Preperitoneal Herniorrhaphy for Inguinal Hernias via the Suprapubic Oblique Mini-Access

The dissertation is devoted to the development and clinical testing of a method of preperitoneal hernioplasty for inguinal hernias performed through a suprapubic oblique mini-access. The research includes a comprehensive set of topographic-anatomical studies, experimental investigations of tissue response to the implantation of a polypropylene mesh implant in the preperitoneal space, and clinical validation of the proposed surgical technique. The scientific novelty lies in the first development and topographic-anatomical justification of the suprapubic oblique mini-access, the creation of a device for determining the incision projection and its trigonometric localization, as well as the clinical study of early and late outcomes of preperitoneal hernioplasty with P-shaped suture fixation of the polypropylene mesh.

Relevance of the Problem

The incidence of inguinal hernias (IH) ranges from 1.5% to 6% in men and 0.3–0.7% in women, accounting for 65–80% of all hernias [35,36]. Operations for IH are among the first-ranked elective surgical interventions and constitute 10–20% of all surgical procedures performed in hospitals. In Russia, up to 200 thousand such operations are performed annually, while in the USA — over 700 thousand per year, with expenditures exceeding 28 billion dollars [114]. The presence of hernias reduces patients' quality of life and frequently leads to complications, the most severe of which is incarceration, capable of resulting in a fatal outcome [64, 77, 174].

Surgical treatment of inguinal hernias is accompanied by a considerable number of recurrences, with no tendency toward reduction, as well as other complications such as postoperative neuromas, epididymitis, ischemic orchitis, and purulent-inflammatory complications of the surgical wound. Recurrences after autoplasty procedures are observed in indirect inguinal hernias in 4.8–21% of cases, in direct hernias in 11–33%, and in recurrent hernias the number increases to 42.5–58% [11, 24, 56, 76]. Moreover, treatment of this patient group carries significant social and economic importance, as patients with inguinal hernias are generally individuals of the most productive age [63]. Males aged 20 to 60 are most commonly affected.

Over the past 100 years, despite the improvement of plastic repair methods, no noticeable improvement in surgical outcomes has been noted. The surge of interest in various variants of laparoscopic hernioplasty observed in recent years is gradually waning, as the complexity, cost of techniques, and the necessity of general anesthesia impede their widespread dissemination, although the recurrence rate after laparoscopic hernioplasty does not exceed 2% [171, 156]. The Lichtenstein hernioplasty has firmly established positions in Europe and is becoming increasingly popular in Russia [111]. This has been made possible thanks to its remarkable reliability, simplicity, and accessibility. The recurrence rate is 0.1% [183]. However, the cosmetic effect of the operation, manipulations on the spermatic cord with possible trauma to it, technical difficulties in recurrent hernias, the time required for the surgical intervention, and the desire to reduce the extent of surgical trauma dictate the necessity of searching for new methods of treating hernias of the inguinal localization.

In recent years, surgeons' interest in minimally invasive surgery methods has grown. In particular, operations through mini-access using special instruments have begun to be widely used in many areas of surgery.

However, the effectiveness of their application in hernia surgery has been practically unstudied, which determined the necessity of conducting this research.

Goal of the Research

To improve the results of surgical treatment of inguinal hernias and the conditions for performing surgical intervention through mini-access.

Tasks of the Research

1. Based on topographic-anatomical studies and mathematical modeling, to determine the optimal projection of the incision of the suprapubic oblique mini-access to the deep inguinal ring and the medial inguinal fossa.

2. To evaluate experimentally the dynamics of morphological changes in the tissues of the anterior abdominal wall upon placement of a polypropylene mesh implant in the preperitoneal space.

3. To develop and clinically test a method of preperitoneal hernioplasty from the suprapubic oblique mini-access.

4. To study the early and late results of treatment of patients with inguinal hernias using the developed method of preperitoneal hernioplasty from the suprapubic oblique mini-access.

Scientific Novelty

1. For the first time, the suprapubic oblique mini-access for preperitoneal hernioplasty has been developed and topographically and anatomically justified; a device for determining the projection of the incision of the suprapubic oblique mini-access has been developed; a trigonometric justification of its localization based on the structure of the hypogastric region of the abdomen has been provided; sonography of the deep inguinal ring on the anterior abdominal wall has been proposed for performing preperitoneal hernioplasty. Indices of wound depth (IWD) to the deep inguinal ring and the medial inguinal fossa have been determined, allowing the selection of optimal conditions for surgical intervention through the suprapubic oblique mini-access.

2. A method of preperitoneal hernioplasty for inguinal hernias from the suprapubic oblique mini-access with fixation of the polypropylene mesh implant by P-shaped sutures has been developed and clinically tested.

3. For the first time, early and late (3-year) results of preperitoneal hernioplasty in patients with inguinal hernias from the suprapubic oblique mini-access with fixation of the polypropylene mesh implant have been studied: absence of trauma to the spermatic cord structures, reduction of the cremasteric reflex, reliable changes in testicle size, and accumulation of pathological fluid on the operative side, as well as a decrease in health-related quality of life (HRQOL) compared with practically healthy residents of Kemerovo of the same age.

Principal Propositions for Defense

1. The suprapubic oblique mini-access provides sufficiently optimal anatomical conditions for performing surgical intervention in patients with inguinal hernias when the thickness of subcutaneous fatty tissue does not exceed 3 cm, and compared with the access according to L. Nyhus and the oblique mini-access, it provides the best operative conditions.

2. Fixation of the polypropylene mesh implant by P-shaped sutures is necessary during early activation of patients in the postoperative period, as its displacement is possible during the first 7–14 days after the operation.

3. The use of preperitoneal hernioplasty from the suprapubic oblique mini-access with fixation of the polypropylene mesh implant by P-shaped sutures is the procedure of choice in the surgical treatment of inguinal hernias, given the absence of trauma to the spermatic cord structures, a low recurrence rate, and the absence of a decrease in HRQOL after the intervention.

Practical Significance

The implementation in clinical practice of the developed method of preperitoneal hernioplasty from the suprapubic oblique mini-access allows performing the intervention without the use of a video stand.

The implementation of sonography of the deep inguinal ring on the anterior abdominal wall in patients with inguinal hernias allows determining the optimal projection of the incision line of the suprapubic oblique mini-access for preperitoneal hernioplasty.

The established optimal conditions for performing the developed preperitoneal hernioplasty from the suprapubic oblique mini-access in the operative treatment of inguinal hernias allow reducing the technical complexity and traumatic nature of the surgical intervention and ensure the wide application of the developed method in practical healthcare.

Defense of Dissertation Materials

The principal propositions of the dissertation were reported and discussed at the All-Russian conference "Multidisciplinary Hospital: Problems and Solutions" (Leninsk-Kuznetsky, 2003), the X Russia-Japan International Medical Symposium (Yakutsk, 2003), the IV All-Russian Congress on Endoscopic Surgery (Moscow, 2003), the Regional Scientific Society of Surgeons (Kemerovo, 2004), the Regional Surgical Society (Novokuznetsk, 2006), the Plenum of the Union of Endoscopic Surgeons of Russia (Barnaul, 2006), and the City Scientific Society of Surgeons (Kemerovo, 2007).

Publications

Based on the dissertation materials, 21 printed works have been published, including in a journal recommended by the VAK RF for the publication of dissertation materials for the degree of Candidate of Sciences. A Russian Federation patent for the utility model "Device for Measuring the Diameter of the Spermatic Cord" No. 50397 dated 20.01.2006, and for "Device for Determining the Oblique Inguinal Mini-Access" No. 66664 dated 28.05.2007 have been obtained. A positive decision of the FIPS was issued for the patent on "Method of Operative Treatment of Inguinal and Femoral Hernias by the Oblique Inguinal Mini-Access" No. 2004120049/14(021795).

Volume and Structure of the Dissertation

The dissertation is presented on 137 pages of typed text. It consists of an introduction, a literature review, a description of materials and methods, two chapters of results of original research and their discussion, a conclusion, conclusions, practical recommendations, and is illustrated with 33 figures and 19 tables. The bibliography contains 233 sources, including 112 foreign authors.