Extraperitoneal inguinal hernia repair

Inguinal hernia is generally divided into inguinal hernia, sacral hernia, and sacral hernia. Elderly patients often have benign prostatic hyperplasia and obvious urinary retention. Mainly by surgical treatment, that is, inguinal hernia repair, different types of inguinal hernia choose different surgical methods. Treatment of diseases: inguinal hernia Indication 1. Unilateral or bilateral inguinal hernia. 2. Recurrence. Contraindications 1. Can not tolerate general anesthesia. 2. Can not tolerate pneumoperitoneum. 3. Incarcerated, strangulated inguinal hernia. Preoperative preparation 1. Patients with acute upper respiratory tract infection should undergo surgery after controlling symptoms. 2. Quit smoking 1 week before surgery, training bed and urine. 3. Preoperative urination, so that the bladder is empty, if necessary, the catheter can be placed to avoid accidental injury to the bladder. 4. Huge sputum, you need to rest in bed for 3 days before surgery, so that the contents of the sputum are returned. Local tissue loosening, reducing edema, is conducive to postoperative healing. 5. Special huge sputum, a part of the abdominal organs fall into the sac and protrude from the abdomen. If it is estimated that the operation can not completely recharge the contents, the pneumoperitoneum can be used before surgery to enlarge the abdominal cavity. 6. Stretch the narrow sputum, pay attention to correct the water, electrolyte and acid-base balance disorder before surgery. Infusion, can be used to prevent shock from colloidal fluid, antibiotics at dose, to prevent infection. Surgery should be done as soon as possible under the premise of active preparation. Surgical procedure 1. Incision: Remove the oblique oblique incision from the inguinal ligament 2cm, parallel to the inguinal ligament, generally the upper end is more than 2cm beyond the inner ring, the lower end to the pubic tuberosity. 2. Incision of the external oblique muscle aponeurosis: After the skin is opened, the subcutaneous tissue is cut, and the branches of the abdominal wall, the veins, and the genital external veins and veins are ligated until the blepharospasm of the external oblique muscles exposes the inguinal canal. On the line connecting the superficial and deep annulus of the inguinal canal, the external oblique tendon was cut along the direction of the aponeurosis fibers of the external oblique muscle. The incision should be slightly over the top of the ring to avoid injury to the inguinal nerve. 3. Find and cut the sac: Use two hemostatic forceps to clamp the upper and lower abdominal oblique aponeurosis, and bluntly separate underneath. The upper piece is exposed to the joint iliac crest and the lower part to the inguinal ligament. Note that when separating the lower piece, do not injure the inguinal nerve. This nerve can be separated from the intra-abdominal oblique muscle. The hemorrhage forceps can be used to pull the lower diaphragm under the nerve from the nerve, and then the diaphragm is everted, so that the nerve is The diaphragm is covered for protection. The sputum patient increased the abdominal pressure, and the bulging mass was seen on the anterior medial side of the spermatic cord. The cremaster muscle and the spermatic fascia were cut longitudinally here, and the gray sac was found on the anterior medial side of the spermatic cord (Fig. 6). Use a toothed scorpion to lift the sac, and cut the sac between the two scorpions longitudinally, and do not injure the contents. The incision was enlarged, and the index was inserted into the hernia sac to probe the contents, mostly the small intestine and the greater omentum. 4. Free sac: The index is inserted into the sac and the contents of the sac are returned to the peritoneal cavity. The edge of the incision is lifted with a small hemostatic forceps. The index refers to the sac in the sac, and the spermatic tissue around the sac is gently blunt. separate. When separating the underside of the hernia sac, do not injure the vas deferens until the neck of the sac is seen, and the extraperitoneal fat is seen. Pay attention to stop bleeding to avoid hematoma formation after surgery. 5. High ligation of the sac: Use a small hemostat to lift the circumference of the sac, and the right hand shows the sac into the sac to further explore the size of the deep ring. It can be further determined whether it is oblique or straight (Figure 10). Longitudinal incision of the hernia sac, the hemostatic forceps around the hernia sac is pulled open to reveal the inner surface of the sac neck. In the deep part of the deep ring of the inguinal canal, that is, the inner surface of the base of the sac sac, the suture is sutured with the 4th line, pay attention to The needle spacing in the capsule should be small, and the needle spacing outside the capsule should be large, so that the purse can be tightened without leaving a cavity, the suture is ligated, and the neck of the capsule is closed. You can use the 7th line to ligature one more 0.5cm above the purse string to prevent the knot from falling off. It is also possible to take the No. 7 line through the sutured neck. After the suture was completed, the excess sac was removed by 0.5 cm from the ligature (Fig. 12). At this time, the stump neck stump can be retracted to the deep side of the intra-abdominal oblique muscle without fixing. It is also customary to suture the sac neck sling line to the inferior oblique muscle in front of it. If the distal hernia sac is small, it can be removed; if it is large, it does not need to be peeled off, open and not sutured. If there is exudate, the subcutaneous tissue can be absorbed. 6. Repair the oblique sputum: There are many ways to repair the sulcus and sulcus. According to the weakness of the anterior and posterior wall of the inguinal canal, different repair methods are adopted. The following are commonly used: (1) Ferguson repair method: This method is characterized by: suturing the lower edge of the inguinal and oblique inguinal ligaments before the spermatic cord to strengthen the anterior wall of the abdominal groove. It is suitable for children and young adults with a complete posterior wall of the inguinal canal. The cut cremaster muscle and the spermatic fascia were sutured with a line 1 to repair the spermatic cord. The cremaster muscle and the intra-abdominal oblique muscle, combined with the iliac crest, can be sutured again with the line 1 to make the inguinal ligament and the joint iliac crest. Use the 7th line to suture the lower edge of the joint iliac crest and the abdominal oblique muscle from the bottom to the upper and the lower ligament. Generally, the suture is 3~4 needles. The next needle should not be too tight, so as to show the fingertips, so as not to overtighten. Oppress the spermatic cord. The sutures of the inguinal ligament should not be in the same interfiber space to avoid tearing the inguinal ligament. The extra-abdominal oblique aponeurosis was sutured and the shallow inguinal canal was reconstructed. Subcutaneous tissue and skin were sutured intermittently with line 1. (2) Bassini repair method: This method is characterized by strengthening the posterior wall of the inguinal canal, which is suitable for the defect of the posterior wall of the inguinal canal of young adults or elderly patients. Find the spermatic cord before looking for the sac. The left hand indicates the separation of the spermatic cord and the inguinal ligament from the inside of the spermatic cord and the pubic tuberosity above the spermatic cord. Take a gauze strip or rubber hose through the sperm line for traction. Use the hook to pull the intra-abdominal oblique muscle upwards, longitudinally cut the cremaster muscle and the inner fascia of the spermatic cord, expose the sac, use the scorpion to lift the sac, cut longitudinally, and extend the left hand into the sac. From the blunt dissection of the surrounding spermatic tissue to the neck of the sac, the suture was sutured in the neck with a line 4, and the sac was ligated at a high position. Lifting the spermatic cord, exposing the transverse abdominis aponeurosis and transverse transverse fascia, using the 7th line to suture the transverse abdominis aponeurosis together with the transverse transverse fascia and inguinal ligament from the top and the bottom, without knotting, and knotting together after the suture . Note that on the medial and lateral sides of the upper end of the spermatic cord, suture the transverse fascia, so that the enlarged inguinal canal is narrowed, so that the spermatic cord is not pressed. The lower edge of the oblique oblique muscle of the abdominal oblique muscle and the iliac crest were pulled and brought closer to the inguinal ligament, and the tension was tested. If the tension is large, the upper part of the aponeurosis of the external oblique muscle can be bluntly separated to reveal the anterior layer of the rectus sheath. At this time, the tension can be relieved. If the combined tendon and inguinal ligament are still not close together, a longitudinal incision can be made on the anterior layer of the rectus sheath, each length of 1 cm, generally 8 to 10 small incisions can be used to relieve the tension. The lower iliac crest, the inferior oblique muscle and the inguinal ligament nodule were sutured from the bottom to the top with line 7. Note that the first needle should be sutured together with the iliac crest, the transverse abdominis aponeurosis, the periosteum near the pubic tuberosity, and the inguinal ligament. The upper and lower oblique layers of the external oblique muscle were sutured and sutured with a 7-gauge thread. The spermatic cord is placed between the combined tendon and the external oblique muscle diaphragm. (3) Halsted repair method: This method is also a method to strengthen the posterior wall of the inguinal canal. Applicable to elderly patients or the inferior wall of the inguinal canal is obviously weak. After ligation of the neck of the sac of the sac, the suture of the transverse abdominis aponeurosis, the combined iliac crest and the inferior oblique sac of the inguinal ligament were sutured, such as the Bassini method, and the superior and inferior oblique muscles of the upper and lower lobes were interrupted under the spermatic cord. Suture, place the spermatic cord between the external oblique muscle aponeurosis and subcutaneous fat. Generally, the spermatic cord is pulled out from the upper 1/3 of the sacral incision of the external oblique muscle. Note that the outlet should not be too tight, and the subcutaneous fat and skin are sutured intermittently with the No. 1 line. (4) Shouldice repair method: for multi-layered hernia repair or Canadian hernia repair. The focus is on repairing the transverse fascia and strengthening the posterior wall of the inguinal canal. The initial separation operation is the same as the previous ones. After the spermatic cord is released, it is retracted with a gauze strip to expose the transverse fascia. Cut and remove part of the cremaster muscle, cut open, free the sac, and suture the high ligament in the neck of the sac and suture the excess sac. The transverse fascia was cut from the inner ring to the pubic tube nodule, and the upper and lower lobes were separated in parallel. The lower flap of the transverse fascia was sutured from the deep side of the lateral rectus sheath and the deep side of the superior ventral fascia and the internal oblique muscle (Fig. 40). The upper abdomen transverse fascia and the inguinal ligament were sutured continuously from top to bottom. Take line 7 from the inner ring from the inner ring from the top to the lower oblique muscles, joint muscles sewed in the deep part of the inguinal ligament, to the direction of the pubic tuberosity will be combined with the iliac crest and the internal oblique and inguinal ligament shallow Continuous suture. The external oblique aponeurosis was sutured with the anterior nodule of the spermatic cord with line 7. Suture the subcutaneous tissue and skin.

The material in this site is intended to be of general informational use and is not intended to constitute medical advice, probable diagnosis, or recommended treatments.