Indirect inguinal hernia repair with Schouldice method

The use of Brazilian fascia inguinal hernia repair, McVeigh's inguinal hernia repair, Foxon's inguinal hernia repair, and Hosted's inguinal hernia repair have cured many patients with inguinal hernia. The shortcoming of these methods is that the posterior wall of the inguinal canal is not really repaired and strengthened, that is, the transverse transverse fascia layer, and the tension is large, and there is a certain recurrence rate. In 1945, Schouldice first published a tension-free repair method. Recently, there have been reports of this method in China. It is believed that the Schouldice inguinal hernia repair is simple, safe, physiological and anatomical, and has a low recurrence rate. It is suitable for various inguinal hernias. . Treatment of diseases: inguinal hernia Indication The Schouldice inguinal hernia repair is suitable for adult patients with large hernia sac and weak abdominal wall. It is characterized by the displacement of the spermatic cord between the intra-abdominal oblique muscle and the external oblique muscle aponeurosis. 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. The incision and hernia sac treatment steps are the same as the aforementioned hernia repair, but the suspension fixation after the sac ligature is not performed. 2. Lift the spermatic cord and the testicular muscles, cut the inner fascia of the spermatic cord, and show the lower edge of the inner ring. Use the indicator finger to extend into the transverse fascia and gently separate between the extraperitoneal fat. 3. Longitudinal shearing of the transverse fascia, until the pubic tubercle site, the transverse fascia is divided into inner and outer leaves, and separated under the two sides of the leaves. 4. The medial non-absorbent suture is used to suture the lateral lateral fascia from the pubic symphysis. The lower side of the medial lobes is sutured under the medial lobe with the sacral or intra-abdominal oblique tendon until the end of the inner ring. 5. Still use this line to suture the medial lateral fascia on the lateral leaf and the inguinal ligament until the pubic symphysis. 6. From the outside of the inner ring, the inferior oblique muscle and the transverse abdominis muscle edge are continuously sutured together with the deep side of the inguinal ligament to strengthen the second layer. 7. Put back the sperm. Rinse the wound. The decidua, subcutaneous tissue and skin of the external oblique muscle were 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.