Due to the shortcomings of traditional inguinal hernia repair techniques with many complications and high recurrence rates, they have been gradually replaced by tension-free repair techniques as the gold standard for inguinal hernia repair in adults [1], and the Kugel technique is the only posterior approach, preperitoneal reinforced peritoneal sac repair technique for tension-free hernia repair, but due to the more complex and traumatic operation, the author applied the modified Kugel technique with inguinal approach to repair 36 cases from March 2005 to March 2007. From March 2005 to March 2007, I applied the modified Kugel technique with inguinal approach to repair 36 cases of inguinal hernia in the elderly, and achieved good results, which are reported as follows.
Clinical data
1.1 General information
There were 36 cases, all male, aged 60-82 years, with an average age of 67.2 years, 27 cases of inguinal hernia, 7 cases of straight hernia, and 2 cases of “trouser hernia”; with reference to the criteria for classification of hernia in the group of hernia and abdominal wall surgery of the Chinese Medical Association Branch of Surgery [2]: 18 cases of type II, 16 cases of type III, and 2 cases of type IV; all 36 cases All 36 cases were accompanied by one or more geriatric chronic bronchitis, prostatic hyperplasia, coronary heart disease, hypertension, diabetes mellitus and other geriatric diseases in different degrees, and 5 cases had a history of prostate surgery. In all cases, the round modified Kugel patch produced by the American Bard Company was used.
1.2 Surgical method
In all cases, continuous epidural block anesthesia was used, and an oblique incision was made in the direction of the internal inguinal ring toward the pubic symphysis, with an incision length of about 4 cm to 6 cm according to the thickness of the abdominal wall, and the upper end of the incision was about 1 cm beyond the mouth of the internal ring, and the tendon membrane of the external oblique abdominal muscle was incised in the direction of the muscle fibers, so that the external ring did not have to be incised, and the spermatic cord was freed to protect it and the posterior wall of the inguinal canal was completely exposed.
The hernia sac is freed to a high position, the oversized hernia sac is transected, the distal end is opened after tight hemostasis, and the proximal end is tightly sutured; the transversus abdominis fascia is incised along the root of the hernia sac, and if necessary, it is enlarged in the direction of the inguinal canal to create a preperitoneal space under the transversus abdominis fascia and in front of the peritoneum that reaches the abdominal white line, under the pubic comb, under the iliac vessels, and above the internal ring opening. The patch is required to completely wrap the free peritoneal sac and completely cover the pubic foramen area in the inguinal canal region.
Note that the freeing should be performed on the deep side of the inferior abdominal wall vessels, taking care to maintain the integrity of the peritoneal sac, and the peritoneum, if broken, should be tightly sutured to prevent contact between the patch and the viscera; the patch positioning tape should be fixed to the joint tendon and inguinal ligament to prevent displacement of the patch; the transverse abdominal fascia should be repaired, and the posterior wall of the inguinal canal should be strengthened with the attached flat sheet, and the incision should be closed layer by layer. Before closing the incision, if a small amount of blood leakage was found, a thin silicone tube was placed to drain the blood, and it was removed within 48 hours.
Results
The average unilateral operation time of our cases was 40 min±5; we could get out of bed 6 hours to 8 hours after surgery and resume daily activities after one week; there was no incision infection in our cases, all of them healed in one stage, 2 cases of subcutaneous plasma exudation, all of them absorbed by themselves; there were no complications such as hematoma and scrotal effusion; there was no recurrence, no foreign body sensation or mild foreign body sensation in the postoperative follow-up of 6 months to 2 years.
Discussion
Modern anatomical studies have shown that weakness of the pubococcygeal foramen area and destruction and defect of the transverse abdominal fascia in the inguinal region are the root causes of inguinal hernia, and traditional surgery has been gradually replaced by tension-free repair in adult hernia repair due to many complications and high recurrence rate, and open tension-free hernia repair with post-access visceral bursa strengthening can be performed simultaneously because it can completely strengthen the weak area of the pubococcygeal foramen in the inguinal region [3, 4]. deal with multiple hernias and prevent recurrent hernias in the inguinal region, especially in elderly patients with weak abdominal walls, where the chances of multiple and recurrent hernias are increased due to more concomitant morbidities such as chronic bronchitis and prostatic hypertrophy that lead to abdominal hypertension.
Peritoneal bursa strengthening plays a better preventive and therapeutic role, the position of the patch is deeper, the foreign body sensation is significantly reduced after surgery, the hydrostatic pressure of the peritoneal bursa makes the abdominal pressure evenly distributed throughout the inguinal area, so that the patch is not easily displaced, the repair is absolutely tension-free and heals firmly, the elastic memory ring of the patch keeps the patch in a flat state without curling, and the soft and multi-ported skirt of the patch makes the patch better The soft and multi-ported skirt of the patch makes the patch better adapt to each position without cutting.
Through the practice of this group of cases, the author experienced that the application of modified circular Kugel patch via inguinal approach has the following advantages.
(1) Easy and simple surgical operation, because after cutting the transversal abdominal fascia of the posterior wall of the inguinal canal, the retroperitoneal space can be freed almost under direct vision, which avoids the blindness of separation in the traditional Kugel operation and overcomes the disadvantages of easy bleeding, damage to the peritoneum and difficulty in separation.
(2) Less trauma, as the already relatively weak abdominal wall muscles do not need to be separated, the integrity of the abdominal wall is better maintained and the trauma is reduced to a minimum.
(3) More reliable repair. After the strengthening of the visceral sac, the posterior wall of the inguinal canal is strengthened by applying the attached flat sheet, which makes the repair more reliable and increases the resistance of the abdominal wall to tension, reducing the chance of hernia recurrence and reoccurrence.
(4) The hernia sac is easier to free and return. It is sometimes difficult to free and return a relatively large hernia sac from above the internal ring, but it becomes simple and easy to free and return it through the inguinal canal.
(5) The patch is easy to implant and in the exact position, and the modified round patch is smaller and more suitable for Chinese body size compared with the oval patch.
(6) Complications are reduced, and since the operation is performed almost under direct vision, complications such as peritoneal injury, subabdominal vascular injury, postoperative bleeding, and residual hernia sac effusion are rare.