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Surgery hernia (hernia plastic)



Inguinal hernia.
Set is fixed and paid in cordon (vas deferens) to strengthen herniyalniyat defect.
In the past it applied quite "strange" methods for treatment of hernia - hernia rip because of entrapment, burning with a hot iron hernia or lead, including kastratsiya.V while there was no anesthetic.
Modern era in the treatment of hernias began around 1880 and is related to the Italian surgeon Eduardo bass. It turns out that the old "standard" operations are not always as effective. Relapses reach 10-15%. In recent years, surgical treatment for herniated change rapidly and substantially. New research shows that hernia varies considerably from patient to patient and the appropriate type of operation must comply in every particular case.
Surgeons specialize in treating hernias (herniolozite) have experience of supervision of anatomical variants and treatment for thousands of operations for hernia. They expertly apply the exact maximum operational approach. Not accidentally the results are excellent. Relapses are rare.
The most common methods are applied for "sewing" the hernia defect izpolzvashtiplatna and methods for strengthening the abdominal wall.
Depending on how the hernia hole to reach the main methods or conventional open surgery and mini-invasive (or so-called bloodless laparoscopic method). "Bloodless" method developed rapidly in recent years due to technological advances. Using a small camera and micro instruments reaches hernia defect through tiny holes in the abdomen and is done with plastic canvas. Advantage is no incision, a small tissue trauma resulting in quicker recovery and no scars.

sled operacia, След операция



“When a man says he is an experienced hernia surgeon and has never had a recurrence, he is a liar in one statement and probably in both.”




For doctors
Development and current status of operational methods for the treatment of inguinal hernias
For the treatment of hernia there is evidence of antiquity. Hammurabi of Babylon (1700 BC) describes the reposition of the hernia and applying bandage. In the 16th century Stromayr defines indirect from direct hernias and draws attention to the high ligation of the indirect hernia sac, followed by castration. Rapid development in the treatment of hernias in the late 19th century. Czerny (1876) describes high ligation and excision of hernialniya bag. Kocher twists hernialniya bag and sewn to the lateral muscle in the external inguinal orifice. Lucas-Ckampionniere first opened apenevrozata the external oblique abdominal muscle for disclosure of all kanal94, 105,166,197.
In 1873 Marcy offers pathogenetically substantiated methods, strengthening and narrowing of the internal inguinal opening later popularized by Ogilvie, Lytle, Zimmerman, Ponka. However, the beginning of the modern era in the treatment of inguinal hernia is considered presentation of the work and results of E. Bassini to Italian Surgical Society in 1987 Genua140, 179.238. He reported recurrence only 8 out of 206 operations for three years. For the time in which recurrence after surgical treatment of hernia is 30-40% in the first year and 80% after 4 years, it is a great success. In the approach outlined Bassini basic and essential moments of its own hernia plastic fabrics:
opening the aponeurosis of the external oblique abdominal muscle;
longitudinal incision of the cremasteric fascia and muscle, followed by resection at the base for discovery of cordon jackets hernia, inguinal inner edges of the hole;
incision in the back wall of the inguinal canal to the discovery of preperitonealnoto space and high ligation of the hernia bag;
the reconstruction of the rear wall of the inguinal canal is sutured medially f.transversalis, transverse and oblique abdominal muscles laterally to ileopubichen tract and "fold" to edge of the inguinal ligament.
Bassini restores aponeurosis of the external oblique abdominal muscles above the cordon keeping physiological oblique course of the inguinal canal. Reforming external inguinal orifice.
The original Bassini method gives good results in the stable group methods using own takani128, 172.
In an effort to seek better results offer a variety of modifications. Problems occur most often when unopened to f.transversalis (so-called. "American" Bassini): more tension in the sewing line, construction of under narrow, shaped mainly by muscle and energized new internal inguinal orifice; herniya105 missed. Simultaneously and independently of Bassini, Halsted published his first version of operation similar to that of Bassini. Using the aponeurosis of the external oblique abdominal muscles to strengthen the back wall, making it duplicates into the cordon, Halsted eliminates the inguinal canal and its physiological protective function. Yukstapolirat is internal and the external inguinal openings. The result is a higher percentage of indirect retsidivi110. The principle of strengthening the back wall of the inguinal canal muskulnoaponevrotichen surface layer and the sacrifice of the inguinal canal and covers methods Postemsky, Kirschner. Comparative studies show higher relapse rate and this type of plastic is not used in specialized hernia tsentrove105, 153.
Sir Astly Cooper (1804) describes the lig. pubicum sup., but first it used Narath from Holland. The first publication is Giuseppe Ruggi (1892). He sutured the inguinal ligament to Cooper in the treatment of femoral hernia, followed by Austrian Georg Lotheissen (1897) in the plasticity of femoral and inguinal hernia Recidivism in which inguinal ligament76 destroyed.
Widespread promotion of Cooper's sculptures merit of McVay and Anson130. Based on its extensive post-mortem tests, they think of the Cooper ligament reconstruction ideal structure in the rear wall of the inguinal canal. The argument is that approximating structures originate and are in the same plan. Aponeurosis of m.transversus abd. and f.transversalis are anchor lig.Cooperi67, 147,196.
Empirical impression of tension in the plastic sewing line with approximate tissue defect and its role in relapses have search methods for compensating for it and bring the relaxing incisions - Wolfer (1892), Halsted (1902), Fallis (1938), Rienhoff ( 1940), Tanner (1940), Mattson (1946), McVay (1946), Rutladge (1980), Read (1982) 80.130.
This operation (Cuper ligament plastic) had many supporters and continues to be important for recovery in hard plastic with large hernia defects and relapse. Demonstrated stable structure of the Cooper ligament is often used as a distal anchor including prostheses for large defekti25, 35,40,52,62,71,194,195.
Defects are considered emerging tensions in the sewing line, postoperative pain, the possibility of damage or pinched femoral vena71, 76,162,186,196. Results are reported in the range of 1.5% to 15.5% recurrences. This is the basis for the argument that the reasons for recurrences are not only applicable method.
Canadian surgeon EE Shouldice has contributed to the development of herniologiyata in the second half of the twentieth century. Originally it applied method (1945) included the mobilization of cordon and cremasteric muscle dissection hernialen indirect sac narrowing of the internal inguinal opening in Marcy and strengthening the back wall of the inguinal canal dublikatura of cremasteric muscle and fascia kremasterika a continuous suture without to incision f.transversalis. This method is applied Shouldice only indirect hernias. According to this author, the first Hungarian surgeon Adam (1937) performed a dublikatura f.transversalis, without her intsiziratsit. at 197.
Due to the inapplicability of the original operation at large, damaged back wall indirect and direct hernia collaborators Shouldice - Nicolas Obney and Ernest Ryan elaborates modern version of "Canadian" sculpture. They excised cremasteric muscle and fascia to complete discovery f.transversalis incision and perform strengthening a healthy muskulnoaponevrotichni duplication of structures with continuous suture. Thus revitalize the basic principles of sculpture by Bassini.
One of the first established specialist centers for the treatment of hernia - clinic Shouldice, methodically implemented and continuous monitoring of surgical patients. Reported results are below 1% recurrence in large series. An interesting and important feature in the policy of the Canadian group's attitudes towards obesity, which according to them is a risk factor and is essential for the success of the operation. They deferred to the reduction of operation tegloto78, 79.
Weakness (inferiority) of the connective tissue structures as a factor in etiology, pathogenesis of hernia is presented in studies Read187 and Cannon & Read86; Peacock and Madden46; Wagh225, 224; Tobin227, Belchev7.
The need for the use of prostheses (bands) to compensate for the insufficiency of the supporting structures of the plastic inguinal hernia has been discussed for more than a century. Are tested multiple auto, xeno-and aloplastichni materials. From avtoplastichnite used: skin - Otto Lowe (1913), Sokolov (1929), Baev (1954), Delchev and Karapandov; dura mater - Tsekov54, 55, Babchiniy (1957), Atanasov (1967), Popkirov (1969), Woll and Koth (1955), Raychev (1978); hernialen bag - Saafei (1976), Angelov (1979), and Todorov Andreevtsit in 7.
The most successful proved f.lata (Kirschner 1909), which was used as suture material, non-free and free flowing style. Disadvantages are the need for a second incision, loss of skeletal mechanical properties with time and lysis of graft in infection. Homotransplantatite are abandoned because they are difficult to prepare, require special storage are burdened with the risk of infektsiya18.
Synthetic prostheses are used by Don Aquaviva (1949) and Rene Bourgeon (1955) in France, followed by Usher (1950) op. at 163, and Koontz (1960) in SASHT214.
There are currently a wide range of synthetic materials which can satisfy different levels.
An important stage in the development of herniologiyata is the introduction of so-called. "Tension-free" (relaxed) plastics. It was started by Usher in 1958 he opened the back wall of the inguinal canal and fixed prosthesis (Marlex - Polypropylene) in f.transversalis, for arcus transversi muscle and medial to lig.inguinalae or lig.Cooperi - laterally. Prosthesis splits and forms a "tail" for kordona219.
Application of "tension-free" principle requires the use of a prosthesis, whether used inguinal, laparoscopic or open preperitonealen access. The most widely received e "onlay patch" plastic developed by Newman and popularized by Lichtenstein133. This is probably the most popular plastic surgery in the U.S. today. In Europe also has significant razprostranenie9, 23,47,84,103,118,125,126,144,161,223,224.
In "Inlay" sculptures - Usher220; Moran153; Alexander62; Schumpelick204; Bendavid77; Rives101; Pélissier176; Celdran87, imposition of the prosthesis is preperitonealnoto space.
For "Plug and patch" sculptures - Per Fix95, 190,192,193 and Prolene Hernia System (PHS) 106 factory used prosthetic devices combining adaptive and "plug" the principle applied by Gilbert107, 109 and "onlay patch" the principle of Lichtenstein.
Strengthening the "whole visceral sac" (Giant prosthetic reinforcement of the visceral sac - GPRVS) prosthesis is a large sculpture of the principle of Stoppa213, 215,216. Also known as "French" sculpture. Stoppa large prosthesis using Mersilene, placed in plan between the peritoneum and f.transversalis, which cover all potential hernialni doors. Wantz233, 157,227 applies the same principle, but unilaterally. Due to intra-abdominal pressure (law of Pascal) prosthesis is pressed against the abdominal wall and fixed with sutures. Defects or defects not suturirat. It is indicated for recurrent and bilateral hernias at high risk of retsidiv75, 178.
Establishment and improvement of preperitonealnite accesses, the development of modern synthetic prostheses and design of laparoscopic technique opens the way for the last twenty years of laparoscopic techniques in the treatment of inguinal hernia. Ger at all (1982) under the close supervision laparoscopic peritoneal hernialen hole and subsequently performed in 12 dogs laparoscopic recovery congenital hernia.
Bogojavlensky (1989) Laparoscopic put "plug" polypropylene suture followed by the internal inguinal opening.
The first series of Laparoscopic report Schultz (1990). Unacceptably high rate of recurrence leads Arregui139 (1991) to develop a methodology to dissect all potential hernialni doors and cover with increasing size prosthesis. Logically leads to the combination of the principle of Stoppa - for a wide denture preperitonealno and laparoskotskiya method.
Access to preperitonealnoto space can be transabdominal (TAPP) or totally preperitonealen (TEP). The last access is technically more difficult, but saves opening the abdominal cavity. For the advantages of the laparoscopic approach is presented lesser postoperative pain and faster return to normal physical activity. Disadvantages are: the need for general anesthesia, obligate prosthesis, technical difficulties, high costs.
The number of publications in which the reported results of laparoscopic recovery are very good and otlichni93, 98,100,120,150,169,181,201,222,236.