From the aponeurosis of the external oblique abdominal muscle. Surgical treatment of groin pain caused by defects in the aponeuroses of the external oblique abdominal muscles Weak aponeurosis of the external oblique abdominal muscle
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The edges of the aponeurosis can be connected in the following ways:
1) using an edge seam (Fig. 34);
2) “overlapping” (Fig. 35);
3) with the formation of duplication (Fig. 36).
Rice. 34. Connection of the aponeurosis “edge to edge”.
Rice. 35. Connection of the edges of the aponeurosis “overlapping”.
Rice. 36. Formation of duplication from the aponeurosis
Conditions required for suturing the aponeurosis
1. Preservation of the anterior and posterior layers of fascia covering the corresponding surfaces of the aponeurosis. By fastening its fibers together, the fascial plates play a “cementing” role. After their removal, the elasticity and strength of the aponeurosis significantly decreases (in particular, the aponeuroses of the broad abdominal muscles, latissimus dorsi, adductor magnus, etc.).
2. A good overview of the surfaces of the connected aponeurosis to avoid damage to deeper vessels and nerves.
For good access to the surface of the aponeurosis, you should use the classic technique of working with a grooved probe and a scalpel. When isolating the aponeurosis using a blunt method, it is recommended to use the edge of a tuffer or a gauze ball.
To prevent disruption of the blood supply to the aponeurosis, tissue should not be peeled off over a significant area. At the same time, insufficient separation of tissue from the surface of the aponeurosis can increase the tension of the wound edges and the cutting of sutures.
Requirements for sutures placed on the aponeurosis
1. Simplicity and reliability.
2. Elimination of fiber disintegration.
3. Ensuring maximum connection strength.
4. Mechanical fastening of the edges of the aponeurosis for a time sufficient to form a strong connective tissue scar.
Variants of a circular suture applied to the aponeurosis
1. Interrupted circular sutures applied with non-absorbable material at a distance of 5-7 mm from each other.
Interrupted circular sutures located transversely to the direction of the aponeurotic fibers can, when tightened, lead to their disintegration, tearing, and even tearing off. Therefore, it is necessary to place the injection and puncture sites of the needle not in a linearly ordered manner, but “chaotically,” eliminating the possibility of such a complication (Fig. 37).
Rice. 37. “Chaotic” suturing of the aponeurosis
2. The use of U-shaped seams is most rational, since they capture a large area of tissue. As a result, the area of direct contact of the tissues being connected increases and, accordingly, the tension for each unit of this area decreases (Fig. 38).
Rice. 38. Applying U-shaped sutures to the edges
To increase the strength of U-shaped seams, the following techniques are used:
the sutures should be oriented at a certain angle relative to the course of the aponeurosis fibers;
To prevent the possibility of fiber disintegration of the aponeurosis, the sutures are placed not in one line, but randomly (chaotically).
When making a suture through the “tucked” aponeurosis of the external oblique abdominal muscle (inguinal ligament), it is necessary to take into account that the femoral vessels - artery and vein - pass under it at the border of the medial and middle thirds of the length.
Rough suturing of the Poupart ligament can lead to damage to the walls of these vessels with the development of bleeding. Therefore, when applying a suture, the needle must be visible through the aponeurotic fibers. This indicates the superficial conduction of the threads and serves as a criterion for the correct application of the suture.
3. The edges of the dissected aponeurosis can be connected using a continuous wrapping suture.
However, the use of this option can most likely lead to the formation of a rough postoperative scar.
When connecting the edges of the aponeurosis “overlapping,” interrupted circular or U-shaped sutures can be used according to previously formulated rules.
The formation of a duplicate from the aponeurosis is usually done with a two-row interrupted circular suture (Fig. 39).
Many foot diseases remain unattended by the patient, causing trouble for the person in the future. If pain occurs in the sole, the main reason is often hidden in wearing uncomfortable shoes. Rarely do people think seriously that pain is caused by an inflammatory process.
Many patients suffer from plantar aponeurosis disease. The disease is equated to a pathology, often manifested by heel pain. The heel always bears a large load during movement; a growth begins to appear on the heel tubercle, causing inflammation. This condition prevents the patient from living normally, and the patient thinks about treatment.
Inflammation of the plantar aponeurosis often occurs when a foot sprain occurs. A person will earn a fortune if he starts walking incorrectly, his foot turns inward. Other reasons for this violation are known:
- The disease develops in people who wear high heels. A complication occurs with prolonged wear, especially on uneven roads.
- The disease is considered a runner's disease.
- People who are overweight are at risk because they put a lot of strain on their legs. Hypertonicity of the calf muscles develops.
More often, the disease occurs in middle-aged people and mainly affects women. Men are exposed to the disease when playing sports.
People who have crossed the age of 40 are at risk; the disease often develops at this age. It is believed that heavy loads on the legs, even aerobics, can provoke the disease. To prevent this, it is quite possible to regulate the loads.
The disease belongs to the category of occupational, often occurring in people in professions where a lot of stress falls on the legs. Sometimes factory workers who have to stand for long periods of time, teachers, and salespeople suffer. The cause of the disease is often thin soles on shoes.
Symptoms of plantar aponeurosis
The disease is difficult to diagnose and is often confused with other disorders. First of all, a person feels severe pain in the heel and sole. Signs present:
- It becomes difficult for the patient to move, the pain subsides after rest. Detection of the disease can only be carried out by a doctor after a series of diagnostic measures.
- If the disease reaches a complex stage, a growth called a spur begins to appear. When studying the cause of the manifestation, the patient is prescribed an x-ray.
These symptoms confidently indicate plantar aponeurosis.
Complications with plantar aponeurosis
The main complication is the appearance of heel spurs; if drug treatment is started in time, the symptom will be eliminated. The patient feels chronic pain, and the phenomenon brings significant discomfort and is not always relieved by painkillers.
Soon the patient begins to feel the development of difficulties with the knee and hip joints, and difficulties arise with the spine. Calcification of the ligaments with plantar aponeurosis is considered a serious complication. Pronounced spurs, as they develop, cause trouble for the patient.
The place of occurrence of violations is the site of attachment of the Achilles tendon. Old age is dangerous in terms of the development of such situations. Treatment is absolutely required to prevent the development of a number of diseases. For example, chronic traumatic pain may develop when walking, an infection called gonorrhea may develop, and rheumatism may appear.
Treatment of plantar aponeurosis
Don't expect treatment to be quick. Healing takes several months. Much depends on the degree. The first symptoms require immediate medical attention. There is a chance to stop the inflammatory process, restore health with the help of physiotherapy, and get massages.
To restore the patient’s health, it is necessary first of all to prepare for treatment, which includes a set of injections. Let's look at the main types of treatment:
Getting rid of the disease is possible only at the initial stage. If the disease is advanced, some symptoms persist for a long time.
Prevention of plantar aponeurosis
To prevent the disease, you should first of all constantly make foot baths; it is important to soften the skin of the feet. It is acceptable to additionally use massage and medications. The doctor will prescribe treatment after a thorough diagnosis.
Remember, difficulties with legs require an immediate response; the cause may be hidden deep in the human body. If the disease is not treated, there is a possibility of remaining disabled for life. Therefore, it is necessary to pay attention to health, and do not leave any deviations in the leg area unnoticed.
Using pedicled flaps
Surgeries for femoral hernia
G. G. Karavanov (1952) proposed a method of operation that consists in closing the femoral ring with a “curtain septum”, which is formed from the aponeurosis of the external oblique muscle under the inguinal ligament at the level of the femoral canal. The aponeurosis flap is cut out 1-1.5 cm wide with its base at the superficial inguinal ring and, after retracting the spermatic cord or round ligament of the uterus, it is grabbed with a forceps from the side of the thigh and brought out to the thigh through the femoral canal. This flap is sutured to the lacunar ligament, to the pectineal fascia and muscle, and to the pupart ligament. At the same time, the lateral edge of the flap is sutured to the sheath of the vessels, which we consider unacceptable due to the possibility of wounding the vein and unjustified as an event strengthening the femoral ring. After excision of the flap, the gap in the aponeurosis is sutured with knotted sutures.
P.Ya. Ilchenko (1955) fixes an aponeurotic flap 8-10 cm long and 1.5 cm wide in front of the inguinal ligament to the pectineal ligament, followed by suturing the remaining part of the aponeurotic flap to the inguinal ligament.
Currently, operations are not used in which the inguinal ligament is brought closer to the upper branch of the pubic bone using U-shaped metal staples (Ru's operation, 1899).
The method of passing a bronze-aluminum wire through the inguinal ligament and specially drilled holes in the pubic bone to close the femoral ring (P. A. Herzen, 1904; A. P. Morkovitin, 1904) also did not become widespread.
Proposed by R.R. Vreden, placing a flap of the aponeurosis of the external oblique muscle using a Deschamps needle or a curved forceps under the pectineus muscle from the medial edge of the femoral vein to the medial edge of the pectineus muscle, followed by suturing it to the pubic tubercle, is practically inapplicable due to its high morbidity and technical complexity.
The proposals of V. N. Shevkunenko and N. F. Mikuli are similar. All these methods, tested in the section, turned out to be complex and physiologically unfounded. These also include the operation proposed by T. S. Zatsepin (1903), the essence of which is to fix the inguinal ligament with a silk thread carried around the horizontal (upper) branch of the pubic bone. After tying the two ends of the thread, the inguinal ligament should be pressed tightly against the bone and close the femoral ring.
The principle of T. S. Zatsepin was used by T. V. Zolotareva (1961), who proposed passing a flap of the fascia lata of the thigh through a hole made in the soft tissues covering the obturator foramen. P. A. Herzen considered it important for the patient to operate behind the horizontal branch of the pubic bone with sutures through the bone or, even worse, under this bone through the obturator foramen.
These modifications were also tested in the dissection room, and we were convinced of their anatomical groundlessness and extreme traumaticity.
Intraperitoneal operations for femoral hernias. For free, uncomplicated femoral hernias, intra-abdominal operations did not spread. A recommendation for an intra-abdominal approach is given by Sudeck (1928). He also joins Elecker’s demand that all laparotomies in the lower abdomen also include the removal of the existing hernia. However, A.P. Krymov believed that transsection for intervention for a femoral hernia has always been and will be more dangerous than simple herniotomy. We fully agree with the opinion of A.P. Krymov.
Aponeuroses of the anterior abdominal wall (indicated in blue) and linea alba
Aponeurosis(ancient Greek ἀπο- - prefix with the meaning of removal or separation, completion, reversal or return, negation, termination, transformation + νεῦρον "vein, tendon, nerve") - a wide tendon plate formed from dense collagen and elastic fibers. The aponeuroses have a shiny, white-silver appearance. In terms of histological structure, aponeuroses are similar to tendons, but are practically devoid of blood vessels and nerve endings. From a clinical point of view, the most significant are the aponeuroses of the anterior abdominal wall, the posterior lumbar region and the palmar aponeuroses.
Aponeuroses of the anterior abdominal wall
The aponeuroses of the muscles of the anterior abdominal wall form the sheath of the rectus abdominis muscle. The vagina has an anterior and posterior plate, while the posterior wall of the vagina at the level of the lower third of the rectus muscle is absent, and the rectus abdominis muscles with their posterior surface are in contact with the transverse fascia.
In the upper two-thirds of the rectus muscle, the anterior wall of the vagina is formed by the bundles of the aponeurosis of the external oblique muscle and the anterior plate of the aponeurosis of the internal oblique muscle; the posterior wall is the posterior plate of the aponeurosis of the internal oblique muscle and the aponeurosis of the transverse abdominal muscle. In the lower third of the rectus muscle, the aponeuroses of all three muscles pass to the anterior wall of the vagina.
Aponeuroses of the posterior lumbar region
The aponeuroses of the posterior lumbar region cover the longitudinal muscles of the lower back: the muscle that straightens the trunk (lat. m. erector spinae) and the multifidus muscle (lat. m. multifidus)
Palmar aponeuroses
The palmar aponeuroses cover the muscles of the palmar surface of the hands.
4. The lower edges of the internal oblique and transverse muscles
5. Inguinal ligament
69. The posterior wall of the inguinal canal is formed by:
1. Parietal peritoneum
2. Inguinal ligament
Transverse fascia
4. Aponeurosis of the external oblique muscle of the abdomen
70. The lower wall of the inguinal canal is formed:
1. The lower edges of the internal oblique and transverse muscles
Inguinal ligament
3. Pectineal fascia
4. Parietal peritoneum
5. Aponeurosis of the external oblique muscle of the abdomen
71. The upper wall of the inguinal canal is formed:
1. Transverse muscle
2. Internal oblique muscle
The lower edges of the internal oblique and transverse muscles
4. Parietal peritoneum
5. Transversalis fascia
72. The transverse fascia is the wall of the inguinal canal:
1. Upper
Rear
4. Front
73. The inguinal ligament is the wall of the inguinal canal:
1. Upper
Lower
4. Front
74. The aponeurosis of the external oblique muscle of the abdomen is the wall of the inguinal canal:
1. Upper
Front
75. The lower edges of the internal oblique and transverse muscles are the wall of the inguinal canal:
Upper
4. Front
76. The contents of the inguinal canal in men are:
Spermatic cord
Ilioinguinal nerve
3. Genital nerve
77. The contents of the inguinal canal in women are:
Round ligament of the uterus
Ilioinguinal nerve
3. Genital nerve
Genital branch of the genital femoral nerve
5. Femoral branch of the genitofemoral nerve
78. The spermatic cord includes three of the five anatomical elements given below:
Vas deferens
2. Urinary duct
Vessels and nerves of the vas deferens and testis
Remains of the vaginal process of the peritoneum
5. Iliohypogastric nerve
79. The spermatic cord includes:
1. Vas deferens
2. Arteries, veins and nerves of the vas deferens
3. Testicular artery
4. Venous pampiniform plexus
5. Lymphatic vessels of the testicle
6. Levator testis muscle
All listed entities
80. The superficial inguinal ring is formed:
1. Transversalis fascia
Divergent legs of the aponeurosis of the external oblique muscle of the abdomen
Interpeduncular fibers
81. The normal dimensions of the superficial inguinal ring in men are:
82. The deep inguinal ring is:
1. Hole in the transversalis fascia
Bulging of the transversalis fascia
3. Hole in the aponeurosis of the external oblique muscle of the abdomen
4. Hole in the transverse abdominis muscle
83. Inguinal hernias most often occur:
