| Backround and objectiveThe highest incidence of hernia was inguinal hernia, accounted for 90% of all hernia[1]. It is due to the unique anatomical characteristics of the groin area. Historically, because of surgical anatomist research in this area, make a huge revolution of inguinal hernia repair.The earliest recorded medical history of inguinal hernia in 1124-1151 BC, Egyptian mummy Ramses V had a clear inguinal hernia, Alexander era had emerged hernia belt, Hippocrates described the differential diagnosis of hernia and scrotal hydrocele.200 AD, Galen proposed hernia is formed in peritoneal ruptured, which accompanied by extension of the fascia and muscle. In 1363, Guy de Chauliac firstly described the difference of femoral hernia and inguinal hernia. During the Renaissance, anatomy founder Benivieni carefully documented clinical data, follow-up and autopsy of his patient, recorded and described the various types of hernia. Ambroise proposed that the peritoneum be sutured after contentsof the hernia should be Reseted, and Condemneded quack who removded the testes of inguinal hernia patients. After the Renaissance, Pott, Richter, Camper, Scarpa, and Morton proposed the name of the structure of abdominal wall and hernia, for example, Gimbernat ligament,Camper fascia,cooper ligament,Hesselbach triangle,Scarpa fascia, Richter hernia, and so on.Based on the knowledge of anatomy, in 1876, Greensville Dowell published the famous paper of "radical surgery on the hernia" in United States, Marcy in 1871 firstly used three principles of hernia surgery:sterile technique, ligation, tightening the inner ring. Bassini created a new era of hernia surgery by analyzing the various ca-uses of failure, He gave up the method of inguinal canal deeply sutured, and reconstructed physiology of groin through Highly ligaturing the hernia sac, sutured joint tendon, abdominal oblique and transverse abdominal fascia to the inguinal ligament. He also conducted a series of follow-up:Compare to today, the mortality and infection rates remain quite low. Halsted created an anther operation, which is difference from the spermatic cord be moved above the external oblique muscle. Georg Lotheissen used Cooper ligament in hernia repair. Anatomist Fruchaund in 1956 proposed the concept of myopectineal orificeand the transveralis fascia. Shouldice developed a Bassini procedure, he focused on repairing transverse fascia, and this operation is the most effective hernia repair to date.As development of materials science, anatomy and laparoscopic surgery,90,20th century, hernia repair change into the tension-free repair and laparoscopic surgery. Lichtenstein firstly proposed the concept of "tension-free repair" [2],which included the anatomy of the inguinal canal and implanting the patch in Extraperitoneal, Reported 1000 cases, and 1 to 5 years follow-up recurrence rate was zero, then the surgical is popular. In 1982, Ger initially reported the first cases of laparoscopic inguinalhernia repair, sutured off hernia sac by Michel clip[3].Later, Bogojavlensky Reported extraperitoneal herniorrhaphy[4], Schultz etc reported transabdominal preperitoneal prosthetic[5], the same time Ferzli in 1992 reported totally extraperitoneal hernia repair[6],Greighton university researchers have also suggested intraperitoneal onlay mesh in the same period[7].Today common laparoscopic hernia repairs (LHR) are TAPP (transabdominal preperitoneal prosthetic), TEP (totally extraperitoneal prosthetic) and IPOM (intraperitoneal onlay mesh), which be Recognized Exact effect, however, the first two are be recognized operational complexity, a larg area of anatomical separation and long operation time. In IPOM, patch and nail clip directly contact with intestine, which is the main reason lead to postoperative adhesions, intestinal perforation and infection etc. severe complications such as abscess. Blind surgery operation may damage the iliac blood vessels, may also damage nerves, and led to postoperative sensation, numbness, pain and discomfort, or even nerve tumors in groin[9,10]. In order to reduce intraoperative and postoperative complications pursuit less invasive, we propose the approach of herniarepair of using inguinal umbilical fold medial, and improve to total peritoneum intraperitoneal onlay mesh (TPIPOM). The same time, we have performed animal experiments, anatomical and clinical study, which provide accurate basis of clinical application for TPIPOM. This study is part of the subject of TPIPOM. This paper will focus on the related anatomy of groin area and medial umbilical fold, and clinical effect of TPIPOM.Part I The anatomy research of groin areaPurpose:Objective studying anatomy of inguinal region and abdominal ring ofsurrounding, to provide accurate anatomic basis of the clinical application for total peritoneum intraperitoneal onlay mesh (TPIPOM).Methods:The cadaver of 18, male 11, female 7, a total of 36 sides. We dissect the structure of inguinal region and abdominal ring of surrounding, and Observe the orbit of ilioinguinal nerve (IGN) and iliohypogastric nerve (IHN) in the groin area, mark the location of two nerves through the three flat muscles oflateral wall of the abdomen. Measure the distance from two point of nerves crossing the muscle and the corresponding bony landmarks With the ruler of precision of 0.5 mm[11]:Through abdominal oblique (to the anterior superior iliacspine), crossing abdominal oblique (to the upper edge of pubic symphysis), throuh external oblique (from the upper edge of pubic symphysis), through external ob-lique (from the pubic tubercle), and distance from IGN to IHN, were recorded as Lhl, Lh2, Lh3, Lgl, Lg2, Lg3, L4; Find the relationship between spermatic cord, spermatic vein,external iliac vein, obturatorartery and vein and other signs with bone landmarks. Open the lateral wall of the abdomen layer by layer from internal abdominal cavity, firstly remove parietal peritoneum of the internal ring as the central of about 10 cm diameter, Anatomy structures of the spermatic cord, vas deferens, spermatic vessels (uterine round ligament), external iliac vessels, abdominal vascular, reproductive femoral nerve, femoral nerve, lateral femoral cutaneous nerve ect, and measuring the distance from them to the signs of bone; measure the angle of triangle triangle of death and triangle of pain; establish local anatomical model of men around the inner ringby 3D image processing software.Incision full-thickness abdominal wall from midline abdominal, display medial umbilical fold and measurethe length and width, open the peritoneum from medial umbilical fold, observed that are there important nerves, blood vessels in extra peritoneal area. Analyzed by spss 13.0, measurement data describe as mean±standard deviation.Results:The average diameter of lengths from the point when iliohypogastricnerve (IHN) thread through the obliquus internus abdominis to anterosuperior iliac spine and from the point IHN run through the aponeurosis of external oblique muscle of abdomen to superior margin of symphysis pubica are 4.09±0.33 cm and 5.02±0.55cm. The average diameter of lengths from the point whenilioinguinal nerve (IGN) thread through the obliquus internus abdominis to ante-rosuperior iliac spine and from the point IGN run through the aponeurosis of external oblique muscle of abdomen to superior surface of tuberculum pubicumare 3.00±0.43 cm and 3.87±0.45 cm. Spermatic cord, vas deferens, spermatic vessels, iliac vessels,abdominal vascular, reproductive femoral nerve, femoral nerve,reproductive femoral nerve, lateral femoral cutaneous nerve,they constitute the twokey areas around inner ring:Triangle of Death and Triangle of pain[12]; Triangle of Death:the lateral sides are vas deferens and testicular artery and vein, whichcross into angle in the internal ring, the average angle is 48.8±3.7°; Pain Triangle:outside of triangle of death, the lateral sides are testicular blood vessels and the inguinal ligament, there are lateral femoral cutaneous nerve and reproductive femoral nerve through the deep surface in this region, the average angle is 21.0±4.0°Conclusion:The quantitative measurement of important structures of inguinal region and establishing the regional anatomy model of abdominal ring of surrounding can provide a significant reference value to reduce intraoperative and postoperative complications of TPIPOM.Part II The anatomy study of the medial umbilical foldPurpose:Studying clinical anatomy of medial umbilical fold, provide accurate anatomic basis of the clinical application for Total peritoneum intraperitoneal onlay mesh (TPIPOM).Methods:Group of autopsy (group A):cut the skin, subcutaneous tissue along the lateralrectus in the lower abdominal, anatomy muscular of the inguinal region, expose ilioinguinal nerve, iliohypogastric nerve, spermatic cordand other structures; Open the peritoneum from the inner port and Fully anatomy peritoneum, to expose the medial umbilical fold and anatomical structure around the inner ring.compare to laparoscopic anatomy. Case of laparoscopic operation be divided into group of TPIPOM and group of no TPIPOM; Sterile transfusion pipe which is with a scale (0.5mm) of 2 mm diameter by self-restrainting, could be took into abdominal through Trocark, to measure thickness (Tl,Tr) and width (Dl,Dr)of medial umbilical fold Under pneumoperitoneum. Medial umbilical fold of Group B is cut, and dissect inward to the midline, down to the pubic symphysis and toreachbasin wall, observe the extraperitoneal structure around medial umbilical fold in vivo. Analyzed by spss 13.0, measured by two-sample t test,P<0.05, difference is statistically significant.Results:Folds and parietal peritoneum are shrinking after formalin immersion in specimens, there is no obvious blood vessels and nerves through this region except of blocking external umbilical artery. Group B were completed by laparo-scopic:we did not find obvious nerves and blood vessels in this triangle area,which is composed by the medial umbilical fold, median umbilical fold and the pubic, and No obvious active bleeding; Small number of cases can be found variant subobturator vessels. Patch can be covered by the dissected medial umbilical fold. The medial umbilical fold can be observed in vivo in B and C Group. The thickness of group B and C is 3.03±0.29mm, the width of Group B and C is 9.98±1.52mm; Bilateral lateral umbilical fold and medial umbilical fold are highly symmetric. Compared thickness and width of bilateral medial umbilical fold of Group B and C, P>0.05, the difference was not statistically significant;Measure thickness and width of bilateral medial umbilical fold of different ages (18-50 years,50 years old), P>0.05, the difference was not statistically significant.Conclusion:Patch can be covered by medial umbilical fold in TPIPOM, which has disadvantages of safety, reliability, minimally invasive.PartⅢThe clinical application research of total peritoneum intraperitoneal onlay meshPurpose:Evaluating the security and superiority of total peritoneum intraperitoneal onlay mesh.Methods:Study group (group A) which had been operated by total peritoneum intraperitoneal onlay mesh are 30 cases, including 24 males and 6 females, meanage 44.77±13.77 years old. Control group (group B) which had been operated by totally extraperitoneal prosthetic are 30 cases, including 28 males and 2 females, mean age 49.60±13.94 years old. Assess Indicators of two groups of the operation time, bed time, postoperative complications, hospitalization time, and cost and recurrence rate. Analyzed by spssl3.0, measured by two-sample t test data, count data with chi-square test, P<0.05, difference is statistically significant.Results:The laparoscopic operations were successfully performed in group A and B. Group A:operative time was 29.77±0.87 min, blood loss was 3.39±0.23 ml, bedtime was 33.83±0.74 hours, length of stay was 3.16±0.13 days, the timeof gastroinestinal function recovered was 15.23±0.72 hours, number of patients using painkillers after surgery are 2 cases, cost was 8358.90±103.31 yuan, no postoperative scrotal seroma; The patients were followed up above one year andrecurrence was not found. Group B: operative time was 53.30.5±1.71 min, blood-loss was 56.80±1.79 ml, bed time was 34.37±0.83 hours, length of stay was3.22±0.17 days, the time of gastrointestinal function Recovered was 15.64±0.65hours, the cost was 88412.40±70.41 RMB, postoperative scrotal seroma were 7 cases; follow-up above one year, Chronic groin pain in 6 cases,1 case of recurrence. Compare to Group B, the operation time, blood loss, the average time to ambulation, length of stay, number of using painkillers, chronic pain after surgery of Group A, which is lower, and P<0.05, difference was statistically significant.Conclusion:TPIOPM compared with the TEP, performed equally safe, reliable and less traumatic. |
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