| Objective: Need to define accurately preperitoneal groin anatomyand explore the feasibility of modified totally extraperitonealrepair (TEP) of inguinal hernia .Methods:1. Methods of anatomy Preperitoneal groin anatomy andMyopectineal orifice was studied with dissections of the groinarea in fresh male cadavers. And measure the distance of arcuateline and the lower margin of umbilicus,the distance of thestarting point of Inferior epigastric artery and pubic tubercle and theangle of the first part of the inferior epigastric artery and inguinalligament.2.Methods of clinical application and evaluating indicatorAdult patients with inguinal hernias underwent modified TEP werecompared with those underwent Mesh plug tension-free inguinalherniorrhaphy (Rutkow) during the corresponding period accordingto the general clinical data, the body mass index(BMI), herniaclassification, typing, operating time, length of postoperative hospitalstay, analgesic use, time required for returning to normal activity,hospital expense, operate miss, operative complications and recurrencerate.Results:1. Results of anatomy The groin areas in six fresh male cadaverswere dissected in April 2005.(1) Myopectineal orifice, the most weakest area of the inguinal region, is the initial area where inguinal hernias occur. Its upper bound is arciform inferior margin made of obliguus internus abdominis and transversus abdominis. Its lower bound is the aponeurosis of superior ramus of pubis (Cooper ligament). it is rectus abdominis on the inner side. The outside is iliopsoas muscle. It is divided into two areas by its preceding inguinal ligament and its posterior tractus iliopubicus. There are inner ring (spermatic cord or round ligament passes through) and Hesselbach' s triangle in its upper area. The blood vessel and nerves pass through its lower area.(2) The Preperitoneal space is a potential one, which is separated easily.(3)Arcuate line that lies in below umbilicus at (48±2. 6)mm is in the range of the line of umbilicus and pubic symphysis upward medial. Rectus abdominis below arcuate line has not the later layer of sheath of rectus abdominis, so Preperitoneal space can be entered approaching the later layer of sheath of rectus abdominis.(4)Inferior epigastric artery that situates in between two layers of transversatis fascia starts from the external iliac artery at the junction of the one-third inguinal ligament internal medial. It is (3.92±0.35)mm away from the starting point of Inferior epigastric artery to pubic tubercle. The angle is 80 degrees between the first part of the inferior epigastric artery and inguinal ligament. Inferior epigastric artery can be avoided being separated as possible during the operation by studying Inferior epigastric artery location and its direction. And it is the identification marker which draws a line between indirect and direct hernias.2. Clinical results From June 2005 to November 2007, twenty-six adult patients with twenty-nine inguinal hernias were underwent modified totally extraperitoneal repair of inguinal hernia, when fifty-two adult patients with fifty-five inguinal hernias were received Mesh plug tension-free inguinal herniorrhaphy(Rutkow).(1)There was not significant differences between the two groups in the general clinical data, body mass index(BMI), hernia classification and typing (p>0. 05).(2)The main operate miss was peritoneal or hernial sac laceration and mistaken dissection of the inferior epigastric vessels in modified TEP. Its general occurrence rate is 27.58%. And the operate miss of Mesh plug tension-free inguinal herniorrhaphy (Rutkow) was hernial sac laceration, femoral artery or vein injury and iliohypogastric nerve or ilioinguinal nerve injury. Its general incidence rate is 16. 36%. The incidence rate of operate miss of modified TEP was higher than that of Mesh plug tension-free inguinal herniorrhaphy (Rutkow). But there was not a significant difference between the two groups(p>0. 05).(3)The main complication of modified TEP was subcutaneouly or scrotum emphysema, hematomas or seroma, temporariness paresthesia, bladder injury and foreign body sensation in the inguinal area. And that of Mesh plug tension-free inguinal herniorrhaphy (Rutkow) was hematomas in incision, foreign body sensation in the inguinal area, hematomas or seroma, temporariness paresthesia and painful ejaculation. The incidence rate of temporariness paresthesia and foreign body sensation in modified TEP were 10.34% and 3.45% respectively. The incidence rate of those in Mesh plug tension-free inguinal herniorrhaphy (Rutkow) were 21.82% and 7.27% respectively. The incidence rate of temporariness paresthesia and foreign body sensation in modified TEP were lower than that of Mesh plug tension-free inguinal herniorrhaphy (Rutkow) without a significant difference(p>0.05).But the incidence rate of hematomas or seroma in modified TEP and in Mesh plug tension-free inguinal herniorrhaphy (Rutkow) were 20.68% and 3.64% respectively. The former was far higher with a significant difference(p<0.05). Subcutaneouly or scrotum emphysema and bladder injury were these special complications of modified TEP.(4)The general incidence rate of complications in modified TEP and in Mesh plug tension-free inguinal herniorrhaphy (Rutkow) were 41.38% and 25.45% respectively. But the difference between the two groups has no statistics significance (p>0. 05).(5)Length of postoperative hospital stay, time required for returning to normal activity in modified TEP were 4.8±1.6 days and 13.2±1.1 days respectively. Those in Mesh plug tension-free inguinal herniorrhaphy (Rutkow) were 6.9±1.8 days and 16.3±1.4 days respectively. At the two aspects modified TEP was more advantageous than the other group with a significant difference (p<0. 05).(6)Postoperative pain could be endured in modified TEP. All the patients didn' t need to use pain-killer. Otherwise pain-killer was injected in ten cases of Mesh plug tension-free inguinal herniorrhaphy (Rutkow), the incidence rate was 18. 18%, which was far higher than the former with a significant difference(p<0. 05).(7)Operating time of modified TEP was 70. 3±23 min. Otherwise that of Mesh plug tension-free inguinal herniorrhaphy (Rutkow) was 48. 6±5. 0 min, which was less than the former with a significant difference(p<0. 05). Hospital expense of modified TEP was 5440±150 yuan, that of Mesh plug tension-free inguinal herniorrhaphy(Rutkow) was 4246±148 yuan, which was more advantageous than the former with statistics significance (p<0. 05).(8)All the patients were followed up for 1-30 months, no recurrence occurred.Conclusion: From the view of Preperitoneal groin anatomy, an adequate mesh that is laid flat on the Preperitoneal space centred around myopectineal orifice can cure and prevent inguinal hernias effectively. Modified TEP is rational, safe and feasible. The key process is the accurate separation of extraperitoneal space. |
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