Plastic surgery of the inguinal canal for femoral hernia

As a result of weakening of the abdominal wall muscles, loops of intestine and omentum can escape through the femoral ring from the abdominal cavity, and in this case a pathology called a femoral hernia develops. In addition to the already indicated reason - weakness of the abdominal wall (this feature is inherited), a femoral hernia can also occur for the following reasons:

• Sharp weight loss.
• Presence of postoperative scars.
• Injury to the abdominal wall.
• Hard physical labor.
• Problems with urination.
• Persistent cough.
• Intestinal dysfunction (frequent constipation).

The method of formation of a femoral hernia is similar to an inguinal hernia in that the gaps on the anterior abdominal wall, which are anatomically designed for vessels, the spermatic cord and the uterine ligaments to pass through, are vulnerable. An inguinal hernia passes through the inguinal canal, and a femoral hernia passes under the inguinal ligament.

Diagnosis, stages and complications of hernia

In order to diagnose a femoral hernia, X-rays are first used - irrigoscopy, with which the colon is examined. To assess the condition of the bladder and abdominal organs, the doctor may also prescribe an ultrasound. In addition, a referral for laboratory and clinical research is required.

A femoral hernia consists of a hernial orifice and a hernial sac. A hernia develops in several stages:

• The hernial sac is practically invisible to an outsider.
• The tumor is located inside the femoral canal.
• The hernia is clearly visible under the skin.

At the third stage, the hernia is not only enlarged and obvious, but also causes a number of consequences: swelling of the legs, blockage of the ureter due to the prolapse of the hernia into the bladder, painful movements. In advanced cases, the femoral hernia can no longer be reduced into the abdominal cavity. A strangulated hernia is the most common complication in which coprostasis develops - stagnation of feces in the area of ​​the large intestine.

Tension technique or plastic with own tissues (Tissue-based)

An old, classic method of treating both indirect and direct inguinal hernias. In principle, there are 2 types of plasty (closing a defect in the groin area at the site of the hernia): posterior plasty and anterior plasty of the inguinal canal. Of the hundreds of modifications of this operation, the most widespread in the world are plastic surgery of the posterior wall of the inguinal canal according to Shouldice (E. Shouldice), the operation of Bassini, Halsted, and Cooper. In Russia, the most frequently performed operation is Postemski plastic surgery. Anterior plastics were practically not used due to their extreme unreliability and high recurrence rate. The exception was the USSR and subsequently Russia and the post-Soviet space, where anterior repairs are still actively used to treat inguinal hernias. Today, tension operations are performed in approximately 20% of cases in the world.

Prices

Price (RUB)In installments* (RUB)Consultation with a surgeon on the operation (SPECIAL)0—Online doctor’s opinion on the operation (SPECIAL)0—Laparoscopic hernioplasty for femoral hernia, category I. complexity55000from 5496Laparoscopic hernioplasty for femoral hernia category II. complexity65000from 6496Laparoscopic hernioplasty for femoral hernia category III. complexity80000from 7995

* You can read more about the conditions here - Treatment on credit or in installments

The cost is preliminary. The exact cost of the operation can only be determined by a surgeon during a free consultation.

Preparing for surgery

Before surgery, it is necessary to undergo an examination to determine the general condition of the patient and identify possible contraindications. The patient undergoes blood tests, ECG and other studies in advance. Familiarize yourself with the procedure for hospitalization and the list of necessary tests before hernioplasty.

Hospital

The hospital stay is determined not so much by the type of operation as by the type and size of the hernia.

Patients operated on for inguinal hernias can be discharged the next day after either open or laparoscopic surgery.

Large hernias that require monitoring of drainage, anesthesia and dressings in the postoperative period can keep the patient in the hospital for several (usually 3-4) days.

Type of surgery and sexual function

The option of access and mesh placement for inguinal hernioplasty does not directly affect the preservation of sexual function.

Tension-free plastic

Operation Liechtenstein

Despite almost thirty years of scattered experience in the use of polypropylene prostheses in hernia surgery, there was no single view on this problem in the world. There was no consensus on either the indications or the technique for performing these operations. It was only in 1986 that Irving Lichtenstein for the first time systematized and clearly described all the stages of tension-free repair for inguinal hernias. And in 1986, he and his colleagues published data on 1000 operations performed using this technique with zero hernia recurrence. At the same time, in this report, he noted that this surgical technique has undeniable advantages: almost complete absence of pain after surgery, minimal hospitalization, immediate return to active work immediately after surgery, no risk of damage to the urinary tract, complications from the lungs and cardiovascular system. vascular system, economic effect of treatment. Everything stated at that time contradicted reality. And even an official letter from a group of famous surgeons was published, directly accusing Liechtenstein of deception and manipulation of numbers. But by 1992, a report had been published on 3,019 patients operated on for inguinal hernias at other specialized hernia centers. The relapse rate was only 0.2%. In 1995, the world was provided with a report on 16,000 operations using this technique, performed by 72 surgeons in non-specialized clinics. The relapse rate was less than 0.5%. Since then, the Lichtenstein operation has been considered the “Gold Standard” in the treatment of inguinal hernias. And in the history of herniology (the science of hernias), Irwin Lichtenstein forever remained the surgeon who completely changed his view of this problem and transferred surgery for inguinal hernias to the category of outpatient interventions. Features of the operation:

1. skin incision 10 cm
2. strengthening the posterior wall of the inguinal canal with a mesh plate behind the spermatic cord
3. the mesh is fixed around the entire perimeter with a continuous seam, see picture

Advantages:

1. low relapse rate - 0.5 - 1%
2. unexpressed pain syndrome
3. possibility of performing on an outpatient basis
4. possibility of performing under any type of anesthesia, including local
5. short rehabilitation period (full occupational and sports rehabilitation max 20 days - 1 month)

Obturation method (Mesh Plug Operative Technique)*

*The Russian-language name of this technique was first used in our center in 2000 by surgeon E.A. Shiryaev. The history of the development of this method of treating inguinal hernia begins in 1968, when the same Irwin Lichtenstein first used a twisted cylinder-shaped Marlex mesh for filling (obturation) of the hernial orifice (the hole through which the hernia emerges) during surgery for femoral and recurrent inguinal hernia. The next stage of development of the technique occurred at the end of the 1980s. Surgeon Arthur Gilbert, experimenting with the technique proposed by Lichtensten in the treatment of oblique inguinal hernias, modernized the shape of the Plug. Instead of a cylinder, he began to use a mesh prosthesis in the form of an umbrella. The stage of standardization and widespread implementation of this method of treatment of inguinal hernias began in 1989 thanks to the work of IMRutkow and AWRobbins (USA). Having studied Gilbert's successful experience in using a prosthesis in the form of an umbrella or a cone and actively using this method, they eventually came to the conclusion that this technique can be used for all types of inguinal and femoral hernias. At the same time, they used prostheses prepared by hand. In the spring of 1993, they, together with the CR Bard Company, developed and put into production a ready-to-use kit for “obturational” plastic surgery. In 2000, it was in our center for the first time in our country this technique was performed and introduced into widespread practice. Features of the operation:

1. Incision 4-6 cm
2. Dissection of the aponeurosis
3. Isolation of the spermatic cord
4. Isolation of the hernial sac
5. The hernial orifice is obturated (sealed) with a specially shaped mesh prosthesis

rice. 1

Fig.2

• the posterior wall of the inguinal canal is strengthened with a flat mesh behind the spermatic cord without suturing

Fig.3

The implant is placed:

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Suturing the aponeurosis:

Suturing the wound:

Advantages:

1. low relapse rate - less than 1%
2. minimal pain syndrome
3. the ability to perform the operation on both sides simultaneously
4. possibility of performing on an outpatient basis
5. possibility of performing under any type of anesthesia, including local
6. start physical activity in a few days
7. short rehabilitation period (full occupational and sports rehabilitation within 20-30 days)

Hernioplasty according to the Lichtenstein type using a self-fixing implant.

A relatively new modification of classical Lichtenstein plastic surgery. The difference is that in this case a self-fixing (similar to the well-known “Velcro” for clothes) implant Parietene Progrip, produced by Covidien, is used. The mesh itself is fixed to the bottom of the wound over the entire surface and does not require suturing.

Endoscopic (synonymous with laparoscopic) hernioplasty.

Contrary to popular belief among patients, the laparoscopic approach for treating hernias is not minimally invasive (Edward H.Phillips)! This thesis is recognized by almost all leading organizations and voiced at most herniological forums. Endoscopic hernioplasty is a method of treating an inguinal hernia, in which suturing or closing the hernial orifice is performed not through an external incision, but from the inside of the abdominal cavity, or from the preperitoneal space (the space between the layers of the abdominal wall). To carry out this operation, special equipment is used, consisting of a video camera and a set of special manipulators, which are inserted through minimal punctures (from 1.0 cm to 0.5 cm) either into the abdominal cavity or between the layers of the abdominal wall. This method developed in parallel with laparoscopy. Back in 1982, attempts began to simply suturing the internal inguinal ring. And in 1990, Popp reported successful operations for indirect inguinal hernia, in which he used a flat mesh or a simulated mesh (Plug) to close the internal inguinal ring. In principle, there are two ways to install the mesh: - abdominal preperitoneal (transabdominal preperitoneal or abbreviated TAPP), when the operation is performed laparoscopically from the abdominal cavity, but the mesh is installed separated between the peritoneum and the muscular-aponeurotic layers of the abdominal wall. - extraperitoneal, when the mesh is installed directly into the space between the peritoneum and other layers of the abdominal wall, without entering the abdominal cavity. This technique is more complex and time-consuming, but has a lower percentage of complications and relapses. Advantages:

1. low relapse rate - up to 1%
2. extremely mild pain syndrome
3. the ability to perform the operation on both sides simultaneously
4. start physical activity in a few days
5. short rehabilitation period (full occupational and sports rehabilitation max 20-30 days)

Flaws:

1. complexity of the procedure (a high level of surgeon training in laparoscopic techniques is required)
2. performed only under endotracheal anesthesia
3. limited possibility of performing it in elderly people and impossibility of performing it in patients with concomitant cardiopulmonary pathology
4. use of complex expensive equipment

As you can see, with all its undeniable advantages, this method has significant drawbacks. In this connection, in world medicine there is a strong tendency to abandon this operation in favor of open “tension-free” operations.

Method using the PHS or UHS system (Ethicon, Johnson & Johnson)

A relatively new method of treating inguinal hernia. This technique uses a specially manufactured implant made of polypropylene (PROLENE Hernia Sistem or PHS) or semi-absorbable material (ULTRAPRO Hernia Sistem or UHS). The essence of the technique is similar to the obturation method described above. Only in this case the shape of the implant has been changed in the form of a monoblock. The role of an “umbrella” for obstructing the hernial orifice is played by the transition cylinder, and the flat parts of the prosthesis strengthen the walls in front and behind. Features of the operation:

1. incision 10 cm
2. the hernial sac and spermatic cord are distinguished.
3. in the preperitoneal space in the area of ​​the hernial orifice, a space is formed where one of the prosthesis plates is placed.
4. the second plate of the prosthesis is located more externally between the layers of the abdominal wall.

Thus, the transition cylinder seals the hernial orifice . Advantages:

1. low relapse rate - up to 1%
2. unexpressed pain syndrome
3. the ability to perform the operation on both sides simultaneously
4. start physical activity in a few days
5. short rehabilitation period (full occupational and sports rehabilitation max 20 days - 1 month)

Flaws:

1. large cut
2. more difficult to implement than previous ones

Operations Trabucco

Just like the methods described above, they are modifications of the Lichtenstein operation. There are several methods of execution, depending on the type and size of the inguinal hernia. In this case, either a one-component flat prosthesis is used, or a two-component one, consisting of two flat prostheses of different shapes. The peculiarity of the method is that the operations are seamless. Those. the prosthesis is not fixed. This became possible thanks to the use of meshes with increased rigidity, which perfectly retain their shape even without hemming. Advantages:

1. the same as with other tension-free plastics

See also: inguinal hernia treatment

Complications after surgery for inguinal hernias

Complications of inguinal hernias can be divided into early and late.

Early complications of inguinal hernia repair – those that developed within 30 days after surgery. Early complications include gray matter, hematoma, urinary retention, purulent-inflammatory complications (suppuration, fistula).

The Lichtenstein technique and endoscopic techniques for inguinal hernias are comparable in the rate of early complications and relapses (with a follow-up period of 1-4 years), with the exception of giant hernias.

Late complications of inguinal hernia repair – those that developed within 30 days after surgery. Late complications, in particular, include chronic pain in the surgical area.

The rate of complications after open surgery for inguinal hernia varies from 15% to 28%. The most common early complications are hematomas and seromas (8-22%), urinary retention and early pain.

The risk of developing a wound infection after elective inguinal hernia repair with mesh is about 1.3%. The use of mesh for inguinal hernia repair does not increase the risk of wound infection. Deep tissue infections are rare. Infection in the postoperative period is not an absolute indication for removal of the endoprosthesis. Wound drainage is recommended only when indicated (extensive blood loss, coagulopathy).

Chronic pain after hernia repair of inguinal hernias

Chronic pain as a complication after surgery depends on many factors: the type of surgery performed, the age of the patient, and others. The incidence of chronic pain after surgical treatment of inguinal hernia is on average 10-17%.

With Lichtenstein plastic surgery, chronic pain is observed in 10-12% of patients. The risk of developing chronic pain after hernia repair with mesh is lower than after hernia repair without mesh. Isolation and identification of the inguinal nerves during open hernia repair significantly reduces the risk of nerve damage and the risk of developing postoperative chronic pain. The risk of developing chronic pain decreases with age. There is a potential short-term benefit for chronic postoperative pain with atraumatic mesh fixation using the Lichtenstein method.

After laparoscopic repair, the risk of developing chronic pain is lower compared to open repair with and without mesh. Risk factors for the development of chronic pain are: a history of other symptoms associated with pain, age under 40 years, severe acute postoperative pain, laparoscopic intervention for a recurrent hernia.

Features of the disease

The pathology develops gradually. When a hernia forms, a femoral canal is formed, through which the protrusion goes out into the subcutaneous tissue. At the first stage, the patient feels a tingling sensation if he is exposed to heavy physical labor. This usually does not bother patients until the pain begins to increase, interfering with normal walking. Then a visible formation appears, increasing over time. It becomes round or oval, and in the later stages it is impossible to straighten it yourself.

Women have a wider pelvis than men, and such hernia occurs more often among them. The prerequisite for its appearance are vulnerable areas under the inguinal ligament and less strong connective tissue.

Inguinal hernia anesthesia

The pain relief option depends on the size of the hernia and the type of surgery.

• With open Lichtenstein surgery, small inguinal hernias can be operated on under local anesthesia. Currently, conduction regional blockades are becoming increasingly common. Another option is spinal (spinal) anesthesia, when the conduction of impulses below a certain segment of the spinal cord is blocked.
• For laparoscopic hernioplasty, the only possible option is surgery under balanced anesthesia with artificial ventilation.