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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1433_Библиотеки_им_академика_М_И_Перельмана.pdf
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J.W. Murphy
reducing incidence and improving outcomes.
all been postulated as causes of chronic groin pain. Nerve damage can result from
if placed in the anterior space, may cause groin pain through incorporation of
dissection needed for placement of an anterior mesh may also play a role in post-
by causing traction on smaller nerve branches as the mesh becomes incorporated.
Many of the causes mentioned above can be avoided by not placing mesh in
the anterior space. By avoiding mesh in the anterior space, the dissection can be
limited to identifying the defect, leaving the nerves in place, and performing the
repair in the preperitoneal space.
Most mesh products to date have been placed in the anterior space, but this is
(as in laparoscopic repair), as both techniques take advantage of intra-abdominal
preperitoneal space, and pose concerns ranging from incidence of bleeding to lack
than any mesh prosthesis). The preperitoneal space also holds the advantage of
in turn greatly reduces the incidence of chronic groin pain.
4.4 Future Advances
41
4 Inguinal Hernia Repair Now and in the Future
procedures seem to have plateaued, general surgical procedures under robotic
assistance increased fourfold to 150,000 since 2009. One in four U.S. hospitals
increased, so has the cost of the robot, from $900,000 for the original device
to $2.3 million for the latest models. In addition, disposables costs run to $1
$3,000-$6,000 incremental cost per procedure, regardless of procedure type. To
quality of care are improved.
equipment and disposables, required longer operating times, and had a very long
easier dissection, and offers some improvement in surgeon ergonomics. Whether
this repair offers any clear advantages over traditional laparoscopic repair, or over
In the more distant future, the entire question of surgical hernia repair may
-
biomarkers and tissue type. There also may be some potential for pharmaceuti-
-
complication of inguinal hernia repair and must be addressed. An increasing
reduces the incidence of chronic groin pain. These and other techniques may help
the problem of inguinal hernia.
42
J.W. Murphy
References
smokers. Ann Int Med 107:680–682
metalloproteinase in fascia transversalis from hernia processes. Eur J Clin Invest 27:510–516
transversalis fascia in adult hernia. Hernia 3:45–51
Am Coll Surg 212:68–79
scaffolds for hernia repair demonstrates variability in mechanical anisotropy, non-linearity,
and hysteresis. J Mech Behav Biomed Mater 38:6–16
postrepair patient. Ann Surg 224:598–602
15:239–249
Res 25:683–696
43
G. Campanelli (Ed), Inguinal Hernia Surgery,
Updates in Surgery
DOI: 10.1007/978-88-470-3947-6_5, © Springer-Verlag Italia 2017
G. Campanelli ()
of Abdominal Wall and Surgical Treatment and Repair of Abdominal Hernia, Istituto Clinico
Sant’Ambrogio
Milan, Italy
e-mail: giampiero.campanelli@grupposandonato.it
5
3D Dynamic Anterior Repair:
ProFlor Technique
Giampiero Campanelli, Andrea Morlacchi, Piero Giovanni Bruni,
and Marta Cavalli
5.1 Introduction
been attempted to reduce discomfort and chronic pain after surgery, but these
of addressing such problems. It is designed for preperitoneal sutureless inguinal
nerve damages or entrapment [2–4]. In addition to this, the particular structure of
this device makes a physiological repair possible.
5.2 Device Characteristics
Despite the fact that the inguinal region is one of the most mobile parts of the
tissue. The idea behind the 3D Dynamic implant is that the inguinal region should
be repaired preserving the physiological resistance to kinetic stresses of this
region.
44
G. Campanelli et al.
a preperitonal disk and a central multilamellar core that gives radial resilience,
into gripping forces, a key point of this sutureless repair. These forces lead to a
shrinkage, as a result of the fact that the tissue covers the Freedom inguinal hernia
to a reduction in recurrence rate and patient discomfort [7].
5.3 Patient Selection
Almost every patient eligible for elective surgery for primary inguinal hernia
Fig. 5.1
45
5 3D Dynamic Anterior Repair: ProFlor Technique
Contraindications for this repair are: previous surgery on the hernia operative
cannot be closed.
5.4 Surgical Technique
This procedure can be performed under local anesthesia and the patient can be
discharged the same day of the operation.
procedure is slightly different for each kind of hernia.
For an indirect defect, identify the internal inguinal ring and remove all the
adhesions and scar tissue around it. Dissect the sac from the cord structures up
to the internal inguinal ring, isolating it circumferentially. Identify the nerves of
the region, taking care not to damage or stretch them. After that, reduce the sac
(Fig. 5.2).
Fig. 5.2 Correct device positioning in a case of indirect defect
46
G. Campanelli et al.
For a direct defect
attention to the nerves, removing adhesions and scar tissue around the hernia.
then check the integrity of the peritoneum (Fig. 5.3).
loops fold open around the cord. Use the Freedom inguinal hernia delivery device
to place the implant into the hernia defect (Fig. 5.4). Gently push the device into
Release the implant by pushing the plunger, and then remove the delivery device.
Fig. 5.3 Correct device positioning in a case of direct defect
47
5 3D Dynamic Anterior Repair: ProFlor Technique
out the implant to verify if proper resistance is present (Fig. 5.5). Then close the
needed.
Fig. 5.4 Implant folded inside the delivery device
Fig. 5.5
48
G. Campanelli et al.
References
Hernia 16:21–27
tailored dell’ernia inguinale. EdiSES, Napoli, pp 135–141
primary inguinal hernia repair: results of the TIMELI trial. Ann Surg 255:650–657
operator case series. Hernia 18:243–250
6. Amato G, Romano G, Agrusa A et al (2015) Biologic response of inguinal hernia prosthetics:
a comparative study of conventional static meshes versus 3D dynamic implants. Artif Organs
39:E10–23
49
G. Campanelli (Ed), Inguinal Hernia Surgery,
Updates in Surgery
DOI: 10.1007/978-88-470-3947-6_6, © Springer-Verlag Italia 2017
G. Campanelli ()
of Abdominal Wall and Surgical Treatment and Repair of Abdominal Hernia, Istituto Clinico
Sant’Ambrogio
Milan, Italy
e-mail: giampiero.campanelli@grupposandonato.it.
6
Total Open Preperitoneal (TOP) Technique
(modified Wantz)
Giampiero Campanelli, Piero Giovanni Bruni, Andrea Morlacchi,
and Marta Cavalli
6.1 Introduction
[1, 2], under the name of “giant prosthetic reinforcement of the visceral sac”
the Stoppa technique for a unilateral repair.
-
triangle, the deep inguinal ring and the Scarpa’s triangle of the femoral region [4].
A mesh placed in this space is compressed by the internal abdominal pressure and
there is an equal increase at every other point in the container.
The posterior preperitoneal approach provides an alternative to the anterior
-
ring, possibly leading to damage to the spermatic cord, nerves, and blood vessels.
femoral regions.