Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 362 - файл
.pdf
22 Local Anesthesia inInguinal Hernia: Indications andTechniques
these perceptions. In cases of easily frightened
or panicking patients, we usually ask the anesthetist to give some sedation or we propose a
different kind of anesthesia, in very selected
patient (GA or SA).
Obviously, LA is contraindicated in patients
with previous allergic reaction to it.
22.4 Surgical Technique
219
We normally use an anesthetic solution with
10 mL of 1% mepivacaine without adrenaline,
buffered with 10mL of sodium bicarbonate (so
the concentration is 0.5%) in a 20 mL syringe
with a 20G spinal needle for skin and supercial
subcutaneous inltration; so with just one prick,
it is possible to perform anesthesia along all the
incision lines and supercial planes (Fig.22.1).
We buffer local anesthetic with sodium bicarbonate to reduce burning sensation and improve
patient satisfaction.
We choose mepivacaine for its low risk in car-
diopathic patients and for its fast onset effect.
After skin incision, we usually use a watereddown solution for a step-by-step inltration: 40mL
of ropivacaine and 60mL of 0.9% saline (so the
concentration is 0.4%). In this step, ropivacaine is
selected for its long-term effect (about 6h) and for
the pain control in the postoperative time.
Fig. 22.1 Anatomical landmarks in right inguinal region.
ASIS: anterior superior inguinal spine. The skin and subcutaneous inltration is done with a 20G spinal needle
Fig. 22.2 The external femoro-cutaneous nerve piercing
the Scarpa’s fascia is visible
The external femoro-cutaneous nerve is identied, inltrated, and, if possible, preserved during the subcutaneous dissection (Fig. 22.2). Its
identication sometimes is very challenging
because it is very thin; the trick for its recognition
is looking for its vasa nervorum.
During this step, it is important to remind that
external oblique aponeurosis is very sensitive, so
rst assistant is required to pull up with the retractors so that the aponeurosis is not touched by the
cautery during the dissection of subcutaneous.
Before proceeding with the opening of the
inguinal canal, the external oblique muscle aponeurosis is properly inltrated so that it is dissected from the nerves running above it in a blunt
way (Fig.22.3). For the same reason, we prefer
always to open it with the scalpel and the scissors, never with the cautery.
Identication, inltration, and respect of the
three sensitive nerves of the groin region (iliohypogastric, ilioinguinal, and genital branch of the
genitofemoral nerve) is mandatory for a pain-free
procedure and optimal patient satisfaction, but it
is important also for the postoperative pain.
Studies reporting the results of the role of the
identication of all three inguinal nerves [21]
concluded that identication and preservation of
all the three nerves during open inguinal hernia
repairs reduces chronic incapacitating groin pain
to less than 1%, and the risk of developing
inguinal chronic pain increased with the number
of nerves concomitantly undetected [21].
220
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Fig. 22.3 Left inguinal region: incision of the external
oblique aponeurosis and the ilioinguinal nerve is visible
running underneath
G. Campanelli et al.
Fig. 22.5 Right inguinal region: iliohypogastric (IH)
nerve running underneath the external oblique aponeurosis, along the conjoint tendon
Fig. 22.4 Left inguinal region: after the external oblique
aponeurosis is open, identication of iliohypogastric (IH)
and ilioinguinal (II) nerve
Evidently, the preservation of nerves requires
a perfect knowledge in the anatomy of the inguinal canal. Iliohypogastric nerve pierces the
internal oblique muscle in a point placed at a
mean of 2.4 cm cranially to the internal ring,
and it is possible to be identied running along
the conjoint tendon, underlying the external
oblique aponeurosis (Figs.22.4 and 22.5), and
perforating it at a mean of 3.8cm cranially from
the external ring.
Ilioinguinal nerve runs parallel with iliohypogastric nerve, caudally to it. In 57% the ilioinguinal nerve pierces the internal oblique muscle
Fig. 22.6 Left inguinal region: the ilioinguinal (II) nerve
runs ventrally to the spermatic cord, the genital branch of
genitofemoral nerve (GF) runs parallel to the blue line
(BL), along the inguinal ligament
laterally closed to iliac spine. In the other 43%,
the ilioinguinal nerve pierces the internal oblique
muscle just laterally from the internal ring. The
ilioinguinal nerve runs ventrally and parallel to
the spermatic cord (Figs.22.4 and 22.6), and it
leaves the inguinal canal by passing through the
external ring.
The vast majority of genital branches of genitofemoral nerve enters the inguinal canal laterocaudally through the internal ring in the
frontal plane and then joins the cremasteric
artery and vein. After running through the inguinal canal at the dorsocaudal side of the sper-
22 Local Anesthesia inInguinal Hernia: Indications andTechniques
matic cord, it passes through the external ring.
The genital nerve is protected by not removing
the cremasteric sheet and keeping the easily visible blue external spermatic vein (the blue line)
en bloc with the spermatic cord when it is being
lifted from the inguinal oor [22] (Figs. 22.6
and 22.7).
During a procedure under LA, handling the
peritoneal sac can be painful, and its overstretching could cause even a vagal reaction, so gentle
gesture is required (Fig. 22.8), and LA can be
used for its hydro-dissection effect. In this way a
Fig. 22.9 Right inguinal region: local anesthesia is used
for hydro-dissection of a small indirect sac
221
Fig. 22.7 Left inguinal region: genital branch of genito-
femoral nerve (GF) runs parallel to the blue line (BL),
along the inguinal ligament
Fig. 22.8 Local anesthesia is advisable in peritoneal sac
before handling it
Fig. 22.10 Left inguinal region: hydro-dissection of an
indirect inguinal sac from the cord
less traumatic and more safe isolation of the hernia sac from the spermatic cord components is
possible [23] (Figs.22.9 and 22.10).
During a procedure in LA, other steps that can
be unpleasant are the preparation of the pubic
tubercle (Fig.22.11), especially if the technique
chosen requires a suture on it, and the isolation of
the internal inguinal ring, the upper part of the
posterior wall, and the medial edge of the external oblique aponeurosis.
Another advantage in LA is that it allows the
patient to have a t of coughing, by surgeon’s
demand, during the intraoperative exploration, so
any hidden and unknown hernia defect (Spigelian
and femoral region included) can be discovered
or, at least, better explored [23].
222
G. Campanelli et al.
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Fig. 22.11 Left inguinal region: isolation and anesthesia
of the pubic tubercle
Conclusion
Being able to perform an inguinal hernia
repair under a “real” LA is proof of deep
knowledge, great professionalism, and serious
dedication to this kind of surgery.
References
1. Gonullu NN, Cubukcu A, Alponat A. Comparison
of local and general anesthesia in tension-free
(Lichtenstein) hernioplasty: a prospective randomized
trial. Hernia. 2002;6:29–32.
2. Gultekin FA, Kurukahvecioglu O, Karamercan A, Ege
B, Ersoy E, Tatlicioglu E. A prospective comparison
of local and spinal anesthesia for inguinal hernia
repair. Hernia. 2007;11:153–6.
3. Nordin P, Zetterstrom H, Gunnarsson U, Nilsson
E. Local, regional, or general anaesthesia in groin
hernia repair: multicentre randomised trial. Lancet.
2003;362:853–8.
4. O’Dwyer PJ, Serpell MG, Millar K, Paterson C,
Young D, Hair A, Courtney CA, Horgan P, Kumar
S, Walker A, Ford I.Local or general anesthesia for
open hernia repair: a randomized trial. Ann Surg.
2003;237:574–9.
5. Ozgun H, Kurt MN, Kurt I, Cevikel MH.Comparison
of local, spinal, and general anaesthesia for inguinal
herniorrhaphy. Eur J Surg. 2002;168:455–9.
6. van Veen RN, Mahabier C, Dawson I, Hop WC, Kok
NF, Lange JF, Jeekel J.Spinal or local anesthesia in
lichtenstein hernia repair: a randomized controlled
trial. Ann Surg. 2008;247:428–33.
7. Nilsson H, Angerås U, Sandblom G, Nordin P.Serious
adverse events within 30 days of groin hernia surgery.
Hernia. 2016;20(3):377–85.
8. Prakash D, Heskin L, Doherty S, Galvin R. Local
anaesthesia versus spinal anaesthesia in inguinal hernia repair: a systematic review and meta-analysis.
Surgeon. 2017;15(1):47–57.
9. Nordin P, Zetterstrom H, Carlsson P, Nilsson E.Costeffectiveness analysis of local, regional and general
anaesthesia for inguinal hernia repair using data from
a randomized clinical trial. Br J Surg. 2007;94:500–5.
10. Song D, Greilich NB, White PF, Watcha MF,
Recovery TWK.Proles and costs of anesthesia for
outpatient unilateral inguinal herniorrhaphy. Anesth
Analg. 2002;91:876–81.
11. Nordin P, Hernell H, Unosson M, Gunnarsson U,
Nilsson E.Type of anaesthesia and patient acceptance
in groin hernia repair: a multicentre randomised trial.
Hernia. 2004;8:220–5.
12. Bay-Nielsen M, Kehlet H. Anaesthesia and postoperative morbidity after elective groin hernia repair:
a nation-wide study. Acta Anaesthesiol Scand.
2008;52(2):169–74.
13. Pollard JB. Cardiac arrest during spinal anesthesia:
common mechanisms and strategies for prevention.
Anesth Analg. 2001;92(1):252–6.
14. Simons MP, Aufenacker T, Bay-Nielsen M, Bouillot
JL, Campanelli G, Conze J, de Lange D, Fortelny
R, Heikkinen T, Kingsnorth A, Kukleta J, Morales
Conde S, Nordin P, Schumpelick V, Smedberg S,
Smietanski M, Weber G, Miserez M.European hernia
society guidelines on the treatment of inguinal hernia
in adult patients. Hernia. 2009;13:343–403.
15. Devlin HB, Kingsnorth AN.Management of abdominal hernias. London: Chapman and Hall Medical;
1998.
16. Ponka JL.Hernias of the abdominal wall. Philadelphia:
Saunders WB; 1980.
17. Teasdale C, McCrum AM, Williams NB, Horton
RE. A randomised controlled trial to compare local
with general anaesthesia for short-stay inguinal hernia
repair. Ann R Coll Surg Engl. 1982;64:238–42.
18. Campanelli G, Cavagnoli R, Gabrielli F, Pietri
P.Trabucco’s procedure and local anaesthesia in surgical treatment of inguinal and femoral hernia. Int
Surg. 1995;80(1):29–34.
19. Campanelli G. La chirurgia ambulatoriale dell’ernia
inguinale e crurale. In Minerva Medica, editor; 1993.
ISBN-13:9788877111937.
20. Campanelli G. Inguinal hernia surgery. Berlin:
Springer; 2017.
21. Aleri S, Rotondi F, Di Giorgio A, Fumagalli U,
Salzano A, Di Miceli D, Ridolni MP, Sgagari A,
Doglietto G, Group Groin Pain Trial. Inuence of
22 Local Anesthesia inInguinal Hernia: Indications andTechniques
223
preservation versus division of ilioinguinal, iliohypogastric, and genital nerves during open mesh herniorrhaphy: prospective multicentric study of chronic
pain. Ann Surg. 2006;243:553–8.
22. Amid PK. Groin hernia repair: open techniques.
World J Surg. 2005;29:1046–51.
23. Campanelli G, Bruni PG, Cavalli M, Morlacchi A.A
complete sutureless, hernia repair for primary inguinal hernia the Trabucco repair: a tribute to Ermanno
Trabucco. Surg Technol Int. 2016;28:141–6.
Bassini Repair
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
EnricoNicolò
23
23.1 Introduction
In 1889, Edoardo Bassini published his epochmaking monograph of 106 pages, Nuovo Metodo
Operativo per la Cura Radicale dell’Ernia
Inguinale. This chapter describes Bassini’s origi-
nal repair technique.
E. NicolÒ, M.D., F.A.C.S., F.I.C.S.
Department of Surgery, Jefferson Regional Medical
Center, Pittsburgh, PA, USA
e-mail: enicolo@aol.com
Edoardo Bassini became personally convinced
that the current operations of Wood and Czerny
(which consisted of introexing the hernia sac
and loosely closing the external inguinal ring,
relying on a single layer of scar tissue, which was
further weakened by the passage of the cord)
were inadequate to resist intra-abdominal pressure, and that the patients would show signs of
recurrence as soon as they abandoned the use of
the truss. All of these indicated to Bassini the
need for another operative method to achieve and
secure the radical cure of inguinal hernia, thus
eliminating the necessity of wearing a truss.
Bassini’s intuition was that in large external
oblique hernias, the inguinal canal became
shorter and straight, losing its obliquity and
length. Both the internal and external rings
became dilated. In this manner, the physiological
shutter mechanism was completely lost. Bassini
emphasized the need to restore the obliquity and
length of the inguinal canal. This consists of
physiologically reconstructing the inguinal canal,
so that it once again possesses two openings,
abdominal and subcutaneous, and two walls,
anterior and posterior, through which the spermatic cord passes.
On December 23, 1884, Bassini operated for the
rst time on an inguinal hernia using his new
method. The operation consisted of high ligation and
excision of the hernia sac, as well as his new tech-
© Springer International Publishing AG, part of Springer Nature 2018
G. Campanelli (ed.), The Art of Hernia Surgery, https://doi.org/10.1007/978-3-319-72626-7_23
225
226
E. Nicolò
nique of reinforcing the inguinal oor. For the reinforcement of the oor, Bassini separated, from the
external oblique aponeurosis above and from the
subjacent properitoneal fat, the outer margin of the
rectus muscle and the “triple layer” corresponding to
the internal oblique muscle, transversus muscle, and
“fascia verticalis Cooperi” (transversalis fascia),
and sutured the “triple layer” to the shelving edge of
Poupart’s ligament with interrupted, tension-free
silk sutures. The two lowermost medial sutures
included the outer margin of the rectus muscle, so
that the obliquity and the length of the canal were
restored and the plasty of the musculoaponeurotic
posterior wall would resist intra-abdominal pressure.
In his monograph, Bassini reported his astonishing
results: an extensive follow-up of more than 90% of
his patients for a period of up to 4½years revealed in
a series of 262 patients an infection rate of only 4%,
no mortality, and seven recurrences (2.6%). His
postoperative care orders included early ambulation,
shortened hospital stay, and, most importantly, no
truss—the so-called radical cure.
23.2 Position ofthePatient
The patient is placed on the OR table in a supine
position with the pelvis elevated (“Paziente col.
bacino rialzato.”—Bassini).
This can be achieved by breaking the OR table
or by placing a pillow under the patient’s
buttocks.
23 Bassini Repair
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
23.3 Skin Incision
A parainguinal skin incision is carried out 2cm
medially and parallel to the Poupart ligament
from the anterior superior iliac spine (ASIS) to
the external inguinal ring.
227
23.5 Incision oftheAponeurosis
oftheExternal Oblique
Muscle: Opening
oftheAnterior Wall
oftheInguinal Canal
andoftheExternal Inguinal
Ring
23.4 Exposure oftheAponeurosis
oftheExternal Oblique
Muscle
After the incision of the skin of the subcutaneous
tissue and the fascia supercialis (Scarpa’s fascia), and after completion of an accurate hemostasis of the supercial epigastric vessels, the
whitish and shiny surface of the aponeurosis of
the external oblique muscle, the external inguinal
ring, and the hernia sac exiting from it are all well
exposed. A self-retaining retractor is applied.
With a knife, a small incision is performed over the
aponeurosis at the superior angle of the wound in
correspondence with and parallel to the medial pillar of the external inguinal ring. The two lips of the
incised aponeurosis are grasped with a Kelly clamp
on each side. With a closed scissor, back of the
knife, or a Kittner, the aponeurosis is separated
from the underlying tissue, internal oblique muscle, and the iliohypogastric nerve, which invariably
lies immediately beneath the aponeurosis (Fig.7).
Then the tip of the index nger is inserted in the
opening to completely free the aponeurosis from the
underlying tissue. The nger is pushed all the way
down to the external inguinal ring, breaking through
the external spermatic fascia with the ngertip so
that the external inguinal ring is completely open;
228
E. Nicolò
the aponeurosis is served and split with scissors
along its bers, caudally, all the way down to the
external inguinal ring bisecting it, and cranially,
about 3cm the internal inguinal ring (Fig.8).
Note: The incision of the aponeurosis is
medial and parallel to the skin incision.
The lateral plat of the aponeurosis of the exter-
nal oblique muscle is larger than the medial ap.
At the superior aspect of the block, in proximity to
the internal inguinal ring, the left index and middle
ngers on one side, and the right index and middle
ngers of the other hand on the other side are positioned under the block, with the thumb of each hand
on the surface of the block so that the block is now
included between the ve ngers. With a special
movement of the ngers, digitoclasia, squeezing
while sliding the tissue, transversely and longitudinally, the bers of the cremasteric muscle are dissociated from the cord and the sac easily and completely,
in two branches, one lateral and one medial.
The hernia block (“tumor”) is formed by the
spermatic cord, the hernia sac with its content, a
lipoma, the cremasteric muscle and tunica, internal spermatic fascia (vaginalis comune), and
accessory layers that may be more or less developed and present.
The entire block is grasped with the thumb and
middle nger of the right hand with the help of the
index nger, in the most distal part just close by
the pubic spine, and is elevated perpendicularly.
23 Bassini Repair
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
229
23.6 Excision oftheCremasteric
Muscle andSuture Ligature
oftheStumps
The dissociated lateral and medial branches of
the cremasteric muscle can be united medially as
one branch, which is clamped proximally and
distally. The part in between is excised and
removed, and the two stumps suture-ligated to
avoid slipping of the ligature and possible bleeding of the cremasteric vessels.
Note: The excision of the cremasteric muscle
is indicated because:
It clearly uncovers the sac and the spermatic
cord, enveloped by the internal spermatic fascia
(vaginalis comune).
“When the cremasteric muscle is dissociated
from the internal oblique muscle, it loses its continuity with the internal oblique muscle, losing its
function and consequently atrophies” (Bassini).
Excision of the sac, the lipoma, and the cremasteric muscles will prepare and clear the area for a
clean reconstruction of the internal inguinal ring.
With a very small hernia in a young patient, or
in small and thin patients, the cremasteric muscle
may be left intact and saved (Fig.17a–c).
Соседние файлы в папке @xirurgi_2025