General Indirect Inguinal Hernia Repair

According to the anatomical features and clinical manifestations of the inguinal hernia, it is proved that the important part of strengthening the posterior wall of the inguinal canal to prevent the recurrence of hernia is to properly sew the transverse transverse fascia at the inner ring. The transverse transverse fascia forms an inner ring around the spermatic cord and enters the inguinal canal in a funnel shape, becoming the inner fascia of the spermatic cord. After the inguinal hernia is formed, the transverse fascia surrounds both the hernia sac and the spermatic cord. Treatment of diseases: pediatric inguinal hernia, inguinal hernia, inguinal hernia, preoperative preparation 1. To determine whether the diagnosis is oblique or straight, or whether the two coexist, whether it is slippery, whether there is incarceration or strangulation. 2. A detailed understanding of the severity of intestinal obstruction, dehydration, shock, etc., as well as serious diseases of the whole body, and actively take appropriate prevention and treatment measures. 3. Empty the bladder before surgery. Surgical procedure (a) spermatic cord in situ inguinal hernia repair (Ferguson) 1. Position, incision: Supine position. From the 3cm above the midpoint of the inguinal ligament to the pubic symphysis, a oblique incision parallel to the inguinal ligament, about 6cm long. 2. Reveal the sac: After cutting the skin, the first layer of superficial fascia (ie subcutaneous fat) is encountered. When this layer is cut, two shallow abdominal arteries (ie, the superficial abdominal artery in the outer segment of the incision and the superficial pubic artery in the incision) should be seen in the surgical field. They should be ligated and cut one by one to prevent unnecessary bleeding. Then cut the deep fascia deep in the direction of the incision. The connective tissue under the deep layer of the superficial fascia was bluntly separated by the fingers of the gauze, and the aponeurosis of the external oblique muscle was revealed. Cut a small opening in the external oblique aponeurosis, first use the scissors to sneak under the aponeurosis, then use the scissors to pick up the aponeurosis, cut up and down in the direction of the fiber, so as not to damage the abdomen under the aponeurosis. Lower nerve and iliac crest nerve. When cutting outwards toward the outer ring, the outer ring can be inserted into the outer ring and opened to prevent damage to the groin nerve through the outer ring. The small hemostatic forceps were used to clamp and lift the two edges of the external oblique aponeurosis, and the fingers wrapped with gauze were separated on both sides of the sacral margin. The inferior lateral margin needs to be separated into the inguinal ligament, and the superior medial oblique muscle, the transverse abdominis free margin and the combined tendon should be separated from the upper medial side. During the separation process, care should be taken not to damage the inferior epigastric and inguinal nerves deep in the aponeurosis of the external oblique muscle. The intra-abdominal oblique muscle and the transverse abdominis muscle are pulled upward with a right angle hook to reveal the spermatic cord and the cremaster muscle overlying it. Cut the cremaster muscle in front and use a small hemostat to gently grasp the cutting edge and pull it to the sides to see the spermatic cord. Carefully separate the spermatic cord, pay attention to the tissue around it, and look for the sac in the inner part of the spermatic cord. In case of difficulty, the patient may be forced to cough or contract the abdominal muscles to make the hernia sac. After discriminating the sac, you can lift and cut it. 3. High ligation of the sac: For the high ligation of the hernia sac, the sac must first be separated up to the inner ring. When separating the hernia sac, the hemostatic forceps can be used to lift the incision edge of the sac, and the left hand is used to extend into the sac. The sac is carefully bluntly separated by the right hand, and the sac is gradually separated from the spermatic cord. If the adhesion is heavier, sharp separation can also be used. When the peritoneal fat is seen by separating the sac from the upper sac, it is already above the neck of the sac. The nearby organizational structure should be identified at the inner ring. On the medial side of the hernia sac, the curved transverse fascia defect edge is often seen. The finger is inserted into the abdominal cavity through the neck of the sac, and the lower abdominal artery can be touched to the inner and lower sides of the inner ring. The spermatic cord is located outside the sac, where the vas deferens are often attached to the sac wall and should be avoided during separation. Then use your fingers to push the contents of the sputum into the abdominal cavity. If the hernia sac is small, it can be sewed and cut in the neck; if the sac is large, the free sac of the sac can be lifted and the sac neck can be pulled out as much as possible. The suture was sutured with a 4th thread at the neck high. After tightening the purse string, the suture reinforcement is performed, so that there is no pocket protrusion in the local peritoneum. The hernia sac was then removed 1 cm distal to the suture. Care must be taken to avoid damage to the spermatic cord and the blood vessels under the abdominal wall during suturing, and to avoid tying the internal organs of the abdominal cavity. If the hernia sac is large, the lower half of the hernia sac may not be separated. The upper half is cut only after the middle part is cut, and the lower half is retained to reduce tissue damage and bleeding. Finally, the stump end of the sac is pushed back into the extraperitoneal space. 4. Repair the abdominal wall: repair the layers of the abdominal wall without the spermatic cord being displaced. Firstly, the upper layer of spermatic cord is gently pulled outwards and downwards, and the arc-shaped defect of the transverse fascia is sutured intermittently with a 4th thread. Generally, 3 to 5 needles are needed, and the inner ring after suturing should make the spermatic cord uncompressed. Pass a hemostat tip. Care should be taken to avoid damage to the medial inferior epigastric artery and the extranephratic and pubic vessels from the deep transverse fascia. Secondly, after the incision of the cremaster muscle was interrupted and sutured, the joint tendon was interrupted on the inguinal ligament with a 4 or 7 silk thread from above, with a needle spacing of about 1 cm. After all the seams are completed, the lines are knotted from top to bottom. The pinholes on the inguinal ligament should be shallow and wide to prevent damage to the femoral movements and veins. Do not sew a few pinholes between the same fiber bundles to prevent tearing after tension and affect the strength after repair. Care should also be taken when suturing to avoid excessive tension and affect healing. Then, the two layers of the external oblique aponeurosis are overlapped and sutured intermittently with a 4th wire. When sewing to the outer ring, care should be taken to retain a gap that can accommodate a small fingertip so as to prevent the newly formed outer ring from being too small, affecting the blood in the spermatic cord. Backflow, postoperative scrotal water sac, and even testicular atrophy. At the same time, it is necessary to pay attention not to sew the lower abdomen, the inguinal nerve and the bladder. 5. Stitching: Carefully stop the bleeding, if necessary, apply the warm saline gauze to the wound, and the small bleeding points should be ligated one by one; then the wound is washed, and the superficial fascia deep and the skin are sutured with thin wires. Under normal circumstances, no drainage is required. (B) spermatic sacral submucosal displacement inguinal hernia repair (Bassini) The initial procedure of the operation is the same as the incision in situ inguinal hernia repair. The spermatic cord is moved between the intra-abdominal oblique muscle and the external oblique muscle aponeurosis only when the abdominal wall is repaired, and the combined muscle is sewed to the inguinal ligament to strengthen the posterior wall of the inguinal canal. In the repair, the rubber cord is used to pull the spermatic cord apart, and the defect on the transverse fascia is intermittently sutured. Then use 4-0 or 7-0 silk suture to suture the tendon and inguinal ligament, about 4 to 5 stitches from top to bottom. Do not ligature first, wait until all are sewn, and then tie them up from top to bottom. The spermatic cord is placed outside the intra-abdominal oblique muscle, the cremaster muscle is sutured intermittently, and the aponeurosis of the external oblique muscle is overlapped and sutured, and the outer ring needs to be able to accommodate a small fingertip. Finally suture the subcutaneous tissue and skin. (C) improved spermatic sacral submucosal displacement inguinal hernia repair - pubic ligament repair (McVay) The pubic ligament is a ligament that extends back into the ligament of the inguinal ligament and then extends outward to the pubic comb line. According to the autopsy, McVay proved that the joint between the tendon and the transverse fascia is not in the inguinal ligament, but in the pubic ligament, so the joint muscle should be sewed on the pubic ligament. As a result of this, the recurrence rate of sputum can be reduced, and there is less chance of femoral hernia after repair. However, the pubic ligament is closer to the femoral vein and the operation is more difficult. The initial procedure of the operation is the same as the incision in situ inguinal hernia repair. In the repair, the spermatic cord is first opened, and the transverse transverse fascia defect at the inner ring is intermittently sutured. The anterior sheath of the rectus abdominis is then cut longitudinally to reduce the tension of the suture. Use the left hand to touch the femoral vein to protect, and then use the 4 or 7 silk suture to suture the tendon and pubic ligament 3 to 4 needles. The spermatic cord was placed outside the intra-abdominal oblique muscle, and the subcutaneous tissue and skin were sutured in turn after overlapping the aponeurosis of the external oblique muscle. (D) subcutaneous subcutaneous displacement of the inguinal hernia repair (Halsted) The method is characterized by moving the spermatic cord to the skin, and the muscles of the abdomen can be used to strengthen the posterior wall of the inguinal canal to reduce the recurrence of the hernia. It is suitable for patients with large age, large hernia sac and weak abdominal wall. When repairing, open the spermatic cord, suture the defect of the transverse fascia at the inner ring with a thin thread, and then suture the combined muscles on the inguinal ligament with a 4-0 or 7-0 silk thread. The upper needle cannot be sewn too. Tight, so as not to oppress the sperm. The spermatic cord is then placed outside the aponeurosis of the external oblique muscle, and the external oblique aponeurosis is sutured. Sometimes in the inner ring of the spermatic cord, the upper end of the incision of the external oblique aponeurosis is cut into a small cross-section, and some of the fibers are cut off so that the spermatic cord is not compressed. Finally, the spermatic cord is placed in the subcutaneous layer, and the subcutaneous tissue and skin are sutured intermittently. (5) Abdominal fascia repair (Shouldice) The most essential part of the Shouldice procedure is the repair of the transverse fascia at the base of the inner ring and the bottom of the inguinal canal. This method is mainly adapted to the huge shackles, straight squats and straight and diagonal squats. The procedure before the hernia sac is removed is the same as before. When separating the neck, it must reach the inner ring mouth, separate the edge of the transverse fascia around the circumference of the inner ring, perform suture or cross-ligation in the neck, remove the distal end of the sac, and retract the sac residue back into the inner ring. Extraperitoneal space. At this time, the ventral transverse fascia of the inner edge of the inner ring is lifted by an anatomical forceps or a hemostatic forceps, and the inferior epigastric artery and other extraperitoneal fat tissue are seen and pushed backward, and the transverse rib of the posterior wall of the inguinal canal is cut in the direction of the pubic tuberosity. membrane. Firstly, the upper lateral fascia of the transverse fascia is lifted, and the lower fat layer is separated, and then the lower side flap is lifted. Note that the branch from the inferior epigastric artery passes through the fascial flap to the cremaster muscle and the spermatic cord, that is, the external spermatic artery, in the branch. The base is cut and ligated. The lower edge fascial flap must be separated until it fuses to the deep part of the inguinal ligament. After adequate hemostasis, abdominal transverse fascia repair and internal ring reconstruction were performed. Using a double-strike suture technique, a 4-0 or 7-0 silk thread was used to perform a continuous cross stitching from the lower end. The lower lateral fascial flap is sutured to the deep side of the superior medial lobes, and is sewed to the outer edge of the inner ring, leaving the spermatic cord exit. Then, the free edge of the superior medial fascial flap is placed over the lateral lobes, and the free edge of the superior valvular flap and the inferior ligament of the inguinal ligament are continuously sewed from top to bottom to the vicinity of the pubic symphysis, with the initial needle. The suture is knotted, and the stitch length is 2mm to 4mm. At different depths, it is sewn into an uneven zigzag shape to increase the strength. Complete the posterior wall repair of the inguinal canal and reconstruction of the inner ring. Finally, the combined tendon and transverse abdominis aponeurosis (bow) were sutured to the inguinal ligament to enhance the posterior wall of the inguinal canal. The spermatic cord is placed under the aponeurosis of the external oblique muscle and the aponeurosis is sutured. complication Systemic complications Common systemic complications after hernia repair include pneumonia, atelectasis, thrombophlebitis of the lower extremities, urinary tract infection, etc., all should be treated after surgery. 2. Incision subcutaneous (or scrotal) hematoma Due to the incomplete hemostasis during surgery. Small hematoma can be puncture and withdrawal; if the hematoma is gradually enlarged, the suture should be re-opened under the aseptic operation of the operating room to stop bleeding. Otherwise, often due to loose scrotal tissue, the hematoma continues to increase, resulting in infection of the incision, affecting healing. 3. Incision infection If you feel a pain in the incision after surgery, the whole body is fever, you should check it in time. If a wound infection is found, in addition to the use of antibiotics throughout the body, local dissection should be considered depending on the situation. 4. Testicular hydrocele Often occurring in patients who have not been removed in the lower half of the hernia sac, the lower half of the hernia sac can be opened during surgery to reduce the chance of fluid accumulation. If it does, care can be taken to puncture the fluid. 5. Recurrence Most of the recurrence of hernia is that the neck of the hernia sac does not have a true high ligation and the transverse fascia defect of the inner ring is not repaired, and part of it is due to the incomplete suture of the posterior wall of the inguinal canal. These should be treated with care during the first operation to avoid recurrence. In addition, patients with older age, poor general condition, and postoperative complications are all factors that cause recurrence.