Basic principles of hernia repair surgery. Surgical treatment of hernias stages of hernia repair Hernia surgery and its stages

In the modern world, surgeons are increasingly having to remove hernias, especially inguinal hernias, and if previously the problem affected mainly athletes, today any person is susceptible to it. Early diagnosis of a hernia can be the key to success, since advanced cases are most often accompanied by complications. If you have been diagnosed with a hernia in the groin area, you may be offered Liechtenstein hernioplasty to remove it.

The essence of the operation

This surgical intervention is the “gold standard” for removing a hernia in the inguinal canal area, which is carried out without tension on the adjacent tissues. During the operation, new polymers are used, and recently composite meshes have gained wide popularity, which in turn have a resolving effect and promote a rapid regeneration process. The Liechtenstein operation is currently gaining enormous popularity due to its ease of execution and extremely low percentage of relapses and complications in all clinics in the world that specialize in hernia removal. Various videos on the operation and its results are available on the Internet.

Stages of implementation

The Lichtenstein operation is performed in all clinics under spinal anesthesia. After administration of anesthesia, a skin incision is made, not exceeding 5 cm, lateral to the pubic tubercle, parallel to the inguinal ligament.

The next step of the surgeon is to dissect the fiber and the aponeurosis of the external oblique muscle itself, down to the very superficial ring of the inguinal canal. The aponeurosis of the external oblique muscle is separated from the spermatic cord to the inguinal ligament, the spermatic cord is taken on a holder, then the hernia is isolated from the spermatic cord, followed by immersion into the depths of the abdominal cavity.

This is followed by the application of the mesh (the threads with which it is attached are identical in chemical composition to it). With the first suture, the medial edge of the mesh used is sutured to the periosteum of the pubic bone, then with a continuous suture the lower edge of the mesh is sutured to the inguinal ligament. The last suture secures the edges of the mesh behind the spermatic cord, while they are sutured to the inguinal ligament, which allows the diameter of the spermatic cord to be accurately determined.

The last step is suturing the aponeurosis of the external oblique muscle and cosmetic suture of the skin, both sutures are continuous. Complications after this type of surgery are minimal, but the risk remains.

Indications and contraindications for surgery

The indication for Lichtenstein plastic surgery is the presence of any type of hernia in the patient in the inguinal canal area. This surgical intervention is a universal means of combating hernias in our time. If you have been diagnosed with this disease, you need to remember that not a single folk remedy can get rid of it, only timely surgery can correct the current situation.

Like any other surgical intervention, the Lichtenstein method imposes a number of restrictions on patients:

The main contraindication is the patient’s individual intolerance to general anesthesia, which is mandatory for this operation, otherwise he risks complications.
In the case of a large inguinal hernia, the doctor has the right to refuse to perform this intervention, because the risk of nerve damage increases, which can lead to loss of sensitivity in the area.
If a person has blood diseases, for example, hemophilia, any operation is contraindicated for him. No drug can quickly and efficiently clot blood; in case of large blood loss, death is guaranteed.
If the patient has chronic heart and lung diseases, laparoscopy cannot be performed. During surgery, the load on the heart increases, which can aggravate an existing disease.
When the hernia is strangulated, the operation is postponed or replaced with another.
In the case of an acute abdomen of unknown etiology, the hernia cannot be removed. To do this, the doctor must establish an accurate picture of what is happening, whether there is a concomitant disease that could provoke the current condition.
In case of intestinal obstruction, this operation is prohibited.
If the patient has had surgery on the lower abdomen, any operation of this kind cannot be performed. This is done so as not to subject one area of the body to heavy loads, which has not yet fully recovered.

If the patient does not comply with these restrictions, he will suffer complications that will require additional time.

Rehabilitation period after surgery

The entire course of the operation to remove an inguinal hernia is carried out exclusively under general anesthesia, and the time it takes is about two hours, it depends on the degree of complexity of the hernia. In this regard, the patient does not require a long hospital stay; the patient stays in the ward for a day so that the doctor can observe how he recovers from anesthesia.

The hernia does not recur, the pain subsides after the third day, which helps the patient return to normal life (this can be seen in the video before and after surgery).

Sutures are removed on the day of discharge. It is not recommended to undergo strong physical activity for a month; the patient can return to work at any time. If you study the statistics in detail, you get a result that cannot but rejoice: complications in patients do not exceed 1-2%, recurrence of the hernia is only (0.08%).

Positive sides

The positive aspects of surgery to remove an inguinal hernia using the Lichtenstein method are:

Possible complications are observed only in 3-5% of patients; in all others, rehabilitation is within normal limits.
After removal of the inguinal hernia, a less pronounced pain syndrome is observed.
This technique contributes to a shorter rehabilitation period.
The patient experiences a low degree of discomfort long after the operation.
If a person is allergic to general anesthesia, then the doctor can perform this surgical intervention under local anesthesia, the patient will also not feel pain.
The operation to remove an inguinal hernia using the Lichtenstein method is the easiest to perform.

Disadvantages of plastic surgery according to Liechtenstein

Hernioplasty according to Liechtenstein has significant disadvantages:

There is a high risk of accidental injury to the inguinal nerves, which leads to partial or complete loss of innervation and sensation in the operated area.
There are scar changes in the area where the spermatic cord passes through the installed implant; the consequence of this is a disruption of the blood supply to the testicular tissue, which leads to its atrophy and disruption of endocrine function.
It is possible to intersect the circular ligament of the uterus, which guarantees its prolapse, and this, in turn, is characterized by severe pain, bleeding and even difficulty urinating.
With this operation there is a risk of infection, although doctors are doing everything in their power, suppuration and inflammatory processes are possible. If the doctor suspects a patient has inflammatory processes or an infection, he prescribes a whole course of antibiotics to prevent this.

Liechtenstein plastic surgery cost

The price for this operation in our country starts from 20 thousand rubles, it largely depends on the quality of the services provided, the length of stay in the hospital and the qualifications of the doctor. The outcome and the risk of complications directly depend on it. An important factor in pricing is the region of the country. Remember that you should not skimp on health, because it is given once in a lifetime and should be taken care of.

Swelling of the scrotum, testicle and spermatic cord, necrosis of the spermatic cord, injury to its vessels with the development of gamatomas, testicular atrophy, septic abscesses of the abdominal wall, intestinal obstruction and others.

Non-strangulated hernias are operated on routinely, strangulated hernias are operated on emergencyly. The need to treat non-strangulated hernias is dictated by the prevention of complications, the most dangerous of which is strangulation.

The task of hernia repair is to eliminate the hernial protrusion and restore the valve mechanism of the inguinal canal with strengthening its walls.

Anesthesia: general anesthesia or local anesthesia. When performing local anesthesia, the branches of the nerves are blocked: n. ileoinguinalis, n. ileohypogastricus, n. genitofemoralis. Points of anesthesia: the upper anterior spine of the ilium and 5-6 cm medial to it, above the middle of the inguinal ligament (projection of the deep ring of the inguinal canal), and 1.5-2 cm above the pubic tubercle (superficial ring of the inguinal canal).

Stages of hernia repair

Surgical intervention for abdominal wall hernias is divided into three main stages:

1. Dissection of tissue in the area of hernial protrusion.

2. Isolation and removal of the hernial sac. At this stage, the principle of high removal of the hernial sac is adhered to for maximum excision of stretched areas of the peritoneum.

3. Plastic surgery of the hernial orifice.

When operating on children, we must remember that their tissue formation process is not yet complete and their development will continue after the operation. Therefore, the operation should be as gentle as possible, and therefore several principles should be adhered to:

1. Engage the muscles in the sutures as little as possible because this leads to their disintegration, atrophy and loss of function,

2. Sew homogeneous tissues to ensure the strength of their fusion,

3. Maintain layers,

4. Handle the spermatic cord with care,

5. Carefully perform hemostasis

Hernia repair begins with layer-by-layer dissection of the skin, subcutaneous fat and superficial fascia in the groin area. The incision is made parallel to the inguinal ligament 2 cm above it from the level of the anterior superior iliac spine and should end above the pubic tubercle.

From the aponeurosis of the external oblique muscle of the abdomen, the fatty tissue is bluntly shifted with a tuffer and the superficial inguinal ring is exposed.

A grooved probe is inserted into the inguinal canal through the superficial ring, through which the aponeurosis of the external oblique muscle is cut.

Then the hernial sac is carefully and atraumatically isolated, separating f. cremasterica m. cremaster, dissect the common vaginal membrane of the testicle and spermatic cord.

The hernial sac, isolated directly to the neck, is removed from the surgical wound and opened in the bottom area. The edges of the dissected hernial sac are taken with clamps, the organs contained in it are examined and gradually, without using much effort, they are reduced into the abdominal cavity. The neck of the hernial sac is sutured with a silk thread under visual control, tied on both sides and 0.5 cm distal from the node, the sac is intersected in the transverse direction and removed. The stump of the hernial sac is immersed in the preperitoneal tissue. First you need to make sure that there is no bleeding from the stump of the hernial sac.

The third stage of hernia repair consists of plastic closure of the hernial orifice, taking into account the possibility of preserving the structure and physiological functions of the anatomical formations of the operated area. For indirect inguinal hernias strengthen the anterior wall of the inguinal canal. There are two groups of methods for strengthening the anterior wall of the inguinal canal with dissection of the aponeurosis of the external oblique abdominal muscle, i.e. the anterior wall of the inguinal canal and without dissecting the aponeurosis.

Methods of hernia repair without opening the anterior wall of the inguinal canal, i.e. aponeurosis of the external oblique abdominal muscle, are more often used in pediatric surgery.

Czerny's method consists in the fact that after isolation, ligation and removal of the hernial sac, 2 sutures are placed on the legs of the aponeurosis of the external oblique abdominal muscle. As a result of the convergence of the legs, a fold is formed on the aponeurosis of the external oblique muscle, onto which 3-4 sutures are applied.

Krasnobaev proposed to narrow the superficial ring of the inguinal canal with one suture, placing it on the legs of the aponeurosis; another 2-3 sutures are placed on the resulting fold of the aponeurosis, which are caught in the assembly and pulled to the inguinal ligament.

Method Ru consists of placing 4-5 sutures on the anterior wall of the inguinal canal. In addition to the aponeurosis of the external oblique muscle, the lower edges of the internal oblique and transverse abdominal muscles are grabbed into the suture from above, and the inguinal ligament is captured into the suture from below. The inguinal ligament must be sutured very carefully and superficially so as not to damage the femoral vessels, which in children are very close to the inguinal ligament.

Oppel method. In addition to suturing the uncut aponeurosis with the underlying muscles to the inguinal ligament, it also includes the moment of narrowing the superficial ring of the inguinal canal by suturing its legs. With all of the above methods, the remaining hole should allow the tip of the index finger to pass through.

When diagnosing a hernia, the first priority is the need for hernia repair and hernioplasty. The patient and his relatives want to know what these terms mean, how interventions are carried out, and what they will face in the postoperative period. Let's look at these questions in more detail.

Hernias are not treated with therapeutic methods. The use of all kinds of bandages, physiotherapy and gymnastic exercises aimed at strengthening the muscle girdle are only preventive measures and cannot eliminate the existing pathology.

Surgical techniques

In the case of a planned operation, when immersion of intestinal loops into the abdominal cavity is not required, it is used hernioplasty(hernia repair in literal translation). If there is a pathological protrusion, then surgical intervention takes place in two stages: hernia repair(reduction of the organ with removal of altered surrounding tissues) and strengthening of the muscle wall.

In practice, different techniques are used in accordance with the location of the hernia and the purpose of the intervention.

Hernioplasty for umbilical hernias

Among the open methods of surgical intervention for umbilical hernia, they resort to plastic surgery according to Sapezhko or Mayo. The basis for strengthening the umbilical ring and the anterior abdominal wall is the creation of an aponeurotic duplication. After preoperative preparation and anesthesia, the intervention begins.

The operation begins with layer-by-layer separation with a scalpel of the skin, subcutaneous fat to the aponeurosis (tendon formation between the muscles). Using special instruments, an incision is made, giving access to the hernial sac containing intestinal loops.

After the intestine is released, its condition is assessed and immersed in the abdominal cavity. Then, areas of excess tissue are excised and plastic surgery begins directly.

The aponeurotic tissues are sutured with a U-shaped suture so that a double fold is obtained. The difference between Mayo plastic surgery and Sapezhko surgery lies in the direction of the incision and, accordingly, the stitching of the tissue. In the first case, the cutting line runs horizontally. The aponeuroses are stitched in the following order: first the upper flap from the outside in, then the lower flap in the same way, after which the thread passes in the opposite direction. In Sapezhko plastic surgery, the right and left aponeurotic parts are compared using the same technique.

If the umbilical ring is small in children, it is possible to use the method developed Lexler. In this case, a purse-string (circular) suture is placed on the hernial orifice, the edges are tightened, and then all the tissues are compared with ordinary interrupted stitches.

Hernioplasty for inguinal hernias

The hernia repair technique is selected in accordance with the type of hernia (oblique and direct) and the purpose of strengthening a specific wall of the inguinal canal.

Martynov's method used to strengthen the front wall. The operation is carried out by determining access. The incision is made approximately 1.5 cm above the inguinal ligament, the layers are alternately separated until the contents of the hernial sac are released and reduced into the abdominal cavity. After that, the upper part of the aponeurosis is sutured to the inguinal ligament, and then the lower part of the connective tissue structure is placed on top of this and stitched. Further layer-by-layer closure of the wound is carried out.

To strengthen the back wall they resort to Bassini technique. After herniotomy, they begin to apply deep sutures behind the spermatic cord between the muscles that make up the upper wall of the canal (internal oblique and transverse), the transverse fascia and the Pupart ligament. In this way, the posterior wall is completely covered by the muscular-fascial layer. Next, compare all the fabrics with each other.

A technique has been developed for creating a “new” inguinal canal to replace the old one. Hernioplasty according to Postempsky carries out suturing of the canalis inquinalis and transfer of the spermatic cord to another location. In this case, after excision of the hernial sac, the superolateral part of the cord is deflected outward and slightly higher, if necessary, slightly excising the internal oblique and transverse muscles with immersion in the resulting space f.spermaicus and fastening between the muscle fibers. From below, the muscle tendons are sutured to the pubic tubercle and Cooper's ligament (between the frontal tubercles). The remaining tissues are connected to the inguinal ligament with U-shaped sutures. Then the lower and upper parts of the aponeurosis are compared using the external oblique. As a result, the spermatic cord is placed in fatty tissue.

Among classical techniques, the use of mesh materials occupies a worthy place. Plastic surgery according to Liechtenstein involves the use of a synthetic graft to strengthen the hernial orifice. After all standard surgical procedures, a mesh flap is sewn into the area of least strength, which subsequently fuses firmly with the surrounding tissues and prevents the occurrence of a hernia.

Alternative operations

Along with hernia repair through open access, endoscopic operations are successfully used. The latter types of interventions are low-traumatic. Operations using endoscopic technology are carried out through punctures at 3 points. Through one of them, optical equipment is passed, which allows you to display the image on the monitor and see everything that is happening in the surgical field. Other punctures are used to introduce special instruments used for direct hernia repair and placement of a mesh implant.

Such an intervention has its advantages in making the postoperative period easier, and the remaining scars at the site of several punctures are hardly noticeable and do not cause aesthetic discomfort. However, despite all the advantages, endoscopic techniques cannot completely replace traditional operations, both for some technological reasons (not all institutions have specialized equipment) and due to the objective need on the part of a number of patients for surgery through open access.

Do not let the disease progress and seek medical help promptly. There are frequent cases of intestinal strangulation in the hernial orifice, requiring emergency surgical intervention.

Actions of doctors after preliminary examination and examination:

anesthesia;
preparation of the surgical field;
layer-by-layer dissection of tissues to the hernial sac;
opening the hernial sac and assessing the condition of the strangulated intestine;
in the presence of peristalsis, pulsation of blood vessels and a good appearance of the organ, after “resuscitation” actions (warming and irrigation with saline solution), its reduction is performed;
in the absence of viability, resection (removal) of a section of intestine is carried out within 40-50 cm to and 15-20 cm from the site of incarceration. If there is damage to the mucous membrane in the remaining areas, resection is performed within healthy tissue. The ends of the adductor and efferent sections are compared, followed by stitching and immersion into the abdominal cavity.
layer-by-layer suturing of tissues.

What is tension and non-tension plastic surgery?

Initially, hernioplasty methods were carried out by connecting only one’s own tissues. In this case, tension of the structures naturally occurs. Tension plastic has a number of disadvantages, which manifest themselves in:

suture failure;
cutting threads and inflammation;
large tissue swelling;
recurrence of hernias, etc.

Video

To reduce complications, the use of synthetic mesh has been suggested. Candidate of Medical Sciences, Head of the Surgical Department E. Lisin talks about such implemented methods. The interview is accompanied by a visual video about the treatment of hernias.

Is there pain relief?

The fear of pain during surgery is understandable and understandable. The operation can be performed either under local infiltrative anesthesia, using epidural administration of analgesics, or under general anesthesia. The type of anesthesia is determined in accordance with the general condition of the patient, the urgency of the intervention and other additional circumstances. In severe cases, combined anesthesia is used, accompanied by respiratory support.

Restrictions in the postoperative period

In the early period after the intervention, the patient is first under the supervision of medical professionals who control bed rest and diet.

The main questions arise after discharge from the hospital. Healing of the wound surface occurs relatively successfully by the end of the second week. Therefore, at first it is important to maintain physical and sexual rest. You can't lift weights. It is necessary to establish split meals with the elimination of spicy, fatty foods, legumes, carbonated drinks and other products that contribute to constipation and flatulence (factors that provoke a relapse of the disease). A cough is also accompanied by an increase in intra-abdominal pressure, so if necessary, you should discuss with your doctor the possible use of antitussive medications and stop smoking. After 14 days, you need to start physical education.

You can gradually master light exercises:

“scissors” (crossing legs in a lying position);
“bicycle” (alternate movements of the legs in a supine position);
bar;
squats.

It must be remembered that classes are carried out in doses, at first in small quantities and according to one’s own strength. You cannot overstrain your body.

The person operated on should be on light work for up to 3-4 months. Lifting weights over 10 kg is strictly prohibited (in individual cases, the permitted weight is several times less).

Note!

Sexual activity is allowed no earlier than 2 weeks. At the same time, during intimate relations, you need to carefully monitor the absence of pressure on the wound area and limit activity.

Hernia repair followed by hernioplasty is the “gold standard” for the treatment of hernias of various locations. Operations are carried out with an individual approach, adhering to developed standards. In the postoperative period, the patient is not left alone with his pain, but is under close medical supervision. The further condition largely depends on the implementation of the recommendations and the lifestyle of the person operated on.

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Surgical tactics

The main principle of surgical treatment of abdominal hernias is an individual, differentiated approach to the choice of hernia repair methods.

When solving this problem, it is necessary to take into account the shape of the hernia, its pathogenesis, the condition of the tissues of the anterior abdominal wall and the size of the hernia defect.

Numerous methods of operations for hernias are systematized according to the principle of preferential use of certain tissues of the abdominal wall. There are 5 main methods of hernioplasty:

1) fascial-aponeurotic,

2) muscular-aponeurotic,

3)muscular,

4) plastic surgery with additional biological or synthetic materials (alloplaty, explantation),

5) combined (use of autologous tissues and foreign tissues).

The first two methods are combined into autoplastic ones, and the remaining two are usually called alloplastic.

There are more than 80 methods of hernia repair proposed for inguinal hernias; It can be noted that 30 of them gave new ideas in surgical treatment. There are about 50 different modifications that are used, and it should be noted that some of them are more successful and expedient than the main methods.

Currently, the main autoplastic method for treating hernias is muscular aponeurotic plastic surgery. With this method, the abdominal wall defect is strengthened not only with the aponeurosis, but also with muscles. The principle of muscular aponeurotic plasty underlies a huge number of surgical methods, many of which are currently of only historical interest. The most widely used methods for inguinal hernias are Girard, Spasokukotsky, Bassini, Postemsky, Kirchner; for umbilical hernias - the Mayo method; for postoperative hernias and hernias of the white line of the abdomen - the Sapezhko method and its numerous modifications.

The most important advantage of muscular aponeurotic plasty is that the abdominal wall defect is strengthened by muscle tissue that is capable of actively dynamically counteracting fluctuations in intra-abdominal pressure due to its inherent contractility and elasticity. Aponeurotic tissues essentially play only a passive strengthening role. Thus, the main condition that determines the success of the operation when using musculoaponeurotic plastic surgery is the preservation of muscle function, but this is not always possible. Muscle tissue is very delicate and easily injured. Any of its movements, compression by sutures, disorders of its circulation and innervation lead to gross morphological changes and dysfunction. Many surgeons, developing methods of operations for hernias, carried away by the goal of reliably strengthening hernia defects through purely mechanical techniques, significantly move the layers of the abdominal wall, without thinking about what conditions will arise in the postoperative period: will the tissues retain their function and ability to regenerate, will the principle of homogeneity be violated? sewn fabrics. Especially gross morphological changes occur in the muscles of the anterior abdominal wall when using the Sapezhko method or its modifications under conditions of significant tension of the stitched tissues. . This is observed when creating a wide muscle duplication with extensive hernia defects. Modern anesthesia using muscle relaxants creates conditions for maximum muscle relaxation during surgery, which makes it possible to tighten the edges of even very large defects without much effort. However, immediately after the operation, the tissues of the abdominal wall find themselves under conditions of excessive tension, which leads to changes in the anatomical structures of the anterior abdominal wall, fiber disintegration or complete destruction of the fascial muscle sheaths, cicatricial degeneration of the aponeurosis and muscle atrophy.

A strangulated hernia is subject to immediate surgical intervention. The only contraindication to surgery is the patient's agonal condition. Forcible reduction of a strangulated hernia is unacceptable, as it can cause hemorrhage into the soft tissues, intestinal wall and mesentery, vascular thrombosis, mesenteric rupture, and intestinal perforation. In addition, such an attempt can lead to an imaginary reduction of the hernia. Only in exceptional cases, when the patient categorically refuses surgery or there are diseases such as fresh myocardial infarction, cerebrovascular accident, and no more than 1-1.5 hours have passed since the infringement, it is permissible to use some conservative measures:

subcutaneous injection of 1 ml of 0.1% atropine solution;

emptying the bladder;

warm cleansing enema;

puncture of tissue near the hernial orifice with a 0.25% solution of novocaine;

lifting the pelvis.

Various options for imaginary reduction are possible. for example, with rough manipulations you can:

separate the entire hernial sac from the surrounding tissues and place it, together with the strangulated organ, into the abdominal cavity or preperitoneal tissue.

tear the neck away from the rest of the hernial sac and place it, together with the strangulated organ, into the abdominal cavity;

move the strangulated viscera in a multi-chamber hernial sac from one chamber to another, which lies deeper, most often in the preperitoneal tissue.

The most important step in case of a strangulated hernia is the isolation of the hernial sac, its opening, and then, after dissection of the strangulating ring, examination and assessment of the viability of the organs. Strangulated parts of the omentum should be resected in all cases. As for determining the viability of the intestinal wall, the correctness of solving this issue largely depends on the experience and qualifications of the surgeon. The main criteria for determining the degree of viability of the small intestine are:

restoration of normal pink color;

absence of strangulation furrow and dark spots visible through the serous membrane;

preservation of pulsation of mesenteric vessels;

presence of peristalsis.

If all these signs are present, then the intestine can be considered viable and immersed in the abdominal cavity.

If there is the slightest doubt, a bowel resection should be performed. Indisputable signs of intestinal non-viability are its dark color, dull serous membrane, flabby thickened wall, lack of peristalsis and pulsation of mesenteric vessels. It has been proven that from the visible border of necrosis it is necessary to resect at least 30-40 cm of the adductor segment of the intestine and 15-20 cm of the efferent segment.

For phlegmon of the hernial sac, a Samtera operation is performed, which begins with a midline laparotomy. A section of the intestine located in the hernial sac is resected, and an anastomosis is performed between the efferent and afferent loops. The laparotomy wound is sutured tightly.

Then, an incision is made over the hernial “tumor” to dissect the skin, tissue, and hernial sac. Remove purulent exudate. The hernial orifice is incised very carefully, just enough so that the strangulated loop and blind ends of the intestine left in the abdominal cavity can be extracted and removed.

The hernial sac is not isolated from the surrounding tissues.

MAIN STEPS OF HERNIATION

There are a huge number of operations for inguinal hernia, but they all differ from each other only in the final stage - plastic surgery of the inguinal canal. the remaining stages of the operation are performed in the same way.

The first stage is access to the inguinal canal. A skin incision is made parallel to the inguinal ligament and 2 cm medial to it, from the anterosuperior iliac spine to the symphysis. After dissection of the skin and subcutaneous tissue, careful hemostasis is performed. The aponeurosis of the external oblique abdominal muscle is completely freed from adipose tissue. Then a Kocher probe is inserted through the external opening of the inguinal canal, through which the anterior wall of the inguinal canal is dissected. The resulting flaps of aponeurosis are captured with clamps and, using a tuffer, separated from the underlying tissues: the upper flap is from the internal oblique abdominal muscle, and the external flap is from the spermatic cord, exposing the groove of the inguinal ligament to the pubic tubercle.

The second stage is isolation from the surrounding tissues and removal of the hernial sac. In case of a direct inguinal hernia, the spermatic cord is taken on a holder and retracted to the lateral side. the hernial sac is located medial to it, covered by the transverse fascia with a thin layer of preperitoneal tissue. With an oblique hernia, the membrane of the spermatic cord is first delaminated, and a hernial sac is found among its elements. To facilitate the search for the hernial sac, the patient is asked to strain or cough. In this case, the sac is well contoured due to the exit of the organs.

Surgery for abdominal hernia should be radical, as simple as possible and least traumatic. It should be borne in mind that while in most uncomplicated abdominal wall hernias (inguinal, umbilical, etc.) good results can be achieved using relatively simple methods of closing the hernia orifice, in some forms (postoperative, recurrent) it is necessary to use complex technical techniques, including reconstructive and plastic. The key to successful herniotomy is knowledge of topography.

The hernia repair operation consists of three stages:

1) access to the hernial orifice and hernial sac;

2) treatment and removal of the hernial sac;

3) elimination of the abdominal wall defect (closing the hernial orifice).

The following requirements are imposed on access: simplicity and security; possibility of a wide view of the hernial canal or hernial opening. In this case, the access should take into account the condition of the tissues in the area of the hernial orifice (inflammatory foci, scars).

Treatment and removal of the hernial sac constitute the second stage of the operation. This stage consists of several sequential techniques:

1. Careful isolation of the parietal peritoneum, which makes up the hernial sac, from the surrounding tissues, which is especially important in areas where the hernial sac is in close contact with important anatomical formations (spermatic, cord in inguinal hernia, femoral vein in femoral hernia, etc. ). This is achieved using the so-called “hydraulic preparation” method, that is, the introduction of a 0.25% novocaine solution around the wall of the hernial sac to facilitate the separation of the parietal peritoneum from the adjacent tissues - intra-abdominal fascia, preperitoneal tissue, umbilical ring, spermatic cord or round ligament of the uterus,

2. Isolation of the neck of the hernial sac. If the neck of the hernial sac is not completely removed, a pocket of parietal peritoneum remains, which contributes to the recurrence of the hernia. There are anatomical landmarks in the hernial orifice that help determine the “adequacy” of the release of the neck of the hernial sac. So, for example, in the inguinal canal at the level of the neck of the pouch, you need to see the pulsating inferior epigastric artery; when the hernial sac is stretched along with its neck, unchanged preperitoneal tissue appears in the hernial orifice, etc.

3. Inspection of the contents of the hernial sac in order to identify pathological changes in the hernial contents, dissection of adhesions (resection of necrotic areas of organs in strangulated hernias, etc.).

4. Stitching and ligation of the neck of the hernial sac to seal the abdominal cavity, followed by cutting off the sac above the ligatures. The neck should be ligated in a taut state to avoid leaving pockets and depressions in the peritoneum.

5. After cutting off the hernial sac, the preperitoneal tissue is removed from the hernial orifice. Preperitoneal tissue, penetrating into the hernial orifice, prevents its strong closure and subsequently, under the influence of intra-abdominal pressure, expands it, contributing to the development of relapse.

After treatment and removal of the hernial sac, the final stage of the operation begins - closing (plasty) of the hernial orifice.

There are several hundred ways to close or strengthen the hernial orifice; they can be divided into three groups:

1) simple;

2) reconstructive;

3) plastic.

Simple ways Strengthening the hernial orifice involves closing the existing abdominal wall defect with sutures. These methods are used for simple forms of hernias. An example of a simple method for closing a hernial orifice is the Lexer method, used for umbilical hernias. This method consists of placing a purse-string suture around the extended umbilical ring, when tightened, the hernial orifice is closed; additionally, the medial edges of the vaginal abdominal muscles are brought together with interrupted sutures.

For small inguinal hernias in children, in order to reduce the trauma of the operation, methods are used to strengthen the anterior wall of the inguinal canal without opening it. At the first stage, the outer ring of the inguinal canal is narrowed (by applying several interrupted or U-shaped sutures. The second stage consists of suturing the aponeurosis of the external oblique muscle (Krasnobaeva) or the aponeurosis and muscles (internal oblique and transverse) to the inguinal ligament (Ru) with U-shaped sutures -Oppel).

A simple one is Rudzhi’s method for closing the hernial orifice in femoral hernias, which consists of suturing the inguinal ligament to the pectineal ligament.

Simple methods have limited use, since they cannot be used with significant changes in the topography of tissue in the area of the hernial orifice, which is observed with large hernias.

Reconstructive methods are aimed at changing the design of the hernial orifice in order to strengthen them. Reconstruction can be performed either using fascia and aponeuroses (fascial-aponeurotic methods) or using both muscles and aponeuroses (muscular-aponeurotic methods).

Fascial-aponeurotic methods include, for example, strengthening the hernial orifice using doubling (creating a duplicate from the aponeurosis of the external oblique abdominal muscle, from the white line, intra-abdominal fascia, etc.).

The duplication of the aponeurosis of the external oblique abdominal muscle is used, in particular, when strengthening the anterior wall of the inguinal canal according to A. V. Martynov. According to this technique, a duplication is created by suturing the upper edge of the aponeurosis of the external oblique abdominal muscle, cut along the inguinal canal, to the inguinal ligament and then applying the lower edge of the aponeurosis of the same muscle to it.

Fascial-aponeurotic methods include the Mayo and K. M. Sapezhko methods used for umbilical hernias. With the Mayo method, the umbilical ring is dissected with two transverse incisions across the entire width of the linea alba, opening the rectus sheath until its inner edge appears. Then U-shaped sutures are applied so that the lower edge of the incision lies under the upper. The second row of interrupted sutures attaches the upper aponeurotic edge to the lower one. A relative disadvantage of this method is that the linea alba does not narrow, but, on the contrary, expands. In addition, the rectus abdominis muscles are also deformed, which is functionally disadvantageous.

Sapezhko's method involves cutting the hernial orifice several centimeters up and down. After this, sutures are placed that capture the edge of the aponeurosis on one side and the posterior wall of the rectus sheath on the other to create a duplication in the longitudinal direction. The second suture connects the remaining free edge of the linea alba incision with the anterior wall of the vagina of the opposite rectus muscle. The Sapezhko method is more beneficial than the Mayo method, since when it is used, the width of the linea alba of the abdomen decreases, the course of the fibers of the rectus abdominis muscles is straightened and their inner edges move closer to each other.

Musculoaponeurotic methods of reconstruction are widely used in the surgical treatment of inguinal hernias. In this case, either the anterior or posterior wall of the inguinal canal is strengthened (muscular aponeurotic tissues are sutured to the inguinal ligament in front or behind the spermatic cord or round ligament of the uterus).

Methods for strengthening the posterior wall of the inguinal canal include the Bassini method.

After opening the inguinal canal and excision of the hernial sac behind the spermatic cord, sutures are placed between the edge of the rectus abdominis muscle with its vagina and the periosteum of the pubic tubercle, and then the internal oblique and transverse muscles with the intra-abdominal fascia are sutured to the inguinal ligament. These sutures close the inguinal gap.

Methods of strengthening the anterior wall of the inguinal canal are more often used for indirect inguinal hernias in young people. According to the method of A. A. Bobrov, the free edges of the internal oblique and transverse muscles are sutured, after opening the inguinal canal and removing the hernial sac, to the inguinal ligament anterior to the spermatic cord or round ligament of the uterus. Then the edges of the aponeurosis of the external oblique muscle, cut during access, are connected.

According to the Girard method, after removing the hernial sac and suturing the deep opening of the inguinal canal, the internal oblique and transverse muscles are sutured to the inguinal ligament along the entire length of the inguinal canal anterior to the spermatic cord. Then a second row of sutures is placed between the upper edge of the dissected aponeurosis of the external oblique abdominal muscle and the inguinal ligament. After this, the lower edge of the aponeurosis is placed on top of the one sutured to the inguinal ligament, forming a duplicate. The disadvantage of the Girard method is the multiple rows of sutures on the inguinal ligament, which severely injure it and disintegrate it.

With the Girard-Spasokukotsky method, to strengthen the anterior wall of the canal, the edges of the internal oblique and transverse muscles are sutured to the inguinal ligament of muscles along with the adjacent aponeurosis of the external oblique muscle. After this, a duplicate is formed from the aponeurosis of the external oblique muscle, as with the Girard method.

One of the unpleasant complications during operations for inguinal hernia is postoperative pain due to damage or entrapment of the ilioinguinal nerve in a ligature. This nerve passes near the lower edge of the internal oblique abdominal muscle and easily enters the ligature when suturing the muscle. As a result, severe pain develops, radiating to the testicle and medial thigh. To avoid this complication, it is necessary to apply sutures under the control of the eye, having previously isolated the nerve. Muscular-aponeurotic strengthening of the anterior or posterior wall of the inguinal canal in most cases ensures radical surgical intervention, closing the inguinal space. The disadvantage of these reconstruction methods is the relative fragility of the postoperative scar due to the connection of dissimilar tissues.

Reduction of the muscles to reduce the inguinal gap is facilitated by making releasing incisions in the anterior wall of the vagina of the rectus abdominis muscle. They have to be resorted to if the height of the gap exceeds 3 cm and a lot of tension arises when applying sutures.

When suturing the inguinal ligament, it is necessary to take into account that under it, at the border of the medial and middle third of the length, there are femoral vessels - an artery and a vein. Careless insertion of the needle can damage these vessels and cause dangerous bleeding.

Plastic methods used for large “old” hernias, significant expansion of the hernial orifice, when one’s own tissues are not enough for radical hernioplasty.

As a plastic material, aponeurotic or muscle flaps on a feeding pedicle from nearby areas are used, less often autodermal flaps, preserved allografts from the dura mater.

The main condition for the use of an aponeurotic or muscle flap on a pedicle is the absence of any tissue tension or kinks in the vessels supplying the flap. For small hernias located along the midline of the abdomen in the lower part and in the groin region, flaps from the aponeurosis of the anterior wall of the rectus sheath or the aponeurosis of the external oblique muscle can be used. For plastic surgery for recurrent inguinal hernias, as well as for femoral hernias, flaps from the fascia lata of the thigh or the sartorius muscle are recommended. By passing the prepared flaps to the area of the inguinal canal under the inguinal ligament, it is possible to close both the inguinal space and the expanded inner ring of the femoral canal. This is beneficial for combined femoral and inguinal hernias.

Synthetic materials for closing hernial orifices (lavsan, fluoride, etc.) have become widespread. Lavsan and fluorolone meshes retain their strength for a long time, they do not cause a rejection reaction, and they grow well with connective tissue during implantation.

There are two possible options for using synthetic material - closing the hernial orifice from the front or back surface. It is believed that in case of hernias of the anterior abdominal wall, it is more advantageous to place the explant under the muscles, suturing it in the form of a patch to the hernial orifice from behind. In this case, a synthetic mesh replaces a section of intra-abdominal fascia, which is usually thinned and does not have mechanical strength.

The most common and life-threatening complication of hernias is strangulation.

The following types of strangulation are distinguished: parietal (strangulation of the intestinal wall without disrupting the movement of contents), antegrade (strangulated loop of intestine is in the hernial sac) and retrograde (strangulated loop of intestine is in the abdominal cavity) which are accompanied by the development of the clinic of intestinal obstruction. When performing operations for strangulated hernias, a certain sequence of stages of surgical intervention must be followed:

Online access;

Isolation of the hernial sac;

Opening the hernial sac;

Fixation of hernial contents;

Dissection of the strangulating ring (hernia orifice);

Inspection of hernial contents and assessment of organ viability by color, luster, peristalsis, pulsation of mesenteric vessels);

In case of necrosis or suspected non-viability of the strangulated organ, resection within healthy tissues;

Plastic surgery of hernial orifices;

At the stage of eliminating the strangulation, the surgeon must clearly know the boundaries of the hernial orifice and which of the walls can be cut.