Ferguson's method for inguinal hernia repair

The groin area is located at the ankle, triangular, with one on each side. The upper boundary is on the horizontal line of the anterior superior iliac spine to the outer edge of the rectus abdominis, the inner boundary is the outer edge of the rectus abdominis, and the lower boundary is the inguinal ligament. The abdominal wall of the inguinal region can be divided into 9 layers from shallow to deep, namely skin, subcutaneous tissue, superficial fascia (Scarpa fascia), external oblique muscle and aponeurosis, intra-abdominal oblique muscle, transverse abdominis muscle, transverse transverse fascia, Extraperitoneal fat and parietal peritoneum. Although its level is the same as that of other parts of the abdominal wall, it is far weaker. In the inguinal region, the inferior epigastric artery is obliquely moved from the outside to the upper side, through the medial edge of the inguinal region, up to the deep rectus abdominis, intersecting the lateral edge of the rectus abdominis. The inferior epigastric artery is on the outer side, the outer rectus abdominis is on the inner side, and the inguinal ligament is on the lower side. A triangular area is formed between the three, called the groin triangle. There is no rectus abdominis in this triangle, and the transverse fascia is weaker than other parts. It is the weakest part of the inguinal region, and the groin is directly protruding to the body surface. Treatment of diseases: inguinal hernia Indication The Ferguson's inguinal hernia repair is suitable for cases where the hernia sac is small and the posterior wall of the groin is strong. It is characterized by no loose spermatic cord and only strengthens the anterior wall of the inguinal canal in front of the spermatic cord. Generally used for young people. Contraindications If the patient with inguinal hernia does not have a cuff or a strangulation, surgery should not be performed under the following conditions. 1. Patients with acute diseases, lesions in the skin of the sputum, or severe cough, etc., increase the intra-abdominal pressure. 2. Elderly paralyzed patients with long-term survival and no serious symptoms are expected. Preoperative preparation 1. Repeat the detailed physical examination and necessary laboratory tests before surgery, paying special attention to the throat, heart, lung, blood and surgical site. 2. Complete the skin preparation in the operating area one day before the operation. 3. If there is an upper respiratory tract infection, chronic cough, chronic constipation or other conditions that increase the intra-abdominal pressure, it should be controlled before surgery. Surgical procedure 1. Begin to the pubis nodules at 1.5 to 2.0 cm above the midpoint of the inguinal ligament, and make a oblique incision parallel to the inguinal ligament, 6 to 8 cm long. The skin and subcutaneous tissue were dissected to reveal the aponeurosis of the external oblique muscle, and the outer end of the incision was exposed. 2. Along the direction of the aponeurosis of the external oblique muscle, make a small incision in the middle of the aponeurosis, lift the aponeurosis on both sides, use the scissors to sneak under the aponeurosis, and then cut the aponeurosis and the outer ring upwards and downwards. Injury of the inferior tibia and inguinal hernia under the diaphragm. 3. Peel and separate the aponeurosis to the sides, fully revealing the inner surface of the inguinal ligament and the joint iliac crest. The inferior epigastric and inguinal nerves are carefully removed from the surface of the abdominal oblique and testicular muscles, and are retracted to the sides to protect the outside and below the aponeurosis of the external oblique muscle. 4. Longitudinal separation of the testicular muscle and transverse transverse fascia fibers, revealing the hernia sac. The sac is located on the anterior medial side of the spermatic cord and is slightly grayish white. When the difficulty is identified, the patient may be coughed, or the nostrils may be pinched to make him suffocate. It is often seen that the sac is protruding along the spermatic cord. 5. Lift the wall of the sac, first cut a small opening on the wall with a knife, and then use scissors to enlarge the incision, taking care not to damage the contents of the sputum. Then, through the incision, the index finger is extended into the abdominal cavity, the position of the inferior epigastric artery is found, and the presence or absence of the second ankle is recognized. 6. Return the contents of the sputum to the abdominal cavity. In the middle of the hernia sac, the spermatic cord and the surrounding tissue outside the sac are peeled off, so that the middle part of the sac is completely free. The sac is cut off horizontally, and after careful hemostasis, the distal sac is placed in the scrotum. Do not sew the distal sac of the sac, so as not to form effusion or blood in the sac. 7. The proximal hernia sac is lifted with a hemostatic forceps. The left hand shows the inner surface of the sac. The right hand shows the gauze and continues to peel the proximal sac to the neck. During the stripping process, be careful not to damage the spermatic vessels and the vas deferens. 8. After the high position of the hernia sac is ligated, the spermatic cord remains in place. The joint iliac crest and the inguinal ligament were sutured together in the front of the spermatic cord with thick, non-absorbent sutures. The method of suturing and the precautions are the same as the Brazilian law. 9. Put the retracted nerve back in place. The aponeurosis of the external oblique muscle was sutured intermittently with a medium-sized non-absorbable suture. If the external oblique aponeurosis is loose, it is also feasible to fold and suture. The subcutaneous tissue and skin are sutured in layers. complication Bleeding during surgery Some have a large amount of bleeding, bleeding can be caused by damage to the following blood vessels: 1 pubic branch of the obturator artery (so-called corona mortis), refers to the obturator artery branch around the hernia sac; 2 abdominal wall artery; 3 movement ,vein. It is cumbersome to infuse the bleeding caused by the two blood vessels in the front, but as long as the incision is extended and the exposure is improved, these blood vessels can be ligated or sewn without causing a big problem. The problem caused by femoral injury is more serious. When the inguinal ligament is sutured, the suture is too deep, which may damage the femoral blood vessels and cause massive bleeding. It is best to withdraw the needle before ligating the damaged blood vessel, and locally stop the bleeding. If the pressure can not stop bleeding immediately, it is necessary to enlarge the incision, fully expose the injured femoral blood vessels, and then local compression to stop bleeding, or use fine needle suture to repair the blood vessel breach. 2. Cut off the vas deferens After accidentally injuring the vas deferens, it should be repaired immediately. The ends of the ends can be anastomosed by a very thin non-absorbent line; the inner support can also be made with a thin plastic tube, and the anastomosis can be sutured with a thin line, and the plastic tube can be removed after surgery. If there is an operating microscope on site, you can also use 6-0 thin wire to do the opposite end, in this case you do not need to use the inner support tube. 3. Damage to the lower abdomen nerve The important nerves encountered during hernia repair include the inferior epigastric nerve and the inguinal hernia, in addition to the sensory branch of the radial nerve and the reproductive branch of the reproductive femoral nerve. Because the inguinal inguinal nerve is located under the aponeurosis of the external oblique muscle near the outer ring, it is easy to damage the nerve when the diaphragm is cut. In the Cooper method, the inferior epigastric nerve is easily damaged when the incision is made in the anterior rectus sheath of the rectus abdominis. Once nerve damage occurs, repair has no real value. The nerve ends can be clamped with silver clips after trimming to avoid neuromas. Due to the overlap and cross-linkage of the segmental distribution of the nerve, the affected part may feel numb gradually after the injury. Inadvertent suture of the suture may cause long-term symptoms. The reproductive branch of the reproductive femoral nerve may be damaged when the testicular muscle near the inner ring is severed. The patient may have a testicular testicular sag before the operation. In the process of repairing and suturing the tendon, if the inguinal ligament is sewed too deeply, the femoral nerve may be sewed sometimes, and the femoral nerve may be incomplete after surgery, and the patient may fall easily when walking. It can be recovered after removing the suture that sewn the nerve. 4. Injury to the testicular arterial blood supply In the process of free hernia sac, the vascular bundle that damages the spermatic cord should be prevented. These blood vessels are thin and difficult to repair. The internal spermatic artery begins in the abdominal aorta, and the distal testicular artery is the main arterial supply of the testes. The internal spermatic artery is connected to the spermatic cord in the inner ring plane. The external spermatic artery is a branch of the inferior epigastric artery. After the spermatic cord tissue is added, the vas deferens is passed through the inguinal canal to provide blood supply to the testicular muscle. It has an anastomosis between the inner and the inner spermatic artery. Due to the presence of the above-mentioned collateral circulation, slight accidental damage to the spermatic vessels does not cause serious consequences. However, in the case of recurrent hernia repair, occasionally the spermatic blood vessels can be transected, which may affect the testicular blood supply. This situation should be avoided as much as possible, otherwise it may cause testicular atrophy. 5. Damage to the abdominal organs In the repair surgery, each stitch should be very careful. Sliding sputum can damage the cecum or sigmoid colon. Due to the lack of knowledge of the sputum, until the sliding sputum is recognized, the intestinal wall may have been cut or the mesenteric vessels have been severed. The hernia sac is located on the anterior medial side of the spermatic cord, so the separation and incision of all hernia sacs should proceed from the front. Mesenteric blood supply enters from behind the sacral sputum, and separation in the latter often causes bleeding or intestinal necrosis due to blood supply disorders. This complication can be avoided by incision in the anterior medial side of the sacral hernia. In case of damage to the colon wall, the colon wall should be repaired as usual. The inside of the iliac crest often has a bladder wall. When the sac is cut open, the bladder can be cut due to carelessness. Seeing a blood-rich lemon-colored adipose tissue to be vigilant, it may be a pre-bladder lipoma, do not cut easily. Once the bladder wall is damaged, the bladder wall should be sutured in two layers with a fine chrome gut or absorbable suture and silk thread, while the catheter is indwelled through the urethra for several days. can be patched as usual.