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 - 881 - файл
.pdf
25 Primitive Groin Hernias
369
immediate resumption of deambulation. Patients never suffer sore throat or acute
urine retention, seldom nausea or vomiting. In the last few years, local anaesthesia
has been associated with laryngeal mask airway ventilation technique. This is very
useful, especially for those patients with low adaptation to surgical settings. Locoregional techniques and general anaesthesia remain very important, especially in an
urgent setting, when the chance of a laparotomy increases. Patients undergoing to
surgical hernia repair are often obese, whereby these techniques can appear more
indicated [9].
Regional anatomy and nerve distribution knowledge is crucial. First of all, an
accurate inltration of the skin and subcutaneous tissue is performed, and then a
small dose of anaesthetic is injected under the aponeurosis of the external oblique
muscle along the next incision line. So ilio-hypogastric and ilio-inguinal nerves are
exposed, and about 0.5mL of anaesthetic into the more proximal part is enough to
obtain an adequate and durable analgesic control. Some millilitres injected near the
pubic tubercle and along the inguinal ligament facilitate the isolation of the spermatic cord and then detection of the genital branch of genitofemoral nerve, which
must also be inltrated. At this point, the surgical times are common to all techniques, and small injections of anaesthetic can be performed, if needed.
For the femoral hernias, there are no special devices, also due to the absence of
important nerves in this site. An anaesthesia is practised to a plan, paying particular
attention to the vessels and accurately inltrating the hernia neck, because this represents the most sensitive spot.
Regarding the type of anaesthetic, one we nd particularly useful is a rapid
action anaesthetic on the surface (lidocaine) and a second one which has slightly
slower but more prolonged action for deep injections (mepivacaine). The necessary
dose varies widely from patient to patient, but it remains well clear of toxic quantities [10].
Because of the increasing number of hernia repairs performed in the outpatient
setting, the use of a laparoscopic approach for hernia repair does not appear to provide any cost-saving benets over existing conventional techniques [4].
25.5 Surgical Technique
Therefore, there is no difference when it comes to the surgical approach, between
the elderly and the general population, concerning inguinal or femoral hernia. Thus,
there is no surgical indication for direct apposition techniques, like Bassini technique (or its evolutions like Shouldice technique), except in some cases that we will
discuss later.
In our experience, Bassini repair was applied until 1990 (in a lot of cases,
Terranova’s modication was applied) [11]. From 1992, all repairs were performed
using the technique, proposed by Lichtenstein in the 1980s, which quickly spread
worldwide thanks to his colleagues [12]. Basically, this theory is developed on two
principles: polypropylene mesh and “tension-free” repair. Moving on from this one,
many more variants have followed, based on the different personal approaches and
the micro-details of each procedure. Nevertheless, what really matters are the nal
results and the prevention of relapses. The operation can be normally performed
370
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
B. Martella et al.
in local anaesthesia: preventive manual reduction, if painful, must be avoided in
order to prevent any patient reaction.
After the injection of local anaesthesia (as previously explained), the incision is
placed along the line between the anterior superior iliac spine and the pubic tubercle, extending 8–10cm up. Opening the subcutaneous fat, the supercial epigastric
vein is tied with laces (sometimes there could be two veins): electrocoagulation is
not advisable due to the haemocoagulation problems previously mentioned.
Then the fascia of Scarpa is opened and the external oblique aponeurosis is
released. Once the external inguinal ring is highlighted, the aponeurosis is incised
to reveal the muscular side of the internal oblique muscle, the spermatic cord, and
the ilio-hypogastric and the ilio-inguinal nerves. The spermatic cord and the inguinal ligament are divided using an instrument with a bevel edge or a swab. The
inguinal ligament is now separated from the free edge of the external oblique muscle, sliding behind the pubic tubercle, and it is surrounded with a cotton band. The
isolation from the other surrounding connections can be perfected with electrocoagulation. The ilio-hypogastric and ilio-inguinal nerves must be isolated and safeguarded. Doing so, the space for the following reconstructive phase is completed.
Cremaster muscle can be cut longways in two halves. While the medial ap is
electro- coagulated, the lateral one is cut and sutured with two laces. The lace around
the inferior ap has to be sufciently long to be found again at the end of the operation. This procedure makes the genital branch of the genitofemoral nerve and funicular vessels visible behind. Sometimes they must be sacriced with laces in order to
simplify the reconstructive time. This can cause annoying paraesthesia in the inner
part of the thigh or in the region of women’s great labia; however, problems like
these are going to be solved spontaneously. If there is a lipoma, it must be completely isolated and then resected with a transxed stitch.
Now, it is possible to focus on the isolation of the hernia sac. Elderly people can
have such large sacs that they can reach deeply the scrotum; in order to avoid bleeding after the operation and, consequently, big hematomas, the sac must be carefully
isolated from the vascular structures around, which could be numerous. On the left
side, the colon could adhere to the sac: in this case, the hernia sac should not be
opened, but just replaced. If the hernia sac is empty, both on the left and on the right
side, it is advisable to inltrate the neck with anaesthetic, to put a transxed stitch,
and then to resect it. Nevertheless, even if resecting the sac is not necessary, it must
always be isolated backside from epigastric vessels and upside and on the medial
side from the internal oblique muscle. Lastly, the sac can be replaced inside.
All the procedures described so far regard the treatment for the external oblique
hernia, with or without slipping.
In the case of direct hernia, which is likely to be larger in elderly people, the
isolation time can be easier than in the previously described one, but it must be done
carefully. After sectioning the connections with the pubic tubercle and the external
oblique muscle and seeing epigastric inferior vessels, the sac is ready to be
invaginated.
Internal oblique hernias are less frequent: the treatment is the same as for the
direct one, but it is not fundamental to visualise the epigastric vessels.
25 Primitive Groin Hernias
371
We are not used to opening the transversalis fascia to look for a concomitant
femoral hernia, because we believe that a proper palpation from above is sufcient
to exclude its presence. In our experience the link between these two hernias is as
rare as the discovery of a femoral hernia during the follow-up.
The surgical technique is the same for women. Isolating the sac of an external
oblique or direct hernia is not so difcult. Sometimes it can be useful to resect the
round ligament in the exact place where it passes through the internal inguinal ring:
in this case, its proximal edge is xed to the internal oblique muscle with a stitch.
As already mentioned, polypropylene meshes are used during the reconstructive
phase. There are many prostheses available on the market. At present, we use a preshaped model (Fig.25.1). If necessary, a strip is fashioned from a propylene mesh
15×15cm. Even though this is not treated with chemical solutions, we protect the
operating eld, being sure to change our gloves before applying the mesh.
Before positioning it, a 2/0 polypropylene continuous suture closes the posterior
wall of the inguinal canal: this passage makes it possible to replace a sliding or direct
sac. In order to clearly see the posterior wall, the spermatic cord is retracted out of
the operating eld with two grippers. The suture starts from the pubic tubercle: care
should be taken not to pass the needle through the periosteum, which causes annoying and long-lasting pains after the operation in this area. 2–3mm are enough to
prepare a valid and secure reinforcement. The suture stops at the internal inguinal
ring, without entrapping the spermatic cord. The last step includes the proximal end
of cremaster muscle to protect the lower edge of the spermatic cord itself.
Now the mesh can be placed. Firstly, the medial most corner of the mesh, previously trimmed, is xed medially to the pubic tubercle (as previously explained).
Finally, the same suture is used as a polypropylene continuous one to attach the
lower border of the mesh with the inguinal ligament. Wrinkles must be avoided.
Alternatively, interrupted stitches can be used as well. Once the internal inguinal
ring is reached, the spermatic cord is placed between the two tails of the mesh. At
this stage, the nerves must be correctly positioned. The suture is continued for two
centimetres and completed. The two tails are overlapped and sutured together with
a stich around the spermatic cord. The mesh should lay lax on the oblique muscle;
an interrupted suture in the middle can be useful to softly x the mesh to the muscle
(Fig.25.2).
Fig. 25.1 Preshaped mesh
372
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Fig. 25.2 Final aspect after
mesh positioning
B. Martella et al.
The reconstruction of the oblique external fascia is now possible with a continuous resorbable suture: the suture includes the distal ap of the cremaster muscle.
This can avoid the slipping down of the omolateral testis as the patient sits down.
The reconstruction is the same for women. If the round ligament has been tied, a
knot-shaped mesh is used: it is xed laterally at the inguinal ligament and laid down
on the oblique with one or two stiches.
The subcutaneous tissue is rebuilt with continuous or interrupted suture, to obliterate any dead space. The skin is sutured with interrupted stitches or metallic agraphes. Sometimes a continuous suture with a resorbable material is used; thus, it is
not necessary to remove it.
Once the medication is done and vital parameters are checked, the patient goes
to the waiting area and can walk to their bed: nowadays hygiene rules do not allow
the patient to go out of the operating room on foot (this would surely be welcomed
by both relatives and patients, as was commonly done in the past). The immediate
postoperative period does not require particular attention: immediately after the
patient can drink something warm and walk on their own feet. If the diuresis is
checked and is normal, the patient can be dismissed. It is also mandatory to ensure
the presence of someone able to take care of them.
The technical approach, described above, regards elective surgery. There are no
contraindications for this approach in emergency cases as long as appropriate precautions are adopted. In our experience, local anaesthesia was applied in 35% of cases. In
65% of cases, general anaesthesia was required in order to perform laparotomy; in
these cases, a bowel resection was performed, almost always for simultaneous intestinal necrosis. Sometimes general anaesthesia is needed for vigorous resuscitation in
very serious cases. As in emergency femoral hernia operations, in a limited number of
cases, bowel resection was performed through the inguinal approach. In these cases,
the original or modied Bassini technique was applied without prosthetic material.
25.6 Femoral Hernia Repair
Femoral hernia is relatively uncommon and represents 3–4% of all abdominal hernias
[13]. However, it is very important as more than one-third occur in surgical emergen-
cies: strangulation is the most frequent one and results in increased morbidity and
25 Primitive Groin Hernias
373
mortality [14, 15]. Scheduled surgery is performed by classical Bassini operation or
Lichtenstein plug repair. In our experience, Lichtenstein technique under local anaesthesia is the primary choice in elderly patients scheduled for operation.
Otherwise, we recommend Bassini repair in an emergency situation due to the
high risk of postoperative infection under these circumstances. The technical
aspects do not differ in elderly patients compared to young adults. Literature
reports other techniques, e.g. Lockwood’s, Lotheissen’s, and McEvedy’s
approaches, in emergency surgery [16]. In our experience a signicant number of
little bowel resections were performed widening the femoral orice by means of
the vertical inguinal ligament opening, so avoiding concomitant laparotomy.
Results are very encouraging in terms of morbidity and rapid recovery, in the
absence of postoperative mortality.
Conclusions
Hernia repair in the elderly patient, also with an asymptomatic inguinal or femo-
ral hernia, may reduce serious morbidity and improve general health. Elderly
patients with a short history of herniation should be referred urgently to hospital
and receive priority on the waiting list, given that the cumulative probability of
strangulation increases in the rst 3months after the onset of symptoms. Femoral
hernias should be operated on with high priority to avoid incarceration. Elective
surgery is safe, less traumatic, and well accepted by older patients, especially if
local anaesthesia is preferred over general anaesthesia, and the procedure is per-
formed in an outpatient setting.
References
1. Fitzgibbons RJ, Giobbie-Hurder A, Gibbs JO, Dunlop DD, Reda DJ, McCarthy M Jr. Watchful
waiting vs repair of inguinal hernia in minimally symptomatic men: a randomised clinical trial.
JAMA. 2006;295:285–92.
2. O’Dwyer PJ, Norrie J, Alani A, Walker A, Duffy F, Horgan P. Observation or operation for
patients with an asymptomatic inguinal hernia. Ann Surg. 2006;244:167–73.
3. Compagna R, Rossi R, Fappiano F, Bianco T, Acccurso A, Danzi M, Massa S, Aprea G, Amato
B.Emergency groin hernia repair: implications in elderly. BMC Surg. 2013;13(Suppl 2):S29.
4. Rutkow IM, Robbins AW.Demographic, classicatory, and socioeconomic aspects of hernia
repair in the United States. Surg Clin North Am. 1993;73(3):413–26.
5. Jenkins JT, O’Dwyer PJ.Inguinal hernias. BMJ. 2008;336:269–72.
6. McGugan E, Burton H, Nixon SJ, Thompson AM.Deaths following hernia surgery: room for
improvement. J R Coll Surg Edinb. 2000;45(3):183–6.
7. Spirch S, Bruttocao A, Militello C, Martella B, Nistri R, Barbon B, Lupia F, Dalla Vecchia
D, Sarri C, Verdoglia S, Vecchiato V, Donà B, Terranova O.Nostra esperienza in 15 anni
di chirurgia dell’ernia inguinale e crurale nel grande vecchio. In: La chirurgia dell’anziano.
Napoli: De Nicola; 2000. p.363–8.
8. Canonico S, Sciaudone G, Pacico F, Santoriello A.Inguinal hernia repair in patients with
coagulation problems: prevention of postoperative bleeding with human brin glue. Surgery.
1999;125(3):315–7.
9. Amato B, Compagna R, Della Corte GA, Martino G, Bianco T, Coretti T, Rossi R, Fappiano
F, Aprea G, Puzziello A.Feasibility of inguinal hernioplasty under local anaesthesia in elderly
patients. BMC Surg. 2012;12(Suppl 1):S2.
374
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
B. Martella et al.
10. Battocchio F.Anestesia locale. In: Battocchio F, editor. Testo atlante di chirurgia delle ernie.
Milano: UTET; 1994. p.13–20.
11. Terranova O, Battocchio F, Nistri R, Martella B, Celi D.Proposte di modica alla tecnica di
Bassini per il trattamento dell’ernia inguinale. Acta Chir Ital. 1989;45:810–2.
12. Lichtenstein IL, Shulman AG.Ambulatory outpatient hernia surgery. Including a new concept,
introducing tension-free repair. Int Surg. 1986;71(1):1–4.
13. Powell BS, Lytle N, Stoikes N, Webb D, Voeller G.Primary prevascular and retropsoas her-
nias: incidence of rare abdominal wall hernias. Hernia. 2015;19:513–6.
14. Gallegos NC, Dawson J, Jarvis M, Hobsley M.Risk of strangulation in groin hernias. Br J
Surg. 1991;78(10):1171–3.
15. Dahlstrand U, Wollert S, Nordin P, Sandblom G, Gunnarsson U.Emergency femoral hernia
repair: a study based on a national register. Ann Surg. 2009;249(4):672–6.
16. Chia C, Chan W, Yau K, Chan C. Emergency femoral hernia repair: 13-year retrospective
comparison to the three classical open surgical approaches. Hernia. 2016;21:89–93.
Incisional Hernias
26
CarmeloMilitello andFrancoMazzalai
26.1 Introduction
Incisional hernia is one of the most frequent complications of laparotomy (and one
that occurs not only to general surgeons but also to vascular surgeons, gynaecologists, and urologists), with a high variable average incidence between 2 and 50%,
probably depending on the heterogeneity of the cohort of patients included and the
follow up duration.
In fact, this complication occurs more frequently in the rst 3years after surgery,
even though it is possible that it can occur after more than 10years [1].
The elderly population (i.e. people over 70years old as worldwide denition) is
an increasing phenomenon everywhere, especially in industrialized countries; the
frequency of many diseases increases with advanced age; and consequently the
number of surgical interventions for this age group is also increasing.
Incisional hernias are burdened with morbidity and mortality, especially in
patients requiring more than one corrective surgery.
Elderly people often suffer from medical comorbidities that can facilitate the
onset of incisional hernia [2]:
– Hypertension
– Diabetes
– Obesity
– Chronic obstructive pulmonary disease
– Use of steroids, smoking
C. Militello, MD (*)
Geriatric Surgery Unit, University of Padua, Padua, Italy
e-mail: carmelo.militello@unipd.it
F. Mazzalai, MD
General Surgery, Treviso Hospital, Treviso, Italy
© Springer International Publishing AG, part of Springer Nature 2018
A. Crucitti (ed.), Surgical Management of Elderly Patients,
https://doi.org/10.1007/978-3-319-60861-7_26
375
376
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
C. Militello and F. Mazzalai
– Coronary or vascular diseases
– Renal disease requiring dialysis
– Malnutrition
– Immunosuppression
– Connective tissue disorders
Constipation or ascites are conditions that increase abdominal pressure; suture
technique (transverse versus midline incision, small bites versus large bites for closure, and slowly resorbable sutures such as PDS versus other resorbable stitches),
emergency surgery, surgical site infections, and multiple laparotomy are other possible contributing factors [3, 4].
26.2 Surgical Approach
The Rives–Stoppa technique is the gold standard in the open treatment of incisional
hernias, because it allows repairing both the anatomy and the aesthetic of the wall defect.
The main technical phases are the restoration of the deep fascial layer, retro muscular and perifascial placement of prosthetic mesh, and nally the reconstruction of
the wall defect.
The rst step is to perform a skin incision with excision of the previous scar,
isolating the hernia sac from the subcutaneous tissue reaching the rectus muscles
fascia and freeing all around the wall defect. The hernia sac should not be opened,
to avoid the risk of adhesion formation (except when the peritoneal cavity must be
explored, e.g. in case of occlusion of suspected ischaemia).
Then the rectus muscle must be detached from its lateral margin, exposing the
retro muscular and perifascial area, where the prosthesis will be placed, using a
continuous suture to close the posterior rectus sheath. This ensures that a fascial
layer separates the abdominal contents from the prosthesis (if the suture leads to
excessive tension and there is residual defect in the closure, we can use part of
resected hernia sac or a prosthesis in resorbable material to close it).
The prosthesis is then xed by stitches to the abdominal wall over the prepared
fascial plan (in the original description, stitches were transcutaneous), and the anterior
fascial layer is sutured over the prosthesis to separate it from subcutaneous tissue.
One of the main problems of this procedure is the seroma, due to the inammatory reaction induced by the prosthesis itself (usually drains must be placed for the
rst day after surgery); there is lively ongoing research for materials causing less
inammatory reaction [
Many studies have demonstrated the feasibility of laparoscopy in the elderly [6,
7], so this technique is expanding its application elds (with a decreasing number of
laparotomies), and incisional hernias of the trocars sites are less frequent [8].
The advantages of laparoscopic repair of incisional hernias are multiple:
5].
– Allows the diagnosis of other, preoperatively unrecognized, defects
– Decreases intraoperative risk of contamination, also because no viscera are
manipulated
26 Incisional Hernias
377
– Allows better cosmetic results, early mobilization and refeeding of the patient,
and earlier discharge from hospital
After creating the pneumoperitoneum (pressure 10–12mmHg), the trocars are
positioned as laterally as possible and far from the hernia defect to have the best
possible view of the operative site. Thereafter the adhesiolysis starts freeing the
contents of the hernia sac (Fig.26.1); this is certainly the most delicate phase, and
sometimes it requires a long operative time, but it is essential to avoid bowel injury
(or repair immediately if created).
We must measure the diameter of the hernia defect (also with transcutaneous
introduction of ne needles), to ensure an overlap of 5cm per side [9]. The prosthesis (necessarily, with a surface ensuring the lowest bowel adhesions) is xed to the
abdominal wall by tacks (Fig.26.2), which can have various forms (spirals, anchors)
and be resorbable or not [10], creating a “double crown” around the defect, taking
Fig. 26.1 Parietal
defect at the end of the
hernia contents
removal
Fig. 26.2 Prosthesis
xation by tacks
applicator to the
abdominal wall
378
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
C. Militello and F. Mazzalai
care not to pierce the epigastric vessels. The more tacks that are used, the higher the
risk of pain (nerves entrapment).
The minimum size defect allowing laparoscopy is 3cm, while there is no agreement on the maximum size.
Not every patient is eligible for laparoscopy: heart and severe pulmonary diseases are anaesthetic contraindications, history of previous surgery with peritonitis
or multiple interventions predicts a more difcult (if not impossibility) adequate
adhesiolysis, and the giant size of the defect (over 20cm) makes it difcult to correctly place the prosthesis, as well as the border incisional hernias [11, 12].
26.3 Prosthetic Mesh
The gold standard for the repair of incisional hernias is a technique that involves the
placement of a prosthesis.
The materials can vary and differ a lot, also depending on the chosen laparotomy
or laparoscopic technique. In case of intraperitoneal placement of the prosthesis,
this must ensure the lowest possible adhesions risk.
The main materials used are:
Polypropylene: Minimal risk of bacterial infection, it can be shaped and it is
stable in time. The polypropylene microstructure promotes the structural integration
with tissues and cell regrowth within its bres. The fundamental problem of polypropylene is the visceral adhesions.
Polypropylene combined: Polypropylene mesh can be associated with a bioresorbable layer (polydioxanone—PDS) in contact with the bowel, one side coated
with oxidized regenerated cellulose layer, which minimizes the formation of adhesions and is completely resorbed within 4weeks.
This prosthesis is suitable for intraperitoneal use.
ePTFE (polytetrauoroethylene): One of the oldest prostheses was obtained by
combining a PTFE layer with polypropylene, modied subsequently to reduce the
thickness and increase the porosity to encourage the colonization of broblasts.
This prosthesis can be used in contact with the bowel.
Another one combines two layers with different porosity (the inner layer has
micropores that minimize adhesion formation; the outer layer has macropores that
promote tissue incorporation). It is also suitable for intraperitoneal use.
In the last few years, the use of biological prostheses, derived from animal tissue
and appropriately modied, has been increasing; also, this device can be used in
contaminated elds. The costs are still high, though.
Many other materials are currently being studied: the main goal is to reduce
seroma, bacterial colonization, and adhesion formation, promoting the colonization
of broblasts for the incorporation of the prosthesis [13].
Соседние файлы в папке @xirurgi_2025