations not edge to edge, but placed on top of them 1 - 1.5 cm beyond the suture line.

After this, the spermatic cord is transferred upward and the same ligature is used to fix the mesh to the Cooper ligament and inguinal ligament to a level slightly lateral to the internal inguinal ring. Strengthening the area of formation of femoral hernias with this technique is advisable to perform in each case. To do this, after suturing the prosthesis to the pubic tubercle with the next one or two stitches, the mesh is sutured to the Cooper ligament with a fold of approximately 1 cm of its lower edge inward, and then further to the inguinal ligament. The folding of the mesh distinguishes the described technique from the original one proposed by Lichtenstein. We believe that this technique allows for more complete closure of the area of potential femoral hernia formation.

The upper edge of the mesh is then secured over the internal oblique and transverse muscles with 3 to 4 separate prolene sutures. In this case, the edge of the mesh should be located approximately 2 cm above the lower edge of the muscles. It is necessary to ensure that the nerves passing through this area do not fall into the suture.

After this, the wide branch of the prosthesis is placed over the narrow one so that the spermatic cord is placed in the hole prepared for it, and they are fixed together with a prolene suture.

The hole for the spermatic cord should not be narrowed to more than 1 cm in diameter. Both branches of the prosthesis, one on top of the other, are tucked under the aponeurosis of the external oblique muscle into the previously formed space.

The aponeurosis of the external oblique muscle is sutured edge to edge without tension. The diameter of the developing external inguinal ring does not matter.

Benefits hernia repair with inguinal canal plastic surgery using the Lichtenstein method are:

· hernia recurrence is observed in only 3% of patients who underwent hernia repair using a plastic polymer mesh

· fast recovery

Low degree of discomfort after surgery

The operation can be performed under local anesthesia

Disadvantages hernia repair with inguinal canal plastic surgery according to the Lichtenstein method:

Larger hernias require more stitches, which increases the risk of nerve damage

The operation can last from 60 to 80 minutes

Complications

Wound infection

Hernia repair is a clean operation that does not require prophylactic antibiotic therapy. For many years, it was believed that the use of meshes increases the risk of wound infection. A detailed analysis of recent years has shown that in most cases this complication develops due to the use of multifilament suture material such as silk. A single intravenous antibiotic during surgery should be recommended, especially in patients over 60 years of age.

Seroma

Seroma is an accumulation of serous fluid in a surgical wound in the area of “dead space” remaining in the tissues after suturing. Seromas also form after conventional hernioplasty, but more often after the use of mesh, as a reaction to injury and a foreign body. The composition of seroma is leukocytes, erythrocytes, macrophages, mast cells, blood serum from damaged venous and lymphatic capillaries.

As a rule, seroma appears on the 3rd or 4th day after surgery. A tumor-like protrusion without signs of inflammation appears in the surgical area, which makes it possible to fear an early recurrence of the hernia. Fluctuation is determined locally, and ultrasound confirms the clinical diagnosis of fluid accumulation in the wound canal area. In this situation, a conservative wait-and-see approach is preferable; the seroma completely resolves after 2-3 weeks. Puncture or opening of the wound is pointless, since it does not prevent the separation of serous fluid, but contributes to the inevitable infection of the wound.

Hematoma

This complication requires sanitation of the wound by opening it and draining it. Hemorrhages can be observed at a considerable distance from the wound, for example, on the opposite side. If bleeding occurs into the scrotum, drainage may be difficult due to blood saturation of the organ tissue.

Neuralgia

This complication is observed to one degree or another in 15% - 20% of patients who have undergone hernia repair, in the form of pain, parasthesia, hypersthesia for up to 6 months after surgery. Signs of neuralgia include pain or a burning sensation in the groin and loss of skin sensation in certain areas. The assumption that laparoscopic hernioplasty will reduce the likelihood of developing neuralgia has not been confirmed.

Inguinal hernia: definition, description

Protrusion of the organs of the abdominal cavity beyond the boundaries of their anatomical location through the inguinal canal is called an inguinal hernia. In surgical gastroenterology, of all pathological protrusions of the abdomen, about 80% are inguinal hernias. Men are much more susceptible to the disease than women.

A hernia consists of elements, each of which has its own name.

The hernial sac is an area closely connected to the wall of the peritoneum, which emerges through weak spots in the serous membrane covering the walls of the abdominal cavity.
Hernial orifices are defective places in the abdominal wall through which the hernial sac with its contents protrudes.
Hernial contents are usually movable organs of the abdominal cavity.
Shell of hernia. For a direct inguinal hernia - the transverse fascia, for an oblique - the membrane of the spermatic cord or round ligament of the uterus.

Protrusions are classified according to anatomical features and are divided into straight, oblique, and combined. For inguinal hernias, the ICD 10 code is K40. This class includes all types of protrusion of organs through an elongated gap in the lower abdominal wall.

Surgical methods for treating inguinal hernia

The main and radical method of treating hernias is surgery. The use of a bandage is a dubious measure and is used only if the operation cannot be performed.

It is preferable that the operation be extremely simple and accessible, low-traumatic and reliable. Manipulation includes surgical removal and repair of damage in the abdominal wall. Reconstruction of the integrity of the abdominal wall and closure of the hernial injury can be done using an aponeurosis (own tissue) or a non-biological graft.

The most effective is the use of a non-tension invasive method using a mesh prosthesis. The hernial orifice is reinforced with a polypropylene mesh from the inside, which serves as a frame and an obstacle to the re-extrusion of organs. In surgery, there are several methods of performing an operation: according to Shouldice, Bassini, according to Trabucco. Plastic surgery according to Lichtenstein is the most preferred in surgical gastroenterology. This method of surgical intervention significantly reduces the risk of recurrence of an inguinal hernia and can be used both in childhood and in old age.

Lichtenstein method: the essence of the operation

Tension-free hernioplasty is more preferable, since the risk of a recurrent hernia is minimal. Hernioplasty according to Lichtenstein is used not only for inguinal hernias, but also for hernias of the abdominal wall (umbilical) and protrusion of abdominal organs under the skin.

The process itself can be divided into two main stages. At the beginning of the operation, the surgeon opens the hernial sac, examines its contents for the presence of fecal stones, gallstones, and assesses the likelihood of inflammation. If there are no complications, it is removed back into the abdominal cavity. The final stage of the operation, which is also the main stage, is plastic surgery of the hernial orifice using a composite mesh. The likelihood of relapse depends on how professionally the plastic surgery is performed. Unlike other methods, this method does not involve cutting the muscles. The implant is sutured to the aponeurosis located under the muscles.

Indications and contraindications

Hernia repair according to Lichtenstein is prescribed to everyone who has a pathological protrusion of the peritoneal organs into the area of the inguinal canal. Doctors strongly recommend the use of this particular method if the course of the disease is complicated by the following factors.

Recurrent inguinal hernias. Especially if the protrusion appears as a result of an incorrectly selected hernioplasty method.
High probability of necrosis when the hernial sac is compressed (strangulated hernia).
Intolerance to previously installed implants.
Danger of rupture of the hernial sac.

The use of Lichtenstein plastic surgery is not possible in the presence of certain indications.

Individual intolerance to synthetic implants.
Recent surgery on abdominal or reproductive organs.
Blood diseases: coagulation disorders, leukemia.
Cardiovascular diseases.
Chronic respiratory diseases.
Pathologies in the acute phase.
The presence of malignant tumors in the abdominal cavity.
Very old age.
Inoperable condition.
Patient's refusal to undergo surgery.

How is hernia repair performed according to Liechtenstein?

Hernioplasty can be performed either traditionally or using a laparoscope.

Children over the age of seven who have an abdominal wall hernia are treated using laparoscopic hernioplasty according to Lichtenstein. Three small incisions of 1-2 cm are made on the abdomen in the navel area. Trocars and a laparoscope with a camera are inserted into them. The camera reflects the progress of the operation on the monitor, and through tubes (trocars) an instrument is inserted into the cavity, with the help of which all stages are performed, as with traditional intervention. This operation has a number of advantages. Small incisions reduce blood loss during the process and ensure quick recovery, which is especially important in childhood.

Stages of hernioplasty

The operation is performed under spinal anesthesia or general anesthesia. A 5 cm long incision is made in the area of the pubic tubercle parallel to the inguinal ligament.

The surgeon gradually cuts the parenteral tissue, connective tissue membrane, external oblique muscle to the superficial canal. The aponeurosis is separated from the spermatic cord and captured by a holder. The hernia is isolated, examined and returned to the abdominal cavity.

A mesh is measured and a longitudinal cut is made in the lower half of it. The implant is sutured with a continuous suture from the pubic tubercle to the inner ring. Separate sutures are placed to secure the mesh to the internal oblique muscle. The manipulation is performed with special care, trying not to touch the iliohypocranial and ilioinguinal nerves.

The extreme tail of the mesh, formed as a result of the cut, is laid and secured with one interrupted seam. The operation ends by suturing the wide tendon plate of the external oblique muscle over the implant with subcutaneous sutures.

Rehabilitation

All inguinal hernias have the same ICD 10 code, and postoperative measures are similar for all surgical interventions after treatment of the bulge.

After hernioplasty, short medical care is provided. It includes active drainage, administration of pain medications and assessment of the condition of the operated organ. If there are no complications, the patient is discharged after a few days. After surgery for an inguinal hernia, rehabilitation proceeds quickly and without complications, provided that medical recommendations are followed. Usually they are as follows:

restriction, or better yet, exclusion of physical activity for 2 weeks;
It is highly advisable to wear a bandage for 2 months;
dieting.

Complications

These include:

decreased sensitivity in the lower abdomen;
there is a high probability of constipation (if the operation was performed on an abdominal wall hernia);
prolapse of the uterus, accompanied by severe pain (can occur when the circular ligament of the uterus is cut);
suture dehiscence followed by recurrence of the hernia;
inaccurate or incorrect fixation of the synthetic mesh with its subsequent migration;
internal hematomas.

In general, the operation goes well, with a mortality rate of less than 0.1% of all cases.

Advantages and disadvantages of the method

Lichtenstein hernia repair has a number of advantages over other operations.

The chance of relapse is almost zero.
Complications occur in only 5% of patients and in most cases are associated with non-compliance with recommendations in the postoperative period.
Composite meshes are made from high-quality materials; their rejection by the body is rare.
Short rehabilitation period, especially if the operation was performed using a laparoscope. The opportunity to return to normal life in 7-8 weeks.
The operation can be performed from the age of seven.

The Lichtenstein method, like any other, has its disadvantages:

the formation of scars near the spermatic cord can lead to impaired blood circulation in the tissues of the testicle and, as a consequence, to its atrophy;
wound infection: although doctors try to maintain sterility, statistics show that the occurrence of infection during surgery was observed in 2% of patients;
there is a high probability of damage to the sensory nerves located near the inguinal ligament, which can lead to disruption of innervation.

When diagnosing an inguinal hernia, it is important not to delay surgical treatment. High-quality plastic surgery according to Liechtenstein will allow you to avoid complications and relapses and return to your usual rhythm of life.

Inguinal hernia in men operation according to Liechtenstein. Treatment of inguinal hernia is Lichtenstein operation. Hernia repair according to Sapezhko

How is hernioplasty performed?

Contraindications for surgery

Advantages of plastic surgery according to Liechtenstein

Disadvantages of the method

Possible complications

Rehabilitation

Similar documents

Inguinal hernia: definition, description

Surgical methods for treating inguinal hernia

Lichtenstein method: the essence of the operation

Indications and contraindications

How is hernia repair performed according to Liechtenstein?

Stages of hernioplasty

Rehabilitation

Complications

Advantages and disadvantages of the method