Presentation on the topic: Strangulated hernia. Incisional ventral hernia Download presentation on hernia
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Complications of abdominal hernias include: Infringement Irreducibility Coprostasis Inflammation
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Incarcerated hernia Incarcerated hernia is the most common and dangerous complication requiring immediate surgical treatment. The organs that have entered the hernial sac are subjected to compression (more often at the level of the neck of the hernial sac) in the hernial orifice.
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Pathological picture. In the strangulated organ, blood and lymph circulation is disturbed, due to venous stasis, fluid is transuded into the intestinal wall, its lumen and the cavity of the hernial sac (hernial water). The intestine acquires a cyanotic color, the hernial water remains clear. Necrotic changes in the intestinal wall begin with the mucous membrane. The greatest damage occurs in the region of the strangulation furrow at the site of compression of the intestine by a restraining ring.
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Clinical picture and diagnosis. Clinical manifestations depend on the type of infringement, the infringed organ, the time elapsed since the onset of the development of this complication. The main symptoms of a strangulated hernia are pain in the area of the hernia and irreducibility of a hernia that has been freely reduced earlier. The intensity of pain is different, a sharp pain can cause a state of shock. Local signs of hernia incarceration are sharp pain on palpation, induration, tension of the hernial protrusion. negative cough symptom. With percussion, dullness is determined in cases where a hernial sac contains an omentum, bladder, hernial water. If there is an intestine containing gas in the hernial sac, then a tympanic percussion sound is determined.
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Treatment If a hernia is incarcerated, emergency surgery is necessary. It is carried out in such a way that, without cutting the infringing ring, open the hernial sac, prevent the incarcerated organs from slipping into the abdominal cavity. The operation is carried out in several stages.
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Stages of surgical treatment of a strangulated hernia Layer-by-layer dissection of tissues up to the aponeurosis and exposure of the hernial sac. Opening of the hernial sac, removal of hernial water. Dissection of the infringing ring under the control of vision, so as not to damage the organs soldered to it from the inside. Determination of the viability of the restrained organs. The indisputable signs of the non-viability of the intestine are dark color, dull serous membrane, flabby wall, absence of pulsation of the vessels of the mesentery and intestinal peristalsis. Resection of a non-viable bowel loop. Hernioplasty.
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Irreducibility of a hernia internal organs between themselves and with the hernial sac, formed as a result of their trauma and aseptic inflammation. Irreducibility may be partial, when one part of the contents of the hernia is reduced into the abdominal cavity, while the other remains irreducible. Prolonged wearing of the bandage contributes to the development of irreducibility. Irreducible are more often umbilical, femoral and postoperative hernias. Due to the development of multiple adhesions and chambers in the hernial sac, an irreducible hernia is more often complicated by the infringement of organs in one of the chambers of the hernial sac or the development of adhesive intestinal obstruction.
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Coprostasis Stagnation of feces in the large intestine. This is a complication of a hernia, in which the contents of the hernial sac is the large intestine. Coprostasis develops as a result of a disorder in the motor function of the intestine. Its development is facilitated by the irreducibility of the hernia, a sedentary lifestyle, plentiful food. Coprostasis is observed more often in obese patients of senile age, in men with inguinal hernias, in women with umbilical hernias. The main symptoms are persistent constipation, abdominal pain, nausea, rarely vomiting. The hernial protrusion slowly increases as the large intestine is filled with fecal masses, it is almost painless, slightly tense, pasty-like, the symptom of a cough impulse is positive. General condition of patients of moderate severity.
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Treatment of coprostasis It is necessary to achieve the release of the colon from the contents. With reducible hernias, one should try to keep the hernia in the reduced state - in this case, it is easier to achieve restoration of intestinal motility. Apply small enemas with hypertonic sodium chloride solution, glycerin or repeated siphon enemas. The use of laxatives is contraindicated due to the risk of developing fecal incarceration. Donetsk National Medical University named after M. Gorky Department of Faculty Surgery. K.T.Ovnatanyan
Assoc. Gredzhev F.A.
Donetsk 2008
Abdominal hernia (hernia abdominalis) is called
protrusion of peritoneal viscerathrough natural or artificial abdominal openings
walls, pelvic floor, diaphragm under the outer covers
body or other cavity.
Mandatory components of a true hernia are:
1) hernial orifice; 2) hernial sac from the parietal
peritoneum; 3) hernial contents of the sac - organs
abdominal cavity.
Excretion of internal organs to the outside through defects in
parietal peritoneum (i.e. not covered by the peritoneum)
called prolapse (prolapse), or eventration.
Hernia gate
natural or abnormal opening in the musculoponeurotic or fascial layer of the abdominal wallcase through which the hernial protrusion comes out.
hernial sac
is part of the parietal peritoneumprotruding through the hernial orifice. It distinguishes
the mouth - the initial part of the bag, the neck - a narrow section
bag located in the canal (in the thickness of the abdominal wall),
body - the largest part outside
hernial orifice, and the bottom - the distal part of the bag.
The hernial sac can be single or multi-cavity.
hernial contents
internal organs located in the cavity of the hernial sac.Any organ of the abdominal cavity can be in a hernial sac.
Most often, it contains well-moving organs: a large
omentum, small intestine, sigmoid colon, appendix. hernial
contents can be easily reduced into the abdominal cavity (reducible
hernias), only partially reduce, not reduce (irreducible hernias)
or be strangulated in a hernial orifice (strangulated hernia).
It is especially important to distinguish strangulated hernias from irreducible ones, since
infringement threatens the development of acute intestinal obstruction,
necrosis and gangrene of the intestine, peritonitis. If most of the internal
organs for a long time is in the hernial sac, then
such hernias are called giant (hernia pennagna). They hardly
reduced during surgery due to volume reduction
abdominal cavity and loss of space previously occupied by them.
External abdominal hernias
External abdominal hernias occur in 3-4% of allpopulation. By origin, there are congenital and
acquired hernias. The latter are divided into hernias from effort
(due to a sharp increase in intra-abdominal pressure),
hernia from weakness due to muscle atrophy, reduction
tone and elasticity of the abdominal wall (in the elderly and
weakened persons). In addition, distinguish
postoperative and traumatic hernias. IN
depending on the anatomical location distinguish
inguinal, femoral, umbilical, lumbar, ischial, obturator, perineal hernias.
Internal abdominal hernia
bowels right and left.
Etiology and pathogenesis
Hernias are most common in children under the age of 1of the year. The number of patients gradually decreases until the 10-year
age, after that it increases again and by the age of 30-40
reaches a maximum. In old age and old age
an increase in the number of patients with hernias was also noted.
The most common are inguinal hernias (75%),
femoral (8%), umbilical (4%), and
postoperative (12%). All other forms of hernia
are about 1%. Men are more likely to have inguinal
hernias, in women - femoral and umbilical.
Predisposing factors
Predisposing factors include heredity,age (eg, weak abdominal wall in infants of the first
years of life, atrophy of the tissues of the abdominal wall in old
people), gender (features of the structure of the pelvis and large sizes
femoral ring in women, weakness of the groin and
inguinal canal formation in men), degree
fatness (rapid weight loss), trauma to the abdominal wall,
postoperative scars, nerve paralysis,
innervating the abdominal wall. These factors
contribute to the weakening of the abdominal wall.
Producing factors
Producing factors cause an increaseintra-abdominal pressure; they include heavy
physical labor, difficult childbirth, difficulty
urination, constipation, prolonged cough. An effort,
contributing to an increase in intra-abdominal pressure,
may be singular and sudden (heavy lifting)
or frequently recurring (cough). The cause of a congenital hernia is
underdevelopment of the abdominal wall in the prenatal period:
embryonic umbilical hernia, embryonic hernia
(hernia of the umbilical cord), non-closure of the vaginal
process of the peritoneum. Initially, hernial
gate and hernial sac, later as a result of physical
efforts internal organs penetrate into the hernial sac.
With acquired hernias, the hernial sac and internal
organs exit through the internal opening of the canal, then
through the external (femoral canal, inguinal canal).
(general principles)
The main symptoms of the disease are swelling and pain in the area of the hernia.when straining, coughing, physical exertion, walking, with the patient in an upright position.
The protrusion disappears or decreases in a horizontal position or after manual
reduction.
The protrusion gradually increases, acquires an oval or rounded shape. With hernias
acutely arising at the time of a sharp increase in intra-abdominal pressure, patients feel
severe pain in the area of a hernia that is forming, the sudden appearance of a protrusion of the abdominal wall
and in rare cases, hemorrhage into the surrounding tissues.
The patient is examined in a vertical and horizontal position. View in vertical
position allows you to determine when straining and coughing protrusions, previously invisible, and when
large hernias set their largest size. With percussion of a hernial protrusion
reveal a tympanic sound if there is an intestine containing gases in the hernial sac, and
dullness of percussion sound, if there is a large omentum or organ in the bag, not
containing gas.
On palpation, the consistency of the hernial contents is determined (elastic consistency
has an intestinal loop, a lobed structure of a soft consistency - a greater omentum).
In the horizontal position of the patient determine the correctness of the contents of the hernial sac. IN
the moment of reduction of a large hernia, you can hear the characteristic rumbling of the intestine.
After reduction of the hernial contents with a finger inserted into the hernial orifice, specify
size, shape of the external opening of the hernial orifice. When the patient coughs, the finger
the examiner feels tremors of the protruding peritoneum and adjacent organs - a symptom
cough impulse; it is characteristic of an external hernia of the abdomen.
With large hernias, to determine the nature of the hernial contents,
x-ray examination digestive tract, Bladder.
Treatment (general principles)
Conservative treatment is carried out with umbilical hernia in children. It consists inthe use of bandages with a pelota, which prevents the exit of internal organs. At
adults use various types of bandages. Wearing a bandage is prescribed
patients who cannot be operated on because they have serious
contraindications to surgery (chronic diseases of the heart, lungs, kidneys in
stages of decompensation, liver cirrhosis, dermatitis, eczema, malignant
neoplasms). Wearing a bandage prevents the exit of internal organs
into the hernial sac and contributes to the temporary closure of the hernial orifice.
The use of a bandage is possible only with reducible hernias. Prolonged it
wearing can lead to atrophy of the tissues of the abdominal wall, the formation of adhesions
between the internal organs and the hernial sac, i.e. to the development of irreducible
hernia.
Surgical treatment is the main method of preventing such severe
complications of a hernia, such as its infringement, inflammation, etc.
With uncomplicated hernias, tissues are dissected over the hernial protrusion,
hernial orifice, secrete the hernial sac and open it. set
the contents of the bag into the abdominal cavity, stitch and bandage the neck
hernial sac. The bag is cut off and the abdominal wall is strengthened in the area of hernial
gate by plasty with local tissues, less often with alloplastic materials.
Herniotomy is performed under local or general anesthesia.
Prevention. Prevention of the development of hernias in children is to comply with
hygiene of infants: proper care of the navel, rational feeding,
regulation of bowel function. Adults need regular exercise
physical culture and sports to strengthen both the muscles and the body in
in general.
Early detection of persons suffering from abdominal hernias is of great importance, and
surgery before complications develop. For this, it is necessary
preventive examinations of the population, in particular schoolchildren and the elderly
age.
inguinal hernia
Inguinal hernias account for 75% of all hernias. Among the sickwith inguinal hernias, men account for 90-97%.
Inguinal hernias are congenital and acquired.
Embryological information
From the third month of intrauterine development of the male embryothe floor begins the process of lowering the testicles. In area
protrusion of the internal inguinal ring
parietal peritoneum - vaginal process
peritoneum. In the following months of intrauterine
development, further protrusion of the diverticulum occurs
peritoneum into the inguinal canal. By the end of the 7th month, the testicles
begin to descend into the scrotum. By the time of birth
the child's testicles are located in the scrotum, the vaginal process
the peritoneum grows. When not fused, it forms
congenital inguinal hernia. In case of incomplete infection
vaginal process of the peritoneum in separate areas
it causes dropsy of the spermatic cord (funicolocele).
Groin Anatomy
When examining the anterior abdominal wall from the inside withsides of the abdomen, five folds can be seen
peritoneum and depressions (pits), which are places
exit of hernias. The external inguinal fossa is
internal opening of the inguinal canal, it is projected
approximately above the middle of the inguinal (pupart) ligament on
1.0-1.5 cm above her. Normally, the inguinal canal is
slit-like space filled with seminal fluid in men
cord, in women - round ligament of the uterus. Inguinal
the canal runs obliquely at an angle to the inguinal ligament and at
male has a length of 4.0-4.5 cm.
Inguinal canal and inguinal gap
The walls of the inguinal canal are formed: Anterior - by the aponeurosis of the external obliqueabdominal muscles, lower - inguinal ligament, back - transverse fascia
abdomen, upper - free edges of the internal oblique and transverse muscles
belly.
The external (superficial) opening of the inguinal canal is formed by the legs
aponeurosis of the external oblique muscle of the abdomen, one of them is attached to
pubic tubercle, the other - to the pubic fusion. Outer hole size
inguinal canal is different. Its transverse diameter is 1.2-3.0 cm,
longitudinal - 2.3-3.0 cm. In women, the external opening of the inguinal canal
somewhat less than in men.
Internal oblique and transverse abdominal muscles, located in the groove
inguinal ligament, approach the spermatic cord and are thrown through it,
forming an inguinal gap of various shapes and sizes. Inguinal borders
gap: below - inguinal ligament, above - the edges of the internal oblique and
transverse abdominal muscles, on the medial side - the outer edge of the straight
abdominal muscles. The inguinal gap may have a slit-like,
spindle or triangular shape. Triangular shape of the inguinal
gap indicates weakness of the groin.
At the site of the internal opening of the inguinal canal, the transverse fascia
funnel-shaped bends and passes to the spermatic cord, forming a common
vaginal membrane of the spermatic cord and testis.
Round ligament of the uterus at the level of the external opening of the inguinal canal
is divided into fibers, some of which end on the pubic bone, the other
lost in the subcutaneous adipose tissue of the pubic region.
Congenital inguinal hernia
If the vaginal process of the peritoneum remains completelyunclosed, then its cavity freely communicates with
peritoneal cavity. Later, it is formed
congenital inguinal hernia, in which the vaginal
the process is a hernial sac. Congenital inguinal
hernias make up the bulk of hernias in children (90%).
However, adults also have congenital inguinal hernias.
(about 10-12%).
Acquired inguinal hernias
Acquired inguinal hernia. Distinguish obliqueinguinal hernia and straight line. Oblique inguinal hernia
passes through the external inguinal fossa, straight -
through the medial. With a channel shape, the bottom
hernial sac reaches the external opening
inguinal canal. With a cord form of a hernia
exits through the external opening of the inguinal canal and
located at different heights of the spermatic cord.
With the inguinal-scrotal form, the hernia descends into
scrotum, stretching it.
Sliding inguinal hernias
are formed when one of the walls of the hernialsac is an organ partially covered by the peritoneum,
e.g. bladder, caecum. Rarely herniated
the bag is absent, and the entire protrusion is formed only
those segments of the slipped organ, which is not
covered with peritoneum.
Sliding hernias account for 1.0-1.5% of all inguinal
hernia They are caused by mechanical contraction.
peritoneum of the hernial sac of adjacent segments
intestines or bladder, devoid of serous cover.
It is necessary to know the anatomical features of the sliding
hernia, so as not to open during the operation instead of
hernial sac the wall of the intestine or the wall of the bladder.
Clinical picture and diagnosis of inguinal hernias
It is not difficult to recognize the formed inguinal hernia. Typical ishistory: sudden onset of a hernia at the time of physical exertion
or the gradual development of a hernial protrusion, the appearance of a protrusion with
straining, in the vertical position of the patient's body and reduction - in
horizontal. Patients are concerned about pain in the hernia, in the abdomen, feeling
discomfort when walking.
Examination of the patient in an upright position gives an idea of the asymmetry
groin areas. If there is a protrusion of the abdominal wall,
determine its size and shape. Finger examination of the external opening
the inguinal canal is produced in the horizontal position of the patient after
reduction of the contents of the hernial sac. doctor pointing finger
invaginating the skin of the scrotum, enters the superficial opening of the inguinal
canal, located inside and slightly higher from the pubic tubercle. Fine
the superficial opening of the inguinal canal in men passes the tip of the finger.
When the posterior wall of the inguinal canal is weakened, the tip can be freely inserted
finger behind the horizontal branch of the pubic bone, which cannot be done with
a well-defined posterior wall formed by the transverse fascia of the abdomen.
It is obligatory to study the organs of the scrotum (palpation of the seminal
cords, testicles and epididymis).
Examination of the patient
Examination of the patient in an upright position gives an idea ofasymmetries in the groin. If there is a protrusion of the abdominal
walls can determine its size and shape.
Finger examination of the external opening of the inguinal canal
produce in a horizontal position of the patient after reduction
contents of the hernial sac. doctor pointing finger
invaginating the skin of the scrotum, enters the superficial opening
inguinal canal, located medially and slightly higher from the pubic
tubercle. Normally, the superficial opening of the inguinal canal in men
misses the tip of a finger. With weakening of the posterior wall of the inguinal
canal, you can freely place your fingertip behind the horizontal branch
pubic bone, which cannot be done with a well-defined posterior
wall formed by the transverse fascia of the abdomen.
Determine the symptom of a cough shock. Examine both inguinal canals.
It is obligatory to examine the organs of the scrotum (palpation
spermatic cords, testicles and epididymis).
Examination of the patient
Diagnosis of inguinal hernia in women is based onexamination and palpation, since the introduction of a finger into the outer
opening of the inguinal canal is almost impossible.
In women, an inguinal hernia is differentiated from a cyst.
round ligament of the uterus located in the inguinal canal. IN
unlike a hernia, it does not change its size when
horizontal position of the patient, percussion sound over
it is always dull, and tympanitis is possible over the hernia.
Differential Diagnosis
Inguinal hernia should be differentiated from hydrocele, varicocele, andfemoral hernia.
The hydrocele has a rounded or oval, rather than pear-shaped, densely elastic consistency, and a smooth surface. Palpable education
cannot be distinguished from the testicle and its appendage. large hydrocele,
reaching the external opening of the inguinal canal, it can be clearly separated from it
on palpation. Percussion sound over the hydrocele is blunt, over the hernia may be
tympanic. An important method of differential diagnosis is
diaphanoscopy (transillumination). It is produced in a dark room using
a flashlight firmly attached to the surface of the scrotum. If palpable
formation contains a clear liquid, then it will be translucent
have a reddish color. Intestinal loops located in the hernial sac,
omentum do not let light rays through.
Varicocele (varicose veins of the spermatic cord), in which
in the vertical position of the patient, dull arching pains appear in
scrotum and there is a slight increase in its size. On palpation, you can
detect serpentine dilatation of the veins of the spermatic cord. Dilated veins
easily fall off when pressing on them or when raising the scrotum up.
It should be borne in mind that varicocele can occur with (testicular pressure
vein tumor of the lower pole of the kidney.
Treatment
The main method is surgical treatment.The main goal of the operation is plastic surgery of the inguinal canal.
The operation is carried out in stages. First stage -
formation of access to the inguinal canal: in the inguinal
areas make an oblique incision parallel and above
inguinal ligament from the anterior superior iliac spine
to the symphysis; dissect the aponeurosis of the external oblique muscle
abdomen its upper flap is separated from the internal oblique and
transverse muscle, lower - from the spermatic cord,
while exposing the groove of the inguinal ligament to the pubic
tubercle.
The second step is to isolate and remove the hernial sac;
The third stage - the deep inguinal ring is sutured to
normal sizes (diameter 0.6-0.8 cm)
The fourth stage is the actual plasty of the inguinal canal.
Access for inguinal hernia
When choosing a method of inguinal canal plasty, one shouldtake into account that the main cause of the formation of inguinal
hernia is a weakness of its posterior wall.
With direct hernias and complex forms of inguinal hernias
(oblique with a straightened canal, sliding, recurrent)
plasty of the posterior wall of the inguinal
channel.
Strengthening of its anterior wall with obligatory suturing
deep ring to normal size can be
used in children and young men with small
oblique inguinal hernias.
Stages of hernia repair
Stages of hernia repair
Stages of hernia repair
Stages of hernia repair
Stages of hernia repair
Stages of hernia repair
Stages of hernia repair
Stages of hernia repair
Stages of hernia repair
Stages of hernia repair
Methods of plastic surgery of the inguinal canal
The Bobrov-Girard method strengthens the anterior wall of the inguinal canal. Abovethe spermatic cord to the inguinal ligament is first sutured to the edges of the internal oblique and transverse
abdominal muscles, and then with separate sutures - the upper flap of the aponeurosis of the external oblique muscle
belly. The lower flap of the aponeurosis is fixed with sutures on the upper flap of the aponeurosis, thus forming
duplicating the aponeurosis of the external oblique muscle of the abdomen.
The Bassini method strengthens the posterior wall of the inguinal canal. After removal
hernial sac, the spermatic cord is moved aside and the internal oblique is sutured under it
and the transverse muscle along with the transverse fascia of the abdomen to the inguinal ligament. spermatic cord
placed on the formed muscle wall. Deep stitching helps
restoration of the weakened posterior wall of the inguinal canal. The edges of the aponeurosis of the external oblique
abdominal muscles sew edge to edge above the spermatic cord.
The Postempsky method consists in the complete elimination of the inguinal canal, the inguinal gap and in
creating an inguinal canal with a completely new direction. The edge of the sheath of the rectus muscle
the abdomen, together with the connected tendon of the internal oblique and transverse muscles, is sutured to
superior pubic ligament. Further, the upper flap of the aponeurosis, together with the internal oblique and transverse
the abdominal muscles are sutured to the pubic-iliac cord and to the inguinal ligament. These seams should
limit to move the spermatic cord to the lateral side. Lower flap of the external aponeurosis
oblique muscle of the abdomen, held under the spermatic cord, is fixed over the upper flap
aponeurosis. The newly formed "inguinal canal" with the spermatic cord must pass through
muscular-aponeurotic layer in an oblique direction from back to front and from the inside outwards so that
its inner and outer openings were not opposite each other. spermatic cord
is placed on the aponeurosis and the subcutaneous adipose tissue and skin are sutured over it.
femoral hernia
Femoral hernias are located on the thigh in the areafemoral triangle and account for 5-8% of all
abdominal hernia.
Especially often, femoral hernias occur in
women, which is explained by the greater
muscular and vascular lacunae and lesser
strength of the inguinal ligament.
Anatomy of femoral hernias
Between the inguinal ligament and the pelvic bones is locatedspace that is divided by the iliac crest
fascia into two gaps - muscular and vascular. IN
muscular lacunae are the iliopsoas muscle and
femoral nerve. The vascular lacuna contains the femoral
artery with femoral vein.
Between the femoral vein and the lacunar ligament is
gap filled with fibrous connective tissue
and the Pirogov-Rosenmuller lymph node. This
the gap is called the femoral ring, through which
femoral hernia comes out.
Borders of the femoral ring: from above - inguinal ligament; bottom -
crest of the pubic bone; outside - femoral vein; To
in the middle - lacunar (gimbernato) ligament.
Under normal conditions, the femoral canal does not exist. He
formed during the formation of a femoral hernia. oval
the fossa on the wide fascia of the thigh is the external opening
femoral canal.
Clinical picture and diagnosis
The characteristic symptom of a femoral hernia isprotrusion in the area of the femoral-inguinal fold in
the form of a hemispherical formation of a small
size located under the inguinal ligament
inside of the femoral vessels. Rarely hernial
the protrusion rises and is located
above the inguinal ligament.
Differential Diagnosis
A femoral hernia is differentiated from an inguinal hernia.hernia. For an irreducible femoral hernia, there may be
lipomas located in the upper
section of the femoral triangle. Lipoma has
lobed structure, not connected with the external
opening of the femoral canal. Simulate
femoral hernia may be enlarged lymphatic
nodes in the femoral triangle
(chronic lymphadenitis, tumor metastases in the lymph nodes).
Treatment of femoral hernias
Bassini method: the incision is made parallel to the inguinal ligament andbelow it above the hernial protrusion. Hernia gate
closed by stitching the inguinal and superior pubic ligaments.
3-4 stitches are applied. The second row of seams between
sickle-shaped edge of the broad fascia of the thigh and comb
fascia sutured the femoral canal.
Ruggi's method - Parlavecchio: the incision is made, as in the inguinal
hernia. The aponeurosis of the external oblique muscle of the abdomen is opened.
Expose the inguinal gap. Dissect the transverse fascia
in the longitudinal direction. Pushing back the preperitoneal
fiber, secrete the neck of the hernial sac. hernial sac
removed from the femoral canal, opened, stitched and
are removed. The hernial ring is closed by suturing
internal oblique, transverse muscle, upper edge
transverse fascia with superior pubic and inguinal ligaments.
Plastic surgery of the anterior wall of the inguinal canal is performed by
duplication of the aponeurosis of the external oblique muscle of the abdomen.
umbilical hernia
An umbilical hernia is called an organ protrusionabdominal cavity through an abdominal wall defect
navel area. The highest incidence
seen in children early age and persons in
about 40 years of age. In women, umbilical hernia
twice as common as in men due to
stretching of the umbilical ring during
pregnancy.
Treatment of umbilical hernias
Only surgical - autoplasty of the abdominal wall according toSapezhko or Mayo method.
Sapezhko method: with separate seams, capturing from one
sides, the edge of the aponeurosis of the white line of the abdomen, and on the other
sides - the posterior-medial part of the sheath of the rectus muscle
abdomen, create a duplication of muscular-aponeurotic
patches in the longitudinal direction. At the same time, the flap
located superficially, sutured to the bottom in the form
duplicates.
Mayo method: skin is excised with two transverse incisions
along with the umbilicus. After isolation and excision of the hernial
bag hernial gate expand in the transverse direction
two incisions through the white line of the abdomen and the anterior wall
sheaths of the rectus abdominis muscles to their inner edges.
The lower flap of the aponeurosis is sutured with U-shaped sutures under
upper, which is in the form of duplication with separate seams
sutured to the bottom flap.
Access for umbilical hernias
Sapezhko method
Mayo Method
Hernias of the white line of the abdomen
Hernias of the linea alba can besupra-umbilical, para-umbilical and sub-umbilical.
The latter are extremely rare.
Paraumbilical hernias are usually located on the side of
navel.
Characterized by pain in the epigastric region,
aggravated after eating, with an increase
intra-abdominal pressure. On examination
the patient is found typical for hernias
symptoms. Research needs to be done to
detection of diseases accompanied by pain
in the epigastric region.
Treatment of hernias of the white line of the abdomen
The operation is to close the hole inaponeurosis with a purse-string suture or separate
nodal sutures. With associated hernia
divergence of the rectus abdominis muscle is used
Napalkov method - dissect straight sheaths
abdominal muscles along the inner edge and sew
first the inner and then the outer edges of the sheets
dissected vaginas. Thus they create
doubling of the white line of the abdomen.
Rare types of abdominal hernias
Hernia of the xiphoid process is formed in the presence of a defect in it. Throughopenings in the xiphoid process may protrude as preperitoneal
lipoma, and true hernia. The diagnosis is made on the basis of the
compaction in the area of the xiphoid process, the presence of a defect in it and data
x-ray of the xiphoid process.
Lateral hernia (hernia of the semilunar line) exits through a defect in that part
aponeurosis of the abdominal wall, which is located between the semilunar
(spigelian) line (border between the muscular and tendon part
transverse abdominis muscle) and the outer edge of the rectus muscle. The hernia is going
through the aponeuroses of the transverse and internal oblique muscles of the abdomen and
located under the aponeurosis of the external oblique muscle of the abdomen in the form
interstitial hernia (between the muscles of the abdominal wall). Often
aggravated by abuse. Diagnosis is difficult, should be differentiated from
tumors and diseases of internal organs.
Lumbar hernias are rare. Their exit points are the upper and
lower lumbar triangles between the 12th rib and the iliac crest
bones along the lateral edge of the latissimus dorsi muscle (m. latissimus dorsi).
Hernias can be congenital and acquired; prone to abuse. Their
should be differentiated from abscesses and tumors.
Rare types of abdominal hernias
Obturator hernia (hernia of the obturator foramen) comes out along withneurovascular bundle (vasa obturatoria, n. obturatorius) through the obturator
a hole under the comb muscle (m. pectineus) and appears on the inner
surface of the upper thigh. More common in older women
due to weakening of the muscles of the pelvic floor. Hernia is usually small
sizes, can easily be mistaken for a femoral hernia.
Perineal hernias (anterior and posterior). Anterior perineal hernia
exits through the vesicouterine cavity (excavaflo vesicouterina) of the peritoneum
in the labia majora in its central part. Posterior perineal hernia
exits through the recto-uterine cavity (excavatfo rectouterina),
passes posteriorly from the intersciatic line through the gaps in the muscle that lifts
anus, and goes into the subcutaneous fatty tissue, is located
in front of or behind the anus. Perineal hernias are more common
observed in women. The contents of the hernial sac are urinary
bladder, genitals. Anterior perineal hernia in women
must be differentiated from an inguinal hernia, which also goes into
large labia. Assists in the diagnosis of digital examination through
vagina; hernial protrusion of the perineal hernia can be palpated
between the vagina and the ischium.
Sciatic hernias can exit through the large or small sciatic
hole. The hernial protrusion is located under the gluteus maximus
muscle, sometimes comes out from under its lower edge. hernial protrusion
is in close contact with the sciatic nerve, so pain can
irradiate along the course of the nerve. Sciatic hernias are more common in
women. The contents of the hernia can be the small intestine, the greater omentum.
Complications of external abdominal hernias
Incarcerated hernia is the most common andserious complication requiring immediate
surgical treatment.
The organs released into the hernial sac are exposed to
compression (usually at the level of the neck of the hernial sac
in the hernia gate).
Infringement of organs in the hernial sac itself
possibly in one of the chambers of the hernial sac, with
the presence of scar bands that compress the organs during
their fusion with each other and with the hernial sac
(with irreducible hernias).
According to the mechanism of occurrence, they distinguish:
Elastic infringement occurs at the moment of a sudden increaseintra-abdominal pressure during exercise, coughing,
straining. In this case, overstretching of the hernial gate occurs, in
as a result of which the hernial sac comes out more than usual,
internal organs. The return of the hernia gate to the former
the condition leads to infringement of the contents of the hernia. With elastic infringement, compression of the organs released into the hernial sac
happening outside.
Fecal infringement is more often observed in older people.
Due to the accumulation of large amounts of intestinal contents in
the leading loop of the intestine, located in the hernial sac, occurs
compression of the efferent loop of this intestine, pressure of the hernial ring on
the contents of the hernia intensify and lead to fecal infringement
elastic joins. This creates a mixed form.
infringement.
mixed
Pathological picture
In the strangulated organ, blood and lymph circulation is disturbed,due to venous stasis, extravasation occurs in the intestinal wall,
its lumen and the cavity of the hernial sac (hernial water).
The intestine acquires a cyanotic color, hernial water remains
transparent. Necrotic changes in the intestinal wall begin with
mucous membrane. The greatest damage occurs in the area
strangulation furrow at the site of compression of the intestine by the infringing
ring.
Over time, pathological changes progress,
gangrene of the strangulated intestine occurs. The intestine acquires a blue-black color, multiple subserous hemorrhages appear.
The intestine is flabby, does not peristaltize, the vessels of the mesentery do not pulsate.
Hernial water becomes cloudy, hemorrhagic with fecal
smell. The intestinal wall may undergo perforation with the development
fecal phlegmon and peritonitis.
Strangulation of the intestine in the hernial sac is a typical example
strangulation ileus.
Clinical picture and diagnosis
Clinical manifestations of hernia incarceration depend onfrom the form of infringement, the infringed organ,
the time elapsed since the infringement.
The main symptoms of a strangulated hernia
are pain in the area of the hernia and irreducibility
previously freely reduced hernia.
Clinical picture and diagnosis
The intensity of pain varies, sharp pain caninduce shock. Local signs
strangulated hernia are a sharp soreness
on palpation, compaction, tension of the hernial
protrusions. cough symptom
negative. Percussion determines
dullness in cases where the hernial sac
contains omentum, bladder, hernial water.
If there is an intestine in the hernial sac,
containing gas, then determine the tympanic
percussion sound.
Clinical picture and diagnosis
Elastic restraint. The onset of the complication is associated with an increaseintra-abdominal pressure (physical work, cough, defecation). At
infringement of the intestine, signs of intestinal obstruction join: on
against the background of constant acute pain in the abdomen, due to (pressure of blood vessels and
nerves of the mesentery of the strangulated intestine, there is cramping pain,
associated with increased peristalsis, there is a delay in stool and gases,
possible vomiting. Without urgent surgical treatment, the patient's condition
deteriorates rapidly: swelling, hyperemia of the skin appear in the area
hernial protrusion, phlegmon develops.
Retrograde infringement. The small intestine is often retrogradely infringed when
in the hernial sac there are two intestinal loops, and the intermediate
(connecting) loop is located in the abdominal cavity. Infringement is subjected to
more binding intestinal loop. Necrosis begins earlier in
intestinal loop located in the abdomen above the restraining ring. In it
time, the intestinal loops in the hernial sac may still be
viable.
Wall infringement occurs in a narrow infringing ring, when
only part of the intestinal wall is infringed, opposite to the line
attachment of the mesentery. It is observed more often in femoral and inguinal hernias,
less often - in the umbilical. Disorder of lymph and blood circulation in the strangulated
part of the intestine leads to the development of destructive changes, necrosis and
bowel perforation.
Treatment of strangulated hernias
If a hernia is incarcerated, an emergency operation is necessary. She is being carried outso that, without cutting the restraining ring, open the hernial
bag, prevent the escape of strangulated organs into the abdominal
cavity. The operation is carried out in several stages.
The first stage is a layer-by-layer dissection of tissues up to the aponeurosis and
exposure of the hernial sac.
The second stage is the opening of the hernial sac, removal of the hernial water.
To prevent slipping into the abdominal cavity of the restrained
organs, the surgeon's assistant holds them with gauze
napkins. It is unacceptable to cut the restraining ring before opening
hernial sac.
The third stage - dissection of the infringing ring under control
vision, so as not to damage the organs soldered to it from the inside.
The fourth stage - determining the viability of the disadvantaged
organs. This is the most critical stage of the operation. Main
small bowel viability criteria are recovery
normal color of the intestine, preservation of the pulsation of the vessels of the mesentery,
absence of strangulation furrow and subserous hematomas,
restoration of peristaltic contractions of the intestine. Undisputed
signs of non-viability of the intestine are dark color,
dull serous membrane, flabby wall, lack of pulsation
vessels of the mesentery and peristalsis of the intestine.
Treatment of strangulated hernias
Fifth stage - resection of a non-viable loopintestines. From the serous cover visible from the side
the borders of necrosis are resected at least 30-40 cm
afferent segment of the intestine and 10 cm of the outlet
segment. Resection of the intestine is performed upon detection
in its wall of the strangulation groove, subserous
hematomas, edema, infiltration and hematoma of the mesentery
intestines.
When infringing a sliding hernia, it is necessary
determine the viability of a part of an organ, not
covered with peritoneum. When necrosis is detected, the blind
intestines resect the right half of the colon
intestines with the imposition of ileotransverse anastomosis. At
necrosis of the bladder wall requires resection
changed part of the bubble with overlay
epicystostomy.
The sixth stage - plastic hernial ring. When choosing
rhinoplasty should be preferred
the simplest.
Forecast
Postoperative mortality increases withlengthening the time elapsed since
infringement before surgery, and is in the first 6 hours -
1.1%, within the period from 6 to 24 hours - 2.1%, later than 24 hours -
8.2%; after resection of the intestine, the mortality rate is 16%,
with hernia phlegmon - 24%.
Complications of independently reduced and forcibly reduced strangulated hernias
A patient with a restrained spontaneousreduced hernia should be
hospitalized in surgery department.
Spontaneously reduced previously restrained
the intestine can become a source of peritonitis or
intra-intestinal bleeding.
irreducibility
Due to the presence of adhesions in the hernial sacinternal organs among themselves and with the hernial sac,
formed as a result of their traumatization and aseptic
inflammation.
Irreducibility may be partial when one part
the contents of the hernia is reduced into the abdominal cavity, and the other
remains irrelevant. Contributes to the development of irreducibility
prolonged wearing of the bandage.
Irreducible are more often umbilical, femoral and
postoperative hernia. Quite often irreducible
hernias are multidimensional. Due to development
multiple adhesions and chambers in the hernial sac irreducible
hernia is more often complicated by infringement of organs in one of the chambers
hernial sac or the development of adhesive obstruction
intestines.
Coprostasis
Coprostasis - stagnation of feces in the large intestine. Thiscomplication of a hernia, in which the contents of the hernial sac
is the large intestine. Coprostasis develops as a result
intestinal motility disorders. Its development
contribute to the irreducibility of the hernia, a sedentary image
life, abundant food. Coprostasis is more common in obese
senile patients, in men with inguinal hernias, in
women - with umbilical.
The main symptoms are persistent constipation, pain in
stomach, nausea, rarely vomiting. Hernial protrusion slowly
increases as the colon fills with stool
masses, it is almost painless, slightly tense,
pasty consistency, symptom of cough shock
positive. General condition of patients of moderate severity.
Prevention of complications
consists in the surgical treatment of all patientswith hernias in a planned manner before development
complications. The presence of a hernia is an indication for
operations.
Internal abdominal hernia
Internal hernia of the abdomen is called the movement of organsabdominal cavity into pockets, fissures and holes of the parietal
peritoneum or chest cavity (diaphragmatic hernia). IN
embryonic period of development as a result of the rotation of the primary
intestines around the axis of the superior mesenteric artery, the upper
duodenal recess (recessus duodenalis superior - pocket
Treitz). This depression can become a hernial orifice with
formation of an internal strangulated hernia.
Hernias of the lower duodenal recess (recessus duodenalis inferior)
are called mesenteric hernias. Loops of the small intestine from this
recesses can penetrate between the plates of the mesentery of the colon
bowels right and left.
More often hernial gates of internal hernias are pockets
peritoneum at the confluence of the ileum into the blind (recessus
ileocaecalis superior et inferior, recessus retrocecalis) or in the area
mesentery of the sigmoid colon (recessus intersigmoideus).
The reasons for the formation of a hernial ring may be not sutured during
time of operation gaps in the mesentery, greater omentum.
Symptoms of the disease are the same as in acute obstruction
intestines, about which patients are operated on.
Treatment of internal hernias
Apply general principles for the treatment of acuteintestinal obstruction. During the operation
carefully examine the walls of the hernial gate, on
touch determine the absence of pulsation of a large
vessel (superior or inferior mesenteric artery).
The hernial orifice is dissected on avascular
plots. After careful release and
displacement of intestinal loops from the hernial sac
he is sutured.
External hernia of the abdomen is the protrusion of the internal organs of the abdominal cavity through defects in the muscular-aponeurotic wall of the abdomen or pelvis along with the parietal sheet of the peritoneum. An internal hernia is the penetration of the organs of the abdominal region into a normally existing or pathologically formed peritoneal sac (hernias of the omental sac, diaphragmatic hernias, hernias of the duodenal-small intestinal fossa (Treits's fossa), retroduodenal fossa (mesenteric hernia) in the region of peritoneal pockets near the blind and sigmoid colon). should be distinguished the following concepts: Eventeration - the exit of the viscera from the abdominal cavity resulting from damage to the abdominal wall (wound, rupture). The parietal sheet of the peritoneum is absent. Prolapse of an organ - the insides protrude from some area and are not covered by the peritoneal sheet (neither visceral nor parietal) For example: prolapse of the rectum, uterus, bladder.
Meet most often - up to 75% of all hernias are oblique and direct, congenital and acquired unilateral and bilateral. Combinations with dropsy of the spermatic cord, testicle, cryptorchidism can occur. Up to 5% there are sliding hernias containing the caecum, bladder, kidney, ureter, uterus, sigmoid colon. When wounded during the operation of these organs, the mortality rate reaches 27%.
Hernias that form in the vascular lacuna - the most common are typical (or medial) femoral hernias that pass through the femoral canal, i.e. medial to the femoral vein. However, there may be so-called lateral vascular-lacunar femoral hernias, when the hernial protrusion is located outward from the femoral artery, and middle vascular-lacunar hernias, when the hernial sac is located under the ligament above the femoral artery and vein. Hernias extending into the region of the muscular lacuna - rare, located under the inguinal ligament in front of the iliopsoas muscle, lateral to the femoral artery. Hernias of the lacunar ligament - are even rarer, occur in older women with a wide lacunar ligament.
Femoral hernias are more common in older women, infringed in 30-60%. In this case, compression of the hernial contents by the sharp edge of the lacunar ligament can quickly lead to necrosis. Therefore, femoral hernias require priority planned surgical treatment; as a rule, there is no need to cut the hernia orifices, i.e. the minimum probability of damage to the "corona mortis", which occurs in 10-15% when a. obturatoria departs from a. epigastrica inferior or directly from a. ileaca externa.
Umbilical hernias account for 2-5% of all hernias. In 85% of cases, they occur in women. The peculiarity of these hernias in children is that: they are detected in the first weeks of life (with incomplete fusion or weakness of the umbilical ring), or up to 3 years (against the background of constipation, coughing, crying), they are small in size (up to 1-2 cm) are rarely harmed. Hernias of the white line of the abdomen occur in 90-95% of men. The most common are epigastric (82%), followed by mesogastric (~15%) and hypogastric in 0.3% of cases. The size of hernias of the white line, as a rule, is up to 10 cm, the contents are most often a strand of the greater omentum. The second most common group of abdominal hernias are postoperative hernias. Among them, it is necessary to single out a group of actually postoperative hernias - this is 3% of all "clean" laparotomies for any disease, 10% of festering surgical wounds and 10% of gunshot wounds of the abdominal cavity. It is also necessary to single out a group of recurrent hernias that occurred after the previous hernia repair. From 18 to 78%, depending on the type and location of the hernia, there are recurrences. A feature is the violation of the topographic-anatomical relationship of tissues, the presence of cicatricial-altered structures of encapsulated "ligature granulomas", "dormant infection" in the scars, and sometimes the presence of fistulas.
Perineal hernias - can be located anterior to the intersciatic line, starting from the vesico-uterine cavity in women, and posterior to this line, starting in men from the vesico-rectal cavity, and in women from the uterine-rectal cavity of the pelvic peritoneum. Lateral hernias of the abdomen - are formed along the Spigelian line and near the rectus abdominis muscles.
Meet with a wide obturator canal. With a fully formed hernia, it is determined on the inner surface of the thigh under the adductor muscles. Most often, obturator hernias are incomplete, their clinical picture is unclear, they are recognized during surgery with infringement.
Compulsory studies - studies that must be carried out for each patient 1) clinical examination; 2) laboratory tests: KLA, OAM, blood group, Rh factor, blood coagulation time, prothrombin index, glucose, blood urea; 3) ECG (in patients over 50 years of age or in patients who are scheduled for surgery under general anesthesia); 4) consultation of the therapist (for the last group of patients); 5) fluorogram of OGK during planned admission.
Recommended studies - studies, the significance of which has been proven when used for most patients 1) blood electrolyte composition (Na +, K +, CL-); 2) blood biochemistry (bilirubin, creatine); 3) coagulogram; 4) acid-base state and one-time blood composition; 5) cystoscopy (cystography) with suspicion of the presence of a bladder in a hernia; 6) consultation with a urologist, breath tests (with planned admission). Supplementary Research - Research Significant to certain categories patients, as well as those performed for the purpose of a more detailed assessment of homeostasis disorders. 1) survey radiography of the abdominal cavity; 2) Ultrasound of the abdominal cavity.
I. Conservative treatment is carried out only in 2 cases: in children under 2 years of age (the application of dressings from a plaster in the form of tiles for umbilical hernias). Indications for surgery are a rapid increase in hernia, irreducibility and infringement. in adult patients with contraindications to planned surgical treatment, i.e. conditions and diseases that make hernia repair life-threatening or are the cause of hernia formation (decompensated heart disease, heart failure, uncorrected coagulopathy, active tuberculosis, malignant tumors and urethral strictures, prostate adenoma, pustular skin lesions, etc.) Such patients should be advised wearing a bandage, which gives only a symptomatic effect - closes the hernial orifice and does not allow the hernial contents to escape into the hernial sac. It is impossible to recommend wearing a bandage to patients who do not have contraindications to surgery, because. prolonged wearing of the bandage contributes to the expansion of the hernial gate (due to pressure on the tissues) and the formation of adhesions between the internal organs and the hernial sac.
4 hours), especially in case of extensive multi-chamber ventral hernia" title=" Incarcerated hernias are subject to emergency surgical treatment. with extensive multi-chamber ventral hernia" class="link_thumb"> 14 !} Strangulated hernias are subject to emergency surgical treatment. There are no contraindications to the operation. In patients in serious condition with many hours of infringement of the hernia contents (> 4 hours), especially with extensive multi-chamber ventral hernias, with the presence of clinical signs of endotoxicosis and homeostasis disorders, as well as with a high anesthetic risk, it is possible to conduct emergency short-term preoperative infusion preparation in the amount of ml / kg body weight of the patient directly on the operating table. The main fundamental difference between the surgical aid for a strangulated hernia (as opposed to an uncomplicated one) is the need for an initial opening of the hernial sac for fixation and examination of the strangulated organs and subsequent dissection of the strangulated ring. 4 hours), especially with extensive multi-chamber ventral hernia "\u003e 4 hours), especially with extensive multi-chamber ventral hernias, with clinical signs of endotoxicosis and homeostasis disorders, as well as with high anesthetic risk, emergency short-term preoperative infusion preparation in the amount of 25-35 ml / kg of the patient's body weight directly on the operating table. The main fundamental difference between the surgical aid for strangulated hernia (as opposed to uncomplicated) is the need for initial opening of the hernial sac to fix and examine the strangulated organs and subsequent dissection of the strangulated ring. "> 4 hours), especially with extensive multi-chamber ventral hernias" title=" Strangulated hernias are subject to emergency surgical treatment. There can be no contraindications to surgery. In patients in serious condition with many hours of incarceration of the hernia contents (> 4 hours), especially with extensive multi-chamber ventral hernias"> title="Strangulated hernias are subject to emergency surgical treatment. There are no contraindications to the operation. In patients in serious condition with many hours of incarceration of the hernia contents (> 4 hours), especially with extensive multi-chamber ventral hernia"> !}
In case of infringement of the intestine, the signs of its vitality are the following (should be reflected in the protocol of the operation): 1. restoration of the pink color of the serous cover; 2. restoration of peristalsis; 3. restoration of pulsation of the vessels of the mesentery. In doubtful cases, the recommended measure is the use of modern instrumental methods: laser Doppler flowmetry and intraoperative biomicroscopy. In the presence of intestinal necrosis, it is necessary to perform its resection and decompressive nasointestinal intubation of the intestine in accordance with the standards adopted for the treatment of acute intestinal obstruction. If it is impossible to perform intestinal intubation in conditions of a sharp overextension of the intestinal loops from the herniolaparotomy access, the latter is either expanded (with p / o and umbilical hernias), or an additional median laparotomic access is performed (with femoral, inguinal hernias).
With necrosis of the bladder wall, the strangulated part of the bladder is resected, an epicystostomy is applied, a urethral catheter is installed, and a flushing system is being established. With a strangulated hernia of Littre, Meckel's diverticulum is resected, regardless of the state of its viability, using either a ligature-purse-string method (similar to appendectomy) or a wedge-shaped resection of the intestine, including the base of the diverticulum. In case of necrosis of the wall of the caecum, it is necessary to perform a right-sided hemicolectomy with the imposition of an ileotransverse anastomosis. If a mistake was made in the differential diagnosis and during the operation for a strangulated femoral hernia, not a hernia was found, but an enlarged inflamed lymph node - Pirogov, then it should not be removed because of the possibility of developing prolonged lymphorrhea and lymphostasis of the limb. The operation ends with the imposition of rare stitches on the wound with drainage leading to the inflamed lymph node.
Spontaneous reduction of a strangulated hernia If this reduction occurred before hospitalization or in the emergency room, then the patient must be hospitalized in the surgical department for diagnostic observation. Spontaneous reduction of a hernia after prolonged strangulation (>4-6 hours) requires emergency laparoscopy. If, during observation for hours, the patient develops abdominal pain, positive symptoms of peritoneal irritation, increasing toxicosis, or a clinic of intestinal obstruction, then it is necessary to perform a median laparotomy, revision and elimination of the cause of obstruction or resection of the strangulated organ according to indications. If spontaneous reduction of the hernia occurred during "induction anesthesia" or the beginning of local anesthesia, then an opening of the hernial sac should be performed with a revision of nearby organs to identify the organ that has been infringed and assess its viability. If it is difficult to find the strangulated organ, it is advisable to perform laparoscopy through the mouth of the hernial sac. If the condition of the abdominal cavity in the next day after the reduction of the hernia does not cause concern, then the patient, after the necessary examination, can be operated on in a planned manner. 4-6 hours), an emergency laparoscopy is necessary. If, during observation for 24-48 hours, the patient develops abdominal pain, positive symptoms of peritoneal irritation, increasing toxicosis, or a clinic of intestinal obstruction, then it is necessary to perform a median laparotomy, revision and elimination of the cause of obstruction or resection of the strangulated organ according to indications. If spontaneous reduction of the hernia occurred during "induction anesthesia" or the beginning of local anesthesia, then an opening of the hernial sac should be performed with a revision of nearby organs to identify the organ that has been infringed and assess its viability. If it is difficult to find the strangulated organ, it is advisable to perform laparoscopy through the mouth of the hernial sac. If the condition of the abdominal cavity in the next day after the reduction of the hernia does not cause concern, then the patient, after the necessary examination, can be operated on in a planned manner. 
Phlegmon of the hernial sac The operation begins with a median laparotomy. If the intestinal loop is infringed, then it is resected in cm from the adductor and in cm from the outlet section. The ends of the strangulated part of the intestine are tied up, and the patency of the intestine is restored by applying an “end-to-end” anastomosis, and only if there is a significant discrepancy between the diameters of the intestine - “side to side”. At this stage of the operation, the peritoneal cavity must be isolated from the cavity of the hernial sac. To do this, the parietal peritoneum is dissected around the mouth of the sac and it is cut off to the sides by 2 cm, the ends of the strangulated section of the intestine are re-tied, cut off at the hernial orifice, and the separated section of the parietal peritoneum is sutured over them. The median wound is sutured tightly in layers. Next, a herniotomy should be performed, the bottom of the hernial sac should be opened, then the pinching ring should be cut so that the pinched organ can be removed and removed. The hernial sac is not isolated from the surrounding tissues. It is stitched at the neck with tampons brought to it, which completes the intervention. Hernioplasty in conditions of purulent infection is categorically contraindicated, not only because it is doomed to failure in advance, but also because it can lead to the development of severe phlegmon of the abdominal wall. With phlegmon of an umbilical hernia, it is possible to use the circular through method of hernia repair according to Grekov.
The modern concept of hernia formation in relation to inguinal hernias as a whole has not been the subject of scientific disputes for a long time. It is based on the universally recognized work on the failure of the connective tissue structures of the posterior wall of the inguinal canal. It follows that the main pathogenetic principle of the treatment of inguinal hernias is to restore the posterior wall of the inguinal canal and give it the necessary mechanical strength, and hernioplasty methods should be evaluated according to the main criterion: whether this goal of the operation is achieved or not. For more than 100 years, operations for inguinal hernias have been performed in Russia according to the principle founded by Bassini in 1884. The Bassini operation was the basis for many other hernioplasty methods.
Author Method of plastic surgery Year Frequency of relapses Nesterenko Yu.A. Bassini, 2% Salov Yu.B. Kukudzhanova 19828.9% Mitasov I.G. .Shouldice19927.0% Nyhus L.Nyhus19936.0%
The main reason for the unsatisfactory results of treatment with traditional methods of inguinal canal plasty is the convergence of heterogeneous tissues under tension, which is contrary to the basic principles of surgery. Muscles sutured to the inguinal ligament undergo degeneration, atrophy and cicatricial degeneration, and tension leads to ischemic tissue necrosis along the suture line, their eruption and further relapse. The noted circumstances contributed to the development and improvement new technology treatment - tension-free hernioplasty. When plastic hernias of the white line of the abdomen, umbilical, small ventral postoperative hernias, in the absence of tissue tension, the use of traditional surgical methods is competent. In strangulated giant ventral hernias, which include most of the contents of the abdominal cavity, especially in elderly people with severe comorbidities, if it is impossible to perform tension-free hernioplasty due to the absence of an allograft, the hernia ring should not be sutured, but only skin sutures should be applied to the wound.
The basis of tension-free plasty is the elimination of the causes of relapses characteristic of traditional types of hernioplasty: 1. Stitching of scar tissue 2. Stitching of heterogeneous tissues (in inguinal hernias) 3. Tissue ischemia due to tension and compression by sutures In tension-free plasty, the hernial orifice remains in its original state. The allomaterial covering the hernial orifice holds the tissues in a fixed position, stimulates the rapid formation of mature connective tissue, which is equal in strength or greater than the strength of the aponeurosis.
1. Elasticity so as not to cause pressure sores of adjacent tissues 2. Resistance to infection 3. Does not cause pronounced inflammatory, allergic reactions 4. Porosity for the penetration of macrophages, fibroblasts, blood vessels and collagen fibers into the pores 5. Long-term mechanical strength and integrity 6. Not have carcinogenic properties
ABSORBABLE polygloctin-910 (vicryl) polyglycolic acid (dexon) They are absorbed on the day after the operation. The main mesh manufacturers are "Ethicon", "B.Braun", "USSC USA", "Ecoflon". NON-ABSORBABLE polypropylene (Surgipro, Marlex, Prolene, Atrium) polyester (Mersilene) polytetrafluoroethylene (Tetlon, Gjre - Tex, Ecoflon) - maximally inert, can be located intraperitoneally without the risk of causing adhesions, because due to the very low surface tension, it is difficult for the fibroblast to adhere to the surface of this plate
It is used in 70-80% of cases with inguinal hernias in America and Europe. Its main principle is to strengthen the posterior wall of the inguinal canal with mesh allomaterial. Since Liechtenstein presented the results of more than 6,000 operations in 1989, this technique has been widely used throughout the world, with almost the same results as those achieved in the USA at the Liechtenstein Institute. This fact: trainability and reproducibility is the highest advantage of any technique.
Author Number of operations Age of patients Recurrence rate Lichtenstein L ,1% Horeyseck J ,25% Kux M ,9% Egiev V.N.,9% Friis M ,9% -14% to 1%): 2. Reducing the trauma of the operation, which reduces the severity of the pain syndrome and allows patients to be discharged on days 3-4 3. Earlier return of patients to a normal lifestyle, due to the presence of an endoprosthesis in the wound, which gives extra strength
Suppuration of the postoperative wound (there is no need to remove the endoprosthesis) Rejection of the endoprosthesis Sensation of a foreign body. There are publications reporting the possibility of discomfort during coition in men under 25 years of age, and therefore the use of this technique in this group of patients should be limited. Seroma Hematoma
General principles of endoprosthesis implantation: It is desirable to avoid contact of the allomaterial with subcutaneous tissue to prevent the formation of seromas After fixation to the tissues, the endoprosthesis should lie without tension Contact of the endoprosthesis with the visceral peritoneum is unacceptable (excl. PTFE)
1. Preperitoneal implantation - the mesh is placed in the preperitoneal space, behind the aponeurosis, which eliminates the problem of formation of subcutaneous tissue by seromas, reduces the risk of infection and eliminates the displacement of the prosthesis with an increase in intra-abdominal pressure.
3. Supraponeurotic implantation - the mesh is located in the subcutaneous fat layer, fixed over the aponeurosis and muscles. With the "tension" option, the hernia ring is pre-produced, the mesh is laid over the seams. With the "non-stretch" method, the mesh is laid and fixed without tension to the aponeurosis along the perimeter with U-shaped seams.
1. Laparoscopic preperitoneal prosthetic hernioplasty: Under conditions of pneumoperitoneum, the peritoneum is cut with scissors in a U-shaped or arcuate manner, skirting the lateral and medial inguinal fossae from above. Next, the peritoneum is cut off to the pubic bone. The hernial sac is bluntly separated from the elements of the spermatic cord and transverse fascia. To close all three pits (femoral, lateral and medial inguinal) - potential places the exit of hernias, the dimensions of the mesh must be at least 6 x 11 cm. The mesh can be applied without a cut (for direct inguinal hernias), or with a preliminary cut to wire it under the elements of the spermatic cord. Fixation of the prosthesis is carried out with a hernia stapler with tantalum clips (10 pieces) avoiding damage to the iliac, lower epigastric, testicular vessels, the vas deferens, and the bladder.
Under endotracheal anesthesia, under conditions of tense carboxyperitoneum, the contents of the hernial sac are removed into the abdominal cavity, the sac itself may not be resected. A polytetrafluoroethylene implant is introduced into the abdominal cavity, exceeding the size of the hernial defect by at least 1 cm along the perimeter. The prosthesis is fixed over the peritoneum using a stapler with clips elongated to 4.8 mm around the perimeter. General absolute contraindications are: pregnancy; concomitant diseases and conditions in which general anesthesia and planned surgical treatment are contraindicated. Relative contraindications include obesity of 3-4 degrees, adhesive process in the abdominal cavity. If an adhesive process is suspected, the question of the possibility of performing an operation should be decided after performing a diagnostic laparoscopy. The presence of additional special equipment allows operations to be performed under the conditions of the adhesive process, however, the risk of intraoperative complications increases. II Local contraindications include: strangulated hernias; sliding; irreducible; giant inguinal hernias associated with dropsy of the spermatic cord and dropsy of the testicular membranes. With the increase in experience in performing endovideosurgical herneoplasty, it becomes possible to perform operations in patients with complicated forms of inguinal hernias.
Occur due to insufficient closure of the hernial orifice due to displacement of the implant with its not quite reliable fixation, as well as with insufficient prosthesis sizes. They usually occur within the first three weeks after surgery. In the late period, relapses are more rare, because. the prosthesis that had time to germinate with connective tissue is securely fixed in the hernial orifice.
FACULTY
SURGERY
Saint Petersburg
2010
External hernia
abdomen (Hernia
abdominalis externa) hernia, in which
abdominal organs
cavities along with
covering them
parietal peritoneum
come out through
natural or
artificial
holes in the abdomen
wall while maintaining
skin integrity
covers.
ANATOMICAL CLASSIFICATION
EXTERNAL HERNIAS - inguinal, femoral,
umbilical, perineal, lumbar;
hernia of the white line of the abdomen; hernia
Spigelian line; hernial protrusions,
exiting through the sciatic or
obturator opening;
postoperative hernia.
INTERNAL HERNIAS diaphragmatic hernia;
hernias that form in the abdominal cavity
pockets and pleats.
ETIOLOGICAL CLASSIFICATION
CONGENITAL HERNIAS
CLINICAL CLASSIFICATION
REDUCIBLE HERNIAS
Hernial contents are easily reduced into
abdominal cavity.
IRREGIBLE HERNIAS
Hernial contents cannot be
completely retracted into the abdominal cavity.
STRENGTHENED HERNIAS
There is an acute dysfunction and
blood supply released into the hernial
bag of organs due to their compression in
hernial ring.
COMPLAINTS
Drawing pain or
discomfort
in the area of hernial
Objective research
Diaphanoscopy
X-ray methods
X-ray contrast herniography
X-ray contrast studies
hollow organs (with suspicion of
sliding hernia)
Laparoscopic diagnostics
1. Bassini method.
After a skin incision and aponeurosis of the external oblique muscle and a high removal of the hernial sac, the spermatic cord is completely isolated and retracted anteriorly. Then so-called deep seams are applied.
They capture from above the lower edge of the internal oblique and transverse muscles, the transverse fascia. In the first two sutures from the pubic joint, the edge of the rectus muscle is also captured along with its sheath and sutured for 5-7 cm to the inguinal ligament, and the periosteum in the region of the pubic tubercle is also captured in the first suture.
The spermatic cord is placed on the created muscle bed and the edges of the aponeurosis of the external oblique muscle are sutured over it with a number of nodular sutures.
or posterior wall of the inguinal canal.
These methods of plastic surgery are used for large, recurrent hernias in cases where it is impossible to repair the inguinal canal with local tissues. In these cases, free plasty by the wide fascia of the thigh is used (Kirchner method, skin flap (Barnov method), or using alloplastic material (tantalum mesh, nylon fabric, nylon and other chemical materials).
Classification
By origin, there are congenital and acquired hernias.
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According to the placement of hernias relative to the abdominal wall, they are divided into external and internal.
According to the anatomical structure and, accordingly, the place of their exit from the abdominal cavity, two types of hernias are distinguished: oblique (hernia inguinalis externa s.obligua) and direct (hernia inguinalis interna s.directa).
In connection with the different options for the placement of the hernial sac, other types of inguinal hernias can rarely be observed: oblique with a direct canal, preperitoneal, intramural, encysted, parainguinal, supravesical, combined.
1) hernia of the umbilical cord (embryonic hernia);
2) umbilical hernia in children;
3) umbilical hernia in adults
1. Elastic
2. Fecal
3. Mixed
2. Chronic
Hernias develop gradually. With heavy physical exertion, running, jumping, the patient feels tingling pains at the site of the forming hernia.
The pains are initially weak, they are of little concern, but gradually intensify and begin to interfere with walking and work. After a certain time, the patient discovers a protrusion that comes out (appears) during physical exertion and disappears at rest.
Gradually, the protrusion increases in size and acquires a rounded or oval shape. If the protrusion at rest, in a horizontal position or by pressing the hand disappears, then such a hernia is called.
inguinal hernia
Inguinal hernia is a disease in which internal organs protrude through the inguinal fossa into the inguinal canal through the uncovered vaginal process of the peritoneum or into the newly formed hernial sac, which is located in the spermatic cord or outside it.
The greatest number of inguinal hernias occur at the earliest childhood(1-2 years) when oblique congenital hernias appear. Inguinal hernia is more common in men (85-90%) and much less often in women. Women in most cases have oblique hernias; direct hernias in women are rare.
1. Czerny's method. After ligation and removal of the bag, without opening the aponeurosis of the external oblique muscle, sutures are placed on its legs. Then 3-4 sutures are applied, capturing from above the formed fold of the aponeurosis of the external oblique muscle, and from below the aponeurosis just above the inguinal fold.
2. Ruji's way. After isolation, ligation and removal of the hernial sac without opening the aponeurosis of the external oblique muscle, starting from the external opening of the inguinal canal, 4-5 sutures are applied, capturing the aponeurosis of the external oblique muscle from above along with the muscles located under it, and from below the inguinal ligament.
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channel to its normal state.
1. Martynov's method. After removal of the hernial sac, 4-5 sutures are placed between the edge of the upper flap of the aponeurosis of the external oblique muscle and the inguinal ligament. The lower flap of the aponeurosis of the external oblique muscle is applied over the upper one and fixed with sutures without much tension.
2. Girard's method.
After removal of the hernial sac, the edge of the internal oblique and transverse muscles is sutured to the inguinal ligament in front of the spermatic cord. After that, separately the edge of the upper flap of the aponeurosis of the external oblique muscle of the abdomen is sutured to the inguinal ligament.
The lower flap is fixed over the upper flap with several sutures, forming a duplication.
channel.
Postempsky way. The aponeurosis of the external oblique muscle is dissected closer to the inguinal ligament.
Separate the spermatic cord. Then the internal oblique and transverse muscles are dissected to the lateral side from the deep opening of the inguinal canal in order to move the spermatic cord to the upper lateral corner of this incision.
After that, the muscles are sutured. The superficial fascia is sutured from above from the spermatic cord.
According to Lovkud, after dissection of the skin and subcutaneous tissue, the hernial sac is isolated, opened, and the contents are pushed into the abdominal cavity. The hernial sac is tied up and cut off. The femoral canal is closed by suturing the inguinal ligament to the periosteum of the pubic bone with 2-3 nodular sutures.
1. The modification of the Bassini operation consists in the fact that after suturing the inguinal ligament to the periosteum of the pubic bone, a second row of sutures is applied to the semilunar edge of the oval femoral fossa and the pectinate ligament.
suturing the stomach to the diaphragm around the esophagus with fixation of its lesser curvature to the abdominal wall to restore an acute angle between the fundus of the stomach and the abdominal part of the esophagus; used to treat reflux esophagitis and sliding hiatal hernia
1) elimination of infringement;
2) revision of the restrained organs and, if necessary, appropriate interventions on them;
3) plastic hernia gate
7. ETIOLOGY
REASONS FOR EDUCATION
(Anatomical features
structures of the abdominal wall
White line of the abdomen
umbilical ring
Spigelian line
inguinal canal
femoral canal
PREDISPOSING
MANUFACTURERS
PREDISPOSING
HERITAGE (constitution,
congenital weakness of the connective
PREGNANCY
OBESITY
SHARP EXHAUSTATION (including with cancer)
DISTURBANCE OF COLLAGEN SYNTHESIS
Post-traumatic
postoperative
abdominal defects
MANUFACTURERS
hard physical work
Some professional
harmfulness (playing on wind
is a protrusion of an organ, part of it, or internal
body tissues through natural channels or
through pathologically formed (abnormal)
holes. Protruding tissues change their
normal position, going beyond that
cavity in which they should be. These fabrics
covered with one or more shells and not
have direct contact with the environment
environment.
peritoneum, exiting through the hernial orifice. IN
it distinguishes the neck, body and apex.
Hernial orifice (HV) - defect (weak point)
in the wall of the abdominal cavity, through which under
under the influence of various causes
protrusion (protrusion) of the hernial sac with
content.
Hernial contents (HS) - what is contained
in the hernial sac. They are usually
mobile organs of the abdominal cavity: omentum,
loops of the small intestine, sigmoid, transverse colon and caecum, vermiform
process, uterine appendages, etc. Content
diaphragmatic hernia can be the stomach,
spleen, liver. sudden or gradual pressure on an organ
abdominal cavity in the hernial orifice, leading to
disruption of its blood supply and necrosis.
one of the most frequent and formidable complications. They belong
to acute surgical diseases of the abdominal organs
cavities and occupy the fourth place among them after acute
appendicitis, acute cholecystitis and acute pancreatitis. By pathogenesis:
1. Elastic
2. Fecal
3. Mixed
By clinical course:
1. Spicy
2. Chronic
Types of infringement:
1. Retrograde
2. Parietal Spastic state of the tissues surrounding the hernial
hole
Narrowness of the hernia
The density and inflexibility of the edges of the hernial opening
Inflammatory changes in the area of hernial contents
and the possibility of infringement
Various physical changes in the
displaced body Elastic restraint
Fecal infringement.
Fecal and elastic infringement.
Retrograde infringement
Wall infringement (Richters) By elastic restraint is meant
sudden release of a large amount
abdominal viscera through narrow hernial
gate at the moment of a sharp rise
intra-abdominal pressure under the influence
strong physical stress. Also known in the literature as
Richter's hernia. With this type of abuse
the intestine is compressed not to its full size
lumen, but only partially, usually in the area,
opposite the mesenteric edge of the intestine. Under fecal infringement understand
compression of the hernial contents, which
occurs as a result of a sharp overflow
adductor intestinal loop,
located in the hernial sac. diverting
the section of this loop is sharply flattened and
is compressed in the hernial orifice along with
adjacent mesentery. It is characterized by the feature that
it in the hernial sac are smaller
at least two intestinal loops in a relatively
good condition, and the greatest
changes are undergoing the third, intermediate
loop, which is located in the abdominal cavity. Infringement of Meckel's diverticulum in the inguinal
hernia. This pathology can be compared to
ordinary parietal infringement with that
the only difference is that due to worse conditions
blood supply to the diverticulum faster
undergoes necrosis than a normal wall
intestines. sudden sharp pain at the moment of infringement;
hernia irreducibility;
tension and soreness of the hernia
protrusions;
signs of OKN (attached later):
(vomiting, bloating, not passing stools and
gases) The process of diagnosing a strangulated hernia is predominantly
clinical and based on complaints and anamnestic data
patient, the results of the objective examination of patients (GPP). The most important
a condition for effective diagnosis is a thorough history taking with
identification of the duration and dynamics of clinical manifestations.
Leading technologies of special (instrumental) diagnostics on
at the present stage are ultrasonic and radiological methods
examination of the inguinal region, scrotum, abdominal cavity, including the small pelvis,
allow with a high degree reliability to identify tissues and organs
as part of a hernial protrusion, to evaluate the parameters of organ blood flow,
identify echographic signs of impaired passage of intestinal contents.
Indications for plain abdominal radiography occur when
presence of clinical signs of acute intestinal obstruction. irreducible hernia;
Coprostasis;
False infringement; Prehospital stage:
1. For pain in the abdomen, a targeted examination is necessary
patient for a hernia.
2. In case of hernia incarceration or suspicion of infringement, even in
case of its spontaneous reduction, the patient is subject to
emergency hospitalization in a surgical hospital.
3. Dangerous and unacceptable attempts to force the reduction
strangulated hernias.
4. Use of pain medications, baths, heat or cold
patients with strangulated hernias are contraindicated.
5. The patient is taken to the hospital on a stretcher in the supine position
on the back.
Stationary stage:
1. The basis for the diagnosis of strangulated hernia are:a) the presence of tense, painful and not self-reducing
hernial protrusion with a negative cough shock;
b) clinical signs of acute intestinal obstruction or peritonitis in
patient with a hernia.
2. Determine: body temperature and skin temperature in the area of the hernial
protrusions. If signs of local inflammation are detected,
differential diagnosis between phlegmon of the hernial sac and others
diseases (inguinal adenophlegmon, acute thrombophlebitis
aneurysmally dilated orifice of the great saphenous vein).
3. Laboratory research: general analysis blood, blood sugar, general analysis
urine and others according to indications.
4. Instrumental studies: chest X-ray, ECG, survey
radiography of the abdominal cavity, according to indications - ultrasound of the abdominal cavity and
hernial protrusion.
5. Consultations of a therapist and an anesthesiologist, if necessary - an endocrinologist.
The diagnosis of strangulated hernia is an indication for emergency surgery. With a hernia that has been crushed, the tactics are active-expectant:
Peculiarities:1. Urgent operation
2. Absolute contraindications to surgical
intervention in case of infringement does not currently exist
3. Unacceptable:
baths, heat, cold on the area of hernial protrusion,
forced manual repositioning
Do not set strangulated hernias! 1) elimination of infringement;
2) revision of the restrained organs and, if necessary,
appropriate interventions on them;
3) hernia repair
3. flabby wall
intestines,
4. absence
vascular pulsations
mesentery,
5. absence
peristalsis
intestines.
signs
vitality
and guts
1.recovery
normal
Pink colour
intestines,
2.lack
strangulation
furrows and
subserous
hematomas,
3. save
small ripples
vessels
mesentery and
peristaltically
x abbreviations
intestines. Sixth stage:
Resection of a non-viable
intestines (at least 30-40 cm
leading segment of the intestine and 15-20 cm of the outlet segment).
(S.V. Lobachev, O.V. Vinogradova,
A.I. Shabanov)
resection of the strangulated omentum
separate areas without
education of a large general
stump seventh stage
Aponeurotic plastic
The Schampioner Method
Hernioplasty
A. V. Martynov's method
Heinrich's method
Brenner method (Brenner)
Operations for oblique inguinal
hernias
The method of N. Z. Monakov
Girard's way
The method of N. I. Napalkov
Method S.I.
Spasokukotsky
Muscular aponeurotic plastics
A. V. Martynov's method
Method M.A.
Kimbarovsky
Operations for direct inguinal
hernias
Bassini way (Bassini)
The method of N. I. Kukudzhanov
The method of I. F. Sabaneev
modified by N. Z. Monakov
The method of A. V. Gabay
Other types of plastic
Alloplasty
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