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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_903_Библиотеки_им_академика_М_И_Перельмана.pdf
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A. Bates and S. Docimo Jr.
2
5
3
Fig. 29.1 Bassini technique. External oblique aponeurosis (1), internal oblique muscle (2), inguinal ligament (3), relaxing incision (4), transversalis fascia (5), nonabsorbable suture (6)
1
4
6
McVay Cooper’s Ligament Repair
McVay repair addresses both inguinal and femoral defects and is the ideal procedure for femoral hernia repairs in contaminated settings whereby prosthetic mesh is
contraindicated. Similar to Bassini and Shouldice approaches, the transversalis fascia is incised, exposing the preperitoneal space. The upper ap is mobilized.
Cooper’s ligament is identied. The upper transversalis ap is sutured to Cooper’s
ligament, beginning at the pubic tubercle and moving laterally, progressively closing the femoral space, in an interrupted fashion. A transition stitch between the
transversalis fascia, Cooper’s ligament, and the inguinal ligament occurs at the femoral vessels. The transition stitch allows for the repair to be continued laterally
along the inguinal ligament and above the femoral vessels laterally to the internal
ring (Fig.29.2). A relaxing incision (2–4cm) is made through the anterior rectus
sheath vertically, originating from the pubic tubercle [9].
Shouldice
The Shouldice Hospital was opened in 1945in Toronto, Canada, and is currently
located in Thornhill, Canada, with an annual average of 7000 patients. Major tenets
of the Shouldice repair include a low body mass index, local anesthesia for nearly
all groin operations, and early ambulation (the patient is helped off the operating
room table and ambulates to his/her wheelchair) [10].
29 Open Techniques: Mesh andNon-mesh Anatomical Repairs
Fig. 29.2 McVay technique. Interrupted suture placement prior to closure
401
Technique
Procaine hydrochloride 1–2% is commonly used with a maximum volume of
100cm3 (2%) or 200cm3 (1%). An incision is made along a line joining the anterior
superior iliac spine and the pubic crest. The external oblique aponeurosis is identied, and 20–30 cm3 of local anesthetic is injected deep to the aponeurosis. The
external oblique aponeurosis is then divided from the supercial inguinal ring to the
deep inguinal ring. The cremasteric bers are incised longitudinally from the pubic
crest to the internal ring. The lateral portion of the cremasteric bers containing the
external spermatic vessels and the genital branch of the genitofemoral nerve are
clamped and ligated (Fig.29.3). An indirect sac will lie on the medial side of the
spermatic cord. The sac should be reduced into the preperitoneal space. The posterior wall should then be incised using a scissor by extending an incision from the
medial side of the deep inguinal ring to the pubic crest (Fig.29.4). Opening of the
posterior wall will allow for observation of the preperitoneal fat within the preperitoneal space of Bogros [10].
Reconstruction commences using gauge 32 or 34 stainless steel (as used in the
Shouldice Clinic) or polypropylene. Two sutures will be required, each contributing
two suture lines to the repair. The rst suture is anchored at the pubic crest and
incorporates the iliopubic tract, transversalis fascia, transversus abdominals, internal oblique muscle, and lateral border of the rectus abdominis (Fig. 29.5). This
suture line is moved laterally to the internal ring. At the internal ring, the suture
reverses course and moves lateral to medial, creating the second suture line. This
second line of suture incorporates the iliopubic tract to the transversalis fascia,
402
Fig. 29.3 Shouldice
technique. Division of the
cremaster muscle and
genital branch of the
genitofemoral nerve
Fig. 29.4 Shouldice
technique. Division of the
transversalis fascia
A. Bates and S. Docimo Jr.
transversus abdominis, and the internal oblique muscle. The previously transected
cremaster stump can be incorporated in the second line of suture (Figs.29.6 and
29.7). The suture is advanced to the pubic crest and tied to the rst stitch [10].
The second suture will create the third and fourth suture lines. The third line
begins at the internal ring and incorporates the transversalis fascia, transversus
abdominis, and the internal oblique muscle and the undersurface of the lateral
Inferior epigastric
Transversalis
29 Open Techniques: Mesh andNon-mesh Anatomical Repairs
403
fascia
Rectus
abdominis
Fig. 29.5 Shouldice technique. Suture Line 1 is anchored to the pubic crest and incorporates the
iliopubic tract, transversalis fascia, transversus abdominals, internal oblique muscle, and lateral
border of the rectus abdominis
vessels
Marginal vein
Fig. 29.6 Shouldice
technique. Suture Line 1
proceeding laterally toward
the internal ring
portion of the external oblique aponeurosis (Fig.29.8). The suture will move in a
lateral to medial direction and reverse course at the pubic symphysis to create the
fourth suture line (Fig.29.9). The fourth suture line will incorporate the undersurface of the external oblique aponeurosis and once again the edge of the transversalis
404
cremasteric
cremasteric
External oblique
External oblique
aponeurosis
aponeurosis
A. Bates and S. Docimo Jr.
Stump of
Stump of
Fig. 29.7 Shouldice technique. Conclusion of suture Line 1 at the internal ring as the lateral
cremasteric stump is incorporated below the triple layer
Fig. 29.8 Shouldice
technique. Suture Line 2 as
it proceeds medially from
the internal ring toward the
pubic symphysis
29 Open Techniques: Mesh andNon-mesh Anatomical Repairs
Fig. 29.9 Shouldice technique. Suture Line 3 originating at the internal ring as it proceeds medially toward the pubic symphysis
Fig. 29.10 Shouldice
technique. Conclusion of
suture Line 4 at the internal
ring
405
fascia, transversus abdominis, and the internal oblique muscle layer (Fig.29.10).
The fourth line moves in a medial to lateral direction to the level of the internal ring
and tied [10]. The spermatic cord is returned to its normal position. The external
oblique aponeurosis is closed using an absorbable suture (we commonly use Vicryl).
We close Scarpa’s fascia with absorbable suture material, and the skin is closed with
staples or a running subcutaneous suture.
406
A. Bates and S. Docimo Jr.
Lichtenstein
The procedure can be performed under local, sedation, or general anesthesia,
depending on patient variables and the degree of dissection expected [11]. A
5–6cm skin incision is made from the pubic tubercle and extended laterally along
a Langer’s line. Dissection is carried down through the subcutaneous tissue and
Scarpa’s fascia to the level of the external oblique aponeurosis. The aponeurosis is
opened in the direction of its bers, extending down to open the external inguinal
ring. The lower leaf of the external oblique aponeurosis is secured and freed from
the spermatic cord. At this point, the ilioinguinal nerve should be identied and
protected. It can be seen coursing along the anterior surface of the spermatic cord.
Care should be taken so as to preserve its investing fascia. The upper leaf of the
external oblique fascia is then secured and freed from the internal oblique underneath. This plane should be dissected superiorly to expose the aponeurosis of the
internal oblique muscle and identify the iliohypogastric nerve running along its
anterior surface within the investing fascia. The plane between the external and
internal oblique is avascular, and dissection can be carried out quickly and
atraumatically.
The spermatic cord is then bluntly dissected away from the inguinal oor. This
dissection is performed within the avascular plane between the cremasteric bers
and the rectus muscle attachments to the pubis. While performing this maneuver,
care should be taken to preserve the spermatic vessels and the genital branch of the
genitofemoral nerve, which run on the underside of the cord. The plane should be
developed approximately 2cm past the pubic tubercle and proximally to the internal ring. The internal ring should always be explored to identify an indirect defect
(Fig. 29.11).
The cremasteric muscle layer should be opened on the anterior surface for
approximately 3–4 cm longitudinally at the level of the internal ring. Complete
skeletonization of the cord structures is not advised due to the risk of trauma to the
vas deferens, spermatic vessels, and nerves. If a hernia sac is identied, it should be
dissected away from the cord structures using gentle traction and judicious use of
electrocautery. Dissection of the sac is continued until it is free down to the level of
the internal ring, where it can then be inverted into the preperitoneal space. Routine
ligation of the hernia sac is not recommended due to the risk of increased postoperative pain. Furthermore, it has been demonstrated that non-ligation of the sac does
not increase recurrence rates. However, in the case of large, non-sliding scrotal hernia sacs, the sac can be ligated to prevent overzealous dissection that predisposes to
ischemic orchitis. This should be performed midway through the canal, and the
distal sac should be opened anteriorly to prevent hydrocele formation. If the internal
ring is too large, one or two Marcy sutures can be placed to close down the transversalis fascia.
The direct space should always be explored. The direct sac can be inverted back
into the preperitoneal space with multiple sutures to the transversalis fascia, taking
care not to involve the lower edge of the internal oblique muscle and add undue
of genitofemoral n.
Internal oblique m.
29 Open Techniques: Mesh andNon-mesh Anatomical Repairs
407
Fig. 29.11 Neuroanatomy
of the inguinal canal
External oblique
aponeurosis
& aponeurosis
Pubic tubercle
lliohypogastric n.
llioinguinal n.
External
spermatic v.
Genital branch
tension on the repair. Narrow-necked direct sacs can be closed with a purse string
suture. The femoral ring should be routinely evaluated via the space of Bogros
through a small opening in the canal oor.
Attention should then be directed to proper placement and xation of the prosthetic mesh. A monolament, macroporous mesh should be used due to its resistance to infection. A 7× 15 cm piece of mesh should be shaped with a tapered
medial edge and squared lateral edge. A modication of an inferior triangular extension can be used to cover femoral defects as well (Fig.29.12).
While gently retracting the spermatic cord superiorly, the tapered medial edge
of the mesh should be sutured, with monolament, nonabsorbable suture, to the
rectus sheath just above its insertion on the pubic bone. The mesh should overlap
the bone by 1–2cm to help prevent medial recurrence. One should avoid suturing
the mesh to the periosteum of the pubis due to the risk of chronic pain. The lower
edge of the mesh is secured, via running monolament suture, to the inguinal ligament until just lateral to the internal ring. In the case of femoral hernia, the triangular extension of mesh can also be xated to Cooper’s ligament to adequately
cover the defect.
A slit is then made on the lateral edge of mesh, leaving two-thirds of the width
above the slit and one-third below. The upper tail is then passed under the cord,
and the two tails are then brought around to encircle the cord and are secured to
each other with a clamp. While retracting the cord inferiorly, the upper edge of
the mesh is laid at on the internal oblique aponeurosis and secured with 2–3
interrupted absorbable sutures. The placement of the superior edge of mesh
between the internal and external oblique layers provides sufcient xation
while avoiding potential trauma to the iliohypogastric nerve. If the nerve was
exposed during dissection and will be in contact with mesh, the nerve can be
resected with proximal ligation to prevent neuroma and then buried in the
408
To Inguinal Ligament To Cooper’s Ligament
A. Bates and S. Docimo Jr.
Fig. 29.12 Standard inguinal hernia mesh shape, 7×15cm (top). Modied mesh shape for concomitant femoral defects (bottom)
internal oblique muscle. Once the superior edge is xed, the two tails are brought
by suturing each with monolament suture to the inguinal ligament just lateral to
the inferior edge completion knot. Avoid xation of the tails to the internal
oblique muscle. The external oblique aponeurosis is then closed over the cord
and mesh using running absorbable suture. The skin is closed with absorbable
sutures or skin staples (Fig. 29.13).
Internal oblique m.
& aponeurosi
of genitofemoral n.
29 Open Techniques: Mesh andNon-mesh Anatomical Repairs
409
Fig. 29.13 Mesh
placement in inguinal oor
s
External oblique
aponeurosis
Pubic tubercle
lliohypogastric n.
IIioinguinal n.
External
spermatic v.
Genital branch
Plug-and-Patch
The plug-and-patch technique was originally developed as a modication of the
original Lichtenstein technique, adding a mesh plug to help ll hernia defects to
promote scarring. The dissection of the groin is identical to the previously described
Lichtenstein repair.
The original use of the plug was by Lichtenstein himself, who created a plug
by rolling a 2cm×5 cm piece of at Marlex mesh into a mesh “cigar” to be
inserted into femoral and recurrent defects. The plug was then held in place using
two nonabsorbable sutures. For larger defects, he would use a wider strip of mesh
over the rst. Upon insertion of the mesh, the plug would uncoil to ll the defect
[12, 13].
In 1989, Gilbert described the use of a hand-rolled plug in an umbrellalike conguration. The tip would be inserted through the defect completely and, once
released, would expand to cover the defect within the preperitoneal space. The
mesh he used was a 2.5in.×2.5in. piece of Marlex mesh [14] (Fig.29.14).
Rutkow and Robbins went further by developing the umbrella/cone plug [15].
Instead of the fanning out within the preperitoneal space, the cone was inserted so
that the widest point of the cone was level with the fascia. The cone was then secured
in place with sutures. In addition, they added the use of a at mesh over the cone
plug as a way to prevent a new hernia, but considered this optional to the repair.
Between 1989 and 1992, they reported their recurrence rate as being 0.1%
(Fig.29.15).
Rutkow and Robbins worked with the Bard Company to produce the rst standardized mesh plug for widespread use [16]. The PerFix plug included eight layers
of mesh leaets to help protect against mesh contraction and migration, as well as