The most common type of external hernia is the inguinal hernia, which accounts for about 90% to 95% of all external hernia. Treatment is mainly surgical. Traditional surgery is very traumatic, with prolonged postoperative pain and discomfort and a high recurrence rate. In recent years, mesh-filled hernia repair has been carried out in Europe and the United States. It is also called tension-free hernia repair, which has achieved very good results.
1. Clinical data
There were 36 male cases in this group, aged 60-82 years old, with an average of 71 years old; among them, there were 25 cases of hiatal hernia, 9 cases of straight hernia and 2 cases of femoral hernia. One of the cases was a recurrent hernia. The average operative time was 40 minutes, the average postoperative bed rest was 3 hours, and the average postoperative discharge was 4 days. There was one case of scrotal edema, and there was no case of infection or recurrence.
2.Surgical methods
(1) Surgical indications: inguinal hernia, straight hernia (including recurrent hernia), femoral hernia.
(2) Surgical operation: Marlex mesh shaped filler and Marlex mesh patch made by Bard, USA were used. The preoperative preparation is the same as traditional hernia repair, and anesthesia can be epidural or local invasive anesthesia. The small hernia sac does not need to be opened and the sac can be freed up to the neck of the hernia sac, while the larger hernia sac needs to be transected and then atretched proximally and then freed in high position.
After evacuation, the hernia sac is turned over and returned to the abdominal cavity. The filling is inserted into the enlarged hernia ring and appropriately fixed with 4-6 stitches for hiatal hernia and 8-10 stitches for direct hernia with transversalis fascia. The spermatic cord is lifted, the Marlex mesh patch is placed behind the inguinal canal and spread flat and covered with the caulking without suture fixation, only the gap of the patch is sutured with one stitch to close the fissure, and the incision is closed with 7 sutures for the extra-abdominal oblique tendon membrane and 1 suture for the remaining layers. The femoral hernia can be put into the plug only, and it is not necessary to put the Marlex mesh patch.
(3) Postoperative management
(1) Bed rest for 2~3 hours, or you can get out of bed after recovery from anesthesia.
(2) Generally, antibiotics are not needed, but can be used for 2~3 days if used.
(3) You can be discharged from the hospital 3 days after surgery, and the stitches will be removed in 7 days in the outpatient clinic.
3. Discussion
(1) Disadvantages of traditional hernia repair
It has been more than 100 years since Bassini pioneered hernia repair. Although its overall efficacy is still satisfactory, the rationale for each procedure and its indications have been debated, and postoperative recurrence and complications of hernia repair are still problematic. The postoperative recurrence rate of primary inguinal hernia is reported to be about 10%, while recurrent hernia can be as high as 20% and the overall complication rate is between 7% and 12%. In contrast, elderly patients, most of whom have chronic respiratory diseases, constipation, prostatic hyperplasia and other diseases, can increase the postoperative recurrence rate.
(2) Modern anatomy and tension-free hernia repair
The basis of surgery for extra-abdominal hernia is based on the knowledge of the local anatomy of the human body and the corresponding changes in the pathological state, and any kind of surgery must take into account such anatomical pathological changes. The better the targeting, the better the surgical outcome. Classical hernia surgery such as Bassini (1887), Halsted (1889), Furguson (1890) and McVay (1948) made great contributions to the establishment and development of hernia surgery, but the many shortcomings of their surgical approaches are also evident.
For example.
(1) All are repaired with adjacent tissues that are already defective in the patient.
(2) Tissues that are not in the normal anatomical area are forcibly pulled together and sutured with great tension, which is not in accordance with the principles of surgery.
(3) The “suture of the joint tendon and inguinal ligament” is a suture between two different tissues, which does not easily produce true healing.
(4) The large number of thread knots left in the repair increases the chance of postoperative complications.
Lichtenstein (1986), after years of practice, first introduced the concept of tension-free hernia repair, in which an artificial biomaterial is used as a patch to strengthen the posterior wall of the inguinal canal. This method overcomes the disturbance of normal anatomy by conventional surgery and the suture is tension-free.
(3) Clinical evaluation of modern tension-free hernia repair
The Marlex Mesh Per-Fix Plug was developed by Gilbert in 1987 to fill the hernia ring with a cone-shaped filling and to reinforce the posterior wall of the inguinal canal, and the Marlex Mesh Per-Fix Plug was developed by Bard in 1993 for hernia repair.
The Marlex patch is biologically compatible and quickly bonds to the tissue under the action of endogenous fibrin. A more solid tissue structure is formed, resulting in an effective repair of the posterior inguinal wall. This surgical method can no longer destroy the normal anatomical structure, the suture is tension-free, and has the characteristics of simple technique, fast, less pain, quick recovery and no restriction of physical activity, especially less than 1% recurrence rate.
It is suitable for all types of geriatric inguinal hernias. In elderly patients, with increasing age, there are different degrees of degenerative changes and even atrophy of the muscles and tendons in the inguinal region, which make the traditional repair of inguinal hernia difficult, and most of them have chronic respiratory diseases, constipation, prostate enlargement and other diseases, which increase the recurrence rate after surgery. Therefore, the use of tension-free hernia repair for inguinal hernia in the elderly is the key to improve the success rate of ventral hernia surgery and reduce the postoperative recurrence rate, and this procedure is being accepted by more and more general surgeons and elderly patients.