A modernized approach to the selection of endovideosurgical and open hernioplasty techniques in the treatment of patients with inguinal hernias

Personalization of the choice of hernioplasty technique in patients with inguinal hernias remains an urgent problem of modern herniology. Performing "embryo-oriented operations" in the treatment of patients with inguinal hernias and difficulties in perceiving the multifascial structure of the anterior abdominal wall determine the need for an in-depth topographic and anatomical study of the anterior abdominal wall and substantiation of options for endovideosurgical inguinal hernioplasty in different categories of patients. The purpose of the study – to clarify the clinical and topographic-anatomical criteria for choosing a rational method of hernioplasty in patients with inguinal hernias to reduce the risks of postoperative complications and disease recurrence. The clinical study was based on data on 1,517 patients with inguinal hernias who underwent surgery at the Clinic of the Faculty of Surgery at the University of Medicine in the period from December 2014 to October 2021. The topographic and anatomical study was carried out using cadaveric material (11 objects) and analysis of plastinated transverse cuts of the abdomen (n = 17) of human corpses to determine the individual features of the transverse and preperitoneal fascia in the main types of human physique. The significance of these anatomical structures in performing endovideosurgical hernioplasty has been determined. It was found that the preperitoneal fascia was visualized during the study on all 11 corpses, the thickness of which differed in different areas of the anterior abdominal wall. The technical possibility of performing endoscopic hernioplasty using the TER technique is available in patients of all body types. The TEP access to the interfascial preperitoneal cellular space, developed and justified from a topographic and anatomical point of view, significantly reduces the risk of damage to the peritoneum, epigastric vessels, and nerves in the "triangle of pain" and reliably installs a mesh prosthesis without stapler fixation, prosthetics all the "weak" points of the inguinal, femoral, and occlusive regions. The modified therapeutic and diagnostic algorithm for choosing a rational minimally invasive method of inguinal hernioplasty made it possible to reduce postoperative pain syndrome, minimized the risk of postoperative complications during TEP surgery from 3.9 to 1 % at p<0.05; reduced TAPP and Lichtenstein operations from 4.5 to 3.6 % and from 9.5 to 6.3 % respectively when p>0.05; reduced the frequency of access conversions by 3 times, recurrence of the disease after TEP surgery from 1.2 to 0.3 % at p<0.05; TAPP from 1.5 to 0.9 % and Lichtenstein surgery from 2.9 to 2.1 % at p>0.05. A modernized differentiated approach to choosing a particular surgical technique in the treatment of patients with inguinal hernias should take into account the type of hernia according to the modern classification, the presence of concomitant surgical diseases of the abdominal cavity, the general comorbid condition of the patient, predict and minimize the possible risks of perioperative complications, as well as the technological capabilities of the medical institution and manual skills of the surgeon.

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