COMPLICATIONS OF EXTERNAL ABDOMINAL HERNIA Complications of external abdominal hernia: strangulation, coprostasis, irreducibility, inflammation. A strangulated hernia is the most common and dangerous complication of a hernia, requiring immediate surgical treatment. The organs that have entered the hernial sac are subject to compression more often at the level of the neck of the hernial sac in the hernial orifice. Infringement of organs in the hernial sac itself is possible in one of the chambers of the hernial sac, in the presence of scar cords that compress the organs during fusion of the organs with each other and with the hernial sac (in irreducible hernias).

1) Elastic infringement. Spasm of the muscular aponeurotic structures -> hernial contents are compressed -> compression of the mesentery -> malnutrition of the compressed intestine -> intestinal edema -> ulceration of the mucous membrane -> dysfunction of the intestine -> symptoms of intestinal obstruction.

The strangulation groove is a place of infringement. 20-40 cm is cut off before pinching, up to 30 cm - after pinching. The best way to stitch is end to end.

• 2) Retrograde strangulation - strangulation of several loops of intestine.
• 3) Fecal impaction - the abductor department compresses the adductor department.
• 4) Lateral strangulation - (Richter's) - part of the intestinal wall is strangulated; phlegmon of the abdominal wall may occur in 5% of cases.

Thrombosis of the node of the great saphenous vein at the place where it flows into the deep vein of the thigh can simulate strangulation of the femoral hernia. When thrombosis of the venous node, the patient experiences pain and a painful seal under the inguinal ligament is detected. Along with this, there is often varicose veins of the lower leg. Emergency surgery is indicated in the case of strangulated hernia and thrombosis of the venous node. In case of a strangulated hernia, the strangulated organ is eliminated and plastic surgery is performed in the area of ​​the hernial orifice. In case of thrombosis of the venous node, the large saphenous vein is ligated and crossed at the point where it flows into the deep vein of the thigh to prevent thromboembolism and the spread of thrombosis to the deep vein of the thigh. The thrombosed vein is excised.

Sudden strangulation of previously undetected hernias. On the abdominal wall, in areas typical for the formation of hernias, protrusions of the peritoneum (pre-existing hernial sacs) may remain after birth. More often, such a pre-prepared hernial sac in the groin area is a patent peritoneal-inguinal process. The cause of the sudden appearance of a hernia and its strangulation is a sharp increase in intra-abdominal pressure (significant physical stress, severe coughing, straining). The main symptom of suddenly occurring strangulated hernias is the appearance of acute pain in typical places where the hernias emerge. The hernial protrusion is small in size, which corresponds to the small size of the pre-existing hernial sac. The hernial protrusion is dense and painful.

Treatment: The first stage is layer-by-layer dissection of tissue up to the aponeurosis and exposure of the hernial sac. The second stage is opening the hernial sac. The third stage - dissection of the pinching ring is carried out under visual control. For femoral hernias, the incision is made medial from the neck of the hernial sac to avoid damage to the femoral vein, located on the lateral side of the sac. For umbilical hernias, the strangulating ring is cut transversely in both directions. The fourth stage is determining the viability of the strangulated organs. After dissecting the strangulating ring and introducing a novocaine solution into the mesentery of the intestine, those parts of the strangulated organs that were above the strangulating ring are removed from the abdominal cavity. If there are no obvious signs of necrosis, the strangulated intestine is irrigated with a warm isotonic sodium chloride solution. The fifth stage - the non-viable intestine must be removed. From the border of necrosis visible from the serous integument, at least 30-40 cm of the afferent segment of the intestine and 15-20 cm of the efferent segment must be resected. Resection of the intestine should be performed with 1 strangulation groove, 2 subserous hematomas, 3 large edema, 4 infiltration and 5 hematomas of the mesentery of the intestine. The sixth stage - the strangulated omentum is resected in separate sections without forming a large common stump. The seventh stage is plastic surgery of the hernial orifice. For small inguinal oblique hernias in young people, the Girard-Spasokukotsky-Kimbarovsky method should be used; for direct inguinal and complex inguinal hernias, the Bassini and Postempsky methods should be used.

Coprostasis (stool stagnation) and fecal impaction. Coprostasis is a complication of a hernia, when the contents of the hernial sac are the large intestine. It develops as a result of a disorder of intestinal motor function associated with a sharp decrease in the tone of the intestinal wall. Coprostasis is promoted by the irreducibility of the hernia, a sedentary lifestyle, and abundant food. Coprostasis is observed more often in obese patients of senile age, in men with inguinal hernias, in women with umbilical hernias.

Symptoms: supporting constipation, abdominal pain, nausea, rarely vomiting. The hernial protrusion slowly increases as the colon fills with feces, it is almost

Coprostasis Occurs slowly, gradually Hernial protrusion is slightly painful, doughy consistency, slightly tense Cough impulse is detected Intestinal closure is incomplete Vomiting is rare General condition of moderate severity Arises suddenly, quickly

Elastic strangulation of the hernia Hernial protrusion is very painful, very tense Cough impulse is not detected Complete intestinal obstruction Frequent vomiting General condition is severe, collapse

Treatment: emptying the colon of its contents. With reducible hernias, you must try to keep the hernia in a reduced state, then it is easier to restore intestinal motility. Small enemas with a hypertonic solution of sodium chloride, with glycerin or repeated siphon enemas with a deeply inserted probe to the sigmoid colon are used. The use of laxatives is contraindicated, since overfilling of the adductor loop with contents can cause the transition of coprostasis to the fecal form of strangulated hernia.

Coprostasis can, due to compression of the efferent loop in the hernial orifice, turn into the fecal form of strangulated hernia. Signs of obstructive intestinal obstruction are increasing. Abdominal pain intensifies, becomes cramping, and vomiting becomes more frequent. Subsequently, due to the overflow of the intestine located in the hernial sac with feces, compression of the entire intestinal loop and its mesentery occurs by the hernial orifice. A mixed form of intestinal strangulation occurs. From this moment on, signs of strangulation intestinal obstruction appear.

Incarceration of the greater omentum causes constant pain in the area of ​​the hernial protrusion. The greater omentum is usually strangulated in umbilical and large epigastric hernias.

Bladder strangulation occurs with sliding inguinal and femoral hernias, accompanied by frequent painful urination, sometimes urinary retention, and decreased diuresis due to a reflex decrease in kidney function.

False strangulation of a hernia. In acute diseases of the abdominal organs (acute appendicitis, acute cholecystitis, perforation of a duodenal or gastric ulcer, intestinal obstruction), the exudate, entering the hernial sac of an unstrangulated hernia, causes the development of inflammation in it. The hernial protrusion increases in size, becomes painful and tense. These signs correspond to signs of a strangulated hernia.

Surgical treatment of the purulent focus is completed by draining the wound.

Irreversibility is caused by the presence in the hernial sac of fusion of internal organs with each other, as well as with the hernial sac. The development of irreducibility is caused by trauma to the organs located in the hernial sac. As a result of aseptic inflammation, dense fusions of organs with each other and with the wall of the hernial sac occur. Irreversibility can be partial, when part of the contents of the hernia can be reduced into the abdominal cavity, while the other part remains irreducible. With complete irreducibility, the contents of the hernia are not reduced into the abdominal cavity. The development of irreducibility is facilitated by prolonged wearing of the bandage. Most often, umbilical, femoral and postoperative hernias are irreducible.

Inflammation of the hernia occurs due to infection of the hernial sac. It can occur from the inside with acute inflammation of the appendix or Meckel's diverticulum located in the hernial sac, as a result of perforation of typhoid or tuberculous intestinal ulcers into the cavity of the hernial sac, or with peritoneal tuberculosis.

With inflammation of the hernia caused by infection from the abdominal organs, the general condition of the patients worsens, the body temperature is high, chills, vomiting, gas and stool retention. The hernia increases in size as a result of swelling and tissue infiltration, and skin hyperemia appears. Treatment: emergency surgery. In case of acute appendicitis, an appendectomy is performed in the hernia; in other cases, the source of infection of the hernial sac is removed. Chronic inflammation of the hernia in peritoneal tuberculosis is recognized during surgery. Treatment consists of hernia repair and specific anti-tuberculosis therapy.

Prevention of complications: surgical treatment of all patients with hernias as planned before their complications develop. Identification of hernia carriers is possible during mass medical examination of the population. The presence of a hernia is an indication for surgery.

Complications after self-reduced, forcibly reduced and operated strangulated hernias. A patient with a strangulated hernia that has spontaneously reduced should be urgently hospitalized in the surgical department. There is a danger of spontaneous reduction of a previously strangulated intestine - as a result of circulatory disorders that have arisen in it, it can become a source of infection of the peritoneum and intraintestinal bleeding. If, during the examination of the patient at the time of admission to the surgical hospital, peritonitis or intraintestinal bleeding is diagnosed, the patient must be operated on urgently. The operation consists of a mid-median laparotomy, resection of the altered section of the intestine to the level of preserved sufficient blood circulation in the afferent and efferent intestinal loops. A patient who, upon admission to the emergency department, did not show signs of peritonitis or intraintestinal bleeding - dynamic observation. Methods for dynamic examination of a patient with a spontaneously reduced strangulated hernia are as follows: Complaints: abdominal pain, dryness of the mucous membranes of the oral cavity. Inspection: skin (pallor); oral cavity (dry mucous membranes). Hemodynamic indicators: pulse, blood pressure, shock index = pulse / systolic blood pressure. Axillary and rectal temperature. Examination of the abdomen, palpation (muscle tension and local soreness), percussion, local soreness, auscultation, weakening of bowel sounds. Examination through the rectum, pain with pressure on the intestinal walls, blood in the contents. Plain fluoroscopy pneumatosis intestinalis, free gas in the abdominal cavity. Inspection of discharge: vomit (admixture of bile), stool (admixture of blood in stool). Measurement of urine output. Laboratory tests, blood tests (leukocytosis, hemoglobin, hematocrit). Early signs of peritonitis are the appearance of constant pain in the abdomen, aggravated by coughing, a feeling of dryness in the mouth, increased heart rate, local pain on palpation and percussion of the abdomen, the appearance of mild local tension in the muscles of the abdominal wall, leukocytosis. Early signs of intraintestinal bleeding are weakness, dizziness, pale skin, increased heart rate, decreased blood pressure, decreased hemoglobin, hematocrit, and blood in the stool. The appearance of signs of peritonitis and bleeding into the intestines is an indication for emergency surgery. The operation consists of a midline laparotomy, resection of the altered section of the intestine to the level of maintaining sufficient blood supply in the afferent and efferent intestinal loops.

A patient whose dynamic observation does not reveal signs of peritonitis or intraintestinal bleeding undergoes routine hernia repair with abdominal wall plastic surgery in the area of ​​the hernial orifice. Late complications observed after spontaneous reduction of strangulated hernias and developed after operations for strangulated hernias are characterized by signs of chronic intestinal obstruction (abdominal pain, flatulence, rumbling, splashing noise).

General information about hernias

Abdominal hernia- exit under the skin of the abdominal organs, covered with the parietal layer of the peritoneum, through various openings of the abdominal wall or pelvis.

If, as a result of an injury, the muscles of the anterior abdominal wall and the parietal peritoneum rupture, and any organ of the abdominal cavity falls out through the resulting defect, then they speak of prolapse (prolapsus).

Subcutaneous eventration (eventratio) - divergence of sutures on the peritoneum, aponeurosis and muscles, with an unbroken wound of the skin (after surgical interventions).

There are external and internal hernias.

External hernias (herniae abdominalis externae) are protrusions that emerge through openings in the abdominal wall. These holes are most often normal anatomical formations, usually filled with fatty tissue, but they can occur as a result of various traumatic injuries or diseases.

By origin, external abdominal hernias can be congenital (congenita) or acquired (acquisita).

Internal hernias (herniae abdominalis internae) – entry of abdominal organs into abdominal pouches or diverticula (bursa omentalis, foramen Winslowi, recessus duodenoje-junalis, etc.). Diaphragmatic hernias are also classified as internal.

Internal hernias often cause a picture of intestinal obstruction and are inaccessible for examination without opening the abdominal cavity.

The components of a hernia are the hernial orifice, the hernial sac and its contents.

Hernial orifices are natural gaps and canals passing through the thickness of the abdominal wall (inguinal, femoral canals, etc.), as well as acquired as a result of injuries or after surgical interventions.

The hernial sac is part of the parietal peritoneum that exits through the hernial orifice. They distinguish between the mouth, neck, body and bottom.

The contents of the hernial sac can be any of the abdominal organs: most often the small intestine, omentum, colon (large intestine), etc.

Classification of hernias by location: inguinal, femoral, umbilical, linea alba, xiphoid process, lateral abdomen, lumbar triangle of Greenfelt-Lesgaft, sciatic, obturator, perineal.

According to their course, hernias are divided into uncomplicated (reducible) and complicated (irreducible, strangulated, with symptoms of coprostasis and inflammation).

Uncomplicated hernias

With uncomplicated hernias, patients complain of pain localized at the site of the hernia, in the abdomen, and lumbar region. The appearance of pain usually coincides with the entry of the hernial contents into the hernial sac or with the reduction of the hernia. Various disorders may occur from the gastrointestinal tract: nausea, sometimes vomiting, belching, constipation, bloating.

One of the objective symptoms characteristic of a reducible hernia is a visually detectable tumor-like formation that appears and disappears in the area of ​​the hernial orifice. Hernial protrusion is usually associated with abdominal tension, coughing (symptom of “cough impulse”), and in the patient’s lying position it goes into the abdominal cavity on its own or with the help of manual reduction.

When hernias begin, the protrusion is determined only by a finger inserted into the hernial canal, which feels it as a push when coughing or straining.

Hernias are classified according to the degree of development:

1) beginning;

2) incomplete, or intracanal;

3) full;

4) huge hernias.

In addition to inspection and palpation, when examining a patient with a hernia, it is necessary to use percussion and auscultation. Thus, the presence of a hollow organ (intestine) in the hernial sac gives a tympanic sound upon percussion, and a rumbling sensation upon auscultation. If there is a dense organ in the hernial sac (for example, the omentum), then percussion produces a dull sound. If there is a suspicion of the presence of a bladder in the hernial sac, an X-ray examination is performed with the injection of a contrast agent into the bladder.

Treatment hernias in the absence of contraindications should only be surgical. During surgical treatment of uncomplicated hernias, absolute and relative contraindications are possible.

Absolute contraindications to surgical treatment include acute infectious diseases or their consequences, decompensated heart disease, and malignant neoplasms.

Relative contraindications to surgical treatment are early childhood, old age with chronic diseases, late pregnancy.

Radical surgery consists of removing the hernial sac after ligating it at the neck and narrowing the hernial canal using plastic techniques to strengthen the muscles and aponeurosis of the abdominal wall, depending on the location of the hernia.

Most hernia repairs are performed under local anesthesia (can be combined with neuroleptanalgesia), some under anesthesia, which is used mainly for children.

These patients do not require special preoperative preparation. On the eve of the operation, they take a hygienic bath, have their hair shaved (1–2 hours before the operation, since otherwise skin irritation may develop, resulting in inflammation and poor healing of the postoperative wound) on the abdomen, pubis and scrotum, and empty their bowels with an enema. Before being taken to the operating room, the patient's bladder must be emptied.

Management of the patient in the postoperative period depends on the type of hernia, the nature of the surgical intervention, the presence of complications, etc. It is necessary to take all measures to prevent postoperative complications, especially in the elderly.

After the operation and discharge of the patient home (with primary wound healing), persons engaged in mental work are issued a sick leave certificate for up to three weeks, then they begin to work. However, they are not recommended to engage in heavy physical labor for 2 to 3 months.

Conservative methods of treating hernias are currently used extremely rarely: only if there are contraindications to surgery and the patient categorically refuses it. Such patients are prescribed to wear a bandage. However, a bandage in the area of ​​the hernia injures organs and tissues and does not protect against strangulation of the hernia.

Prevention of hernias should be aimed at eliminating reasons for their formation. A.P. Krymov notes two groups of such reasons:

1. Increasing intra-abdominal pressure:

1) disorder of defecation (constipation, diarrhea);

2) cough;

4) difficulty urinating (urinary canal strictures, prostate adenoma, phimosis);

5) playing wind instruments;

6) tight tightening of the abdomen;

7) difficult childbirth;

9) heavy physical work (lifting weights, carrying loads, working in a bent or other uncomfortable position, etc.).

2. Weakening the abdominal wall:

1) pregnancy, which stretches and thins the abdominal wall, especially repeated pregnancy;

2) diseases that cause weight loss and weakening of body muscles;

3) all kinds of injuries to the abdominal wall.

Prophylactic Physical therapy helps prevent the formation of hernias. Sports exercises, carried out under the supervision of a doctor, strengthen the muscles of the anterior abdominal wall.

To prevent hernias in childhood, proper child care is of great importance. Moments that increase intra-abdominal pressure should be avoided: tightly swaddling infants, throwing them up when crying and screaming.

Inguinal hernia

Inguinal hernias are formed within the inguinal triangle, the lower side of which is the Poupartian ligament, the upper side is a horizontal line drawn from the point located on the border between the outer and middle thirds of the Poupartian ligament to the intersection with the rectus abdominis muscle. The third side of the triangle will be a perpendicular running from the pubic tubercle to the horizontal line indicated above, which corresponds to the outer edge of the rectus abdominis muscle.

Inguinal canal has four walls and two holes. The anterior wall is formed by the aponeurosis of the external oblique abdominal muscle, the posterior wall is formed by the transverse abdominal fascia, the upper wall is formed by the edges of the internal oblique and transverse abdominal muscles, and the lower wall is formed by Poupart’s ligament.

External (subcutaneous) inguinal opening formed by the legs of the aponeurosis of the external oblique abdominal muscle, which are attached to the pubic tubercle.

Internal (abdominal) opening of the inguinal canal is an opening in the transverse fascia of the abdomen and is located corresponding to the external inguinal fossa (fovea inguinalis externa). In men, the spermatic cord passes through the inguinal canal, consisting of the vas deferens, spermatic artery, vein, nerve and lymphatic vessels; in women, only the round ligament of the uterus.

Inguinal hernias are divided into oblique and direct.

Indirect inguinal hernia exits through the external inguinal fossa and is located outward from the art. epigastrica inferior. The course of the oblique inguinal hernia strictly corresponds to the course and direction of the spermatic cord, i.e., the path along which the testicle followed in the process of descending into the scrotum. With oblique inguinal hernias, the internal opening of the inguinal canal, located in the external inguinal fossa, does not coincide with its external opening, but lies 4–5 cm to the side of it. To exit through the opening of the inguinal canal, the hernial sac must pass through this oblique path 4–5 cm long. 5 cm, which is why such hernias are called oblique.

Indirect inguinal hernias can be acquired or congenital. At congenital hernias The abdominal organs enter the ungrown vaginal process of the peritoneum with the testicle lying at its bottom. For congenital inguinal hernias, it is necessary to pay attention to the location of the testicle in the hernial sac. The testicle, in the process of its descent into the scrotum, does not enter the hernial sac (open peritoneo-inguinal process), but only approaches the wall of the peritoneo-inguinal process and is covered with peritoneum.

Direct inguinal hernia exits through the internal inguinal fossa (fovea inguinalis media), which is a permanent anatomical formation and is located between the lateral vesico-umbilical ligament and fold a. epigastrica inferior (plicaepigastrica).

A direct inguinal hernia has a straight direction due to the fact that the internal fossa (internal hernial ring) is located opposite the external opening of the inguinal canal. The hernial sac goes in a straight (sagittal) direction, and for this reason such hernias are called direct inguinal. In direct hernias, the hernial sac lies medially in relation to the elements of the spermatic cord, which is why they are called internal. In oblique hernias, the hernial sac is located outward, lateral to the elements of the spermatic cord.

According to their etiology, direct inguinal hernias are always acquired and are observed mainly in elderly people.

Sometimes when sliding hernias internal organs, partially covered by peritoneum (cecum, bladder), form part of the wall of the hernial sac. The sliding of these organs passes through the retroperitoneal tissue, through the hernial orifice. Sliding inguinal hernias are most often irreducible; their hernial orifices are larger than usual. Patients with sliding inguinal hernias experience constipation, bloating, abdominal pain in the area of ​​the hernial protrusion during defecation, frequent urge to urinate, as well as pain radiating to the lumbar region.

For preoperative diagnosis of sliding inguinal hernias, X-ray examination is of great importance. In women, bimanual examination helps make a diagnosis before surgery. However, an accurate diagnosis of sliding inguinal hernias is most often established during surgery, but we must remember that during the operation, instead of the hernial sac, a hollow organ can be opened.

Differential diagnosis. Indirect inguinal hernias descending into the scrotum must be differentiated from hydrocele of the testicle, as well as from hydrocele of the spermatic cord.

Hydrocele of the testicle(hydrocaele) develops slowly, without causing any pain. The fluid produced by the serous membrane of the testicle accumulates in the cavity formed by the testicle and its own membrane. As fluid accumulates, the cavity of the dropsy becomes more and more stretched, becomes tense and does not fit into the abdominal cavity, the testicle and epididymis are not palpable. When feeling the spermatic cord at the external opening of the inguinal canal with hydrocaele, you can freely close your fingers at its upper pole, feeling the vas deferens between them, whereas with an inguinal-scrotal hernia you cannot close your fingers. Diaphanoscopy can also be performed. In a dark room, a brightly glowing cystoscope bulb is placed under the scrotum. With hydrocele of the testicle, the half of the scrotum, stretched from the accumulation of serous fluid, turns into a glowing bright pink lantern, at the bottom of which the shadow of the testicle, which does not transmit light, is clearly visible.

The clinical difference (hydrocaele communicans) from hydrocele of the testicle is the phenomenon of emptying of the hydrocele at night when the patient is in a lying position, and filling the sac again during the day when walking. In this case, diaphanoscopy also helps to carry out differential diagnosis.

In addition, inguinal hernias must be differentiated from dilatation of the veins of the spermatic cord(varicocaele), which occurs predominantly on the left, where the spermatic vein flows at a right angle into the renal vein. Upon examination, you can see nodes of intertwined varicose veins running along the spermatic cord, which extend high into the inguinal canal. In such cases, patients complain of pain along the spermatic cord, radiating to the lower back, and a feeling of heaviness in the lower abdomen.

It is also necessary to carry out a differential diagnosis with lymphadenitis, in which, in addition to pain in the protrusion area, there may be redness of the skin, local hyperthermia, a negative cough impulse, and leukocytosis.

It is also necessary to carry out a differential diagnosis of in-slot hernias with tumor lesions of both the testicle and lymph nodes.

Treatment. To decide on surgical intervention for inguinal hernias, it is necessary to carefully examine the patient, establishing indications and contraindications for surgical treatment.

The goal of surgical intervention for inguinal hernias is to eliminate the hernial sac and close the hernial orifice.

Operations for indirect inguinal hernias. Pain relief is often carried out locally with a 0.25% solution of novocaine; in excitable individuals it can be combined with neuroleptanalgesia; in children - only general.

The surgical intervention consists of the following stages: an incision of the skin, subcutaneous tissue and superficial fascia 8–12 cm long, 2 cm above the inguinal ligament; dissection of the aponeurosis of the external oblique abdominal muscle; separation of the hernial sac from the external flap of the aponeurosis of the external oblique abdominal muscle and from the elements of the spermatic cord; opening the hernial sac and repositioning the contents into the abdominal cavity; suturing the neck of the hernial sac and cutting off its peripheral part. Plastic surgery of the inguinal canal is performed according to one of the methods.

In plastic surgery of the inguinal canal, the methods of Girard, S. I. Spasokukotsky, A. V. Martynov, M. A. Kimbarovsky, V. I. Lichtenstein, as well as other methods of operations that the surgeon is well versed in, are often used.

Girard's method involves strengthening the anterior wall of the inguinal canal over the spermatic cord. First, the edge of the internal oblique and transverse muscles is sutured with interrupted silk sutures to the inguinal fold over the spermatic cord, and then, along the entire length of the incision, the internal flap of the aponeurosis is sutured to the edge of the inguinal ligament. The outer flap of the aponeurosis is laid on top of the inner one (like the flaps of a double-breasted coat) and hemmed to the latter with interrupted silk sutures. Catgut sutures are placed on the subcutaneous tissue and silk sutures on the skin. Aseptic bandage on the skin, suspensor.

By method Spasokukotsky The internal flap of the aponeurosis of the external oblique abdominal muscle, together with the edges of the internal oblique and transverse abdominal muscles, is sutured to the Pupart ligament with one row of interrupted silk sutures, and the external flap of the aponeurosis is placed on top of the internal one. Many surgeons use the mixed Girard-Spasokukotsky method.

Way Martynova comes down to the formation of a duplicate from the leaves of the dissected aponeurosis: the internal flap of the aponeurosis of the external oblique abdominal muscle is sutured to the Pupart ligament, the external one is laid on top of the internal one and sutured to the latter.

By method Kimbarovsky the internal flap of the dissected aponeurosis of the external oblique abdominal muscle and the underlying muscles are stitched from the outside to the inside, retreating 1 cm from the edge of the incision; the needle is passed a second time only through the edge of the internal flap of the aponeurosis, going from the inside to the outside, then the edge of the Poupart ligament is stitched with the same thread; The outer flap of the aponeurosis is sutured over the inner flap.

But all of the above methods relate to tension; currently, more and more attention is paid to non-tension methods (when the defect in the aponeurosis is closed without tissue tension), these include hernial orifice plastic surgery using allo- or autografts. Specially treated patient skin or a fascial-muscular flap taken from another part of the body can serve as autografts. Special hypoallergenic meshes (Lichtenstein plastic) are used as allografts. A flap of the required size is cut out from the grafts and sewn on.

Operations for direct inguinal hernias. In direct inguinal hernias, the hernial sac usually has a wide base, so the neck of the sac is sutured with an internal purse-string suture, and the sac is excised distal to the ligature.

Plastic surgery of the inguinal canal is performed using the Bassini method or the N.I. Kukudzhanov method.

Way Bassini is as follows:

1) the spermatic cord is retracted upward and outward;

2) using interrupted silk sutures, the edge of the internal oblique and transverse muscles along with the underlying transverse fascia is sutured to the inguinal ligament;

3) in the area of ​​the pubic tubercle, the edge of the sheath of the rectus abdominis muscle is sutured with 1–2 sutures to the Pupart ligament and periosteum of the pubic bone;

4) having tied all the sutures one by one, the spermatic cord is placed on the created muscle bed;

5) over the spermatic cord, the edges of the aponeurosis of the external oblique abdominal muscle are sutured with a series of interrupted sutures.

The basis of the method Kukudzhanova lies the principle of strengthening the posterior and anterior walls of the inguinal canal; in the area of ​​the internal hernial orifice, the preperitoneal fatty tissue is sutured with several sutures, the spermatic cord is retracted anteriorly, the transverse fascia is sutured with two mattress sutures, the iliopubic and inguinal ligaments are captured in the sutures, the sheath of the rectus muscle and the aponeurotic fibers of the internal oblique and transverse muscles are sutured to the medial iliac section - pubic and inguinal ligaments. The spermatic cord is placed in place and sutured over it to duplicate the edge of the dissected aponeurosis of the external oblique abdominal muscle.

Operations for congenital inguinal hernias. For congenital inguinal hernias, two methods of surgical intervention are mainly used - without opening the inguinal canal (according to Roux-Oppel) and with opening the inguinal canal.

By method Ru–Oppel after dissecting the skin and subcutaneous tissue, the hernial sac is isolated and opened, the hernial contents are inserted into the abdominal cavity. The hernial sac brought into the wound is bandaged at the neck, cut off, and the stump is immersed in the preperitoneal tissue. The external opening of the inguinal canal is sutured with two or three silk ligatures. Interrupted sutures are placed on the anterior wall of the inguinal canal, capturing the aponeurosis of the external oblique abdominal muscle and the underlying muscles slightly above the inguinal canal in the suture on one side, and the inguinal ligament on the other. This method is used for small initial hernias, both congenital and acquired.

With the method opening the inguinal canal access to the hernial sac is the same as for acquired indirect inguinal hernias. Along the spermatic cord, the fascia cremasterica is dissected along with the fibers of the m. cremaster and fascia spermatica interna secrete the anterior wall of the hernial sac and open it at the neck. The hernial contents are reduced into the abdominal cavity, the posterior wall of the hernial sac at the neck is separated from the elements of the spermatic cord, and then dissected in the transverse direction. The neck of the isolated part of the hernial sac is sutured with a silk ligature, bandaged and cut off, and the testicle is removed into the wound along with the rest of the hernial sac. The latter is excised and turned around the testicle and spermatic cord, sewing it together with rare interrupted sutures. If the hernial sac is larger; then it is excised over a large area, leaving the peritoneum only on the spermatic cord and testicle. Plastic surgery of the inguinal canal using one of the methods.

Femoral hernia

The localization of femoral hernias corresponds to the area of ​​Skarpov's triangle, the upper border of which is the Poupartian ligament. The iliopectineal ligament extends from the Pupart ligament to the pubic tubercle, which divides the entire space between the inguinal ligament and the bones (iliac and pubic) into two sections: the muscular lacuna (lacuna musculorum) - the outer section - and the vascular (lacuna vasorum) - internal department.

The muscle lacuna has the following boundaries: in front - the inguinal ligament, in the back - the ilium, from the inside - the iliopectineal ligament.

The vascular lacuna is limited by the following ligaments: in front - the inguinal fascia and the superficial layer of the lata fascia fused with it, behind - the iliopubic fascia (lig. iliopubicum) and the pectineal fascia starting from it, outside - lig. iliopectineum, from the inside – lig. lacunare.

The femoral vessels pass through the vascular lacuna, of which the femoral artery is located on the outside, the vein on the inside. Both vessels are surrounded by a common sheath, in which the artery is separated from the vein by a septum.

Knowledge of all anatomical spaces is of great importance in the differential diagnosis of various types of femoral hernias that form under the Pupart ligament along its entire length.

The inner third of the vascular lacuna, corresponding to the space between the femoral vein and the lacunar ligament, is called the internal femoral ring. In front it is bounded by the Pupart ligament, behind by the iliopubic ligament and the pectineal fascia starting from it, from the inside by the lacunar ligament, and from the outside by the sheath of the femoral vein.

The path that the femoral hernia makes for itself is called the femoral canal (its length is 1 - 2 cm). It has a triangular shape, and its walls are: in front - the falciform process of the lata fascia, behind and inwardly - the pectineal fascia, outside - the sheath of the femoral vein. Normally, the femoral canal does not exist.

Unlike inguinal hernias, femoral hernias extend below the Pupart ligament: within the upper half of the fossa ovalis, inside the femoral vein. In practice, typical femoral hernias arising from the femoral canal are more common.

N.V. Voskresensky divides all femoral hernias into:

1) muscular-lacunar (Hesselbach’s hernia);

2) emerging within the vascular lacuna:

a) external, or lateral external, vascular-lacunar, extending outward from the femoral artery;

b) median, or prevascular, extending into the area of ​​the vessels and located directly above them;

c) internal (typical femoral hernia), exiting through the femoral canal between the femoral vein and the lacunar (gimbernate) ligament;

3) hernia of the lacunar ligament.

Femoral hernias are more often observed in women, which is explained by the large size of the female pelvis.

The following forms of typical femoral hernias are distinguished:

1) initial, when a small hernial sac is located in the area of ​​the internal opening of the femoral canal;

2) canal - the hernial sac moves into the femoral canal, reaches the outer femoral ring, forming an incomplete femoral hernia;

3) a complete hernia that extends beyond the femoral canal and is determined by examination and palpation.

Femoral hernias must be differentiated from enlarged lymph nodes of this area in various diseases, metastases of malignant neoplasms in the lymph nodes of this area, benign tumors of the femoral area, varicose veins of the lower extremities, aneurysmal nodes, specific edema abscesses, cysts located under the Pupart ligament.

Treatment. Depending on the method of operation, various skin incisions are made.

For hernia repair with closure of the hernial orifice from the hip side, the most common is the Lockwood method. A skin incision 10–12 cm long is made vertically above the hernial tumor, the beginning of which is 2–3 cm above the Poupart’s ligament, or an oblique incision passing over the hernial tumor parallel to and below the Poupart’s ligament. The hernial sac is isolated from the bottom to the neck, opened and its contents are inserted into the abdominal cavity. The neck of the bag is sutured high with a silk ligature, bandaged and cut off, and its stump is set under the inguinal ligament. The internal opening of the femoral canal is closed by suturing the inguinal ligament to the periosteum of the pubic bone with two or three knotted silk ligatures.

For hernia repair with closure of the hernial orifice from the hip side using the Lockwood method, modifications by Bassini, A.P. Krymov, as well as the method of A.A. Abrazhanov are used.

For hernia repair with closure of the hernial orifice from the side of the inguinal canal, the methods of Ruggi, Parlavecchio, Reich, and Praxin are used.

Way Ruji is as follows:

1) the skin is cut above and parallel to the Pupart ligament, as with inguinal hernias;

2) open the inguinal canal;

3) dissect the posterior wall of the inguinal canal - the transverse fascia;

4) the hernial sac is isolated and dislocated into the wound from under the Pupart ligament;

5) the hernial sac is opened and the hernial contents are inserted into the abdominal cavity;

6) the neck of the bag is sutured and the latter is cut off distal to the ligature;

7) with three or four sutures the inguinal ligament is sutured to the iliopubic ligament, which closes the hernial orifice;

8) restore the inguinal canal.

If a large hernial orifice is difficult to close by suturing the inguinal ligament to the iliopubic ligament, then they resort to the plastic methods of G. G. Karavanov, Watson - Cheyne, etc.

Umbilical hernias

Umbilical hernia (hernia umbilicalis) is a protrusion of abdominal organs through defects in the abdominal wall in the navel area.

The layers that form the navel consist of dense tissue, the anterior surface of which is fused to the skin, umbilical fascia and peritoneum. There is no subcutaneous or preperitoneal tissue. The umbilical vein, which runs from the navel to the liver, is located in a canal often called the umbilical.

Both the umbilical ring and the umbilical canal can be the site of a hernia. The umbilical canal has an oblique direction, therefore umbilical hernias emerging through it are called oblique.

Umbilical hernias follow in frequency behind inguinal and femoral hernias, although in fact an anatomical predisposition to them arises from the day of birth.

N.V. Voskresensky divides all umbilical hernias into hernias: adult, childhood, embryonic, developing with underdevelopment of the abdominal wall in the midline, umbilical cord.

Fetal umbilical hernias are subject to surgical treatment immediately after the birth of the child. Surgical treatment is contraindicated for very large or, conversely, small congenital hernias.

There are three ways to treat embryonic umbilical hernias: ligation of the hernial sac, extraperitoneal and intraperitoneal. Simple ligation of the hernia at the border of the skin with the amnion is used for a small and reducible hernia. However, this method is rarely used.

Extraperitoneal method Olsthausen consists of the following: at the border with the hernia, the skin is dissected and the outer (amniotic) membrane and Wharton's jelly are separated from the hernial sac. Next, the umbilical cord formations are bandaged and cut off. The hernial sac along with its contents is inserted into the abdominal cavity. The edges of the skin are refreshed and sewn together with silk sutures, closing the hernial orifice.

At intraperitoneal(intraperitoneal) method, the hernial sac is opened and its contents are inserted into the abdominal cavity, the hernial membranes are completely resected and the abdominal wall is sutured in layers.

Umbilical hernias of children and adults can be operated on either extraperitoneally or intraperitoneally. However, in most cases the operation is performed intraperitoneally.

For medium and large umbilical hernias, the methods of K. M. Sapezhko and Mayo are used, and for small ones, the Lexer method is used.

Way Sapezhko is as follows. The skin is cut over the hernial protrusion in a vertical direction, the hernial sac is isolated, and the hernial ring is cut up and down along the white line of the abdomen. The hernial sac is treated according to the generally accepted method. Using interrupted silk sutures, the edge of one side of the dissected aponeurosis is sutured to the posterior wall of the vagina of the rectus abdominis muscle of the opposite side. The remaining free edge of the aponeurosis is placed on the anterior wall of the rectus sheath on the opposite side and secured with a series of knotted silk ligatures. Sutures are placed on the skin.

With the method Mayo two semilunar skin incisions are made in the transverse direction around the hernial protrusion. After peeling off the skin flap from the aponeurosis around the hernial orifice for 5–7 cm, the hernial ring is dissected in the transverse direction. Having isolated the neck of the hernial sac, it is opened and the contents are inserted into the abdominal cavity. Then the hernial sac is excised along the edge of the hernial ring and removed along with the skin flap, and the peritoneum is sutured with a continuous catgut suture. The lower flap of the aponeurosis is sutured to the upper one with a row of interrupted U-shaped sutures so that when they are tied, the upper flap is layered on the lower one, the free edge of the upper flap is sutured with a series of interrupted sutures to the lower one. Interrupted silk sutures are placed on the skin.

With the method Lexera a semilunar skin incision, semi-bordering the hernial tumor, is made from below. The skin with subcutaneous tissue is peeled upward and the hernial sac is isolated, which is opened, and its contents are inserted into the abdominal cavity. The neck of the bag is stitched with a silk ligature, bandaged and the bag is cut off. The hernial orifice is closed with a purse-string silk suture, over which 3–4 silk sutures are placed on the anterior walls of the rectus abdominis muscle sheaths. The skin flap is placed in place and sewn with a series of interrupted sutures.

With this method of hernial orifice repair, the navel can be removed or left.

Hernia of the white line of the abdomen

The linea alba is formed by the intersecting tendon bundles of the six abdominal muscles, separates both rectus muscles and corresponds to the midline of the body. It stretches from the xiphoid process to the symphysis and above the navel it looks like a strip, the width of which increases towards the navel. In the linea alba of the abdomen there are through slit-like spaces that pass through its entire thickness to the peritoneum, and through them there are vessels and nerves or adipose tissue that connects the preperitoneal tissue with the subcutaneous tissue. Usually the size of such hernias is small. Most often, the contents of the hernial sac are the omentum, less often the small intestine and transverse colon (only for large hernias).

Clinical course Hernias of the white line of the abdomen are varied. Sometimes they are discovered by chance. Some patients complain of pain in the epigastric region, which increases with palpation. They are worried about nausea, belching, heartburn, and a feeling of fullness in the pancreas.

Examination of a patient with a hernia of the white line of the abdomen must be carried out lying down and standing with the patient straining and with complete relaxation of the abdominal wall.

If a patient complains of abdominal pain and dyspeptic disorders, it is necessary to exclude gastric and duodenal ulcers, gastritis, cholecystitis, appendicitis using general and special examination methods.

Hernias of the white line of the abdomen are operated on using the following method: Sapezhko – Lyakonova. A skin incision over the hernial protrusion is made either longitudinally or transversely. The hernial sac is isolated and treated in the usual way. The hernial ring is dissected along the linea alba and a duplicate is created from flaps of the aponeurosis of the linea alba in the vertical direction, first applying 2 to 4 U-shaped sutures, as with the Mayo method. The edge of the free aponeurosis flap is sutured with interrupted sutures to the anterior wall of the rectus abdominis sheath. Stitches on the skin.

Causes of recurrent hernias of the white line of the abdomen:

1) healing of a postoperative wound by secondary intention due to infection;

2) sagging tissue or scar changes in the hernia area;

3) excessive physical activity, especially in the early postoperative period;

4) technical errors during the operation.

Postoperative hernias

According to the location of the surgical intervention, postoperative hernias can be of different locations. Most often they are formed through surgical access along the white line of the abdomen. In men they occur after operations on the stomach, in women - after operations on the pelvic organs. Postoperative hernias can appear after appendectomy, cholecystectomy and other surgical interventions, especially if tampons are placed in the abdominal cavity.

V. M. Voylenko distinguishes three forms of postoperative hernias:

1) hemispherical, with a wide base and wide hernial orifices;

2) flattened from front to back due to adhesions connecting the walls of the hernial sac and the insides;

3) typical, with a narrow neck and widened bottom.

It is better to operate large postoperative hernias under anesthesia using relaxants, small ones - under local anesthesia.

Postoperative hernias are operated as follows:

1) the skin is cut within healthy tissue on both sides of the postoperative scar, which is excised;

2) free the aponeurosis from fatty tissue;

3) dissect the hernial sac and conduct an inspection of the abdominal cavity;

4) cut off the entire hernial sac;

5) perform plastic surgery of the hernial orifice.

V. M. Voilenko divides all methods of plastic surgery into three groups:

1) aponeurotic;

2) muscular aponeurotic;

3) other types of plastic surgery (skin flap plastic surgery, alloplasty, etc.).

In aponeurotic plasty, to close a defect in the abdominal wall, the edges of the aponeurosis are simply sutured, connecting them by doubling, and one or two flaps cut from the aponeurosis are sutured to the edges of the defect. The most common methods of aponeurotic plastic surgery are the methods of A. V. Martynov, N. Z. Monakov, P. N. Napalkov, Champion, Heinrich, Brenner.

In muscular aponeurotic repair, the aponeurosis along with the muscles is used to close the hernial orifice. This group of plastics includes the methods of V. P. Voznesensky, K. M. Sapezhko, A. A. Troitsky, as well as I. F. Sabaneev modified by N. Z. Monakov and the method of I. V. Gabay.

In practice, the most common method is Voznesensky, which consists of the following:

1) make a midline incision with excision of the postoperative scar;

2) open the abdominal cavity;

3) the left and right rectus abdominis muscles are sutured throughout their entire thickness with catgut thread from the peritoneal side and then tied alternately, starting from the upper corner of the wound;

4) the second row is applied more superficially, capturing the rectus muscles;

5) excess peritoneum and aponeurosis are excised, their edges are sutured with a continuous silk suture; stitches are placed on the skin.

Patients with postoperative hernias must be carefully prepared for surgery. Two days before, a laxative is given, then cleansing enemas are prescribed. In the postoperative period, early rising is prohibited, sutures are removed on the 10th – 12th day.

Rare forms of hernias

Rare forms of hernia include xiphoid hernia, lateral abdominal hernia, lumbar, obturator, sciatic and perineal hernia, etc.

Hernia of the xiphoid process rarely occurs. The main symptoms are pain in the area of ​​the xiphoid process, the presence of a protrusion there, after the reduction of which it is possible to palpate the hole.

Treatment is removal of the xiphoid process and excision of the hernial sac.

A lateral abdominal hernia can appear in the area of ​​the rectus abdominis muscle, along the Spigelian line in the muscular part of the abdominal wall, and due to injury - anywhere in the abdominal wall. When any of the muscles of the abdominal wall are underdeveloped, congenital abdominal hernias occur, which can manifest clinically at any age.

There are three types lateral abdominal hernias: hernia of the rectus sheath, hernia of the Spigelian line, hernia from arrest of development of the abdominal wall.

Hernias of the rectus sheath are more common in the lower abdomen, where there is no posterior layer of the vagina, and with traumatic ruptures of the rectus muscle.

Spigelian line hernias can be subcutaneous, intertitial or preperitoneal. Such hernias are localized along the line connecting the navel and the anterior superior iliac spine, but sometimes they are located below or above

pubic line.

The main symptoms of a lateral abdominal hernia are pain and hernial protrusion of various sizes depending on the width of the hernial orifice.

Treatment of lateral abdominal hernias is only surgical. For small hernias, after removal of the hernial sac, the hernial orifice is sutured using layer-by-layer sutures on the transverse and internal oblique muscles, as well as on the aponeurosis of the external oblique muscle. For large hernias, plastic methods are used.

Lumbar hernia- a hernial protrusion on the back and side walls of the abdomen, emerging through various cracks and spaces between the muscles and individual bones of the lumbar region.

Lumbar hernias exit through such anatomical formations as the Petit triangle, the Greenfelt-Lesgaft gap and the aponeurotic fissures. The most common contents of the hernial sac are the small intestine and omentum. The main symptom is an increase in hernias with physical activity. Complications of a lumbar hernia include strangulation. The radical method of treatment is surgery.

An obturator hernia occurs through the obturator canal, which passes under the pubic bone, and occurs mainly in older women. Their symptoms can be very diverse. Treatment of obturator hernias is only surgical. The operation is performed femorally, using laparotomy or a combined method.

A sciatic hernia extends to the posterior surface of the pelvis through the greater or lesser sciatic foramen and occurs predominantly in older women with a wide pelvis and large sciatic foramina. There are three types of sciatic hernias, emerging above the piriformis muscle, under the piriformis muscle and through the lesser sciatic foramen.

Treatment of sciatic hernias is only surgical. The surgical technique is very diverse and depends on the approach to the hernial orifice.

The most common complication of a sciatic hernia is strangulation. It is recommended to operate a strangulated sciatic hernia using a combined method, starting with laparotomy, and when dissecting the hernial orifice, one should remember the possibility of injury to the gluteal vessels.

Diaphragmatic hernia– exit of the abdominal organs into the chest cavity through a physiological or pathological opening in the diaphragm of congenital or traumatic origin. In this case, we can talk about the hernial orifice and hernial contents, but the hernial sac is mostly absent.

Diaphragmatic hernias are divided into traumatic and non-traumatic. The trauma factor is of great importance in the development of the disease, determines the type of hernia, diagnosis and prognosis.

Non-traumatic hernias are located in certain typical places - in the esophageal hiatus, Bochdalek's foramen, Larrey's fissure, and the dome of the diaphragm.

According to the clinical course, traumatic diaphragmatic hernias are divided into acute and chronic.

The symptoms of diaphragmatic hernia are associated with dysfunction of both displaced abdominal organs and compressed thoracic organs. Thus, with a diaphragmatic hernia, disorders of the digestive tract, respiratory and circulatory disorders, as well as diaphragmatic symptoms can be observed.

The X-ray method of examination is the main one in the diagnosis of diaphragmatic hernias. It makes it possible to establish which organs have emerged from the abdominal cavity, where the hernial opening is located and what its size is, whether there are fusions of the emerging organs in the hernial orifice and with the organs of the thoracic cavity.

The most severe complication of a diaphragmatic hernia is strangulation, which can occur immediately after damage and formation of a hernia, but more often develops much later, after 2–3 and even 10–15 years.

The presence of a diaphragmatic hernia is an absolute indication for surgery. It can be operated on by thoracotomy, laparotomy, or a combination.

Complications of hernias

Complications of hernias include strangulation, coprostasis, and inflammation.

Strangulated hernia. A strangulated hernia is understood as a sudden compression of the contents of the hernia in the hernial orifice. Any organ located in the hernial sac can be injured. It usually occurs with significant tension in the abdominal muscles (after lifting heavy objects, with strong straining, coughing, etc.).

When any organ is strangulated in a hernia, its blood circulation and function are always disrupted; depending on the importance of the strangulated organ, general phenomena also arise.

There are the following types of infringement: elastic, fecal, and both at the same time.

With elastic strangulation, intra-abdominal pressure increases. Under the influence of this and the sudden contraction of the abdominal muscles, the viscera quickly pass through the hernial orifice into the sac and are pinched in the hernial ring after intra-abdominal pressure normalizes.

With fecal strangulation, the contents of the overcrowded intestine consist of liquid masses mixed with gases, less often - of solids. In the latter case, the infringement can join with coprostasis.

Pathological changes in the strangulated organ depend on the period elapsed from the onset of strangulation and the degree of compression by the strangulation ring.

When the intestine is strangulated, a strangulation groove is formed at the site of the strangulation ring with a sharp thinning of the intestinal wall at the site of compression. Due to stagnation of intestinal contents, the afferent segment of the intestine is significantly stretched, the nutrition of its wall is disrupted and conditions are created for venous stasis (stagnation), resulting in plasma leakage into both the thickness of the intestinal wall and the intestinal lumen. This further stretches the adductor section of the intestine and impedes blood circulation.

Changes at the site of the strangulated intestinal loop are more pronounced than in the adductor region. When more pliable veins are compressed, venous stasis is formed, and the intestine takes on a bluish color. Plasma sweats into the lumen of the pinched loop and its wall, increasing the volume of the loop. As a result of increasing edema, compression of the mesenteric vessels increases, completely disrupting the nutrition of the intestinal wall, which becomes necrotic. The vessels of the mesentery at this time can be thrombosed over a significant extent.

Most often, strangulation occurs in patients who have suffered from hernias; in exceptional cases, it can occur in people who have not previously noticed their hernias. When a hernia is strangulated, severe pain occurs, in some cases it causes shock. The pain is localized in the area of ​​the hernial protrusion and in the abdominal cavity, often accompanied by reflex vomiting.

An objective examination of the anatomical location of the strangulated hernia reveals an irreducible hernial protrusion, painful on palpation, tense, hot to the touch, dulling upon percussion, since there is hernial water in the hernial sac.

It is most difficult to diagnose parietal strangulation, since they may not interfere with the movement of contents through the intestine, and besides, parietal strangulation sometimes does not produce a large hernial protrusion.

Forcible reduction of a strangulated hernia is unacceptable, since it can become imaginary. The following options are possible:

1) moving the pinched viscera from one part of the bag to another;

2) transition of the entire strangulated area together with the hernial sac into the preperitoneal space;

3) reduction of the hernial sac along with the strangulated viscera into the abdominal cavity;

4) rupture of intestinal loops in the hernial sac.

In all these variants, hernial protrusion is not observed, and all symptoms of intestinal strangulation remain.

It is also necessary to keep in mind retrograde strangulation, in which there are two strangulated intestinal loops in the hernial sac, and the intestinal loop connecting them is in the abdominal cavity and turns out to be the most altered.

Patients with strangulated external abdominal hernias should undergo urgent surgery.

When performing surgery for strangulated external abdominal hernias, the following conditions must be met:

1) regardless of the location of the hernia, the strangulating ring cannot be cut before opening the hernial sac, since the strangulated viscera without revision can easily slip into the abdominal cavity;

2) if the possibility of necrosis of strangulated areas of the intestine is suspected, it is necessary to inspect these areas by removing them back from the abdominal cavity;

3) if it is impossible to remove the intestines from the abdominal cavity, laparotomy is indicated, in which the presence of retrograde strangulation is simultaneously determined;

4) special attention must be paid to dissecting the pinching ring and accurately understanding the location of the adjacent blood vessels passing through the abdominal wall.

If during the audit it is determined that the strangulated intestine is not viable, then it is removed, then the hernial orifice is repaired and sutures are placed on the skin. The minimum boundaries of the resected non-viable small intestine: 40 cm for the afferent loop and 20 cm for the efferent loop.

After the operation, the patient is taken to the ward on a gurney; the issue of management of the postoperative period and the possibility of getting up is decided by the attending physician. This takes into account the patient’s age, the state of the cardiovascular system and the nature of the surgical intervention.

Coprostasis. With irreducible hernias, coprostasis (fecal stagnation) is observed in the intestinal loop located in the hernial sac.

Hernia inflammation occurs acutely, accompanied by sharp pain, vomiting, fever, tension and severe pain in the area of ​​the hernial sac. Treatment is urgent surgery.

In case of phlegmon of the hernial sac, it is necessary to perform a laparotomy away from the phlegmonous area with the imposition of an intestinal anastomosis between the adducting and efferent ends of the intestine, going to the strangulating ring. The disconnected loops of intestines to be removed are tied at the ends with gauze napkins and fairly strong ligatures. Having completed the operation in the abdominal cavity, the inflamed hernial sac is opened and the dead loops of strangulated intestines are removed through the incision, and the phlegmon is drained.

(lat. hernia) - protrusion of organs from the cavity, through a pathologically formed or naturally existing hole. At the same time, the shells retain their integrity. The formation can extend into the intermuscular space, under the skin, or into internal cavities and pockets. Eventration (prolapse of internal organs through a defect in its wall) and prolapse (exit of an organ through a natural opening during prolapse) are not hernias.

Types/classification of the disease

Highlight uncomplicated And complicated(inflammation, rupture and phlegmon of the hernial sac, strangulation) of the hernia.

The disease happens along the way:

primary;
recurrent(re-formation of a hernia in the same place);
postoperative(ventral).

By origin of hernia there may be acquired, developing as a result of illness or injury or congenital(for example, central Schmorl's hernia), which are developmental defects and have their own characteristics.

According to reducibility they are distinguished:

Reducible- a protruding hernial sac is reduced independently or can be easily reduced through the hernial orifice;
Irreversible– usually due to the formation of adhesions, strangulation or adhesions, a hernia that was previously reduced cannot be returned to its place.

Anatomically, hernias can be external(internal organs fall out under the skin, and the hernia looks like an oval or rounded protrusion), they make up 75%, these are the femoral, epigastric, inguinal, umbilical, sciatic, white line of the abdomen, xiphoid process.

Internal a hernia occurs in 25% of all such pathologies, has no clear external symptoms, organs protrude into crevices, pockets or anatomical cavities or defects. They are divided into intra-abdominal and diaphragmatic.

Symptoms and signs

A protrusion is observed at the site of the hernia formation; when palpated, a hernial orifice is felt. Sac-like swelling can be of varying sizes.

Intervertebral hernia

Dystrophic changes in the lumbosacral spine most often appear in adults between 20 and 50 years old. Pathology often becomes the basis for temporary loss of ability to work and even disability. Osteochondrosis in almost all cases provokes the development of a back hernia. In this case, a pain syndrome appears, which can be accompanied by sensory disturbances, paralysis and paresis of the leg muscles, and dysfunction of the pelvic organs. 18% of patients with intervertebral hernias require surgical intervention.

The pathology develops as a result of a disc rupture, the hernia goes back, puts pressure on the nerve root, causing swelling and inflammation. The clinical picture begins to appear one day after the onset of the disease. In almost all patients, the main complaint is pain. Most often it appears in adolescence after a long stay in an uncomfortable position, physical activity or in bed. The disease develops when turning to the side occurs parallel to bending, sometimes the person also lifts weights.

Lumbar and sacral hernia(sequestrated) begins with a dystrophic process, then changes occur in the spinal motion segments, the strength of the fibrous ring decreases, the microcirculation of this area is disrupted, an adhesive process develops, and swelling of local tissues develops. The symptoms are caused by myofixation as a result of tension in the back muscles, which provokes compensatory curvature of other parts of the spinal column. The long course of the disease leads to dysfunction of the joint-ligamentous apparatus, accompanied by severe pain.

If the intervertebral disc falls into the lumen of the spinal canal, it develops dorsal hernia, which, like other types of pathologies of the lumbosacral region, can manifest itself as autonomic disorders, such as redness, dryness and swelling of the skin, and impaired sweating.

Often, patients take a forced position, with its help the pressure on the spine is reduced, that is, scoliosis is smoothed out, flexion and extension of the body is facilitated, and tension in the long back muscles is eliminated. Occasionally, patients cannot straighten their leg due to pain. Due to atrophy, the muscles “deflate”. Motor disorders (paresis, paralysis) occur only in severe cases.

When coughing and moving, the pain intensifies and often becomes very severe; the patient needs bed rest.

Cervical and thoracic hernia are very rare and have similar symptoms:

Headache;
acute pain radiating to the arms, shoulder blades, shoulders;
unsteadiness of gait;
numbness of fingers;
restriction of movement;
hypertension or hypotension;
dizziness;
weakness in the limbs, decreased reflexes;
sleep disturbance;
chronic fatigue;
memory impairment.

Inguinal hernia- protrusion of the peritoneum into the cavity of the inguinal canal. It is 10 times more likely to form in men than in women. The main signs of the disorder are a feeling of discomfort and pain in the groin area, intensifying while walking, dysfunction of urination and digestion. A lump forms in the groin and grows when coughing and straining. In men with inguinal hernias of significant size, the affected side of the scrotum enlarges, because of this the penis moves to the opposite side, and with large volumes of formation, the penis can be completely hidden under the skin.

Brief interesting data
- It was Claudius Galen (born around 130 AD) who first introduced the term “hernia.”
- There is a term “giant hernia”, it is used to refer to hernias larger than 40 cm.
- Most often, namely in 80-90%, inguinal hernias occur.
- Statistics indicate that multiple hernias are much more common than single ones.

The linea alba is formed by tendon fibers. When a hernia forms, the patient experiences pain, as with a stomach ulcer and other gastrointestinal ailments. On the line itself there is a protrusion, which occurs mainly when straining in the epigastric region. The pain intensifies after eating, with physical activity and sudden movements. Dyspeptic disorders are often observed: belching, nausea, constipation and heartburn.

Strangulated hernia of the white line cannot be reduced and is manifested by unbearable pain, blood in the stool, nausea and vomiting, retention of gases and bowel movements.

Hiatal hernia usually has no external manifestations. With this pathology, the stomach contents backflow into the esophagus, which causes hiccups, indigestion, heartburn, belching and chest pain.

Umbilical hernia- The abdominal organs extend into the navel area. Most often found in infants. This is due to the fact that the abdominal wall has a defect in which the umbilical ring, which usually closes before birth, remains uncovered. Pathology sometimes appears in children even after they begin to walk early. A hernia of less than a centimeter in a child may disappear on its own by the age of two. If a hernia was diagnosed in a newborn in time, then it can be cured simply with the help of gymnastics, massage and proper placement on the tummy. If necessary, surgery is performed no earlier than 5 years of age.

The acquired form of the disease proceeds a little more favorably. The child most often does not have any symptoms; the pathology manifests itself as a cosmetic defect. The dimensions of the bulge, as a rule, do not exceed 5 cm in diameter. Very rarely, adults experience aching or nagging pain, especially during physical activity, and constipation.

Not only in children, but also in dogs, namely puppies, an umbilical hernia often forms. The animal may refuse food and be depressed.

Complications

Intervertebral hernias cause some discomfort, but when complications arise, rather unpleasant symptoms develop: acute pain, migraine, numbness of the limbs, even paralysis. With disorders in the spinal region, the following develop: lumbodynia, lumbago, lumboischialgia or cauda equina syndrome. If the cervical vertebrae are affected, cervicalgia and cervicobrachialgia may appear, and the thoracic vertebrae - thoracalgia, intercostal neuralgia.

Abdominal hernias are often complicated by strangulation; this is an acute condition that requires urgent help. This disrupts blood circulation, the functioning of the pinched organ, and even tissue necrosis is possible. Severe pain develops, and when the intestinal loops are compressed, digestion is disrupted, up to intestinal obstruction. Internal organs and the hernial sac can become inflamed, which leads to the formation of an abscess, phlegmon, and peritonitis.

Causes of the disease

Abdominal hernias develop as a result of defects in muscle and tendon fibers. An elastic human corset helps maintain the desired position of organs in various body positions and counteract intra-abdominal pressure.

Causes of hernia formation:

Loss of elasticity in muscle tissue due to exhaustion or aging;
increased intra-abdominal pressure in combination with other negative factors;
congenital hole in the abdominal wall;
degenerative disorders at the site of injury or wound;
congenital abnormalities of connective tissue development;
various suppurations affecting the anterior abdominal wall.

Predisposing factors include: family history, individual differences in body structure, heavy physical labor, malnutrition, pregnancy, sharp fluctuations in intra-abdominal pressure (ascites, constant screaming, crying, difficulty urinating, cough, prostate adenoma and constipation), intestinal dyskinesia.

A spinal hernia is usually the consequence of carrying heavy objects, sedentary work, prolonged vibration or incorrect posture. It develops as a result of pinched nerve trunks and narrowing of the spinal canal.

Diagnostics

First of all, the doctor will conduct an examination, since many hernias are visible to the naked eye. To confirm the diagnosis and early prediction of complications, instrumental diagnostics are performed. For different localizations, the information content of the examination differs. Often, during the study of a disease, such as osteochondrosis, a herniated disc is accidentally discovered.

Diagnostic methods that are most often used:

Ultrasound (ultrasound examination);
MRI;
X-rays are sometimes used when a contrast agent is injected;
CT (computed tomography).

Differential diagnosis is carried out with:

Hematoma, endometriosis, cyst;
dysplasia, osteochondrosis, arthrosis;
varicocele, hydrocele, lymphadenitis;
general diseases of organs and systems (pancreatitis, gastric ulcer);
neurofibroma and lipoma.

Treatment

The main treatment for hernias and their complications is surgery. During surgery, a special mesh is applied to prevent the hernia from coming out, or the damaged area is sutured. Currently, operations are performed endoscopically or using autoplasty (recovery is carried out using one’s own tissues). In order for the patient to return to normal life, a recovery period and intensive rehabilitation are necessary.

Removal of a spinal hernia is performed as a last resort; if there are no complications, traction is recommended. After the end of the acute period or during the recovery period, it is recommended to carry out massage, perform physiotherapeutic procedures (electrophoresis, diadynamic currents, hirudotherapy, acupuncture), exercises to strengthen the muscular-ligamentous frame of the back, and therapeutic exercises also contribute to this. For pain syndrome, NSAIDs (Voltaren, Ketorol, Diclofenac), glucocorticoid ointments (Lorindene, Deperzolon) are prescribed. For almost all types of hernias, to prevent complications, it is recommended to wear an orthopedic bandage.

Treatment of a hernia can be carried out in a sanatorium, where specialists will help carry out a set of measures for treatment and rehabilitation after surgery.

Prevention

To prevent this disease it is recommended:

Do not sleep on soft mattresses;
do not overeat and control weight;
stop smoking and take care of your liver;
avoid excessive loads and sudden movements;
keep your back and head straight when walking;
increase immunity and eliminate stress;
move more, play sports (swimming, yoga);
Treat constipation, urological diseases, cough in a timely manner.

Traditional methods of treatment

Any home remedy can only be used with the permission of a doctor. If you are scheduled for surgery, then traditional treatment is unlikely to be effective.

Umbilical hernia treatment is carried out using a cake made of red clay, which is placed on top of the bandage for 24 hours. You can secure it using dressing material and cling film. The cake must be changed every day for 14 days. You can replace it with a copper coin, which must be applied for 3 days. Fix with a sticky bandage and repeat several times. You can also put cut garlic cloves on the hernia for up to 12 hours, but this procedure can cause a burn.

For vertebral hernia, red clay is also used or horse fat is used in the form of a compress of horse fat, which is applied to polyethylene in a thick layer for a day. It is good if the lower back is constantly wrapped in a belt made of dog hair.

Strangulation of an abdominal hernia is considered the most common and most dangerous complication that can occur with this pathology. In this case, the internal organs that have entered the hernial sac are subject to compression, usually in the area of ​​the hernial orifice, although it can occur in the area of ​​the neck of the hernial sac, and directly in the sac itself, or rather in one of its chambers (with multi-chamber hernias). The main clinical sign of a suddenly strangulated hernia is the appearance of acute pain at the site of its exit. The situation requires immediate surgical resolution.

An irreducible hernia is one whose contents cannot be reduced back into the abdominal cavity. This problem arises as a result of the formation of connective tissue adhesions between the walls of the hernial sac and the internal organs that have emerged into its lumen. Often such hernias are multi-chamber. An irreducible hernial protrusion (unlike a strangulated one) is painless or gives a slight discomfort, is not tense and is not accompanied by symptoms of intestinal obstruction. When straining, an irreducible hernia may increase slightly in volume. May be complicated by coprostasis and partial intestinal obstruction. Herniotomy is carried out as planned, but if strangulation is suspected, urgent surgery is indicated.

Coprostasis, or, in other words, fecal stagnation in the hernial sac develops as a result of weakened intestinal peristalsis and is usually observed in elderly people and old people who are prone to constipation. Predisposing factors here include a sedentary lifestyle, obesity and rich food. Symptoms increase slowly. Patients complain of persistent stool retention, general malaise, unexpressed pain, and nausea. The hernial protrusion has a doughy consistency and slowly increases in size. Such patients are managed conservatively, prescribing a light massage of the hernial protrusion, enemas with vaseline oil or glycerin and emptying the stomach with a probe. Laxatives are contraindicated due to the fact that, due to overflow of the afferent loop, they contribute to the transition of coprostasis into the so-called fecal form of strangulation.

Inflammation of an abdominal hernia occurs due to infection of the hernial sac and its contents. By the way, it is from the latter side that, as a rule, this pathological process begins. However, infection can occur from the abdominal cavity and from the skin. Inflammation of the hernia usually occurs in an acute form of the serous, serous-fibrinous, purulent or putrefactive type. Treatment of inflammation of a ventral hernia, if it is caused by infection from the hernial contents, involves urgent surgical intervention to remove the source of infection. If the cause is inflammation of the skin, the tactics are conservative.

In practice, such a complication as hernia tuberculosis is rarely encountered. Basically, it is secondary in nature and is expressed either in isolated damage to the walls of the hernial sac or the internal organs contained in it, or a mixed version develops. During the examination, special attention is paid to the condition of the lymph nodes of the mesentery and ileocecal region. If a tuberculosis process is detected during surgery for strangulated or non-strangulated hernias, the intervention is performed according to the usual plan, followed by complex antibacterial therapy.

Foreign bodies (calculi, detached sections of the omentum and fatty appendages of the colon) in the hernial sac, damage to it and its contents, tumors (fibromas, lipomas, fibrolipomas, sarcomas and carcinomas) are very rare.

Strangulated hernias

Strangulation is the most severe complication of hernias, observed in 3-15% of patients with hernias. In recent years, there has been a slight increase due to the lengthening of life expectancy - over 60% of patients are over 60 years of age (Petrovsky). Strangulation is a sudden compression of the hernial contents in the hernial orifice, or the scarred neck of the hernial sac, followed by disruption of the nutrition of the strangulated organ. A distinction is made between elastic strangulation - due to a sudden contraction of the abdominal muscles and fecal strangulation - with an abundant flow of intestinal contents into the loop lying in the hernial sac. In addition, there are parietal strangulation (Richter's) - strangulation of the part of the intestinal wall opposite the mesentery, in a small hernial orifice (often with femoral hernias or in the internal ring with oblique inguinal hernias) and retrograde strangulation - strangulation of the intermediate loop lying in the abdominal cavity, and not visible in the hernial sac - may be accompanied by necrosis of the loop in the abdominal cavity (in this case, 2 or more intestinal loops are identified in the hernial sac). Most often, the intestinal loop is strangulated, then the omentum, and the degree of changes in the strangulated organ depends on the duration of the strangulation and the degree of compression.

Clinical picture

Severe pain in the area of ​​the hernial protrusion, up to shock; rarely the pain is minor.

Irreversibility that came on suddenly.

An increase in the size of the hernial protrusion and its sharp tension due to the presence of hernial water (absent in Richter's strangulation).

Disappearance of the “cough impulse” symptom.

Symptoms of intestinal obstruction are vomiting that turns into feces, failure to pass gas and feces, bloating (absent with Richter’s strangulation, as well as with strangulation of the omentum).

General symptoms are pallor, cyanosis, cold extremities, dry tongue, small rapid pulse.

Locally - in advanced cases, inflammation in the area of ​​the hernial sac is hernial phlegmon.

Differential diagnosis is carried out with an irreducible hernia, inflammation of the hernia, coprostasis, hernial appendicitis, inguinal lymphadenitis, acute orchiepididymitis, intestinal obstruction of another origin, peritonitis, pancreatic necrosis. Diagnostic errors are observed from 3.5 to 18% of cases; when localization is established - femoral or inguinal - up to 30%.

Decisive importance must be attached to the anamnesis. Inspection of all possible hernial orifices in acute diseases of the abdominal cavity is mandatory. “In case of intestinal obstruction, you should first examine the hernial orifice and look for a strangulated hernia” (Mondor).

Always prompt, as early as possible after the injury. 3 days after strangulation, mortality increases 10 times. Even with timely surgery, deaths are currently observed in 2.5% or more. The operation is to eliminate the strangulation; in case of necrosis, resection of the altered intestine followed by herniotomy and plastic surgery.

Features of the operation:

The strangulating ring is not cut until the hernial sac is opened, the strangulated organs are examined and fixed. The strangulating ring for femoral hernias is dissected medially.

Be careful when cutting the ring to avoid damage to the strangulated organs and vessels of the abdominal wall.

Remember about possible infection of “hernial water” - covering with napkins, suction, culture.

Caution when reducing intestinal loops (performed after the introduction of novocaine into the mesentery).

If there are visible changes in the intestine, cover with napkins moistened with warm saline solution for 5-10 minutes. Signs of intestinal viability: a/ restoration of normal color and tone. B/ shine and smoothness of the oerosis, c/ presence of peristalsis, d/ presence of pulsation of mesenteric vessels.

If there are several loops in the bag, remember the possibility of retrograde entrapment.

Resection of the intestine is carried out within healthy tissues, with the removal of at least 40 cm of the unchanged adductor and 15-20 cm of the efferent intestine, better, “end to end”; novice surgeons can do it “side to side”. In extremely severe patients, intestinal fistulas are applied; in particularly severe patients, the necrotic loop is removed without resection. The simplest, least traumatic methods of plastic surgery are used.

In case of hernial phlegmon, a median laparotomy is performed with resection of the intestine from the abdominal cavity, then they return to the hernia and excise the strangulated part of the intestine in one block. With mandatory drainage of the abdominal cavity. Plastic surgery of the defect is not performed in these cases.

Mortality: during surgery on the first day - 2.9%, on the second - 7%, after two - 31.3% (Sklifosovsky Institute). Complications - peritonitis, pulmonary complications, embolism and thrombosis, late bleeding.

Conservative treatment - (as an exception!!!) Permissible only in the first 2 hours after strangulation and only in particularly seriously ill patients in a state of cardiac decompensation, myocardial infarction, severe pulmonary diseases, inoperable malignant tumors, etc., as well as in weakened premature infants children.

It includes:

Emptying the bladder and bowels

Warm bath, heating pad,

Raised pelvic position

Atropine injections,

Cleansing enemas with warm water,

Spraying chloroethyl,

A few deep breaths

Very careful manual reduction.

After reduction, digital control of the hernial canal is required to determine the “cough impulse”. In case of spontaneous reduction, observation in a hospital followed by planned hernia repair. At the slightest deterioration of the condition, urgent surgery is required.

Prevention - a dispensary method of active identification of hernia carriers, timely planned surgery, sanitary and educational work among general practitioners and the population about the need for surgical treatment of hernias.

Coprostasis

Coprostasis is fecal stagnation in the hernial sac, observed in people with intestinal atony, more often with large irreducible hernias, in old age.

Features of the clinic: in contrast to strangulation, the increase in pain and increase in protrusion is gradual, the pain and tension of the protrusion are insignificant, the cough impulse phenomenon is preserved. Picture of partial intestinal obstruction. The general condition suffers little.

Treatment: reduction (for reducible hernias), high enemas, ice pack. Giving laxatives is contraindicated!!! The operation is desirable after the elimination of coprostasis in a few days, but if conservative measures are unsuccessful, an urgent operation is required.

Inflammation

Inflammation - most often begins secondary, from the hernial contents - hernial appendicitis, inflammation of the uterine appendages, etc., less often - from the hernial sac or skin (with eczema, when using a bandage. Inflammation is often serous, serous-fibrinous, sometimes purulent or putrefactive, with tuberculosis - chronic.

Features of the clinic. The onset is acute, pain, fever, local hyperemia, swelling, even phlegmon. Treatment is surgical (often the basis is infringement, often parietal).

Irreversible hernias

An irreducible hernia is a chronic complication - the result of the formation of adhesions of the hernial contents with the hernial sac, especially in the cervical area, with constant trauma at the time of the release of the viscera, when using a bandage.

Features of the clinic. Unlike strangulation, irreducibility occurs in the absence or slight pain, absence of tension in the hernial protrusion, or intestinal obstruction. May be complicated by coprostasis, partial intestinal obstruction. Irreversible hernias are often accompanied by dyspeptic symptoms and are often strangulated. Treatment. Herniotomy is performed as planned; if strangulation is suspected, an urgent operation is performed.