In surgical practice, hernia repair is carried out by several methods, each of which has advantages and disadvantages. Operations are classified according to the method of tissue strengthening (tension, non-tension) and the presence of direct access to the hernial sac (open, endoscopic).
With tension plastics, the walls of the inguinal canal are strengthened by suturing or duplicating with their own tissues. With the tension-free method, alloplasty is performed - an operation using synthetic materials (polyester, polypropylene meshes, etc.), which are sutured to the muscles and ligaments after the defect is reduced and the hernial sac is removed.
Mesh endoprosthesis contributes to the formation of a strong wall of connective tissue.
open way
Inguinal hernioplasty (hernia repair) can be performed by the following methods:
- By Bassini. Refers to the methods of tension plastics.
- According to Shouldice. It is characterized by the imposition of a continuous two-layer or three-layer seam. It has a high (up to 10%) risk of recurrence.
- By Liechtenstein. It implies a traditional abdominal operation with plastic Teflon or polypropylene mesh. The risk of re-hernia is less than 1%.
- Obturation plastic. Access and strengthening of the wall is provided in the same way as for the Liechtenstein method. Instead of opening the hernial sac, it is immersed in place with a polypropylene mesh in the form of a shuttlecock, the narrow end of which is directed inside the peritoneum. After repositioning, the base of the "frill" is attached to the surrounding tissues.
- With PHS. Canal plasty with this method is performed similarly to the Lichtenstein operation, but instead of a two-dimensional mesh, a complex three-dimensional prosthesis is used.
In the treatment of children, Duhamel hernioplasty is widely used, in which the hernia is isolated through the external inguinal ring, and then sutured and cut off. The intervention takes place without opening the inguinal canal.
Laparoscopy
Laparoscopy, or endoscopic hernia repair, is carried out through 3 small (up to 1.5 cm) punctures. Surgical instruments and a video camera are inserted into them. Carbon dioxide is injected into the area of the hernia, which pushes internal organs and gives the surgeon the opportunity to act. Hernioplasty itself is performed according to Liechtenstein.
All incisions can be made not with traditional instruments, but with a laser: this avoids bleeding and some postoperative complications.
Hernia repair is divided into several types according to the type of plastic surgery of the tissues of the abdominal wall:
- plasty with local tissues (autoplasty), the patient's own tissues are used;
- alloplasty, synthetic materials (mesh, prosthesis) or donor tissues are used;
- combined option (alloplasty autoplasty).
Symptoms
Signs of an inguinal hernia include:
- the appearance in the groin (scrotum) of a rounded protrusion;
- pulling pains in the area of the defect;
- an increase in the size of the protrusion during physical exertion (including during defecation);
- stool and urination disorders;
- vomiting, nausea, sharp pain, fever, discoloration of the protrusion when the defect is infringed.
In men, these symptoms occur 6-10 times more often than in women, but the risk of strangulated hernia is much lower.
Operation
Before any operation, the patient must undergo a series of studies, which will allow the surgeon to draw up a plan for the operation, have a number of drugs in case of complications, and generally navigate the general condition of the patient.
Such studies include:
- general analysis blood;
- blood chemistry;
- general urine analysis;
- electrocardiogram;
- tests that show the ability of blood to clot;
- analysis for the determination of viral diseases that are easily transmitted through the blood: HIV infection, hepatitis, syphilis;
- allergy tests.
Surgical intervention begins with two incisions, which are made in the place of a large accumulation of adipose tissue in the transverse direction. The surgeon borders the hernial formation.
Having gained access to the internal environment of the body, the specialist separates the layer of connective tissue from the subcutaneous tissue with a transverse incision. Thus, the doctor receives a hernia in a “naked” form, while manipulating the protrusion becomes easier.
After that, the hernia ring is dissected, and then the hernial sac itself is in the hands of the doctor. Its contents are revealed. Specialists inspect the filling, evaluate, study the state of the organs located there, which are then set back to their anatomical location. In the presence of adhesive processes with the inner side of the hernial sac, the adhesions are dissected and removed.
After these manipulations, the incision on the peritoneum is sutured with a continuous catgut suture. If the peritoneum is soldered to a part of the hernial ring, it is sutured together with the aponeurosis. After that, a series of silk seams in the shape of the letter "P" is applied. This method allows you to layer parts of the seams on top of each other. At this stage, the operating period ends.
During a planned operation, the doctor prescribes a complete examination of the patient, which includes:
- clinical analyzes of urine and blood, analysis of blood glucose;
- biochemical analysis;
- study of blood clotting;
- analysis for hepatitis, HIV, syphilis;
- fluorography;
- Ultrasound of the inguinal region.
During preparation for the operation it is necessary:
- do not take acetylsalicylic acid and do not smoke 2 weeks before surgery;
- do not use alcohol, narcotic and psychotropic drugs;
- on the eve of the operation, make an enema, eat no later than 18.00-20.00 and carefully shave the intervention area.
It is possible to talk about long-term preparation only in the case of a planned surgical intervention. In order to properly prepare for the operation, it is necessary to perform a number of diagnostic procedures and laboratory clinical studies. There is a standard package of laboratory tests before abdominal surgery:
- Complete blood count, including leukocyte count and platelet count;
- Coagulogram (assessment of the state of the proteins of the patient's coagulation system at the time of the study);
- Study of biochemical parameters (transaminase levels, total protein, creatinine, alkaline phosphatase, etc.);
- Determination of blood group and Rh factor;
- Test for HIV, hepatitis B and C, Wasserman reaction.
AT without fail a patient preparing for surgery is prescribed an ECG, fluorography, a general urine test. If indicated, other studies are added. For example, ultrasound of the abdominal region, hernial protrusion or computed tomography, fibrogastroduodenoscopy, fibrocolonoscopy.
open surgery
Unlike laparoscopic surgery, this type surgical intervention It takes place under both general anesthesia and local anesthesia. Small uncomplicated inguinal and femoral hernias are often treated with epidural anesthesia.
The operation itself consists of 4 stages:
- Opening access to the hernial sac by layer-by-layer dissection of tissues.
- Isolation and release (or excision) of the hernial sac
- Closing the hernial ring with various kinds plastics.
- Layer-by-layer suturing of the postoperative wound.
The skin incision in an umbilical hernia is longitudinal along the midline a few centimeters above the navel, bypassing it on the left and continuing 3-4 cm below.
In obese patients with an umbilical hernia, a semilunar or oval incision is often made, bordering the hernial protrusion from below. The skin and subcutaneous tissue are dissected to the aponeurosis of the white line of the abdomen.
By dissecting the skin flap from left to right, the skin with subcutaneous tissue is separated from the hernial sac of the umbilical hernia. It is isolated until the hernial orifice formed by the dense aponeurotic edge of the umbilical ring is clearly visible.
Mayo hernia repair is most often performed under local anesthesia. It is relevant in cases where the hernial formation is small or medium in size.
If it is large, then it is better to choose epidural anesthesia for pain relief. In both cases, the patient remains conscious.
Although some patients are nervous about this, however side effects and the harm from epidural or local anesthesia is much less than from general anesthesia.
Operation steps
- skin incisions,
- Department of the aponeurosis
- muscle dissection,
- Opening the hernial sac and examining the contents,
- protrusion reduction,
- Suturing the aponeurosis and the edges of the surgical wound.
Mayo umbilical hernia repair begins with providing access to the hernial protrusion. For this, two skin incisions are made. They are performed transversely in the form of a crescent and border the hernial protrusion.
Operations for hernias of the white line are often performed under local anesthesia according to A.V. Vishnevsky. A skin incision is made over the hernial protrusion in the longitudinal or transverse direction. The hernial sac is isolated and processed in the usual way. Around the hernial orifice for 2 cm, the aponeurosis is freed from fatty tissue, after which the hernial ring is cut along the white line.
Hernial ring plasty is performed according to the Sapezhko-Dyakonov method. i.e., a duplication is created from flaps of the aponeurosis of the white line of the abdomen in the vertical direction by first applying 2-4 U-shaped sutures, similar to how it is done with the Mayo method. followed by suturing the edge of the free flap of the aponeurosis with interrupted sutures to the anterior wall of the sheath of the rectus abdominis muscle.
If the operation is performed on a preperitoneal lipoma, then the latter is separated from the surrounding subcutaneous tissue and from the edges of the aponeurosis, and then dissected to make sure that there is no hernial sac in it. In the absence of a hernial sac, the lipoma is bandaged at the base of the leg and cut off. The stump is immersed under the aponeurosis, the edges of which are sutured with a purse-string suture or interrupted sutures.
Umbilical hernias of childhood and adult hernias can be operated on both extraperitoneally and intraperitoneally. The extraperitoneal method is rarely used, mainly for small hernias, when the reduction of the hernial contents is not difficult. In other cases, the hernial sac is opened.
The intraperitoneal methods of surgical treatment of umbilical hernias include Lexer methods. K. M. Sapezhko. Mayo and others. The Lexer method is used for small umbilical hernias. For medium and large umbilical hernias, the methods of K. M. Sapezhko or Mayo are more appropriate.
Lexer method. The skin incision is carried out semi-lunar, bordering the hernial tumor from below, less often - circular. During the operation, the navel can be removed or left. If the hernia is small, then the navel is usually left. The skin with subcutaneous tissue is peeled upward and a hernial sac is isolated.
It is often very difficult to isolate the bottom of the hernial sac, which is intimately soldered to the navel. In such cases, the neck of the hernial sac is isolated, it is opened and the hernial contents are set into abdominal cavity.
The neck of the bag is stitched with silk thread, tied up and the bag is cut off. The stump of the bag is immersed behind the umbilical ring, and its bottom is cut off from the navel.
Having finished processing the hernial sac, proceed to the closure of the hernial ring. To keep it under control index finger introduced into the umbilical ring, a silk purse-string suture is applied to the aponeurosis around the ring, which is then tightened and tied.
Over the purse-string suture, another 3-4 interrupted silk sutures are applied to the anterior walls of the sheaths of the rectus abdominis muscles. The skin flap is placed in place and sutured with a number of interrupted sutures.
Method K. M.
Sapezhko. The skin incision is made over the hernial protrusion in the vertical direction.
The hernial sac is isolated from the subcutaneous fatty tissue, which is exfoliated from the aponeurosis to the sides by 10-15 cm. The hernial ring is cut up and down along the white line of the abdomen.
The hernial sac is treated according to the generally accepted method. After that, the edge of the dissected aponeurosis of one side is sutured with a number of interrupted silk sutures to the posterior wall of the sheath of the rectus abdominis muscle of the opposite side.
The remaining free edge of the aponeurosis is placed on the anterior wall of the sheath of the rectus abdominis muscle of the opposite side and is also fixed with a number of interrupted silk sutures. As a result of this, the sheaths of the rectus abdominis muscles are layered on top of each other along the white line, like the floors of a coat.
The operation is completed by suturing the skin. If necessary, several sutures connect the subcutaneous fatty tissue.
Mayo method. Two semilunar skin incisions are made in the transverse direction around the hernial protrusion.
The skin flap is grasped with Kocher clamps and peeled off from the aponeurosis around the hernial orifice for 5-7 cm. The hernial ring is cut in the transverse direction along the Kocher probe.
Having selected the neck of the hernial sac, it is opened, the contents are examined and set into the abdominal cavity. In the presence of adhesions of the hernial contents with the hernial sac, the adhesions are dissected.
The hernial sac is excised along the edge of the hernial ring and removed along with the skin flap. The peritoneum is closed with a continuous catgut suture.
If the peritoneum is fused with the edge of the hernial ring, then it is sutured together with the aponeurosis. Then, several U-shaped silk sutures are applied to the aponeurotic flaps so that when they are tied, one flap of the aponeurosis overlaps the other.
The free edge of the upper flap is sutured next to the interrupted sutures to the lower one.
The skin incision is closed with several interrupted silk sutures.
Repair of postoperative ventral hernias is usually performed under general anesthesia. An excision of the old postoperative scar is performed, after which the hernial sac is isolated and processed.
After opening the hernial sac and immersing its contents (abdominal organs) back into the abdominal cavity, the defect in the muscle layer is sutured. The cut mesh endoprosthesis is fixed to the tissues of the anterior abdominal wall.
Finally, the incision is closed with a cosmetic suture.
After hernioplasty with a mesh prosthesis, the recurrence rate of hernias is less than 1%. Postoperative pain syndrome is minimal due to the lack of tension of local tissues.
Intense physical activity is possible 1 month after hernioplasty, while physical activity in everyday life is practically not limited.
Hernioplasty with the installation of a mesh endoprosthesis is often performed on an outpatient basis, and the patient can leave the hospital on the day of the operation. The advantage of this technique is the possibility of its implementation using local or epidural anesthesia, which is extremely important for elderly patients and patients with cardiopulmonary pathology.
In Moscow, hernioplasty of a hernia of the white line of the abdomen costs 38036 rubles. (average). The procedure can be completed at 138 addresses.
By the beginning of the 21st century, the epidemiology of hernias had changed significantly. The increased number of surgical operations has led to a sharp increase in the number of patients with incisional ventral hernias.
The main reason for their formation is the divergence of the muscular-aponeurotic layers of the anterior abdominal wall in the area of surgical access. In addition, the cause of the formation of postoperative ventral hernias can be a violation of the innervation of the muscular-aponeurotic structures of the anterior abdominal wall after the surgical intervention.
At the same time, paralytic relaxation of the muscles develops, followed by their atrophy and a violation of the frame function of the anterior abdominal wall.
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In the first months of hernia formation, the hernial ring usually has an elastic consistency. Then progressive cicatricial fibrosis leads to the formation of strands and bridges.
Hernial gates become rough and rigid, multiple chambers are often formed, degeneration of the muscle structures that form them develops. The size of the hernial orifice of postoperative ventral hernias is variable, their multiple nature is often diagnosed, and the hernial sac has a pronounced vascularization.
The contents of the hernial sac of postoperative ventral hernia can be any organs of the abdominal cavity. As a result of the development of the adhesive process, the hernial contents are usually adherent to the walls of the hernial sac over a long distance, which significantly complicates the surgical operation.
Diagnosis of postoperative hernias is not difficult.
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There is no single generally accepted classification of ventral hernias. When carrying out planned surgical interventions and determining the method of plastic surgery of the anterior abdominal wall in patients with ventral hernias, the SWR classification developed by J.
P. Chevrel and A.
This classification takes into account three parameters of ventral hernia, is simple and convenient in practical application(Table 68-2).
Table 68-2. SWR classification of ventral hernias (according to J.P. Chevrel and A.M. Rath, 1999)
The first laparoscopic operations for incisional hernias were performed in 1991. Indications for them are hernias that are difficult to close with local tissues, or there is a need for simultaneous intervention on the abdominal organs.
The position of the patient on the operating table and the operating team depends on the location of the hernia, while the operating surgeon must be located on the opposite side of the hernia, and the hernia zone must be above other parts of the abdominal cavity.
The first trocar is inserted into the abdominal cavity as far as possible from the hernial orifice, where adhesions are least likely. After performing diagnostic laparoscopy, additional trocars are introduced, intra-abdominal adhesions are separated, the hernial contents are separated from the walls of the hernial sac, the location of the hernial ring and their dimensions are determined.
After determining the size of the abdominal wall defect, the mesh is cut out so that its dimensions are 3-4 cm larger than the size of the hernial orifice. The parietal peritoneum around the hernia orifice is then dissected and separated from the transverse fascia, creating a "pocket" in the preperitoneal space to accommodate the explant.
The mesh is folded into a tube and inserted through the trocar into the abdominal cavity. There it is straightened and placed in the prepared preperitoneal space.
The mesh is fixed to the abdominal wall using an endoscopic hernia stapler, after which the peritoneum is sutured over it. Surgical intervention is completed by washing the plastic area with an antiseptic solution and suturing the wounds after the introduction of trocars.
Contraindications
The presence of a hernia in the groin in the absence of contraindications to surgery is already an indication for surgical removal of the defect. However, the determining role in the doctor's decision is played by the type of defect (reducible or irreducible), complications and the patient's condition.
The type of pathology is determined simple test: in a horizontal position of the body or when pressed, the reducible defect disappears, appearing again when physical activity(laughing, coughing, defecation, heavy lifting).
Removing a hernia in the groin is a full-fledged operation, so there are a number of contraindications to it:
- infectious diseases in the acute stage (including colds, flu, etc.);
- decompensated severe chronic pathologies ( diabetes, organ failure, malignant tumors, diseases of the hematopoietic and vascular systems);
- postoperative period after intervention for other diseases;
- prostate adenoma 2 or 3 stages;
- pregnancy;
- general depletion of the body;
- age up to 6 months.
Relative contraindications to surgery are also considered elderly age and a high degree of obesity.
In a planned manner, small hernial protrusions that can be self-reduced are operated on. In any case, surgical intervention is inevitable, so it is not worth delaying the operation.
Possible Complications
In medicine, there are complications in the early and late period. The first group includes the accession of local bacterial flora, which causes suppuration, deterioration in the work of some departments intestinal tract, intestinal obstruction and some consequences after the use of general anesthesia.
Such conditions are recorded even at the stage of hospital treatment, so the patient can count on professional help from the medical staff.
megan92 2 weeks ago
Tell me, who is struggling with pain in the joints? My knees hurt terribly ((I drink painkillers, but I understand that I am struggling with the consequence, and not with the cause ... Nifiga does not help!
Daria 2 weeks ago
I struggled with my sore joints for several years until I read this article by some Chinese doctor. And for a long time I forgot about the "incurable" joints. Such are the things
megan92 13 days ago
Daria 12 days ago
megan92, so I wrote in my first comment) Well, I'll duplicate it, it's not difficult for me, catch - link to professor's article.
Sonya 10 days ago
Isn't this a divorce? Why the Internet sell ah?
Yulek26 10 days ago
Sonya, what country do you live in? .. They sell on the Internet, because shops and pharmacies set their margins brutal. In addition, payment is only after receipt, that is, they first looked, checked and only then paid. Yes, and now everything is sold on the Internet - from clothes to TVs, furniture and cars.
Editorial response 10 days ago
Sonya, hello. This drug for the treatment of joints is really not sold through the pharmacy network in order to avoid inflated prices. Currently, you can only order Official website. Be healthy!
Sonya 10 days ago
Sorry, I didn't notice at first the information about the cash on delivery. Then, it's OK! Everything is in order - exactly, if payment upon receipt. Thanks a lot!!))
Margo 8 days ago
Has anyone tried folk methods joint treatment? Grandmother does not trust pills, the poor woman has been suffering from pain for many years ...
Andrew a week ago
What only folk remedies I didn't try anything, nothing helped, it only got worse...
Ekaterina a week ago
I tried to drink a decoction of bay leaves, to no avail, only ruined my stomach !! I no longer believe in these folk methods - complete nonsense !!
Maria 5 days ago
Recently I watched a program on the first channel, there is also about this Federal program for the fight against diseases of the joints spoke. It is also headed by some well-known Chinese professor. They say they have found a way to permanently cure the joints and back, and the state fully finances the treatment for each patient
When diagnosing a hernia, the question of the need for hernia repair and hernioplasty arises as a priority. The patient and his relatives want to know what these terms hide in themselves, how interventions are carried out, what they will face in the postoperative period. Let's analyze these questions in more detail.
Treatment of hernias is not carried out by therapeutic methods. The use of all kinds of bandages, physiotherapy and gymnastic exercises aimed at strengthening the muscle belt are only preventive measures and cannot eliminate the existing pathology.
Surgical techniques
In the case of a planned operation, when it is not required to immerse the loops of the intestine into the abdominal cavity, it is used hernioplasty(hernioplasty in literal translation). If there is a pathological protrusion, then the 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 localization 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 according to Mayo. The basis for strengthening the umbilical ring and the anterior abdominal wall is the creation of an aponeurotic duplication. After preoperative preparation, anesthesia, the intervention is started.
The operation begins with a layer-by-layer separation of the skin with a scalpel, subcutaneous fat to the aponeurosis (tendon formation between the muscles). With the help of special instruments, an incision is made, giving access to the hernial sac containing intestinal loops.
After the release of the intestine, its condition is assessed and immersed in the abdominal cavity. Then excised areas of excess tissue and proceed directly to the plastic.
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 tissues. In the first case, the cutting line runs horizontally. The aponeuroses are sutured in the following order: first, the upper flap from the outside to the inside, then the lower one in the same way, after which the thread passes in the opposite direction. When plastic according to Sapezhko, the right and left aponeurotic parts are compared by the same technique.
With small sizes of the umbilical ring in children, it is possible to use the method developed by Lexler. In this case, a purse-string (circular) suture is applied to the hernial ring, the edges are pulled together, and then all tissues are compared with ordinary knotted stitches.
Hernioplasty for inguinal hernias
The technique of hernia repair is chosen in accordance with the type of hernia (oblique and direct) and the purpose of strengthening a certain wall of the inguinal canal.
Method according to Martynov used to reinforce the front wall. The operation is carried out with the definition of 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 repositioned 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 applied over this and stitched. Carry out further layer-by-layer closure of the wound.
To strengthen the back wall resort to Bassini technique. After hernia repair, deep sutures are applied 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. Thus, there is a complete closure of the posterior wall by the muscular-fascial layer. Next, compare all the tissues 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 canalis inquinalis and transfer of the spermatic cord to the area of another localization. At the same time, after excision of the hernial sac, the upper-lateral part of the funiculus is deviated outward and slightly higher, if necessary, slightly excising the internal oblique and transverse muscles with immersion in the resulting space f.spermaicus and fixing between the muscle fibers. From below, the muscle tendons are sutured to the pubic tubercle and the Cooper ligament (between the frontal tubercles). The remaining tissues are connected to the inguinal ligament with U-shaped sutures. Then compare the lower and upper parts of the aponeurosis of the external oblique. As a result, the spermatic cord is placed in fatty tissue.
Among the classical techniques, the use of mesh materials occupies a worthy place. Plastic according to Liechtenstein involves the use of a synthetic graft to strengthen the hernial ring. After all standard surgical manipulations, a mesh flap is sutured in the area of least strength, which subsequently fuses firmly with the surrounding tissues and prevents the occurrence of a hernia.
Video
3D simulation of such an operation as a teaching material.
Alternative operations
Along with hernia repair by open access, endoscopic operations are successfully used. The latter types of interventions are less traumatic. Operations using endoscopic technique are carried out by means of punctures at 3 points. Through one of them, an optical technique is carried out, which allows you to display the image on the monitor and see everything that happens in the surgical field. Other punctures are used to introduce special instruments used for direct hernia repair and mesh implant placement.
Such an intervention has its advantages in the easier course of the postoperative period, 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 to operate through open access.
Do not start the disease and seek medical help in a timely manner. There are frequent cases of infringement of the intestine in the hernial orifice, requiring emergency surgical intervention.
The actions of doctors after a preliminary examination and examination:
- conducting anesthesia;
- preparation of the operating field;
- layer-by-layer dissection of tissues up 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 looking good the organ after "resuscitation" actions (warming and irrigation with saline solution) is reduced;
- in the absence of viability, resection (removal) of a section of the intestine is carried out within 40-50 cm to and 15-20 cm from the site of infringement. If there is damage to the mucosa in the remaining areas, a resection is performed within healthy tissues. The ends of the inlet and outlet sections are compared with subsequent stitching and immersion in the abdominal cavity.
- layer-by-layer suturing of tissues.
What is tension and non-tension plastic?
Initially, hernioplasty methods were carried out by connecting only one's own tissues. In this case, the tension of the structures naturally occurs. Tension plastic has a number of disadvantages, which manifest themselves in:
- failure of the seams;
- thread cutting and inflammation;
- large tissue edema;
- recurrences of hernias, etc.
Video
To reduce complications, it was proposed to use a synthetic mesh. E. Lisin, Candidate of Medical Sciences, Head of the Surgical Department, talks about such implemented methods. The interview is accompanied by a visual video about the treatment of hernias.
Is anesthesia provided?
The fear of pain during surgery is understandable and understandable. The operation can be performed both under local infiltrative anesthesia, with the use of epidural analgesics, and under general anesthesia. The type of anesthetic benefit 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
AT 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. The healing of the wound surface is relatively successful by the end of the second week. Therefore, at first it is important to observe physical and sexual rest. You can't lift weights. It is necessary to establish fractional nutrition 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). Cough is also accompanied by an increase in intra-abdominal pressure, therefore, if necessary, it is worth discussing with the doctor the possible connection of antitussive drugs and quit smoking. After 14 days, you need to start physical education.
Gradually, you can master easy exercises:
- "scissors" (crossing the legs in the prone position);
- "bicycle" (alternate movements of the legs in a position on the back);
- plank;
- squats.
It must be remembered that classes are carried out in a dosed manner, at first in small quantities and to the best of one's own strength. You can't overexert your body.
Up to 3-4 months, the operated person should be on light labor. Lifting weights over 10 kg is strictly prohibited (in individual cases, the permitted weight is several times less).
Note!
Sex life is allowed no earlier than 2 weeks. At the same time, during an intimate relationship, 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 localization. Operations are carried out with an individual approach, adhering to the developed standards. In the postoperative period, the patient is not left alone with his pain, but is under close medical supervision. The further state mostly depends on the implementation of the recommendations and the lifestyle of the operated.
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Hernioplasty - a surgical method for removing hernias (literal translation from Latin - hernia repair). Previously, the terms used in medicine were hernia repair or hernia removal.
Types of hernioplasty
There are the following types of hernioplasty:
- tension, in the process of surgical intervention, only the body's own tissues are involved, they seem to be stretched over the site of the hernial protrusion, creating a duplication;
- tension-free, mesh implants are used to close the pathological space of the hernia;
- for certain types of operations, both of these types can be combined.
In modern medicine, a greater percentage of hernioplasty is performed by a tension-free method, since pathological tissue stretching is not created, the mesh implant immediately takes on the entire mechanical load without any consequences, and the frequency of relapses is minimized. The implant, "overgrown" with connective fibrous tissue, creates an even better barrier.
The operation is carried out in several ways:
- open;
- endoscopic (laparoscopic).
Stages of hernia repair:
- Tissue incision and organization of access to the hernia.
- The bag with hernial contents is removed (excised) or set, depending on the indications.
- Sewing of the hernial ring.
There are many techniques that are used for specific hernias, or are suitable for several types.
Hernioplasty according to Liechtenstein (hernia repair)
The most famous method of tension-free hernia repair. It is used for plastic hernias of the white line of the abdomen, as well as umbilical, inguinal, femoral hernias.
The method is quite simple and does not require special preparation before the intervention.
The mesh graft is sutured under the aponeurosis, no muscles and fascia are affected, that is, traumatism of body tissues is minimal. The mesh is attached with a "margin", since the edges of the hernial ring are directly affected pathological changes and do not have sufficient strength. Hernioplasty according to Liechtenstein is performed open way or laparoscopically.
Hernia repair according to Bassini
The method of tension hernioplasty has a good result with small, first formed hernias, it is possible to perform plastic surgery under local anesthesia. It is used for inguinal hernias, both direct and oblique.
Operation technique:
- An incision is made over the hernial protrusion.
- Manage education.
- Hernia repair or resection is performed, depending on the indications.
- Then the edges of the transverse and internal oblique muscles of the abdomen with the transverse fascia are sutured to the inguinal ligament, thereby strengthening the wall of the inguinal canal.
Mayo hernia repair
Tension surgery method, mainly used for umbilical hernias and hernias of the linea alba. The skin flap from the aponeurosis exfoliates after the hernial sac is opened. The protrusion is reduced into the cavity, while, if necessary, adhesions are dissected, the hernial sac is excised along the edge of the hernial ring and removed with a skin flap.
When the peritoneum is fused with the edge of the hernial ring, it is sutured with aponeurosis with several sutures (resembling the letter P) in such a way that when they are tied, the aponeurosis flaps overlap each other.
Hernia repair according to Postemsky
It's stretch plastic.. Anesthesia during the operation is local. In this case, the inguinal canal is completely removed, a duplicating canal is created with the spermatic cord placed in it in the physiological direction. The muscles under the canal are sutured in such a way that they do not squeeze it.
Hernia repair according to Sapezhko
It is used for plastic surgery of umbilical hernias.
Operation technique:
- The deformed flabby umbilical skin is excised along with the navel (it is possible to save it only with small hernias).
- The bag with a hernia after excision is sutured, before that its contents are set inward.
- The hernial orifice is dissected in a vertical direction up and down to the place where the white line of the abdomen is not changed.
- The peritoneum is carefully peeled a few centimeters from the posterior surface of the sheath of one of the rectus muscles and the edge is sutured to the aponeurosis on one side, and the posteromedial part of the sheath of the rectus muscle on the other, to create a duplication.
Hernia repair according to Lexer
Applied in the case of soldered navel with the bottom of the hernial sac.
Operation technique:
- The neck of the hernial sac is isolated from the surrounding tissues.
- After opening it, the contents are pushed into the cavity and the bag is cut off.
- A suture is placed on the aponeurosis under the umbilical ring, which is tightened and tied.
- The skin flap is placed in its original place and sutured with interrupted sutures.
Hernia according to Duhamel
Widely used in pediatric hernia surgery. The intervention is performed without opening the inguinal canal, the neck of the hernial sac (peritoneal process) is isolated through the external inguinal ring, then it is sutured and cut off.
Hernia repair according to Martynov
Tension method of hernioplasty, used mainly in the elimination of oblique inguinal hernia. The upper flap of the aponeurosis of the external oblique muscle of the abdomen is sutured to the inguinal ligament, while the muscles are left intact, and they are sutured over the existing suture to the lower flap of the aponeurosis.
Hernia repair according to Krasnobaev
It is used for hernia repair in children from 6 months of age.
The technique of conducting surgical intervention is interesting in that the aponeurosis is not affected.
The subcutaneous layer is mechanically shifted, after a skin incision, a bag with hernial contents is isolated and cut off, applying a silk suture. After that, 2-4 more sutures are applied to the formed fold of the aponeurosis, they strengthen the wall of the inguinal canal.
Video: umbilical hernia hernioplasty
Obstructive hernioplasty
The method is tension-free, a mesh graft is used. The technique is similar to the Lichtenstein method, but has some advantages. Firstly, the incision on the skin is less than half. Secondly, the hernial sac is pushed into the cavity without opening it. Then a mesh is applied and the wound is sutured in layers.
Endoscopic hernioplasty
This is an operation performed inside the abdominal cavity, through small incisions 2-3 cm in size, using a special video device and manipulators. The technique of the operation is similar to the Lichtenstein method, performed under general anesthesia. Traumatism in this type of surgery is minimal, the recovery period is much shorter, and there is a good cosmetic effect.
Possible Complications
As with any other type of surgery, complications are possible. These include:
- inflammation and suppuration of postoperative sutures;
- hematoma;
- recurrence of pathology;
- damage to organs accompanying the operation (spermian cord, esophagus, intestines, etc.);
- excessive tension of stitched fabrics;
- displacement of the implant, as a result of improper fixation;
- complications after anesthesia.
Rehabilitation and recovery
Modern technologies and advanced developments in medicine, observation by a specialist and the correct behavior of the patient after surgery will help speed up recovery and avoid possible complications. Wearing bandages is not necessary, but can be used according to indications, at the discretion of the doctor.
Herniotomy passes without severe pain in the early rehabilitation period, but sometimes they are still present, then painkillers are prescribed.
It is necessary to limit physical activity, lifting weights is strictly prohibited, both in the early recovery period and in the late one. After permission from the doctor, you can begin to strengthen the muscles of the press with the help of exercise therapy, physiotherapy, massage. It is necessary to give up bad habits that contribute to the decrepitude of all tissues of the body, normalization of the patient's weight.
Prices for hernioplasty
In hernia repair, the cost is determined by several factors:
- type of surgical intervention;
- type of anesthesia performed during surgery (general or local anesthesia);
- the cost of mesh for hernioplasty;
- management of the patient in the rehabilitation period (application medicines, procedures in a later recovery period).
Video: Liechtenstein hernioplasty
By now there is a large number of methods of reconstructive interventions for abdominal hernia repair. They are conditionally divided into five main groups:
- methods using fascial-aponeurotic plastics;
- fascial-aponeurotic hernioplasty with additional strengthening of the hernial ring with muscle tissue;
- muscle plasticity;
- alloplasty with additional synthetic or biological materials;
- alloplasty using own tissues together with non-biological, alien ones.
Each of these methods has been studied in detail to date and has its own contraindications and indications. Due to this, surgeons have at their disposal a significant number of different pathogenetically determined and effective methods of operations.
Inguinal hernia repair
Inguinal hernia surgery is carried out by two main methods:
- tension hernioplasty - closure of the hernial defect by tightening and stitching the patient's own tissues;
- tension-free - plastic hernia with a mesh.
Plasty of direct inguinal hernia according to Bassini
Perform strengthening of the posterior wall of the inguinal canal. The movement of the spermatic cord (push it to the side) is carried out after the removal of the hernial sac and under it, the transverse and internal oblique muscles are sutured to the inguinal ligament along with the transverse fascia of the abdomen.
The spermatic cord is placed on the newly formed wall of the inguinal canal. By applying deep sutures, the weakened posterior wall is restored and narrowed to normal sizes its inner hole. The hernial orifice is closed with muscles and fascia, reconstructing the anterior wall of the inguinal canal together with the external inguinal ring.
Inguinal hernia repair according to Kukudzhanov
It is used for plastic surgery of straight lines, as well as complex forms of inguinal hernias. The sheath of the rectus abdominis muscle and the aponeurotic fibers of the transverse and internal oblique muscles are sutured to the inguinal ligament. The sutures are tied behind the spermatic cord.
In order to close the outer part of the posterior wall of the inguinal canal, an additional purse-string suture is applied. After that, the spermatic cord is placed on the newly formed back wall of the inguinal canal. The edges of the dissected aponeurosis of the external oblique muscle of the abdomen are sutured in the form of a duplication and the external opening of the inguinal canal is formed.
The number of relapses with this method is small - about 2%.
Plasty of oblique inguinal hernia according to Girard
Perform strengthening of the anterior wall of the inguinal canal. First, the edges of the transverse and internal oblique muscles of the abdomen are sutured to the inguinal ligament above the spermatic cord, after which the upper flap of the aponeurosis of the external oblique muscle is sewn with separate sutures. The lower flap is fixed on it with sutures, thus forming a duplication consisting of flaps of the aponeurosis of the external oblique muscle.
Inguinal hernia repair according to Postemsky
A complete removal of the inguinal space and inguinal canal is performed, and an inguinal canal is created with a new direction. Close to the inguinal ligament, an incision is made in the aponeurosis of the external oblique muscle, the spermatic cord is isolated, the hernial sac is processed, the transverse and internal oblique muscles are dissected, and the spermatic cord is displaced to the upper lateral angle of this incision.
Under the spermatic cord, the muscles are sutured so that they do not squeeze it, but at the same time fit snugly. Strengthen the wall of the inguinal canal by suturing the aponeurosis of the muscles to the pubic and inguinal ligaments. The newly created inguinal canal, containing the spermatic cord, now passes in an oblique direction through the musculoaponeurotic layer so that its external and internal openings are not opposite each other. The spermatic cord is placed on the aponeurosis and the subcutaneous fat and skin are sutured over it in layers.
Inguinal hernia repair according to Liechtenstein
The Liechtenstein operation is a tension-free hernia repair and is considered the “gold standard” for inguinal hernia surgery.
Method features:
- skin incision length 10 cm;
- strengthen the back wall of the inguinal canal with a special polypropylene or teflon mesh for hernia repair, which is placed behind the spermatic cord;
- the mesh plate is fixed around the entire perimeter with a continuous seam.
Advantages of the method:
- pain syndrome is mild;
- low percentage of relapse, about 0.5-1%;
- can be performed on an outpatient basis;
- performed under any type of anesthesia, including local anesthesia;
- a short rehabilitation period (return to work and vigorous activity in a month).
Umbilical hernia repair
Umbilical hernias in children and adults are operated extraperitoneally (without opening the hernial sac, with a small protrusion, when the hernia is easily reduced) and intraperitoneally (with opening the sac and repositioning its contents into the abdominal cavity). The latter methods are used more often, these include Sapezhko, Mayo and Lexer operations.
Mayo umbilical hernia repair
Two transverse converging skin incisions are made, bordering the hernial protrusion. The hernial ring is dissected in the transverse direction, the neck of the sac is isolated and opened, the contents are examined, and then set back into the abdominal cavity. The hernial sac is excised and removed.
U-shaped silk sutures are applied to the aponeurotic flaps in such a way that when tying, the aponeurosis flaps overlap one another. Then the free edge of the upper flap is sutured to the lower one with interrupted sutures.
Umbilical hernia repair according to Sapezhko
Under general anesthesia, arcuate longitudinal skin incisions are made around the hernia. A hernial sac is isolated from the subcutaneous fat. The hernial ring is dissected downwards and upwards along the white line of the abdomen. Having processed the hernial sac, the edge of the aponeurosis of the muscle of one side is sutured with interrupted silk sutures to the posterior wall of the sheath of the rectus muscle on the opposite side.
The free edge of the aponeurosis is laid on the anterior wall of the sheath of the rectus abdominis muscle on the other side and fixed with interrupted silk sutures. The result is a layering of these muscles along the white line of the abdomen (as if "coat floors").
Femoral hernia repair
Methods of surgical treatment of femoral hernias are divided into 4 groups:
- plastic hernia from the side of the inguinal canal;
- hip plasty;
- autoplasty;
- heteroplastic.
When closing the hernial ring from the side of the thigh, the methods of Lockwood, Abrazhanov, Bassini, Krymov are used.
SHARE WITH OTHERS IF YOU LIKE THIS ARTICLE Table of contents of the subject "Hernia. Intestinal Seams.":skin incision with umbilical hernia longitudinal along the midline a few centimeters above the navel, bypassing it on the left and continuing 3-4 cm below.
In obese patients with umbilical hernia often make a semi-lunar or oval incision, bordering the hernial protrusion from below. The skin and subcutaneous tissue are dissected to the aponeurosis of the white line of the abdomen.
By dissecting the skin flap from left to right, the skin with subcutaneous tissue is separated from the hernial umbilical hernia sac. It is isolated until the hernial orifice formed by the dense aponeurotic edge of the umbilical ring is clearly visible.
Between the neck hernial sac of umbilical hernia and a grooved probe is inserted into the umbilical ring and the ring is cut through it in the transverse direction or along the white line up and down. The hernial sac is finally isolated, opened, the contents are set, the peritoneum is cut off and sutured with a continuous catgut suture.
Mayo plastic surgery for umbilical hernia is performed when the umbilical ring is cut in the transverse direction. Apply U-shaped seams. The upper flap of the aponeurosis is sutured with silk, first from the outside to the inside, stepping back from the edge by 1.5 cm; then a stitch is made with the same thread on the lower edge of the aponeurosis from the outside to the inside and from the inside to the outside, departing from its edge by only 0.5 cm, and exit at the upper edge at the same level. Such seams are usually applied 3: 1 in the center and 2 on the sides.
When tying, the lower edge of the aponeurosis is moved under the upper one and fixed in the form duplicates. The free edge of the upper flap of the aponeurosis is sutured to the surface of the lower flap with separate interrupted sutures (second row of sutures).
Plastic according to Sapezhko with umbilical hernia is performed when the umbilical ring is cut longitudinally. On the Kocher clamps, the assistant pulls the left edge of the aponeurosis and bends it so as to twist its inner surface as much as possible. To it, the surgeon pulls and hem the right edge of the aponeurosis with separate interrupted or U-shaped silk sutures, trying to bring it as far as possible. The free left edge of the aponeurosis is placed over the right one and sutured with separate sutures. Aponeurotic doubling of the abdominal wall is achieved.
Lexer plastic surgery for umbilical hernia is more often performed in children with small umbilical hernias by suturing the umbilical aponeurotic ring with a silk purse-string suture, over which separate interrupted sutures are applied.