Aponeurosis - what is it? Signs and symptoms of the disease. Method for plastic surgery of defects of the aponeurosis of the external oblique muscle of the abdomen Aponeurosis of the internal oblique muscle of the abdomen

Surgeons periodically encounter such a problem among their patients as groin pain. Timely and correct diagnosis of the causes of their occurrence is the key to successful treatment. Research shows that in more than 20% of cases, the cause of groin pain is a defect in the aponeurosis of the external oblique abdominal muscles. Moreover, such a defect can be either congenital or acquired. It should be noted that most of the pain in this area with similar symptoms is caused by muscle damage with the development of myofascial syndrome, which requires careful differential diagnosis and other therapeutic approaches.

However, among patients with groin pain there are also patients with an acquired defect of the aponeurosis of the cervical inguinal tract as a result of a previous appendectomy or surgery for ectopic pregnancy.

Diagnosis and treatment

The following types of defects are distinguished:

Linear defect
- inclusion of terminal branches n into the defect area. iliohypogastricus
- “muscle hernia” - fibers of the internal oblique abdominal muscle protruding into the area of ​​the defect
- an anomaly in the development of the inguinal falx, when there are almost no tendon fibers in this area.

Typical complaints in patients with aponeurosis defects are groin pain, intensifying after sudden movement, such as kicking a ball, turning in bed, coughing or sneezing, during sex, and while climbing stairs. The difficulty of diagnosis lies in the ambiguous interpretation of ultrasound examinations when studying pathology in this area. Thus, the diagnosis is established as a result of the participation of specialists from different fields - a surgeon, gynecologist, urologist, and radiology specialist.

And this is precisely the reason for all unsuccessful attempts conservative treatment this kind of groin pain by specialists who do not have the necessary qualifications and experience in the surgical treatment of aponeurosis defects. However, these specialists can and should suspect a similar problem in the absence of evidence of symptoms of a gynecological or urological disease, or in the event of long-term unsuccessful treatment for it.

According to our results of surgical treatment of the aponeurosis defect of the LMBI in 54 patients, all patients noted complete (52 people or 96.3%) or almost complete (2 people or 3.7%) disappearance of pain and restoration of motor functions that were impaired due to pain syndrome. In most cases, after surgery, no special rehabilitation methods were required, except for exercise therapy. In 3 patients with duration pain syndrome Over 3 years, myofascial release of secondary affected muscles was required. The athletes began training 2 weeks after the operation, and after another 2-2.5 weeks they trained at full strength.

Close interaction between gynecologists, urologists, surgeons and a specialist in the treatment of groin pain and early diagnosis of the causes of their occurrence is the key to successful treatment and early rehabilitation with the restoration of all motor functions. And the most important thing is to relieve the patient from constant pain.

Like all muscles, when you look at your abdominal muscles, you see red and white. In the same way, like any muscle, each abdominal muscle contains parts of two types:

- the “red” part, consisting of contractile fibers (which can actively taper), this is the “active” part,

Parts that look like whitish napkins. These parts cannot contract.

These are muscle aponeuroses.

They can have two forms and two functions:

In some places they envelop the muscle like a cover,

Elsewhere, they continue the area of ​​contraction as a fibrous tissue that can be stretched (for the abdominal muscles, these extensions are located in the front of the abdomen and are called anterior aponeuroses).

Here is the external oblique muscle and aponeurosis

Anterior aponeuroses of the “broad” muscles

Each “wide” muscle is wrapped in two aponeuroses: internal and external. Therefore, there are six aponeuroses in total. The contracting part of the “broad” muscles ends in the front of the abdomen. The six aponeuroses thus overlap each other (like puff pastry). First of all, they stick together. They are then redistributed to wrap around the rectus muscles before rejoining at the midline of the abdomen to form the linea alba.

This is a rather complex device that changes depending on the level:

In the upper two thirds of the abdomen there are aponeuroses transverse muscle and the internal aponeurosis of the internal oblique muscle pass behind the rectus muscles, while the aponeuroses of the external oblique muscle and the external aponeurosis of the internal oblique muscle pass in front of the rectus muscles,

In the lower third of the abdomen all aponeuroses broad muscles pass in front of the rectus muscles. This zone is visible in the lower part of the abdomen; it seems to form a horizontal line, below which the abdomen looks more “retracted”.

Each “wide” muscle pulls its aponeurosis outward. The aponeurosis does not shorten (it is not able to contract). It does not stretch (it is not stretchable or elastic, only capable of deformation): it tenses under the influence of the tension of the contracting part (red).

When the latissimus muscles contract simultaneously on both sides, they pull the right aponeurosis to the right and the left aponeurosis to the left. In this case, the white line is involved in spreading.

Contraction of the transverse muscle pulls the aponeurosis perpendicular to the linea alba along the entire width of its line of action. It tries to move apart, to open this white line, like lightning, which is being pulled apart in different directions.

Contraction of the oblique muscles moves the linea alba rather obliquely:

The internal oblique muscle is mainly upper area,

The external oblique muscle is mainly in the lower region.

Thus, the contraction of the three “wide” muscles creates a strong tension that can stretch the linea alba, especially if they all work together. This occurs when one tries to draw in the abdomen while exhaling, since in this case the transverse muscle, the most powerful dilator of the three, dominates.

The fibers of the rectus muscle are parallel to the linea alba. Their contraction does not create any effect of moving apart onto the white line.

Contraction of the three “broad” muscles expands the linea alba. The rectus muscle is the only abdominal muscle that does not extend the linea alba.

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 soft tissues, closing 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. By 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.

Sheath of the rectus abdominis muscle. Each rectus abdominis muscle is located in the rectus abdominis sheath, which is formed by the aponeuroses of all three vastus abdominal muscles. The vagina has an anterior and posterior plate, with the posterior wall of the vagina present only at the level of the upper 2/3 of the rectus muscle; in the lower section, below the arcuate linea arcuata, the posterior wall of the vagina is absent, and here the rectus abdominis muscles with their posterior surface are adjacent to the fascia transversalis.

Above this line, the anterior wall of the vagina is formed by the bundles of the aponeurosis of the external oblique muscle of the abdomen and the anterior plate of the aponeurosis of the internal oblique muscle, the posterior wall - by the posterior plate of the aponeurosis of the internal oblique muscle and the aponeurosis of the transverse abdominal muscle, and in the uppermost section - by the muscle bundles of the transverse muscle. Below the arcuate line, the aponeuroses of all three muscles form a denser anterior vaginal wall; the rectus sheath does not have a posterior wall below this line; here only the transversus abdominis fascia remains.

Linea alba, linea alba, looks like a tendon strip running from the xiphoid process to the pubic fusion. The linea alba is formed by intertwining bundles of aponeuroses of all three pairs of broad muscles of the abdominal wall. In the upper section, where the linea alba is thinner and wider, gaps remain between the intertwining bundles of aponeuroses, which can be the site of the formation of hernias of the white line of the abdomen. Approximately in the middle of the linea alba there is an umbilical ring made of loose scar tissue, the so-called navel, umbilicus s. umbo, in place of which in the prenatal period of development there was a rounded hole that allowed the umbilical vessels to pass through.

Fascia of the abdomen. The superficial fascia of the abdomen is distinguished by the presence of elastic fibers. Along the midline, the superficial fascia fuses with the linea alba, and below with the inguinal ligament.

In the lower section, above the symphysis, dense cords called ligaments of the penis are formed, there are two of them:

the sling-shaped ligament of the penis, which gives rise to two legs that encircle the penis from the sides;

the suspensory ligament of the penis; in women, the suspensory ligament of the clitoris. The fascia bands in the area of ​​these ligaments are partially reinforced by the tendon bundles of the rectus and external oblique abdominal muscles.

Fascia iliaca (see fascia of the pelvis and thigh).

The transverse fascia covers the inner surface of the transverse abdominis muscle and the inner surface of the posterior layer of the rectus sheath, and below the linea arcuata - the inner, posterior surface of the rectus muscle. Inferiorly it fuses with the edge of the inguinal ligament. In the area of ​​the navel, the fascia transversalis is denser and is called the umbilical fascia. In the area of ​​the lower section of the white line, due to the concentration of longitudinal beams, a support for the white line is formed.

IN groin area The transverse fascia forms a funnel-shaped protrusion - the internal spermatic fascia. The peritoneum, peritoneum, is adjacent to the inner surface of the subperitoneal fascia. On the peritoneum of the anterior abdominal wall there is a number of folds corresponding to the course of ligaments and vessels in the preperitoneal tissue. Between the plica umbilicalis medialis and the plica umbilicalis lateralis is the medial inguinal fossa, corresponding to the outer ring of the inguinal canal. Between the medial and median umbilical folds there is a supravesical fossa. These pits can be the starting points of hernias, which then, after passing through the abdominal wall, come out through the external inguinal ring.