Strangulated hernias in children. Postoperative ventral hernias Hernias of the white line of the abdomen

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Presentation on the topic: Strangulated hernia

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A strangulated hernia is an acute compression of the contents of the hernial sac in the hernial orifice. This complication is observed, according to various statistics, in 8-20% of patients with abdominal hernias. Patients with strangulated hernias make up on average about 4-5% of all patients with “acute abdomen”. Strangulated hernias occur 1.5 times more often in women than in men. A strangulated hernia is usually accompanied by intestinal obstruction, which causes a fairly high mortality rate - 8-11%, and the mortality rate progressively increases with increasing time from the moment of strangulation to surgery.

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Strangulation without proper emergency medical care ultimately leads to necrosis of part or all of the organ. External hernias (located in defects of the pelvic floor or abdominal walls) and internal hernias (located in the walls of the diaphragm or in pockets of the peritoneum) can be subject to strangulation. Strangulated hernias come in different types. Whether the strangulated hernia belongs to one type or another depends on the anatomical region. The first classification of strangulated hernias is external and internal hernias.

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Clinical picture. Abdominal pain in the area of ​​the hernia is the main sign of strangulation; it usually occurs acutely due to physical stress, severe coughing, etc. Often the pain, although it occurs suddenly, intensifies gradually, and patients associate its occurrence with prolonged constipation. In some cases, it is so strong that patients cannot resist moaning and screaming. The pain is mostly constant. Particularly severe pain occurs when the intestinal mesentery is compressed in the hernial orifice, which leads to disruption of the blood supply to the strangulated intestinal loops.

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Types of strangulated hernias Strangulated hernias vary by anatomical region. First of all, they are divided into internal and external. Internal ones include diaphragmatic hernias. They are formed when part of the abdominal organs “enters” the chest cavity and is compressed by the muscles of the diaphragm. These hernias are rare and, as a rule, become strangulated even less often, since their symptoms appear very early. Most often, the following can be injured: the stomach, the lesser omentum (a connective tissue apron with a large amount of fatty tissue covering the stomach, liver and other organs of the upper abdomen) and the lower esophagus. All other hernias are external. Because they are based on the “exit” of part of the abdominal organs through the anterior abdominal wall. They, in turn, are: inguinal oblique and inguinal straight. This division is based on the direction of the hernial protrusion. ventral or hernia of the white line of the abdomen - the line that divides the abdomen into two halves.

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There are elastic and fecal strangulation. Elastic entrapment occurs suddenly, usually under the influence of some kind of stress (for example, lifting weights, heavy physical work). In this case, a larger than usual amount of viscera, such as loops of intestine, is pushed out of the abdominal cavity, which overwhelms the hernial sac. In a narrow place, in the hernial orifice, they are compressed, and thin-walled veins are compressed first, while blood continues to flow through the arteries for some time. Venous stagnation develops and fluid begins to leak from the veins into the cavity of the hernial sac; soon the intestinal wall becomes permeable to bacteria and the “hernial fluid” becomes infected. After some time, the intestinal loops become dead. In addition to the loop of intestine located in the hernial sac, the afferent loop of intestine is affected, which also loses its viability. Inflammation of the peritoneum develops, which causes death.

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Fecal strangulation develops slowly, gradually. It usually occurs with large inguinal hernias in patients suffering from constipation. The point here is that feces, filling the intestine located in the hernial sac, cannot overcome the obstacle - the bend of the efferent part of the intestine in the hernial orifice. Gradually, more loops of intestines are squeezed into the bag and the mesentery is compressed, just as with elastic strangulation. Therefore, this form of strangulation is very insidious, it can be expected with large hernias in elderly people suffering from constipation.

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In addition to the complete strangulation described above, with small ones, especially with femoral and umbilical hernias, so-called parietal strangulation can occur. This is an elastic strangulation, but in the hernial orifice it is not the mesentery of the intestinal loop that is strangulated, but a section of its wall. Diagnosing parietal entrapment is often very difficult. The passage of intestinal contents is not disrupted, and the hernial sac does not overflow. The patient complains only of more or less severe pain in the hernia area, and only with a very careful examination can sharp pain be detected at the site of the hernia orifice. Parietal strangulation is often the first sign of a femoral hernia. Slide description:

Another main complication of strangulated hernias is phlegmon of the hernial sac, which develops as a result of purulent melting of strangulated tissues. Then the clinical picture of a strangulated hernia is accompanied by signs of inflammation: fever, hyperemia of the skin under the hernial protrusion, etc. Stage of Grekov’s operation for a strangulated umbilical hernia, complicated by phlegmon of the hernial sac.

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Main complications First of all, the danger of a strangulated hernia lies in the appearance of necrosis (death) of the tissue that is subjected to compression. And also that part that is located outside the abdominal cavity. If, after some time, the hernia is strangulated (the reverse process of strangulation), a patch of dead tissue appears in the abdominal cavity. Toxins almost immediately begin to enter the blood. And quickly enough, immune cells “approach” the site of necrosis, causing aseptic inflammation. After a few hours, the intestinal flora penetrates beyond its boundaries and peritonitis develops. And this condition, even at the current stage of medical development, is characterized by high mortality.

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Treatment. Treatment of strangulated hernias is only surgical. The patient’s life directly depends on the time elapsed from the moment of injury to the operation. There are no contraindications for surgery for a strangulated hernia. If there is a suspicion of strangulation or self-reduction of the hernia, urgent hospitalization in the surgical department is necessary. In case of a serious condition of the patient with a full-blown picture of peritonitis or intestinal obstruction, infusion therapy during transportation is indicated.

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It is strictly forbidden to reduce a strangulated hernia, since this can very easily rupture the strangulated intestine. This will lead to the development of peritonitis. It happens that when shifting or transporting a patient, the strangulated hernia is independently reduced. Such patients still need to be hospitalized for observation, since often the reduced bowel loop is not viable.

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A cranial hernia is a rather rare developmental defect (occurs in 1 in 4000-8000 newborns), in which the membranes of the brain, and sometimes its substance, prolapse through defects in the bones of the skull (araphia, dysraphia).

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Etiology.

The occurrence of cranial hernias is associated with disruption of the development of the skull and brain in the early stages of the embryonic period, when the formation of the brain plate and its closure into the brain tube occur. Among the causes of cranial hernias are infectious and other diseases of the mother during pregnancy. Great importance is attached to heredity.

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Classification.

Anterior or sagittal (orbitonasal and frontal) 84.6%

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Posterior (occipital) 10.6%

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Hernias of the base of the skull (basal). 4.6%

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Most often there are anterior hernias, localized in places of embryonic fissures - at the root of the nose, at the inner edge of the orbit. Posterior cerebral hernias are located in the foramen magnum (above or below it). In the rarest basilar (basal) hernias, the defect is localized in the region of the anterior or middle cranial fossa, and the hernial contents protrude into the nasal or oral cavity.

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According to the contents of the hernial sac

Meningocele is a form in which the contents of the hernial sac are only the membranes of the brain (soft and arachnoid) and brain fluid. The dura mater and medulla remain intact. The dura mater, without participating in the formation of the hernial protrusion, is attached to the edges of the bone defect from the side of the cranial cavity.

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A true cerebral hernia, or meningoencephalocele, in which the sac contains the meninges and brain tissue.

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Encephalocystocele is the most severe form, in which the contents of the hernial sac are the medulla with part of the enlarged ventricle of the brain.

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The size of cerebral hernias varies greatly and can sometimes exceed the size of the child’s head. The size of the bone defect through which the hernia protrudes also varies, but most often does not exceed several centimeters. A hernia is not always covered by skin. This is an indication for urgent surgical treatment.

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Clinical picture.

When examining a child, a tumor-like formation is determined, most often located in the bridge of the nose, at the inner corner of the eye, or less often in the occipital region. The skin over the tumor is unchanged, palpation is painless. With anterior hernias, true hypertelorism attracts attention. The consistency of the hernial protrusion is soft-elastic, sometimes fluctuation is detected. When the child is restless, the formation becomes more intense, sometimes it is possible to detect fluctuations, which indicates a connection with the cranial cavity. The edges of a bone defect of the skull are determined much less frequently.

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With anterior cranial hernias, deformations of the facial skeleton, flattening of the bridge of the nose, widely spaced eyes, and strabismus come to the fore. Posterior cerebral hernias, in which the brain suffers more severely, are often accompanied by microcephaly and mental retardation. Symptoms of a central nervous system disorder may be absent, but if they are mild, especially in newborns, they are difficult to detect. At an older age, children are found to have lesions of the cranial nerves, asymmetry of tendon reflexes, and pathological reflexes; Sometimes paresis of the limbs and epileptic seizures are observed. Children with meningocele develop relatively normally, both physically and intellectually, while with a true cerebral hernia, pronounced disturbances in the central nervous system appear.

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Differential diagnosis.

Differential diagnosis of anterior cranial hernias is carried out mainly with dermoid cysts, which are sometimes located at the inner corner of the eye. Unlike cerebral hernias, dermoid cysts are usually small (rarely more than 1-1.5 cm) and have a dense consistency. The cause of the diagnostic error may be the usuration (the process of formation of a gap in the bone plate) of the bone plate, detected during radiographic examination and taken for a bone defect in a cerebral hernia

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Less often, a cranial hernia has to be differentiated from lipoma, hemangioma and lymphangioma. With tumor-like formations of soft tissues, the bone defect and pulsation characteristic of a cranial hernia are never determined.

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The following symptoms allow one to distinguish an intranasal cerebral hernia from a nasal polyp: a peculiar deformation of the nasal skeleton in the form of a wide bridge of the nose, bulging of one of its sides. The nasal septum is sharply pressed in the opposite direction. The color of the hernia is bluish in contrast to the gray color of the nasal polyp. Hernias are usually unilateral and have a wide base. When a hernia is punctured, cerebral fluid is detected in the punctate.

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Diagnostics

Analysis of complaints and medical history (questioning of parents): how the pregnancy with this child proceeded (did the pregnant woman have any infectious diseases, especially in the first trimester, did she take medications, drugs, alcohol, did she smoke); whether there were cases of such a developmental defect in the family. Neurological examination: assessment of the presence of a tumor-like soft formation on the head or face, the state of muscle tone (can be either increased or decreased), movements of the eyeballs (squint, limited mobility of the eyeballs may be observed). Examination by a pediatric otolaryngologist: examination of the nasal cavity, search for a hernia in the nose, assessment of the presence of leakage of cerebrospinal fluid (cerebrospinal fluid that provides nutrition and metabolism to the brain) from the nose. CT (computed tomography) and MRI (magnetic resonance imaging) of the head: allow you to study the structure of the brain layer by layer, assess the contents of the hernial sac (a protrusion, the walls of which are formed by the skin and membranes of the brain), and the size of the defect in the skull bones.

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Indications and contraindications for surgical treatment.

If there are no urgent vital indications (for example, in case of rapid growth of swelling and the danger of rupture of thinned tissues, it is necessary to operate in the first days after birth), then it is more profitable to operate on a hernia in children at the age of no earlier than 5-6 (2-3) years. . Surgical intervention is often resorted to in adults when patients decide to undergo surgery for cosmetic purposes. When a hernia is combined with dropsy of the brain, the dropsy is first cured and only after that the hernia is operated on. It is unacceptable to do the opposite, since after the defect is closed and the hernial sac is closed, the dropsy can sometimes progress or sharp headaches appear. Pleocytosis in the cerebrospinal fluid and the presence of meningeal symptoms are a contraindication for any method of surgical intervention.

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There are two methods of surgical intervention for anterior cerebral hernias:

extracranial (extracranial) - involves removing the hernial sac and closing the bone defect without opening the cranial cavity. It is used for laced hernias and small bone defects in children under 1 year of age.

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In 1881, N.V. Sklifosovsky for the first time undertook extracranial excision of a cerebral hernia, which resulted in recovery. Since that time, surgical thought has followed the path of radical surgery for congenital cerebral hernias.

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Depending on the size of the hernia and the condition of the skin, a linear, oval or bordering incision is made over it with the removal of excess skin. After this, the hernial sac is separated, isolated up to the external bone opening, and after stitching and tying the neck with a strong ligature, it is cut off. A small bone defect is closed by layer-by-layer suturing of soft tissue over it. If the diameter of the external opening of the hernial canal is more than 1 cm, it is closed either with a bone flap cut out from the outer plate of the skull bones, or by introducing an appropriate size organic glass pin into the bony hernial canal, after which the soft tissue is sutured in layers.

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However, frequent failures with this operation have led to the fact that in recent decades the extracranial method has begun to be used only for small hernias with a small bone defect, provided that the hernial sac is completely detached from the cerebrospinal fluid spaces of the brain. In cases where the hernial sac communicates with the cerebrospinal fluid spaces, the extracranial approach creates a risk of infection of the cranial cavity with the development of cerebrospinal fluid fistulas and meningitis.

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The intracranial method - closing the internal opening of a bone defect with an approach to it from the cranial cavity - is used in children over 1 year of age. The operation is performed in two stages: the first stage is intracranial plastic surgery of the skull bone defect, the second stage is removal of the hernial sac and rhinoplasty (performed after 3-6 months). The method was first proposed by P. A. Herzen (1926).

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A skin incision in the form of an arc is made along the border of the scalp of the forehead and both temples. A large aponeurotic skin flap is turned anteriorly towards the nose. The periosteum is cut along the edge of the bone incision, then along the sagittal suture and parallel to the upper edge of the orbits on both sides.

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Milling holes are placed along the cut line of the periosteum in such a way that after cutting through the bone, two bone flaps are formed, each of which could be turned to the side on a stem from the temporal muscle (in the form of two flaps). The anterior cut should be located as close as possible to the edge of the orbit, so that it is easier to approach the neck of the hernial sac. It is better to make a median cut of the bone, slightly retreating from the midline, so as not to damage the sagittal sinus. You should not be wary of damage to the frontal sinuses, since with anterior hernias they are rudimentary or completely absent.

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After exposing the dura mater, the latter is gradually separated from the bone with a wide spatula or rasp, pushing both frontal lobes posteriorly. Step by step, in this way, they approach the neck of the hernial sac and begin to separate it from the internal opening of the bony hernial canal using a curved rasp. Repression of the frontal lobes and isolation of the neck of the hernial sac is easier if 20-30 ml of cerebrospinal fluid are previously evacuated through the lumbar or ventricular route. The neck must be separated carefully so as not to damage the dura mater, which is very thin and can be soldered to the bone.

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After isolating the neck of the hernial sac, the dura mater in the area of ​​this neck is carefully dissected with a circular incision, 2-3 cm away from the bone defect, and then cut off. The dura mater on the side of the frontal lobe is carefully sutured with interrupted sutures. Then they begin to close the hernial bone hole from the side of the cranial cavity. A bone plate cut from the frontal bone or organic glass plastic is used.

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A month or later, the second stage of the operation is carried out to remove the hernial sac with its contents cut off during the first stage (as with the extracranial method). Sometimes the second stage turns out to be unnecessary since the hernial sac and its contents atrophy over time, scar and collapse.

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External abdominal hernia - 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 layer of the peritoneum. An internal hernia is the penetration of abdominal organs into a normally existing or pathologically formed peritoneal sac (hernia of the omental bursa, diaphragmatic hernia, hernia of the duodenal-small intestinal fossa (Treits's fossa), retroduodenal fossa (mesenteric hernia) in the area of ​​peritoneal pockets near the cecum and sigmoid colon). The following concepts should be distinguished: Eventeration - the release of viscera from the abdominal cavity resulting from damage to the abdominal wall (wound, rupture). The parietal layer of the peritoneum is absent. Organ prolapse - the viscera protrude from any area and are not covered by a peritoneal layer (neither visceral nor parietal) For example: prolapse of the rectum, uterus, bladder.

They occur most often - up to 75% of all hernias - oblique and direct, congenital and acquired, unilateral and bilateral. Combinations with hydrocele of the spermatic cord, testicle, and cryptorchidism may occur. Up to 5% there are sliding hernias containing the cecum, bladder, kidney, ureter, uterus, sigmoid colon. If these organs are injured during surgery, the mortality rate reaches 27%.

Hernias that form in the vascular lacuna - the most common are typical (or medial) femoral hernias passing 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 outside the femoral artery, and - middle vascular-lacunar hernias, when the hernial sac is located under the pupart ligament above the femoral artery and vein. Hernias extending into the area of ​​the muscle lacuna are rare, located under the inguinal ligament in front of the iliopsoas muscle, lateral to the femoral artery. Hernias of the lacunar ligament are even less common, occurring in old women with a wide lacunar ligament.

Femoral hernias are more common in older women and are strangulated 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 dissect the hernial orifice, i.e. the probability of damage to “corona mortis” is minimal, occurring 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 of age (against the background of constipation, coughing, crying), and are small in size (up to 1-2 cm) , are rarely infringed. 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 is usually up to 10 cm, the contents are most often a strand of the greater omentum. The second most common group among abdominal hernias are postoperative hernias. Among them, it is necessary to highlight the group of postoperative hernias themselves - 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 identify a group of recurrent hernias that occurred after a previous hernia repair. From 18 to 78%, depending on the type and location of the hernia, relapses occur. A special feature is a violation of the topographic-anatomical relationship of tissues, the presence of scar-altered structures of encapsulated “ligature granulomas”, “dormant infection” in scars, and sometimes the presence of fistulas.

Perineal hernias can be located anterior to the intersciatic line, starting from the vesico-uterine recess in women, and posterior to this line, starting from the vesico-rectal recess in men, and from the uterorectal recess in women from the pelvic peritoneum. Lateral abdominal hernias are formed along the Spigelian line and near the rectus abdominis muscles.

Occurs 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 when they are strangulated.

Mandatory studies are studies that must be carried out for each patient: 1) clinical examination; 2) laboratory tests: CBC, TAM, blood group, Rh factor, blood clotting time, prothrombin index, glucose, blood urea; 3) ECG (in patients over 50 years of age or in patients who are planning surgery under general anesthesia); 4) consultation with a therapist (for the last group of patients); 5) fluorogram of the OGK during planned admission.

Recommended studies are studies whose significance has been proven when used for most patients: 1) electrolyte composition of the blood (Na+, K+, CL-); 2) blood biochemistry (billirubin, creatine); 3) coagulogram; 4) acid-base status and one-time blood composition; 5) cystoscopy (cystography) if there is a suspicion of the presence of a bladder in a hernia; 6) consultation with a urologist, breathing tests (for planned admission). Additional studies are studies that are significant for certain categories of patients, as well as those performed for the purpose of a more detailed assessment of homeostasis disorders. 1) plain 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 (application of tile-shaped bandages for umbilical hernias). Indications for surgery include rapid enlargement of the hernia, irreducibility and strangulation. in adult patients in the presence of 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, uncorrectable 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 - it 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 have no contraindications to surgery, because Long-term wearing of a bandage contributes to the expansion of the hernial orifice (due to pressure on the tissue) and the formation of adhesions between the internal organs and the hernial sac.

4 hours), especially with extensive multi-chamber ventral hernia" 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 strangulation of the hernial contents (> 4 hours), especially with extensive multi-chamber ventral hernia" class="link_thumb"> 14 !} Strangulated hernias are subject to emergency surgical treatment. There can be no contraindications to surgery. In patients in serious condition with long-term strangulation of the hernial contents (> 4 hours), especially with extensive multi-chamber ventral hernias, with clinical signs of endotoxemia and homeostasis disorders, as well as with a high anesthetic risk, it is possible to carry out emergency short-term preoperative infusion preparation in a volume of ml/kg the patient's body weight directly on the operating table. The main fundamental difference between the surgical procedure for a strangulated hernia (as opposed to an uncomplicated one) is the need for an initial opening of the hernial sac to fix and examine the strangulated organs and subsequent dissection of the strangulating ring. 4 hours), especially with extensive multi-chamber ventral hernias "> 4 hours), especially with extensive multi-chamber ventral hernias, with the presence of clinical signs of endotoxemia and homeostasis disorders, as well as with a high anesthetic risk, it is possible to carry out 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 procedure for a strangulated hernia (as opposed to an uncomplicated hernia) 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 for extensive multi-chamber ventral hernia" title="Strangulated hernias are subject to emergency surgical treatment. There can be no contraindications to surgery. In patients in serious condition with strangulation of the hernial contents for many hours (> 4 hours), especially with extensive multi-chamber ventral hernia"> title="Strangulated hernias are subject to emergency surgical treatment. There can be no contraindications to surgery. In patients in serious condition with long-term strangulation of the hernial contents (> 4 hours), especially with extensive multi-chamber ventral hernias"> !}

In case of intestinal strangulation, the signs of its vitality are the following (must be reflected in the operation protocol): 1. restoration of the pink color of the serous cover; 2. restoration of peristalsis; 3. restoration of pulsation of mesenteric vessels. 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 in accordance with the standards adopted for the treatment of acute intestinal obstruction. If it is impossible to perform intestinal intubation in conditions of sharp overstretching of the intestinal loops from the herniolaparotomy access, the latter is either expanded (for p/o and umbilical hernias) or an additional median laparotomy access is made (for femoral, inguinal hernias).

In case of 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 established. In case of strangulated Littre's hernia, 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 resection of the intestine, including the base of the diverticulum. In case of necrosis of the wall of the cecum, it is necessary to perform a right hemicolectomy with ileotransverse anastomosis. If an error is made in the differential diagnosis and during surgery for a strangulated femoral hernia, not a hernia is discovered, but an enlarged inflamed lymph node - Pirogov, then it should not be removed due to the possibility of developing prolonged lymphorrhea and lymphostasis of the limb. The operation ends with the application of rare sutures to the wound and the provision of drainage 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. In case of spontaneous reduction of the hernia, after prolonged strangulation (>4-6 hours), emergency laparoscopy is necessary. If, during observation for hours, the patient develops abdominal pain, positive symptoms of peritoneal irritation, increasing toxicosis, or clinical signs 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 of anesthesia” or the beginning of local anesthesia, then an opening of the hernial sac should be performed with inspection of nearby organs to identify the organ that has been strangulated 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 24 hours after the hernia repair does not cause concern, then the patient, after the necessary examination, can be operated on as planned. 4-6 hours), emergency laparoscopy is necessary. If, during observation within 24-48 hours, the patient develops abdominal pain, positive symptoms of peritoneal irritation, increasing toxicosis, or clinical signs 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 of anesthesia” or the beginning of local anesthesia, then an opening of the hernial sac should be performed with inspection of nearby organs to identify the organ that has been strangulated 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 24 hours after repair of the hernia does not cause concern, then the patient, after the necessary examination, can be operated on as planned.">

Phlegmon of the hernial sac The operation begins with a median laparotomy. If the intestinal loop is strangulated, then it is resected cm from the adductor and cm from the efferent section. The ends of the strangulated part of the intestine are ligated, and intestinal patency is restored by applying an “end to end” anastomosis and only if there is a significant discrepancy in the diameters of the intestine - “side to side”. At this stage of the operation, the peritoneal cavity must be isolated from the hernial sac cavity. To do this, the parietal peritoneum is dissected around the mouth of the sac and separated to the sides by 2 cm, the ends of the strangulated section of the intestine are re-ligated, 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 strangulated ring should be cut so that the strangulated organ can be extracted and removed. The hernial sac is not isolated from the surrounding tissues. It is stitched at the cervix with tampons placed on it, which completes the intervention. Repair of the hernial orifice in conditions of purulent infection is strictly 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. For phlegmon of the 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 in general has not been the subject of scientific debate for a long time. It is based on 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 assessed 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. Bassini’s operation was the basis for many other methods of hernioplasty.

Author Method of plastic surgery Year Recurrence rate Nesterenko Yu.A. Bassini, 2% Salov Yu.B. Kukudzhanova 19828.9% Mitasov I.G. Postemski 19856.0% Tran V. et al. Bassini, 0% Panos R. et al .Shouldice19927.0% Nyhus L.Nyhus19936.0%

The main reason for unsatisfactory treatment results with traditional methods of inguinal canal plastic surgery is the convergence of heterogeneous tissues under tension, which contradicts the basic principles of surgery. The muscles sutured to the inguinal ligament undergo degeneration, atrophy and cicatricial degeneration, and tension leads to ischemic necrosis of tissue along the suture line, their eruption and further relapse. The noted circumstances contributed to the development and improvement of a new treatment technology – tension-free hernioplasty. When repairing hernias of the white line of the abdomen, umbilical, small ventral postoperative hernias, in the absence of tissue tension, it is legal to use traditional surgical methods. In case of strangulated giant ventral hernias, which include most of the contents of the abdominal cavity, especially in elderly people with severe concomitant pathology, if it is impossible to perform tension-free hernioplasty due to the lack of an allograft, the hernial orifice should not be sutured, but only skin sutures should be placed on the wound.

The basis of tension-free repair is the elimination of the causes of relapses characteristic of traditional types of hernia repair: 1. Stitching of scar-modified tissues 2. Stitching of heterogeneous tissues (for inguinal hernias) 3. Tissue ischemia due to tension and compression by sutures With tension-free repair, 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, the strength of which is equal to or greater than the strength of the aponeurosis.

1. Elasticity so as not to cause bedsores of adjacent tissues 2. Resistance to infection 3. Do 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 the day after surgery. The main manufacturers of mesh are "Ethicon", "B.Braun", "USSC USA", "Ekoflon". NON-ABSORBABLE polypropylene (Surgipro, Marlex, Prolene, Atrium) polyester (Mersilene) polytetrafluoroethylene (Tetlon, Gjre - Tex, Ecoflon) - maximally inert, can be placed intraperitoneally without the risk of causing an adhesive process, because due to the very low surface tension, it is difficult for the fibroplast to attach to the surface of this plate

It is used in 70-80% of cases for 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: learnability and reproducibility are the highest advantages 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% Advantages of hernioplasty according to Lichtenstein: 1. Significant reduction in the frequency of relapses (from 6 -14% to 1%): 2. Reduced surgical trauma, which reduces the severity of pain and allows patients to be discharged on days 3-4 3. Earlier return of patients to their normal lifestyle, due to the presence of an endoprosthesis in the wound, which provides additional 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 unpleasant sensations during coitus 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 implantation of endoprostheses: It is advisable to avoid contact of the allomaterial with the subcutaneous tissue to prevent the formation of seromas. After fixation to the tissues, the endoprosthesis should lie without tension. Contact of endoprostheses with the visceral peritoneum is unacceptable (except PTFE)

1. Preperitoneal implantation - the mesh is placed in the preperitoneal space, behind the aponeurosis, which eliminates the problem of seroma formation in the subcutaneous tissue, reduces the risk of infection and eliminates displacement of the prosthesis when intra-abdominal pressure increases.

3. Nadaponeurotic implantation - the mesh is located in the subcutaneous fat layer, fixed above the aponeurosis and muscles. With the “tension” option, plastic surgery of the hernial orifice is performed beforehand, and the mesh is placed over the sutures. With the “non-tension” method, the mesh is laid and fixed without tension to the aponeurosis around the perimeter using U-shaped sutures.

1. Laparoscopic preperitoneal prosthetic hernioplasty: In conditions of pneumoperitoneum, the peritoneum is dissected with scissors in a U-shape or arcuate manner, bending around the lateral and medial inguinal fossae from above. Next, the peritoneum is separated to the pubic bone. The hernial sac is bluntly separated from the elements of the spermatic cord and transverse fascia. To cover all three fossae (femoral, lateral and medial inguinal) - potential sites of hernia exit, the mesh dimensions 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 elements of the spermatic cord. The prosthesis is fixed with a herniostapler using tantalum staples (10 pieces), avoiding damage to the iliac, lower epigastric, testicular vessels, vas deferens, and bladder.

Under endotracheal anesthesia, in 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 inserted into the abdominal cavity, exceeding the size of the hernia defect by at least 1 cm around the perimeter. The prosthesis is fixed over the peritoneum using a stapler with staples extended to 4.8 mm along the perimeter. IGeneral 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, adhesions in the abdominal cavity. If an adhesive process is suspected, the question of the possibility of surgery should be decided after performing diagnostic laparoscopy. The presence of additional special equipment allows operations to be performed under conditions of adhesions, however, the risk of developing intraoperative complications increases. II Local contraindications include: strangulated hernias; sliding; irreducible; giant inguinal hernias in combination with hydrocele of the spermatic cord and hydrocele of the testicular membranes. With increasing experience in performing endovideosurgical herneoplasty, it becomes possible to perform operations on patients with complicated forms of inguinal hernias.

They arise due to insufficient closure of the hernial orifice due to displacement of the implant when its fixation is not entirely reliable, as well as when the size of the prosthesis is insufficient. They usually occur within the first three weeks after surgery. In the later period, relapses are more rare, because The prosthesis, which has managed to grow with connective tissue, is securely fixed in the hernial orifice.

Abdominal hernia (hernia abdominalis) is called

Hernial orifice

Hernial sac

Hernial contents

External abdominal hernia

Internal abdominal hernias

Etiology and pathogenesis

Predisposing factors

Producing factors

(general principles)

Treatment (general principles)

Inguinal hernia

Embryological information

Anatomy of the groin area

Inguinal canal and inguinal space

Congenital inguinal hernia

Acquired inguinal hernias

Sliding inguinal hernia

Clinical picture and diagnosis of inguinal hernias

Examination of the patient

Examination of the patient

Differential diagnosis

Treatment

Access for inguinal hernia

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

Femoral hernia

Anatomy of femoral hernias

Clinical picture and diagnosis

Differential diagnosis

Treatment of femoral hernias

Umbilical hernias

Treatment of umbilical hernias

Access for umbilical hernias

Sapezhko method

Mayo method

Hernia of the white line of the abdomen

Treatment of hernias of the white line of the abdomen

Rare types of abdominal hernias

Rare types of abdominal hernias

Complications of external abdominal hernias

According to the mechanism of occurrence they distinguish:

Pathological picture

Clinical picture and diagnosis

Clinical picture and diagnosis

Clinical picture and diagnosis

Treatment of strangulated hernias

Treatment of strangulated hernias

Forecast

Complications of self-reduced and forcibly reduced strangulated hernias

Irreversibility

Coprostasis

Prevention of complications

Internal abdominal hernias

Treatment of internal hernias