Inguinal hernia repair

Repair of indirect inguinal hernia

indicate

Both reversible and irreversible indirect hernia should be treated surgically.

Surgery is not appropriate under the following circumstances:

1. Factors that increase intra-abdominal pressure cannot be alleviated or alleviated, such as chronic cough, intractable constipation, dysuria, ascites caused by various reasons, pneumoperitoneum, etc.

2. Other systems have serious diseases, which are generally not suitable for operators, such as severe heart failure, advanced malignant tumor and diabetes.

3. There is infection in the operating area or the whole body.

4. The baby's abdominal muscles can become stronger with the growth of the body, so indirect inguinal hernia may heal itself in infancy, so infants under 1 year old do not advocate surgery.

For incarcerated hernia with short time, manual reduction can be tried, and if the reduction is unsuccessful, surgical reduction will be performed.

No matter what age, once strangulated hernia occurs, surgery should be performed.

Preoperative preparation

1. Patients with acute upper respiratory tract infection should control their symptoms before operation.

2. Quit smoking before operation 1 week, and train to urinate in bed.

3. Preoperative urination makes bladder empty. If necessary, a catheter can be placed to avoid accidental damage to the bladder.

4. Huge hernia, need to stay in bed for 3 days before operation, so that the hernia contents can flow back. The local tissue is loose, which reduces edema and is beneficial to postoperative healing.

5. Special giant hernia, in which a part of the abdominal organ descends into the hernia sac and protrudes out of the abdomen. If it is estimated that the contents can not be completely refluxed during operation, pneumoperitoneum can be performed before operation to enlarge the abdominal cavity.

6. Strangulated hernia, pay attention to correct the disorder of water, electrolyte and acid-base balance before operation. Colloidal liquid can be given to prevent shock during blood transfusion, and antibiotics can be used according to the dose to prevent infection. Under the premise of active preparation, the operation should be carried out as soon as possible.

anesthetize

Local anesthesia, epidural anesthesia or general anesthesia can be used. Local anesthesia is ideal, and its advantages are: good anesthesia effect, few complications, safety and reliability. During the operation, patients can be instructed to increase abdominal pressure to distinguish indirect hernia from direct hernia. Before and after the repair, the patient was asked to raise his head or shoulder to test the strength and repair effect of the posterior wall of the abdominal femoral tube.

attitude

Lie flat, with the foot of the bed slightly raised.

Surgical procedure

1. Incision: Take off the oblique abdominal incision, 2cm above the inguinal ligament and parallel to it (Figure 1). Generally, the upper end exceeds the inner ring by about 2cm, and the lower end reaches the pubic tubercle.

2. Incision of the aponeurosis of the external oblique abdomen: after skin incision, the subcutaneous tissue is cut, and the branches of the superficial abdominal artery and vein and the external pudendal artery and vein are ligated (Figure 2) until the aponeurosis of the external oblique abdomen exposes the superficial ring of inguinal canal. On the connection line between the superficial ring and the deep ring of inguinal canal, the external oblique abdominis tendon was cut along the aponeurosis fiber direction (Figures 2 and 3). The incision should be shallow on the ring mouth to avoid damaging the ilioinguinal nerve.

3. Find and cut the hernia sac: use two hemostatic forceps to pick up the upper and lower pieces of the aponeurosis of the external oblique abdomen, and then separate them under it, with the upper piece exposing the ligament union and the lower piece reaching the inguinal ligament (Figure 4). Be careful not to hurt the ilioinguinal nerve when separating the next slice. This nerve can be separated from the internal oblique muscle (Figure 4), and the lower aponeurosis can be pulled to the lower part of the nerve with hemostatic forceps, and then the aponeurosis can be everted and covered with aponeurosis to protect the nerve (Figures 5 and 6).

The patient was asked to increase abdominal pressure, and prominent hernias could be seen in the front and inside of the spermatic cord. Here, the levator testis and the intima of spermatic cord are cut vertically, and a gray hernia sac can be seen in front and inside of spermatic cord (Figure 6). Lift the hernia sac with toothed tweezers, and cut the hernia sac vertically between the two tweezers (Figure 7) to avoid injury to the hernia contents. Expand the incision, put your finger into the hernia sac and explore its contents (Figure 8), mostly small intestine and omentum.

4. Free hernia sac: the index finger reaches into the hernia sac to push the hernia contents back to the peritoneal cavity, and hemostatic forceps lifts the edge of the incision, indicating that the hernia sac is pushed upward in the hernia sac, and the spermatic cord tissue around the hernia sac is gently separated (Figure 8). When separating the lower part of the hernia sac, don't hurt the vas deferens (Figure 9) until the neck of the hernia sac, that is, you can see the extraperitoneal fat. Pay attention to stop bleeding and avoid postoperative hematoma.

5. High ligation of hernial sac: lift the periphery of hernial sac with hemostatic forceps, and put the index finger of the right hand into the hernial sac to further explore the size of the deep annular opening, or further determine whether it is oblique hernia or straight hernia (Figure 10). Cut the hernia sac longitudinally, and pull hemostatic forceps around the hernia sac to expose the inner surface of the neck of the hernia sac. In the deep part of the inguinal canal, that is, the inner surface of the neck base of the hernia sac, the hernia sac was sutured with No.4 thread (Figure 1 1). Pay attention to the small needle distance in the hernia sac and the large needle distance outside the hernia sac, so as to tighten the purse without leaving a cavity, tie the suture and close the neck of the hernia sac. You can use thread 7 to make another one 0.5cm above the purse-string suture to prevent the knot from falling off. Thread 7 can also be used to suture the neck of hernia sac. After the suture was completed, the extra hernia sac was removed at a distance of 0.5cm from the ligation knot (Figure 12). At this time, the neck stump of hernia sac can be retracted to the deep surface of internal oblique muscle without fixation. It is also customary for some people to sew and fix the ligation line of hernia sac neck on the internal oblique muscle in front of it (Figure 13).

If the distal hernia sac is small, it can be peeled off; If it's big, it doesn't need to be peeled off and stitched. If there is exudate, subcutaneous tissue can absorb it.

6. Repair of indirect hernia: There are many ways to repair indirect inguinal hernia. According to the weakness of the anterior and posterior walls of inguinal canal, different repair methods are adopted, which are commonly used:

(1)Ferguson repair method: This method is characterized by suturing the lower edge of the combined ligament and the internal oblique muscle of abdomen with inguinal ligament before spermatic cord, so as to strengthen the anterior wall of the abdominal sulcus tube. Suitable for children and young adults with intact posterior wall of inguinal canal. Suture the incised levator testis muscle and the fascia inside the spermatic cord with 1 thread to repair the spermatic cord (Figure 14). The levator testis, internal oblique muscle and commissural tendon can be sutured intermittently with 1 line (Figure 15) to make the inguinal ligament close to the commissural tendon.

Suture the combined tendon, the lower edge of the internal abdominal oblique muscle and the abdominal femoral ligament intermittently with line 7 from bottom to top. Usually sew 3 ~ 4 stitches, and the last stitch should not be too tight, so that the fingertips can be accommodated and the spermatic cord can be avoided from being too tight. The suture of inguinal ligament should not be in the same fiber gap, so as not to tear the inguinal ligament (Figure 16). Then, the aponeurosis of the external oblique abdomen was overlapped and sutured to reconstruct the superficial ring of inguinal canal (Figure 17, 18).

Intermittently suture subcutaneous tissue and skin with 1 thread (Figure 19).

(2)Bassini repair: This method is characterized by strengthening the posterior wall of inguinal canal, which is suitable for young and middle-aged patients with posterior wall defect of inguinal canal.

Untie the spermatic cord before finding the hernia sac. The index finger of the left hand protrudes from the inside of the spermatic cord and is located above the pubic tubercle and below the spermatic cord, separating the spermatic cord from the inguinal ligament (Figures 20 and 2 1). Pull the gauze strip or rubber tube through the spermatic cord (Figure 22).

Pull the internal oblique muscle of abdomen upward with a retractor, longitudinally cut the levator testis and fascia inside spermatic cord to expose the hernia sac, lift the hernia sac with tweezers, longitudinally cut it (Figure 23), put the left index finger into the hernia sac and jack it up, passively separate the surrounding spermatic cord tissue until it reaches the neck of the hernia sac (Figure 24), suture the neck with No.4 thread, and ligate the hernia sac at a high position (Figure 25).

Lift the spermatic cord to expose the aponeurosis and fascia of transverse abdominis muscle (Figure 26), and suture the aponeurosis, fascia of transverse abdominis muscle and inguinal ligament intermittently from top to bottom with No.7 thread (Figures 27 and 28), without knotting first, and then knot it after sewing. Pay attention to suture the transverse fascia of abdomen on the inside and outside of the upper end of spermatic cord, so as to narrow the enlarged deep ring of inguinal canal, and it is advisable not to compress the spermatic cord.

Pull the curved lower edge of internal oblique muscle and conjoined tendon to inguinal ligament, and test its tension (Figure 29). If the tension is high, the aponeurosis of the external oblique abdomen can be passivated to expose the anterior layer of the rectus abdominis sheath (Figure 30), and the tension can be released at this time. If the conjoined tendon and inguinal ligament cannot be combined together, longitudinal incision can be made in the anterior layer of rectus abdominis sheath (Figure 3 1), and each incision is 1cm long. Generally, a small incision of 8 ~ 10 can relieve tension (Figure 32).

Suture the commissural tendon, the lower edge of the internal oblique muscle and the inguinal ligament nodule from bottom to top with line 7 (Figure 33). Note: 1 Needle should sew the syndesmosis, aponeurosis of transverse abdominis, periosteum near pubic tubercle and inguinal ligament together (Figure 33).

Fold and sew the upper and lower layers of the aponeurosis of the external oblique abdomen with line 7 (Figures 34 and 35). The spermatic cord is placed between the ligament joint tendon and the aponeurosis of the external oblique abdomen.

(3) halsted repair: This method is also a method to strengthen the posterior wall of inguinal canal. It is suitable for elderly patients or those whose posterior wall of abdominal femoral canal is obviously weak. After high ligation of the neck of the hernia sac, the aponeurosis of transverse abdominis muscle, ligament syndesmosis and the lower edge of internal oblique muscle were sutured to the inguinal ligament by Bassini method, and the upper and lower external oblique muscles were sutured intermittently under the spermatic cord, and the spermatic cord was placed between the aponeurosis of external oblique abdominal muscle and subcutaneous fat (Figure 36). Generally, the spermatic cord is pulled out from the upper 1/3 of the aponeurosis incision of the external oblique abdomen, and the outlet should not be too tight (Figure 36). The subcutaneous fat and skin are sutured intermittently with 1 thread (Figure 37).

(4)Shouldice repair method: multilayer reinforced hernia repair or Canadian hernia repair. The key point is to repair the transverse fascia of abdomen and strengthen the posterior wall of inguinal canal.

The initial separation operation is the same as the previous maintenance. After the spermatic cord is released, it is pulled open with gauze strips to expose the transverse fascia of abdomen (Figure 38). Remove part of the levator testis muscle, cut the free hernia sac, perform internal purse-string suture and high ligation at the neck of the hernia sac, and remove the redundant hernia sac (Figure 39). The transverse fascia of abdomen was cut longitudinally from the inner ring orifice to the pubic tubercle (Figure 39), and the upper and lower flaps were separated in parallel.

Suture the lower flap of transverse abdominal fascia to the deep surface of the lateral rectus sheath, the deep surface of transverse abdominal fascia and the oblique muscle in the upper flap from above the pubic tubercle with line 7 (Figure 40). Then the transverse fascia and inguinal ligament of the epithelial flap were sutured continuously from top to bottom (Figure 4 1). Then suture the internal oblique muscle of abdomen and symphysis tendon in the deep part of inguinal ligament from top to bottom with line 7 (Figure 42), and continue to suture symphysis tendon and internal oblique muscle and superficial part of inguinal ligament in the direction above pubic tubercle (Figure 43).

Suture the aponeurosis of the external oblique abdomen with the tubercle of the anterior spermatic cord with line 7 (Figure 44). Suture subcutaneous tissue and skin.

Polizel's therapy

1. General treatment: Take supine position after operation. Add a small pillow at the nest to bend the buttocks to reduce the tension of suture and the discomfort and pain of incision.

2. Prevent hematoma, compress the operation area with sandbags 24 hours after operation, and hold up the scrotum with a T-belt to avoid hematoma. You can also use cold compress.

3. Prevent the increase of intra-abdominal pressure: The increase of intra-abdominal pressure after operation is easy to cause hernia recurrence, and upper respiratory tract infection should be prevented first to avoid coughing; Constipation patients can take laxatives orally and eat more foods with high cellulose content to make their stools unobstructed.

4. Prevention of infection: Incision infection can lead to hernia recurrence. Besides paying attention to aseptic operation during operation, the treatment of postoperative incision is also very important.

5. Disposal of residual hernia sac and hydrops: puncture and drainage are needed first, but puncture can be repeated, and surgical drainage is feasible if it is ineffective.

6. Rest and labor recovery: the hernia is repaired without tension, and you can get out of bed 2 ~ 3 days after operation. There was no strenuous activity in 3 weeks after operation, and light manual labor could be recovered in 2 months, and heavy manual labor could be recovered in 3 months.

Operation type

Ferguson method

Reinforce the anterior wall of inguinal canal. It is suitable for children and adolescents with no obvious defect of transverse aponeurosis arch and sound posterior wall of inguinal canal. The repair focused on the level of transverse fascia of abdomen. It has been widely used since 1970s, and it is suitable for adults with huge indirect inguinal hernia and direct inguinal hernia.