Choice of Hernioplasty Method for Various Types of Inguinal Hernia

The research addresses the problem of selecting the optimal method of hernioplasty for various types of inguinal hernia. The work examines modern approaches to inguinal hernia treatment, including tension and tension-free techniques as well as endovideoherniological technologies. A comparative analysis of traditional and tension-free surgical treatment methods was conducted on a clinical material of 885 patients. The research is aimed at developing an individual differentiated approach to the choice of hernioplasty method depending on the type and characteristics of the inguinal hernia.

The results of the research have been implemented in clinical practice and are used in the educational process. The work contributes to the development of the surgical hernia school by substantiating a differentiated approach to the choice of hernioplasty method for various types of inguinal hernia.

The most common pathology of man requiring surgical treatment is hernias of the anterior abdominal wall, with an incidence of up to 50 patients per 10,000 population. Inguinal hernias account for more than 66% [8, 13, 45, 141, 142].

The concept of reconstruction of the posterior wall of the inguinal canal developed by Bassini in 1884 revolutionized the surgical treatment of inguinal hernias. The principles of plastic surgery used by the author became the basis for the most various interventions, however, their essence can be reduced to the following tenets: restoration of anatomical relationships, reinforcement of weak areas with aponeurotic duplications and muscles [58, 59].

By this time, there exists a huge number of modifications and improvements of the Bassini technique proposed by various authors. But a fully satisfying technique has still not been developed. The frequency of recurrences after traditional techniques, including plastic surgery according to Shouldice ('gold standard'), remains high, reaching 10%, and for complex types of hernias — 30% and more [94, 97, 149, 151].

In search of ways to reduce the number of recurrences, I. B. Useinov with co-authors (1987, 1991) developed the concept of a 'tension-free' technique. The authors believed that the main cause of hernia recurrences is suturing with tension of heterogeneous tissues, which contradicts the biological patterns of wound healing. The use of various implants for hernioplasty made it possible to significantly reduce the percentage of recurrences. The results of using this plastic surgery in non-specialized surgical centers are close to the results of treatment of inguinal hernias in specialized clinics, which is proof of the simplicity, safety, and effectiveness of this technique [53, 54, 137, 140, 146].

With the development and implementation of laparoscopic surgery technology in the 1990s, a number of successful attempts were made to combine laparoscopic access with the method of prosthetic hernioplasty. Publications attest to substantial advantages of endovideohermoplasty. The essence of the operation lies in 'tension-free' reinforcement of the posterior wall of the inguinal canal by endoscopic implantation of non-absorbable synthetic material without surgical plastic surgery of muscle-aponeurotic structures [1, 18, 42].

Literature data indicate that the recurrence rate does not exceed 1.1-2.2%. According to some forecasts, laparoscopic technology will be used in 50-70% of all operations for inguinal and femoral hernias (Presentation to the Minimally Invasive Surgery Conference. Arlington. 9 April, 1992, p. 154), currently in most clinics in Germany and the USA, only tension-free techniques are used both in endovideoherniological interventions and through traditional access.

At present, techniques appear that combine the advantages of endovideoherniology and the Lichtenstein technique. A. Darzi proposed the use of mini-access in combination with video technologies for plastic surgery of the inguinal canal [78, 79]. Most likely, such a combination of different techniques has a great future and deserves scientific research aimed at their further improvement.

Thus, existing data confirm the prospectiveness of applying 'tension-free' techniques for plastic surgery of inguinal hernias, not denying the problems of this technique. The development of universal endoscopic and tension-free techniques using traditional access for the treatment of abdominal hernias is an urgent necessity of surgery.

Existing data confirm the high effectiveness of applying tension-free techniques for the surgical treatment of inguinal hernias, regardless of the access (traditional or laparoscopic). Unfortunately, new technologies are difficult to take root in surgical wards of Russia. Only individual operations are performed. To this day, especially in domestic literature, there is a limited number of articles and scientific works devoted to the results of using tension-free techniques in clinical practice. Discussions about the necessity of wide implementation of tension-free techniques in clinical practice, the place of each of these interventions in hernia surgery continue, and this served as the starting point for our research.

Goal of the research

Improvement of treatment outcomes for patients with inguinal hernias through development of a concept of individual and differentiated approach to the choice of hernioplasty method for various types of inguinal hernias.

Research objectives

1. To develop indications and contraindications for the application of traditional (tension) plastic surgery techniques for inguinal hernias depending on the type of hernia.

2. To develop indications and contraindications for the application of tension-free plastic surgery techniques for inguinal hernias depending on the type of hernia.

3. To compare the effectiveness of various hernioplasty methods.

Novelty of the research

In a large clinical material (885 patients), the nature and severity of postoperative complications were evaluated when using tension-free and traditional hernioplasty techniques. An analysis of the causes of inguinal hernia recurrences was conducted. For the first time, indications for the application of this or that type of hernioplasty for various types of inguinal hernias were clarified. Technological techniques of various stages of plastic surgery were developed. Possible complications of plastic surgery were identified and ways to prevent and eliminate them were determined.

Practical significance

The practical significance of the work lies in the implementation into clinical practice of a method of differentiated approach to the choice of hernioplasty depending on the type of inguinal hernia. Technical techniques for performing tension-free hernioplasty for inguinal hernias are proposed. Possible complications of traditional and tension-free techniques, ways to prevent and treat them are described.

Implementation of the work

The results of the research and development have been implemented in the practical activities of the Saint Petersburg Regional Center for Endoscopic Surgery and Gynecology (Bishop Hospital of Holy Princess Elizabeth, Saint Petersburg), Penza City Herniological Center (Municipal Institution City Hospital No. 1, Penza).

The research materials are used in the educational process for resident physicians at the Department of Surgery of Penza State Medical University.

Defense of the work

The main provisions of the dissertation were reported at the XIV scientific readings dedicated to the memory of Academician N. N. Burdenko 'Actual Questions of Modern Clinical Medicine' (Penza, 2004), Penza Scientific and Practical Society of Surgeons named after S. V. Kulnev (Penza, 2005), International Surgical Congress 'New Technologies in Surgery' (Rostov-on-Don, 2005), Department of Faculty Surgery of Saint Petersburg State Medical University named after Academician I. P. Pavlov (Saint Petersburg, 2005).

Publications

6 scientific works have been published on the topic of the dissertation.

Structure of the dissertation

The dissertation is presented on 126 pages of typed text and consists of an introduction, 3 chapters, conclusion, findings, practical recommendations. The bibliography contains 215 titles of literary sources, of which 163 are foreign authors. The text is illustrated with 15 tables and 26 figures.