Inguinal hernia, unspecified, inguinal hernia without further specification
RCHD (Republican Center for Healthcare Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols MH RK - 2013
Unilateral or unspecified inguinal hernia, without obstruction or gangrene (K40.9)
Gastroenterology, Surgery
general information
Short description
Approved by the minutes of the meeting
Expert Commission on Healthcare Development of the Ministry of Health of the Republic of Kazakhstan
No 23 on 12/12/2013
Herniais a congenital or acquired defect of muscular-aponeurotic integrity abdominal wall, which makes it possible for any formation to protrude through it, which in normal conditions not happening here.
An inguinal hernia is a type of hernia of the anterior abdominal wall, in which the hernial sac is in the inguinal canal.
The main criterion for hernia- the presence of a defect in the abdominal wall in the inguinal canal. In this case, the presence of a hernial sac is not necessary, although usually the components of a hernia are: hernia gate, hernial sac, the contents of the hernial sac.
Hernia gate- a congenital or acquired defect in the musculo-aponeurotic layer of the abdominal wall.
Hernial sac- a part of the parietal peritoneum protruding through the hernial orifice.
Hernial sac contentscan be represented by any organ of the abdominal cavity, but most often - by a strand of the greater omentum or a loop of the small intestine.
Sheaths of the hernial sac- the layers covering the hernial sac.
Distinguish the following types of hernias:
- Asymptomatic inguinal hernia is not accompanied by discomfort or pain syndrome;
- Inguinal hernia with minimal symptoms - the presence of complaints that do not affect the daily activity of a person;
- Symptomatic inguinal hernia - the presence of symptoms characteristic of an inguinal hernia;
An irreducible inguinal hernia is an inguinal hernia in which the contents of the hernial sac cannot be reduced into abdominal cavity... In chronic cases - spliced, in acute - infringement.
Restrained inguinal hernia - an inguinal hernia that cannot be adjusted and manifests itself as strangulation symptoms (vascular disorders of the contents of the hernial sac) and / or intestinal obstruction.
There are the following types of hernioplasty:
- Anterior plastic - inguinal canal plastic according to Lichtenstein (Liechtenstein);
- Back plastic - endoscopic plastic inguinal canal;
- IPOM - intraperitoneal onlay mesh (intraperitoneal hernioplasty using the onlay method;
- TEP - total extra peritoneal plastic. Completely extraperitoneal endoscopic hernioplasty, in which both access to the inguinal femoral region and placement of the prosthesis are extraperitoneal;
- TAPP - transabdominal preperitoneal. Transabdominal preperitoneal endoscopic inguinal hernia surgery, in which access to the inguinal femoral region is transabdominal (transabdominal), and the final placement of the prosthesis is extraperitoneal (extraperitoneal).
I. INTRODUCTORY PART
Protocol name:Inguinal hernia
Protocol code:
ICD 10 code:
K40 Inguinal hernia
K40.0 Bilateral inguinal hernia, with obstruction, without gangrene
K40.1 Bilateral inguinal hernia, with gangrene
K40.2 Bilateral inguinal hernia, without obstruction or gangrene
K40.3 Unilateral or unspecified inguinal hernia with obstruction, without gangrene
K40.4 Unilateral or unspecified inguinal hernia with gangrene
K40.9 Unilateral or unspecified inguinal hernia, without obstruction or gangrene
Abbreviations used in the protocol:
HIV - Human Immunodeficiency Virus;
CT scan - cT scan;
MRI - magnetic resonance imaging;
PG - inguinal hernia;
Ultrasound - ultrasonography;
ECG - electrocardiography;
IPOM - intraperitoneal onlay mesh;
TAPP - transabdominal preperitoneal (transperitoneal preperitoneal hernia repair);
TEP - totally extraperitoneal (completely extraperitoneal hernia repair).
Protocol development date: 04/19/2013
Patient category: adult patients with unilateral or bilateral inguinal hernia without obstruction or gangrene.
Protocol users: a surgeon of a hospital or an outpatient surgery center providing planned surgical care adults.
Note: This protocol uses the following classes of recommendation and levels of evidence
There is a special Oxford system " evidence-based medicine”, (As revised in March 2009) with the levels of evidence (Table 1), which are determined by analyzing the scientific literature, and the choice of the grade of recommendation (Table 2), which depends on the level of evidence.
The purpose of categorizing recommendations is to provide transparency between the recommendations and the evidence on which they are based.
Table 1. Levels of evidence
| Level | Therapy / Prevention, Etiology / Risk |
| 1a | Systematic Reviews (with homogeneity) of randomized clinical trials (RCT) |
| 1b | Selected RCTs |
| 1c | Series of “all-or-none results” cases |
| 2a | Systematic Reviews (with homogeneity) of Cohort Studies |
| 2b | Selected cohort trials (including low-quality RCTs, e.g.<80% follow-up) |
| 2c | Research reports. Environmental studies |
| 3a | Systematic Reviews (with homogeneity) of case-control studies |
| 3b | Selected Case Control Studies |
| 4 | Case series (both low-quality cohort and case-control studies) |
| 5 | Expert opinion without precise critical assessment, or based on physiology and other principles |
It should be noted that when determining the grade of recommendation, there is no direct relationship between the level of evidence and the grade of recommendation. Data from randomized controlled trials (RCTs) are not always ranked as Grade A recommendation when there are methodological gaps or inconsistencies between the published results of several studies. Also, the lack of high-level evidence does not preclude a Level A recommendation if there is a wealth of clinical experience and consensus. In addition, there may be exceptional situations in which confirmatory studies cannot be carried out, perhaps for ethical or other reasons, in which case precise advice is considered useful.
Note:
"Extrapolation" is when data are used in a situation where there may be clinically significant differences than are unambiguously confidently described in the original studies.
Classification
Clinical classification
Inguinal hernias are divided into:
- congenital,
- acquired
- recurrent.
Congenital inguinal hernia are formed when the vaginal process of the peritoneum is not completely overgrown, which becomes a hernial sac. If it is not segmental, then cysts of the spermatic cord are formed. Congenital inguinal hernias are often associated with dropsy of the testicle.
Acquired inguinal hernia there are oblique and straight. They are formed under the influence of various factors with the complete overgrowth of the vaginal process of the peritoneum. In this case, the hernial sac is a protrusion of the parietal peritoneum in the region of the medial or lateral inguinal fossa. Combined inguinal hernias are also distinguished, which have several hernial sacs communicating with the abdominal cavity through separate openings.
A combination of oblique and straight hernias is more common. Rare forms of inguinal hernias include intramural (intraparietal), enclosed (Cooper's hernias), and external supravesical inguinal hernias.
Intra-mural inguinal hernias are characterized by the emergence of the hernial sac from the membranes of the spermatic cord between the layers of the anterior abdominal wall. More often, such hernias are found with cryptorchidism. A buried hernia has two sacs enclosed in one another. Only the inner sac communicates with the abdominal cavity.
An external supravesical inguinal hernia exits through the supravesical fossa.
In their development, hernias go through a number of stages.
In the formation of an oblique inguinal hernia, there are 4 stages:
1) incipient hernia - characterized by the appearance of a tumor-like formation in the inguinal canal during straining;
2) canal hernia - the bottom of the hernial sac reaches the external opening of the inguinal canal;
3) cable hernia (hernia of the spermatic cord) - the hernia comes out through the external opening of the inguinal canal and is located at different heights of the spermatic cord;
4) inguinal-scrotal hernia - the hernial sac is located in the scrotum.
According to the structure of the inner wall of the hernial sac, ordinary and sliding hernias are distinguished. Part of the inner wall of sliding hernias is usually the bladder (in direct hernias), ascending and descending sections of the colon (in oblique hernias).
The contents of an inguinal hernia are most often the small intestine or omentum, however, there are cases of blind or sigmoid exit being difficult.
Recurrent inguinal hernia do not have clear anatomical features. Their characteristics depend on the type of plastic surgery performed and the reasons for the formation of a relapse.
According to the clinical course, hernias are divided into:
- uncomplicated (reducible)
- complicated.
The latter include irreducible and restrained hernias.
According to the classification of L.M. Nyhus L.M. all hernias are divided into four types:
Type I - oblique inguinal hernia, found mainly in children, adolescents, young people. In this type, the inner inguinal ring, as a rule, is not expanded, and the hernial protrusion extends from the inner inguinal ring to the middle third of the inguinal canal (in the domestic literature, this type is called “canal inguinal hernias”).
Type II - oblique inguinal hernia with a significantly expanded inner inguinal ring. With this type, the hernial sac does not descend into the scrotum, however, when straining, a hernial protrusion under the skin in the groin area is determined.
Type III is divided into straight and oblique inguinal, as well as femoral hernias:
Type IIIa - all types of direct inguinal hernias. With these hernias there is weakness and stretching of the transverse fascia, which leads to a violation of the structure of the posterior wall of the inguinal canal;
Type IIIb - oblique inguinal hernia of large sizes, usually inguinal and scrotal. With this type, there is a defect in both the anterior and posterior walls of the inguinal canal. The inner groin ring is significantly widened. Sliding hernias are often observed. Direct and oblique inguinal hernias can occur simultaneously, which in the foreign literature is called "pantalone hernia";
Type IIIc - all femoral hernias;
Type IV - recurrent hernias:
IVa type - recurrent straight inguinal hernia;
IVb type - recurrent oblique inguinal hernia;
IVc type - recurrent femoral hernia;
IVd type - a combination of recurrent straight, oblique inguinal and femoral hernias.
Classification L.M. Nyhus allows you to accurately determine the type of hernia and, when studying various types of hernia repair, objectively evaluate the advantages and disadvantages of each method, depending on the type of hernia.
Diagnostics
II. METHODS, APPROACHES AND PROCEDURES OF DIAGNOSTICS AND TREATMENT
List of basic and additional diagnostic measures
Basic:
1. Taking anamnesis
2. Inspection of the groin area
3. Palpation of the groin area with digital examination of the external inguinal ring
4. Percussion of hernial protrusion
5. Rectal examination
6. Complete blood count
7. General urine analysis
8. ECG
9. Microreaction
10. Blood test for HIV
11. Fluorography
12. Determination of blood glucose
13. Coagulogram
14. Feces for eggs of worms
Additionally:
1.Ultrasound of the inguinal canals (intervals) and the scrotum (in men)
2. Magnetic resonance imaging or computed tomography with a Valsalva sample (Valsalva)
3. Radiopaque herniography
4. Irrigoscopy
5. Ultrasound of the abdominal and small pelvis
6. Consultations (according to indications) of an oncologist, urologist; gynecologist; therapist
Diagnostic criteria for PG
Complaints and anamnesis
Patients complain of a swelling in the groin above the pupar ligament, which increases with straining and coughing. Patients note pain when straining and coughing. With large hernias, complaints of discomfort when walking and dyspeptic disorders appear.
With a hernia with the involvement of the bladder, the symptoms of an inguinal hernia are very specific: when urinating, dysuric disorders occur.
When pressing on the hernial protrusion, the urge to urinate appears. Urine may contain blood. Instrumental studies confirm the degree of involvement of the bladder hernia.
Physical examination
During examination of the groin area, a tumor-like formation of a soft-elastic consistency is revealed, which, in the horizontal position of the patient or with pressure, is set into the abdominal cavity. However, when coughing and straining, it reappears. Oblique inguinal hernias are most often one-sided, have an oblong (oval) shape, are located in an oblique direction, which corresponds to the course of the inguinal canal, and often reach the bottom of the scrotum. The spermatic cord on the side of the hernia is thickened. Direct inguinal hernias, as a rule, occur simultaneously on both sides, lie closer to the midline of the abdomen, near the medial part of the inguinal ligament, medially from the spermatic cord. The shape of the hernia is round. The hernia rarely descends into the scrotum.
With a digital examination of the external inguinal ring, a significant expansion of the external opening of the inguinal canal is found, a positive symptom of a cough thrust. In patients with oblique inguinal hernia, a cough jolt is felt in the region of the deep opening of the inguinal canal. Pulsation a is determined medially from the finger. epigastrica inferior. For a direct inguinal hernia, the presence of a cough thrust near the superficial opening of the inguinal canal is typical, and pulsation is a. epigastrica inferior - from the lateral side.
Supravesical inguinal hernias are rounded. They are located above the bladder, near the midline of the abdomen.
Finger examination with initial hernias allows the surgeon to reveal the expansion of the external inguinal ring, its direction, length, size and shape of the external, in some cases and internal, inguinal canal openings. The symptom of "cough impulse" is revealed with a finger.
The correct diagnosis of rare types of inguinal hernias is usually made only during surgery.
Laboratory research: usually not restrained (not complicated) inguinal hernia does not affect the indicators in the general analysis of blood and urine.
Instrumental research
(Level 1b): If there is an obvious protrusion, a non-instrumental examination will be sufficient. Differential diagnosis of direct and indirect hernia is not necessary.
Only in the case of vague pain and / or discomfort in the area of \u200b\u200bprotrusion in the groin area, a more thorough diagnosis is required.
In modern clinical practice, the sensitivity and specificity of ultrasound for the diagnosis of inguinal hernia is low. Computed tomography (CT) has a limited place in the diagnosis of inguinal hernias. Magnetic resonance imaging (MRI) is sensitive in more than 94% of cases for the diagnosis of inguinal hernias, and is also used for the diagnosis of other muscle-tendon pathology. Herniography has high sensitivity and specificity to clarify the diagnosis, but does not identify ligament lipomas.
Ultrasound of the inguinal canals (spaces) and the scrotum (in men) reveals the type of hernia, the size and contents of the hernial sac. The use of ultrasound examination of the inguinal spaces before the operation facilitates the choice of the method of hernioplasty.
Magnetic resonance imaging or computed tomography with a Valsalva sample (Valsalva) is performed in cases of low information content of ultrasound.
Radiopaque herniography is the introduction of a special contrast agent (Sodium amidotrizoate, Yogeksol) into the abdominal cavity and X-ray examination to examine the inguinal hernia. Herniography should be used to identify and clarify the type of bilateral hernia of the groin-femoral region in diagnostically difficult cases (if ultrasound, MRI, CT did not provide complete information). Irrigoscopy is performed for the differential diagnosis of inguinal hernia and colon pathology. Ultrasound of the pelvic organs is also performed for differential diagnosis and detection of pelvic pathology.
Indications for specialist consultation:
- consultation with an oncologist for the differential diagnosis of inguinal hernia from tumor lesions of the inguinal lymph nodes;
- consultation with a urologist to identify adenoma and prostate cancer;
- consultation of a gynecologist for the differential diagnosis of inguinal hernia and gynecological pathology, including tumor genesis;
- consultation of a therapist to clarify the general somatic condition and determine the degree of operational risk.
Differential diagnosis
Differential diagnosis of inguinal hernia
Inguinal hernias are most often differentiated from femoral hernias, in men - with dropsy of the testicular membranes, varicocele, in women - with a cyst of the round ligament of the uterus.
The accumulation of fluid in patients with dropsy of the testicle gives the scrotum a round or oval shape. The resulting formations are painless, with a smooth surface, and a dense elastic consistency. The testicle is pushed back and downward. Percussion over dropsy is determined by a dull sound. On diaphanoscopy, dropsy is reddish in color.
Varicocele is observed mainly on the left and is accompanied by the appearance along the spermatic cord of the nodes of the dilated veins, intertwined with each other. Patients are worried about the sagging of the scrotum, which increases with walking, heaviness, pain in the groin, pain in the scrotum or along the spermatic cord. The pain radiates to the lower back, perineum, penis, lower abdomen. Palpation reveals varicose veins in the scrotum, which collapse when the scrotum is lifted or pressed.
The cyst of the round ligament of the uterus is characterized by a dense consistency, does not change in size in the horizontal position of patients. When percussion over it, tympanitis is revealed.
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Treatment
Purpose of treatment with inguinal hernia- elimination of hernial protrusion through the inguinal gap, reduction of internal organs into the abdominal cavity and plastic of the hernial orifice.
Surgical treatment tactics
Level 1A: Mesh surgery results in a lower recurrence rate than mesh repair. Sholdyce hernioplasty is best without mesh. Endoscopic hernia repair is associated with the lowest incidence of wound infection, hematomas and an earlier return to normal life than Lichtenstein hernioplasty, but it is more time-consuming and associated with a higher risk of seromas.
Level 1B: Mesh repair reduces the risk of chronic pain rather than increases it. Endoscopic techniques are also associated with a very low risk of chronic pain. In the long-term postoperative period (3-4 years), chronic pain decreases, but the decreased sensitivity (if present in the early postoperative period) does not disappear over time.
In recurrent hernias after standard open hernioplasty, the endoscopic technique reduces the risk of postoperative pain and promotes faster convalescence than Lichtenstein repair.
Lightweight meshes have advantages in terms of duration of discomfort and foreign body sensation at the site of application, but they often increase the risk of recurrent inguinal hernia (possibly due to inadequate fixation and / or coverage).
Other open hernia repairs with mesh: Prolen hernia system (PHS), Kugel patch, plug and patch (mesh plug), Hertra mesh (Trabucco), in the early stages are more often associated with relapses compared to the Lichtenstein technique.
In young men (18-30 years old) with unilateral inguinal hernia, the risk of recurrence is about 5% with hernioplasty without the use of a mesh (observation over 5 years).
Level 2C: Endoscopic hernia repair using a small mesh (no larger than 8 x 12 cm) is associated with a higher risk of recurrence compared to the Lichtenstein technique. Women are at a higher risk of recurrence (inguinal or femoral hernias) than men. Moreover, femoral hernias are more common in women.
For large scrotal (irreducible) inguinal hernias, a history of recent abdominal surgery, and in cases where general anesthesia is not possible, Lichtenstein is the treatment of choice.
For recurrent hernias after posterior plasty, open anterior plasty with alternative tissue preparation and mesh implantation is preferred. The Stoppa operation is still the operation of choice for combined hernias.
Drug-free treatment
Before surgery, at the stage of preparation for surgical treatment - wearing a special bandage, it is recommended to avoid physical activity, exclude factors that increase intra-abdominal pressure (prevention of cough, constipation).
Drug treatment:
Open hernioplasty can be performed under local anesthesia with 0.5% lidocaine solution or epidural anesthesia with 2% lidocaine solution. In the postoperative period, analgesic drugs are prescribed, including narcotic drugs on the first day after the operation.
In laparoscopic hernioplasty, the operation is performed under general anesthesia using neuroleptanalgesia (NLA) with artificial lung ventilation (ALV).
Level 1B: Anterior open tension-free Lichtenstein inguinal hernia repair can be performed under local anesthesia, except for anxious patients with morbid obesity and entrapment.
Regional anesthesia using high doses and / or long-acting drugs is not beneficial for open hernia repairs and increases the risk of urinary retention. Spinal anesthesia with high doses of long-acting anesthetics should be avoided.
Level 1B: Infiltration anesthesia during surgery leads to a reduction in pain in the postoperative period.
Level 1A: in traditional hernia repair (without mesh), antibiotic prophylaxis does not significantly reduce the incidence of wound infection.
Level 1B: For open mesh repair in low-risk patients, antibiotic prophylaxis does not significantly reduce the incidence of wound infection.
Level 2B: In endoscopic hernia repair, antibiotic prophylaxis also does not significantly reduce the incidence of wound infections.
Other treatments
Conservative treatment (hernia bandage) and follow-up is acceptable for men with asymptomatic or minimal inguinal hernias (Level 1B).
Elderly patients over 65 years of age who wear a hernial band have no greater risk of mortality from an inguinal hernia than patients after an inguinal hernia (Level 3).
Surgical principles
For acquired inguinal hernias, open surgery is performed in four stages.
1. The first stage is preparation of access to the inguinal canal. An incision of the skin, subcutaneous tissue, superficial fascia of the abdomen of 8-12 cm and 2 cm above and parallel to the inguinal ligament is performed. The aponeurosis of the external oblique muscle is dissected parallel to the course of the fibers. With a tupfer, the inner flap of the aponeurosis is exfoliated from the internal oblique muscle and the transverse muscle, the external one is exfoliated from the spermatic cord, while simultaneously highlighting the groove of the inguinal ligament to the pubic tubercle.
2. The second stage of hernioplasty - isolation and removal of the hernial sac. Fascia cremasterica is cut along the spermatic cord, m. cremaster, transverse fascia. The exposed hernial sac is separated bluntly and sharply from the surrounding tissues from the bottom towards the neck. Then it is opened. The contents of the hernial sac are examined and set back into the abdominal cavity. The wall of the hernial sac is dissected to the neck. At the level of the cervix, the hernial sac is sutured under vision control and tied. The part of the hernial sac located distal to the imposed ligature is excised.
3. The third stage of hernia repair - suturing of the deep inguinal ring to the usual size. It is most convenient to produce it according to the Ioffe method: clamps are applied to the upper and lower edges of the medial part of the deep inguinal opening (the edge of the transverse fascia). Under the clamps with a thin thread (preferably atraumatic), the hole is sewn up with a twisted seam to the desired diameter. The sheath of the spermatic cord is also captured in the suture.
4. The fourth stage of hernioplasty is the plastic of the inguinal canal. Many methods of inguinal canal plasty have been developed. They are subdivided depending on: 1) used access to the hernial sac: a) inguinal; b) preperitoneal (extraperitoneal, extraperitoneal); 2) the method of plastic surgery of the inguinal canal: a) with and without opening it; b) with strengthening of the posterior or anterior wall of the inguinal canal.
(Level 1A) According to international experience in herniology and based on current clinical guidelines, the use of tension free technology is recommended, which reduces the likelihood of hernia recurrence and has better long-term (long-term) results.
At the same time, according to the clinical guidelines of the European Society of Herniology, the choice of the method of surgical technique can be as follows:
1. Primary unilateral or bilateral inguinal hernia: The use of tension-free mesh replacement according to the Lichtenstein method or the use of endoscopic hernia repair (TEP or TAPP) is indicated. For inguinal-scrotal hernia, especially with contraindications to general anesthesia, Liechtenstein operation is recommended. In women, endoscopic surgery is more preferable because of the risk of femoral hernia. For endoscopic methods, a mesh of at least 10 × 15 cm should be used.
2. Recurrent inguinal hernia: if the anterior wall was strengthened, then open extraperitoneal alloplasty with strengthening of the posterior wall or endosurgical technique (TEP or TAPP) is used, and in case of strengthening of the posterior wall, Liechtenstein operation or endoscopic technique (TEP or TAPP) is used.
Types of surgical treatment
1. Operation Liechtenstein
American surgeon I.L. Liechtenstein (1986) developed, tested and introduced into wide practice the technique of surgery for inguinal hernias with strengthening the posterior wall of the inguinal canal with a polypropylene mesh. The technique is currently recognized as the "gold standard" ("Gold standard") for open treatment of inguinal hernia.
Unlike the methods of E. Bassini, E.E. Scholdyce, S.B. McVay et al., Plastic surgery for inguinal hernias by the method of I.L. Lichtenstein is performed without tension of tissues (aponeurosis, muscles, ligamentous apparatus) by suturing mesh material into the hernial defect.
In 1993 I.L. Liechtenstein described the following technical details of the operation. Surgery is performed, as a rule, under local anesthesia. A 5-6 cm long skin incision is made in the projection of the inguinal canal parallel to the inguinal ligament. The aponeurosis of the external oblique muscle of the abdomen is dissected in the usual way. Its upper leaf is separated from the underlying internal oblique muscle 3-4 cm up. Sufficient mobilization of the external oblique aponeurosis allows visualization of the iliohypogastric nerve and creates sufficient space for the mesh prosthesis. Next, the spermatic cord and the inguinal ligament are isolated. When performing the intervention, fibers m. The cremaster is crossed to the level of the inner opening of the inguinal canal. If the hernia is oblique, then the hernial sac is found and isolated among the elements of the spermatic cord. The small bag is simply dipped into the abdominal cavity. With inguinal-scrotal hernias, if the excretion of the sac is not difficult, it is excised. With large inguinal-scrotal hernias, when the release of the hernial sac is traumatic, it is crossed in the middle of the inguinal canal. The proximal part is isolated and immersed in the abdominal cavity, the distal part is dissected longitudinally and left in place. After isolation of the hernial sac, the inguinal canal is carefully examined, and through the Borgos space, the femoral canal is examined for femoral hernias. In direct hernias, the hernial sac, after exposure, is invaginated into the abdominal cavity. The polypropylene mesh is modeled, and its supposed lateral edge is cut longitudinally. In this case, the width of the upper branch is 2/3 of the transverse size of the mesh, and the lower one is 1/3. The mesh is placed under the spermatic cord and fixed first with a continuous suture to the pubic tubercle and inguinal ligament to the inner inguinal ring (Fig. 1, and). In the medial part of the wound, the mesh should overlap the pubic bone by 1.5-2 cm. It has been noted that insufficiently complete overlap of the pubic bone can lead to recurrent hernia. The pubic periosteum is not taken into the suture. With separate sutures with a non-absorbable material, the mesh is fixed with four to five sutures to the tendon part of the internal oblique muscle of the abdomen and to the sheath of the rectus muscle. The upper branch of the mesh is placed over the spermatic cord and behind the inner inguinal ring is fixed to the inguinal ligament (see Fig. 1, b). An important criterion for the quality of the plastic is the wrinkling of the mesh after the end of the stage of its fixation, which provides the plastic without tension. The excess of the prosthesis is cut off along the lateral edge, while at least 5-7 cm of mesh is left behind the inner inguinal ring. 
Fig. 1. Operation I.L. Liechtenstein: and- the lower edge of the mesh prosthesis is fixed to the inguinal ligament with a continuous suture; b- with separate sutures, the upper and medial edge of the mesh are sewn to the sheath of the rectus abdominis muscle and the tendon part of the internal oblique muscle, fixing the upper branch of the mesh prosthesis to the inguinal ligament.
The branches of the mesh prosthesis are tucked in the lateral direction under the aponeurosis of the external oblique abdominal muscle, which is then sutured over the spermatic cord with a non-absorbable end-to-end suture without tension. The described technique is basic. After the mesh grows with connective tissue, intra-abdominal pressure is evenly distributed over the entire area of \u200b\u200bthe synthetic prosthesis. The aponeurosis of the external oblique muscle of the abdomen firmly holds the mesh in place, playing the role of external support when intra-abdominal pressure increases.
Level 1B: Lightweight meshes have advantages in terms of the duration of discomfort and foreign body sensation at the site of placement in open hernia repairs (if only chronic pain is involved).
Level 2A: Prophylactic resection of the ilio-inguinal nerve does not reduce the risk of chronic pain after hernioplasty.
Level 2B: Identification of all inguinal nerves during open hernia repair reduces the risk of nerve damage and the occurrence of postoperative chronic groin pain.
2. Transabdominal preperitoneal inguinal hernia repair (TAPP)
The position of the patient on the operating table is on the back with the legs together. The head end of the table is lowered 20 °. The monitor is placed in the patient's legs on the side of the hernia, the surgeon stands on the side opposite to it. After revision of the abdominal cavity, the table plane is tilted 15-20 ° in the direction opposite to the localization of the hernia. Instrumentation for performing laparoscopic hernioplasty includes:
1) trocars 12, 10 and 5 mm;
2) curved scissors;
3) grasping forceps, dissector;
4) a telescope with oblique optics;
5) herniostepler. 
Figure: 2. Trocar placement sites for TAPP
The operation begins with the insertion of the first trocar (10 mm) for the introduction of the laparoscope, which is performed immediately above the navel. After the introduction of the laparoscope, the abdominal cavity is revised. It is important to inspect both groin areas so as not to miss the beginning hernia from the opposite side. The main landmarks of the groin area (except for the hernial sac itself) are the lower epigastric vessels and the spermatic cord. It is possible to insert a trocar below the navel. The second and third trocars are placed in the right and left iliac regions. A 5 mm trocar is inserted into the abdominal cavity on the side of the hernia. Depending on the type of hernio stapler used (Endouniversal, Protack, etc.), a third port with a diameter of 12 mm or 5 mm is used. The trocar insertion points are shown in Fig. 2. It is possible to install lateral ports pararectally at the level of the navel or slightly below it.
The intervention begins with the capture and retraction of the hernial sac into the abdominal cavity (Fig. 3, and). Then an incision of the parietal leaf of the peritoneum is performed over the upper edge of the hernial orifice (see Fig. 3, b), which is arcuately extended in the medial and lateral directions. In this case, the incision should bend around the lateral and medial inguinal fossa. The peritoneal flap, together with the hernial sac, is bluntly separated from the underlying tissues from top to bottom. In case of oblique hernias, the wall of the hernial sac is dissected from the elements of the spermatic cord. Dense fibrous cords are cut with coagulation scissors. Among such strands, a differentiated sometimes obliterated vaginal process of the peritoneum should be noted, which can be mistaken for ductus deferens. The difference is that it starts from the peritoneum. It should be remembered that electrocoagulation, due to the proximity of the elements of the spermatic cord, should be used only if clearly necessary. Blunt separation of tissues is more gentle and safer. Care should be taken when mobilizing the peritoneal flap to avoid damaging the inferior epigastric vessels. You also need to be careful when highlighting the anatomical structures in the area of \u200b\u200bthe "fatal triangle". Another area of \u200b\u200bconcern is the pubic tubercle and Cooper's ligament, where bladder wall damage is possible. This is facilitated by a pronounced cicatricial process in large direct and recurrent hernias, as well as previous surgical interventions on the lower floor of the abdominal cavity.
Isolation of the hernial sac is performed until it ceases to go into the inguinal canal (see Fig. 3, in). The hernial sac should be loose in the abdominal cavity. If bleeding occurs from small vessels, it is stopped by electrocoagulation. The presence of complete hemostasis after isolation of the hernial sac is important to prevent hematomas of the scrotum, preperitoneal space and bleeding into the abdominal cavity. It is necessary to strive for a complete selection of the anatomical structures to which the mesh will be attached. This will ensure reliable fixation of the mesh prosthesis. It is also helpful to separate the upper edge of the peritoneum from the underlying tissue in order to place the mesh underneath. 
and b
in r
Fig. 3 TAPP (oblique inguinal hernia on the left): and- the hernial sac is pulled into the abdominal cavity; b- the line of dissection of the peritoneum; in- the peritoneum is separated from the underlying tissues, a bed for the mesh is formed; r- installed and fixed mesh prosthesis
Sickle aponeurosis (Arcus aponeurosis transversalis) is isolated with a dissector or scissors, i.e. the upper boundary of the Hesselbach triangle. The Cooper's ligament and pubic tubercle should be clearly differentiated. The lower epigastric vessels are the border between the medial and lateral inguinal fossa. Laterally from the inner inguinal ring, the lower edge of the transverse abdominal muscle and the ilio-pubic tract are isolated. The size of the synthetic mesh prosthesis should be at least 10 × 15 cm or more, depending on the local characteristics of the operation area. The mesh prosthesis is prepared for plastic. At the same time, various types of material cut can be used, it is also possible to use a mesh without its cut. Opening of the prosthesis is often done as follows (see Fig. 3, r). Having stepped back 1/3 from the long edge of the mesh, an incision about 5 cm long is made from its short side to accommodate the structures of the spermatic cord. The edges of the prosthesis can be rounded off with scissors. The uncut mesh is placed on the elements of the spermatic cord. If a cut is made, then the spermatic cord is placed in the cut hole. When using a cut mesh prosthesis, the elements of the spermatic cord are isolated at the point of their bend over the edge of the inner inguinal ring. In this case, a dissector is often used. After preparation of the prosthesis, it is rolled up with a tube and, using an insert sleeve, is inserted into the abdominal cavity through a 10 or 12 mm trocar. The mesh is straightened and placed in the prepared bed in the desired position. At the same time, it should overlap all zones of possible exit of inguinal and femoral hernias (medial, lateral inguinal and femoral fossa) and fixation points. A narrower branch of the cut prosthesis is dragged under the mobilized elements of the spermatic cord to the lateral side (see Fig. 3, r). A herniostepler is introduced into the abdominal cavity through the trocar. The most convenient are herniosteplers with the function of rotation and changing the geometry of the working part (Endouniversal, etc.). Having properly placed the mesh, it is fixed to the abdominal wall with staples in a total of 5 to 10 pieces. Fixation usually begins with a cut part of the mesh with both jaws gripping into staples. It is continued along the perimeter to the transverse fascia, pubic tubercle, ilio-pubic tract and Cooper's ligament. Avoid accidental stitching of the lower epigastric vessels, the location of clips in the projection of the "fatal triangle" and "triangle of pain". When attaching the mesh, the technique of moderate "back pressure" is sometimes used, when the abdominal wall is shifted towards the working part of the herniostepler with the free hand. If the mesh was not cut (Fig. 4, and) and it is placed in front of the spermatic cord (more often with direct inguinal hernias), it is important to initially fix the mesh to the Cooper's ligament and the transverse fascia. After attaching the mesh, the peritoneum is restored using a herniostapler (Fig. 4, b). At this stage, the plastics can be considered complete. The instruments are removed from the abdominal cavity. Wounds of the anterior abdominal wall are sutured.
(Level 2B) There is no scientific evidence to support the use of mesh slit incision for laparoscopic alloplasty of inguinal hernia.
(Level 2B) One study found some hernia recurrences were associated with insufficient closure of the mesh slit. Therefore, it is advisable not to cut the mesh, as this does not bring any technical advantage to the surgeon or better clinical results for the patient.
With a pronounced inconsistency of the posterior wall of the inguinal canal or large hernial orifices, it is considered that it is necessary to suture the defect with a manual laparoscopic suture, followed by plastic surgery. Transabdominal preperitoneal inguinal hernioplasty has significant advantages: speed of execution with proper experience, mild pain syndrome in the early postoperative period and, as a result, early social and labor rehabilitation. 
Figure: 4. TAPP (straight inguinal hernia on the left): and- uncut mesh prosthesis; b- the peritoneum was restored
3. Total (completely) extraperitoneal plastic surgery for inguinal hernias (TEP)
The operation is performed under general anesthesia. The patient on the operating table is in the Trendelenburg position. The placement of the operating team is the same as for TAPP hernioplasty. The first trocar is placed under the navel along the midline (Fig. 5). It is introduced to the preperitoneal space without entering the abdominal cavity. The easiest way to do this is by the "open" method. In this case, a mini-incision of 1-2 cm of skin, fiber, the anterior wall of the vagina of the rectus abdominis muscle on the side of the hernia is made. The rectus muscle is pushed to the side and pulled down to create space with a balloon dissector or endoscope. Then the posterior wall of the rectus sheath is perforated at the point where the transverse fascia forms an arcuate line of rectus sheath. The peritoneum is not opened, but with a blunt balloon dissector or endoscope, carefully peel off from the transverse fascia. 
Figure: five... Trocar placement sites for TEP
A trocar with a diameter of 10 mm is introduced through the formed canal into the preperitoneal space, and through it an endoscope with beveled optics. The end of the endoscope produces lateral movements, forming a small pocket in the injection zone. You can also remove the endoscope and create the space with a special trocar with a dissecting balloon, also towards the pubic bone (Fig. 6, and). The dissecting balloon or endoscope is passed to the bosom (see Fig. 6, b). After that, under pressure through a conventional trocar or by inflating a special balloon called a spacemaker with the introduction of carbon dioxide or saline, I create a working space (see Fig. 6, in). The process of detachment of the peritoneum is carried out under visual control of the image obtained on the monitor screen through the endoscope inserted through the trocar directly or through the cavity of the balloon (see Fig. 6, in). The balloon is kept inflated for 3-4 minutes. After creating the working space, two working trocars with a diameter of 10-12 and 5 mm are installed along the midline (see Fig. 5). The second trocar with a diameter of 10-12 mm is placed along the midline at the level of a straight line connecting the anterior superior spine of the iliac bones, the third, 5 mm in diameter, along the midline at a point located 3 transverse fingers above the pubic bone. 
a b
in g
Fig. 6. TEP. Operational access: and- insertion of the endoscope into the preperitoneal space; b- an endoscope with a balloon is held up to the bosom; in- the balloon is inflated; r- a trocar with an obturator is inserted into the preperitoneal space
After creating a working space, a trocar with a special obturator is inserted into the wound under the navel, which allows maintaining the pressure of carbon dioxide in the preperitoneal space (Fig. 6, d). In the case of a balloon-less working space, the trocar is sealed under the navel by introducing a gauze swab.
When performing the intervention, it is very important not to damage the peritoneum or the instrument does not fall into the abdominal cavity, otherwise the continuation of the operation in a purely preperitoneal way becomes difficult. The necessary instruments are introduced into the preperitoneal space through the working trocars, the loose adhesions are separated in a blunt way, the hernial sac is isolated from the surrounding tissues, the elements of the spermatic cord and the transverse fascia. A mesh prosthesis is inserted through trocars of 10 or 12 mm, which is straightened and placed in the same way as in laparoscopic hernioplasty. After straightening and placing the prosthesis in the correct position, it is fixed with a herniostapler (Fig. 7). With this type of hernioplasty, it is more convenient to use a herniostapler with a working part rotating and bent to an angle of 45 ° (Endouniversal, etc.). The advantage of this type of surgical technique is the possibility of performing endoscopic inguinal hernioplasty with adhesions in the lower abdominal floor. 
Figure: 7. TEP. The mesh is fixed in the area of \u200b\u200bthe hernial defect
The IPOM hernioplasty technique was first proposed in 1991 as a way to reduce or eliminate the technical difficulties or possible complications of the preperitoneal technique and to maintain the “non-tension” concept.
(Level 1B) However, in the high-quality validated literature, the relapse rate at 41 months was 43% for the IPOM and 15% for the open method.
(Level 1B) When comparing IPOM and TAPP, it was found that if after 32 months TAPP had no relapses, then during the same period using the IPOM technique, 11.1% of cases of hernia recurrence were detected.
Given the high long-term relapse rate, IPOM should not be widely used.
Preventive actions
(Level 1b) The patient must empty the bladder before surgery.
The transverse fascia is dissected with caution in open surgery for direct hernia. The bladder can be the contents of a hernia; in the presence of a large hernial sac, it is transected to the distal part to avoid ischemic orchitis. Damage to the structures of the spermatic cord should be avoided.
Patients with a history of major surgery in the lower abdomen or radiation therapy of the pelvic organs are prohibited from performing endoscopic hernioplasty. For endoscopic hernioplasty, the TEP technique is used to avoid intestinal adhesive disease and the risk of intestinal obstruction. Defects of the anterior abdominal wall after trocar insertion of 10 mm or more must be sutured.
The first trocar in the endoscopic TAPP hernioplasty technique should be placed using an open technique.
Postoperative rehabilitation period
In addition to pain relief, on the first day after surgery, male patients should wear a special suspensor or swimming trunks to keep the scrotum in an elevated state. Getting up early and walking slowly within the room is recommended.
As a rule, after endoscopic alloprosthetics, three hours after the operation, the patient can already walk independently.
The dressing takes place daily, lasting up to nine days. The stitches are removed on days 7-9, depending on age and concomitant pathology.
After the operation, the patient must not lift anything heavy for two to three weeks (maximum weight up to five kilograms). Normal physical activity should be returned gradually over the course of a month. Weights should not be lifted for six months, since there is still no strength in the abdominal wall of the operated area. Six months later, you can engage in full-fledged physical labor
Level 1A: Endoscopic hernia repair promotes an earlier return to normal life than Lichtenstein hernia repair. Therefore, when rapid postoperative recovery is required, endoscopic hernia repair is recommended.
Level 3: Time restrictions for sports or work after hernia repair are not necessary. It is only necessary to restrict heavy lifting for 2-3 weeks.
Class B: in open hernioplasty, surgical evacuation of the hematoma is necessary, since the hematoma can lead to skin tension. Drainage of the wound is used only according to indications (massive blood loss, coagulopathy).
Grade C: Seromas are not aspirated.
Level 1B: The risk of chronic pain during hernioplasty with mesh is lower than without mesh. The risk of chronic pain with endoscopic techniques is lower than with open surgery.
Level 2A: The total incidence of chronic pain after hernioplasty is 10–12%. The risk of chronic pain after hernia repair decreases with age.
Level 2B: Preoperative pain may increase the risk of chronic pain after hernia repair.
Preoperative presence of chronic pain correlates with the development of chronic pain in the postoperative period. Severe pain in the early postoperative period correlates with the development of chronic pain. Women are more likely to develop chronic pain syndrome after hernioplasty than men.
Treatment effectiveness indicators:
1. Disappearance of hernia manifestations after surgery
2. Postoperative wound healing by primary intention
3. Absence in the late postoperative period of ligature fistulas and manifestations of hernia recurrence
4. Full restoration of working capacity
Hospitalization
Indications for planned hospitalization:
1. The presence of a symptomatic unilateral or bilateral inguinal hernia without signs of impingement is an indication for elective surgery (Level 1b).
2. Strangulated inguinal hernias (with signs of strangulation and / or bowel obstruction) should be operated on urgently (Level 1b).
Information
Sources and Literature
- Minutes of meetings of the Expert Commission on Healthcare Development of the Ministry of Health of the Republic of Kazakhstan, 2013
- 1. Tension-free hernioplasty / Under total. ed. V.N. Egieva. - M.: Medpraktika - 2002 .-- 148 p. 2. Features of classifications of hernias in modern surgery (literature review) / A.V. Protasov [et al.] // Endoscopic surgery. –2007. - No. 4. - P. 49–52. 3. Plastic surgery of the inguinal canal according to Liechtenstein and its modifications / D.V. Chizhov [and others] // Herniology. - 2004. - No. 1. - P. 43–51. 4. Toskin KD, Zhebrovsky V.V. Hernia of the abdominal wall. - M .: Medicine, 1990 .-- 269 p. 5. Shalashov S.V. Inguinal hernia in adults: A guide for physicians / S. V. Shalashov; Ed. prof. L.K. Kulikov. - Novosibirsk: Nauka, 2011. –136 p. 6. Bittner R., et all. Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal Hernia)
