HERNIA
Hernia of the abdominal wall or external hernia (herniae abdominalis externae) is such surgical disease, which is characterized by outlet of the visceral organs from the place of their physiological placement through the natural channels or defects of the abdominal and pelvic wall. In such case all visceral organs covered by parietal peritoneum and skin cover are not damaged.
Internal hernia (herniae abdominalis internae) is such disease, visceral organs hit the peritoneum pouch. It formed in the place of natural peritoneum fold or recess and generally kept in the abdominal cavity.
Etiology and pathogenesis
Hernias are divided into two main groups: congenital (herniae conqenitae) and acquired (herniae acguisitae). The main reason of congenital hernias is malformation. Thus, inguinal hernia arose in case of noclosure of the process of peritoneum, which passes by inguinal channel during descending the testis. On such hernias testis is located in the hernia pouch. Acquired inguinal hernia has hernia pouch and testis located outside it. Many factors are of great importance in the beginning and developing of the acquired hernia. One of them contributes, other – causes disease. The first are hereditary, anatomical inferiority of the abdominal wall, sex (inguinal area weakness in males and largeness internal femoral ring in females), age (atrophic processes in older age, anatomical inferiority of the abdominal wall in babies), weight loss, injury, postoperative scar, physical activity, pregnancy, during which abdominal wall stretched (for example, midline increased in 12 times).
Such reasons, as increased abdominal pressure and weakness of the abdominal wall, cause hernia. That arise after hard physical activity, continued cough, constipation, nerves palsy, which innervated abdominal wall, injury of muscles or aponeurosis of the abdomen.
Pathomorphology
Each abdominal hernia consists of hernia gate, hernia sac and hernia contents. Hernia sac forms by outpouching of parietal peritoneum and can contain any organ from abdominal cavity, but mostly – small intestine and omentum. Sometimes it containes other organs: large intestine, urinary bladder, ovary, and appendix.
The main parts of the hernia pouch are neck, body and fundus. Through the hernia’s gate, peritoneum is outpouching. In the case of sliding hernia organ in the hernia pouch has mesoperitoneal disposition and not enclosed by peritoneum.
Classification
Hernia of the abdominal wall is divided:
1) Depends on anatomical localization: inguinal (indirect and direct), midline hernia, omphalocele, femoral hernia, lumbar hernia, sciatic hernia, (enterischiocele), lateral hernia, ischiorectal [perineal] hernia (perineocele).
2) depends on etiology: congenital (herniae conqenitae) and acquired (herniae acguisitae).
3) Depends on clinical presentations: complete and incomplete, reducible and nonreducible, traumatic and postoperative, complicated and noncomplicated.
Clinical management
The typical symptom of hernia is swelling, which arises on vertical position of the patient or during rise of intraperitoneal pressure. These can disappear in a state of dormancy, on vertical position of the patient or after applying small pressure. Such factors make it possible to confirm hernia.
In the case of hernia primary formation skin over the swelling almost not changed. Hernia is determined by finger examination of the inguinal channel. We can feel positive symptom of the “cough push”, which is caused by cough or by the rise of intraperitoneal pressure. In the case of late stage of hernia developing evagination appear on changing body position from horizontal to verticalor after rising of the intraperitoneal pressure. If hernia sac contained small intestine than every next tension of the abdominal muscle inflated hernia sac by intestinal loop.
Diagnostics of the noncomplicated external abdominal hernias is easy. Anamnesis of patients and clinical data are enough. However, we should remember about nonreducible hernias. Such hernia’s shape and dimension often does not change. Patients complicated for continuous pain in the hernia region, which irradiated to other abdominal organs. The main danger of the nonreducible hernias is jamming.
Clinical variants and complications
Inguinal hernias is developed in two ways: through the internal (middle) inguinal cavity and external (lateral). In the first case formed direct in other – indirect inguinal hernia.
Indirect hernias could be congenital and acquired. Direct hernias are only acquired and occur in older patients.
There are two main signs, which differentiate direct and indirect hernias. Direct hernia is always located medially from a. epigastrica inf. Indirect hernia is always located laterally from a. epigastrica inf. The other sign is: direct hernia located medially from deferent duct, indirect hernia located inside it
Femoral hernias are such pathological formation, which is encountered 10-20 times more often in males then females. This is explained by anatomical peculiarity of the females’ pelvis, wider interval between femoral vein and lacunar [Gimbernat’s] ligament and inguinal [Poupart’s] ligament weakness.
There are distinguished femoral hernias, vasculo-lacunar, rural pectineal [Cloquet’s] hernia, Hesselbach’s hernia.
In addition, there are some kinds of femoral hernias, which can be identified only during the operation:
1) Medial vascular-lacunar femoral hernia, most common;
2) Hernia, which passed through the middle part of vascular lacuna or through the vascular sheath;
3) Lateral vascular-lacunar hernia, which pass outside of the femoral vessels.
Besides, there is middle or prevascular hernia.
Medial vascular -lacunar femoral hernia has three stages of developing:
1) Beginning femoral hernia – swelling does not pass outside internal femoral ring;
2) Incomplete (interstitial) hernia – swelling does not pass outside of superficial fascia;
3) Complete femoral hernia – swelling passed through all anatomical part of the femoral channel and outgoing to the subcutaneous cellular tissue on the anterior femoral surface below inguinal [Poupart’s] ligament.
In spite of small size of the hernia sac, femoral hernia could contain omentum, small intestine and urinary bladder. It is more difficult to diagnose femoral hernia in overweight patients because of inexpressive clinical signs.
We should differentiate femoral hernias with inguinal hernias, increased or varicose changed lymphatic nodes. In those cases, we should determine external inguinal ring and inguinal ligament.
Midline [epigastric] hernia usually has males in giving age.
There are distinguished supraumbilical, umbilical and paraumbilical hernias.
Very often, such kind of the hernia has no clinical signs and can be determined on the medical examinations. The usual clinical signs are: swelling on linea alba and intermittent pain.
Umbilical hernias occur in 2 % from all kinds of hernia. The most frequent hernias in females (the ratio is 5:1), which is explained by anatomical peculiarity of the females’ umbilicus after pregnancy. Such hernia often has two- and three-chambers hernia sacs, which could contain omentum, small intestine, and sometime stomach. Clinical signs depend on those contents. However, it always characterized by pain and swelling. In some patients swelling is very large.
Diagnosis of the umbilical hernia in typical case is not very difficult. Sometimes it is arduous to differentiate incarcerated umbilical hernia and umbilical metastasis of tumor. We should remember about umbilical evagination (without organs) in the patients with liver cirrhosis because of presence ascitic fluid in the abdominal cavity.
Lumbar hernias are abdominal wall or retroperitoneal outpouchings. It does not occur very often. The area of the hernia orifice includes the superior costolumbar triangle and the inferior iliolumbar triangle. Besides that, it could be in aponeurosis slit.
Lumbar hernias could be congenital and acquired. Congenital lumbar hernias are frequently the result of aponeurosis slit or enlargement of the Pti triangle or Hrunfeld interval. Acquired lumbar hernias are usually result of injury those anatomical structure or after pyoinflammatory diseases.
The most frequent clinical sign is pain. The other signs depend on hernia content. The hernia contents may include any intra- and retroperitoneal structures, e.g., the kidney, small bowel, and omentum.
Diagnosis is made by clinical examination: in the horizontal patient position on healthy side, swelling disappeared, and on the vertical patient position appeared again.
Obturator hernia is the result of wide obturator channel. In those cases hernia sac formes inside pelvic cavity, and than passes through the obturator channel, and arises on internal femoral surface.
Diagnosis of the obturator hernias is not easy, especially in the patients without swelling on the hip. In such cases, patients have complaints for pain along obturator nerve with irradiation to knee joint or hip joint. Pain increases during leg rotation or abduction. Sometime pain irradiates to the foot.
Sciatic hernias is divided into two main types: hernia of the major sciatic foramen, which passes above and under piriform muscle and hernias of the small sciatic foramen, which passes under sciatic muscle. Patients complained for pain in the sciatic region, which increased during walking. Sometime pain irradiated along sciatic nerve.
Ischiorectal [perineal] hernia is formed in the urogenital diaphragm or in the perineum muscle. Anterior and posterior hernias are distinguished depending on whether the hernia is anterior or posterior to the transverse perineal muscle and sacrospinal ligament. Hernia ring formed by rectouterine [
Diagnosis of the anterior ischiorectal hernias, which passed to perineum, usually is not difficult. Diagnostic pitfall should be on the patients with posterior hernias, which is located under large sciatic muscle and looks like sciatic hernia. In such cases, we performed vaginal and rectal examination or X-Ray examination of the urinary bladder and intestine as required.
There are three types of the lateral abdominal hernias:
1) Acquired hernia of the rectus sheath;
2) Acquired hernias of the Spigelian line;
3) Congenital hernias because of congenital hypoplasia of the abdominal wall.
Clinical signs of lateral abdominal hernias are the same as for other types of hernias, so diagnosis is not very difficult.
The most common complications for all those hernias are incarceration.
Diagnosis program
1. Anamnesis and physical examination.
2. Digital investigation of the hernia channel.
3. Sonography of the hernia pouch.
4. Common blood analysis.
5. Common urine analysis.
Tactics and choice of treatment method
Inguinal hernia usually should be surgically repaired. On oblique inguinal hernias, we should strengthen anterior wall of the inguinal channel. On direct inguinal hernias, we should strengthen posterior wall of the inguinal channel. On recurrence hernias – we should strengthen anterior and posterior wall of the inguinal channel.
Bassini repair. After extraction of the hernia sac, we are taking spermatic duct on holders. Between the borders of transverse muscle, internal oblique muscle, transverse fascia and inguinal ligament interrupted sutures placed. Except that, couples sutures placed between border of abdominal rectus muscle sheath and pubic bone periosteum.
In such way, inguinal space closured and posterior wall strengthened. Spermatic duct placed on the new-formed posterior wall of the inguinal channel. Over the spermatic duct aponeurosis restored by interrupted sutures.
Girard in such kind of the operations propose to attach the edges of the internal oblique muscle and transversal muscle to the inguinal ligament over the spermatic duct. The aponeurosis of the external oblique muscle sutured by second layer of the suture. Excess of the aponeurosis is fixed to the muscle in the form of duplication.
Spasokukotskyy proposed to catch the edges of the internal oblique muscle and transversal muscle with aponeurosis of the external oblique muscles by single-layer interrupted suture.
Martynov proposed the fixation to the Poupart’s ligament only internal edge of the external oblique muscle aponeurosis without muscles. External edge of the aponeurosis sutured over internal in the form of duplication.
Kimbarovskyy, based on the principles of joining similar tissues, proposed special suture: Sutures placed on
Kukudganov proposed to restore back wall of inguinal interval. Sutures are placed between the Couper’s ligamentum, vagina of direct abdominal muscle and aponeurosis of the transversal muscle.
Postempskyy proposed the deaf closing of inguinal interval with the moving of spermatic duct.
The plastic narrowing of internal inguinal ring of to
FEMORAL HERNIA
The are some methods of surgical treatment of the femoral hernia, when the plastic are performed intraperitoneal from the side of thigh through the inguinal channel.
The Bassini method is attributed to “femoral”. It is performed from a cut, that passes under inguinal fold. After removal of hernia sack a hernia gate is liquidated by suturing of inguinal to the pectineal ligament.
The Rudgi-Parlavecho Method. A cut passes parallel to the inguinal fold and higher it (the same as at inguinal hernia). A hernia sack is removed. After that the edges of the transversal and internal oblique muscles and inguinal ligament sutured to the periosteum of pubic bone.
UMBILICAL HERNIA
For operative treatment of umbilical hernia a few methods are used. The Lexer operation is most widespread. It performed by imposition of sutures on an umbilical ring.
After the Meyo method defect of anterior abdominal wall in the umbilical ring is sutured by U-shaped stitches in transversal direction.
Sapezhko proposed to form duplication of the abdominal white line by stitches in longitudinal direction.
At surgical treatment of hernia of abdominal white line, abdominal lateral hernia, lumbar and obturator hernia, sciatic and ischiorectal hernias after deleting of hernia sack it is needed to try to close a hernia orifice by suturing of fissures in aponeurosis and muscles.
INCARCERATED HERNIA
Incarcerated hernia is sudden pressing of hernia contents in a hernia orifice. Incarceration is the most frequent and most dangerous complication of hernia diseases.
Etiology and pathogenesis
Depending on mechanism, the elastic and fecal incarceration is distinguished. At the elastic incarceration, after increasing intraabdominal pressure, one or a few organs relocated from an abdominal cavity to the hernia sack, where it is compressed with following ischemia and necrosis in the area of hernia gate. At the fecal incarceration in the intestinal loop which is in a hernia sack, plenty of excrement passed quickly. Proximal part of loop is overfilled, and distal is compressed in a hernia gate. So, arose its strangulation, as well as at the elastic incarceration.
Most often the loop of bowel is incarcerated. Thus three parts are distinguished in it: proximal, distal loop, central part. The heaviest pathological changes during incarceration takes place in a strangulated furrow in the central part of the incarcerated bowel.
Pathomorphology
At incarcerated hernia an important role has all internal rings: inguinal, umbilical, “weak places” in a diaphragm, orifice of the omental bursa, numeral and “variant” folds of peritoneum.
In the place of compressing of the bowels and mesentery, as a rule, it is possible to find a strangulation furrow. If circulation of blood changes, the wall of bowel cyanotic, with hemorrhages and necrosis of a different size. The loop of bowel which is located proximally the places of strangulation are extended, and distal loop mainly without changes.
Classification of the incarcerated hernia
The incarcerated hernia is divided into the complete and incomplete. The other types of incarceration is partial (the Richter’s hernia) and retrograde. The incarcerated hernia can be without the destructive changes of hernia contents and with the phlegmon of hernia sack.
Clinical management
The clinic of the incarcerated hernia depends on pulling in organ, character and duration of jamming. The clinical signs of the incarcerated hernia can be divided into three groups: 1) local changes; 2) common signs; 3) complication. From the most characteristic signs of local changes the most common is sharp pain, irreducible hernia, tension of hernia sack that and negative symptom of the “cough push”.
Pain sometimes is so intensive that causes pain shock. In the case of intestinal obstruction a pain is attack-like. In case of occurring of peritonitis pain changes the character and becomes permanent.
It is necessary to mean that tensions of hernia sack and incarceration of the hernia, as signs of jamming, lose it value, if hernia was irreducible.
From other side, the isolation of hernia sack from an abdominal region during jamming is the reason of the negative symptom of the “cough push”.
The common signs at the incarcerated hernia has phase character. Nausea and vomits during first hours of disease has reflex reason, and on 2nd and 3rd days has toxic reason, that is consequence of antiperistaltic and reflux of intestinal contents to the stomach.
The temperature of body at first time is normal, and than rises, but usually low grade fever.
The clinic of acute intestinal obstruction and peritonitis develops at the protracted jamming of intestine. The phlegmon of hernia sack can develop in the area of the hernia swelling.
Clinical variants and complications
There are different forms of incarceration of internal organs, and accordingly — different clinical variants.
Retrograde incarceration. In such cases a hernia sack contains no less than two loops of intestine. But these loops are damaged less, than loop which is in an abdominal cavity. At this variant of jamming peritonitis arose quicker. So, surgeon during operation must always remember about the necessity of careful revision of the incarcerated loops of bowel.
Parietal incarceration (the Richter’s hernia). Unlike retrograde, which has wide hernia gate, a similar pathology arises in case of narrow hernia gate. In a hernia sack in such patients located part of bowel wall, opposite it mesentery edge.
Thus, as a rule, patency of bowel is not broken. Such variant of jamming is dangerous, because there are no evident clinical signs or some of them are quite absent and intestinal patency almost is always present. Necrosis of bowel wall comes quickly and in 2-3 days the perforation with subsequent development of peritonitis begins after jamming.
The Littre’s hernia. Jamming of Meckel’s diverticulum can come at oblique inguinal hernia. Clinical signs of this pathology reminds the parietal incarceration. Sometimes is possible to palpate dense, short, thick tension bar in a hernia sack.
Incarceration at sliding hernia. It is observed at patients with inguinal hernia. At sliding hernia of colon, as a rule, there is the fecal incarceration. A bowel is the external wall of hernia sack in such cases. About it is necessary to remember during opening of hernia sack. Jammings of urinary bladder meet enough rarely, mainly at older-men at oblique sliding hernia of inguinal channel. It is necessary to ask before the operation, whether a patient had disorders of urination before jamming. Frequent urges, or, opposite, the reflex delay of urination is arose at the beginning of jamming already, and in urine expose macro- or microhematuria. If during operation at opening of hernia sack it medial wall has dense, doughy consistency, it is an urinary bladder.
At the incarcerated hernia the contents of hernia sack can be also omentum, appendages of colon, internal female genital organs. Sometimes combination of the incarcerated inguinal hernia with different pathological changes of testicle and deferent duct can take place.
Rough manual reduction of the incarcerated hernia can bring to pseudoreduction. Then the local signs of the incarcerated hernia disappear, and jamming of organs and its consequences is kept. There are five variants of the pseudoreduction: 1) at multicompartment hernia sacks there is the possible moving of strangulated organs from one chamber in other, that located more deep or in a preperitoneal adipose tissue; 2) separation and reduction of hernia sack together with it content in an abdominal cavity or in a preperitoneal adipose tissue; 3) abruption of the neck from other part of hernia sack and reduction it together with content in an abdominal cavity or in a preperitoneal adipose tissue; 4) abruption of the neck from a hernia sack and from a parietal peritoneum with reduction of the incarcerated organs in an abdominal cavity; 5) break of the incarcerated bowel at the rough reduction of hernia.
Untimely operative at the incarcerated hernia, usually, is complicated by the gangrene of bowel, peritonitis or phlegmon of hernia sack. Such complications considerably worsen clinical status of patient and require other surgical tactic.
Diagnosis program
1. Anamnesis examination.
2. Physical examination.
3. Blood analysis and urine analysis.
4. Digital investigation of the rectum.
5. Survey X-Ray of abdominal cavity organs.
Differential diagnostics
As experience shows, the incarcerated hernia we should differentiate with irreducible, which as a rule, is not tense, positive symptom of the “cough push”, painful on palpation. A patient complained for long duration of the disease. The incarcerated hernia needs to be differentiated with coprostasis. In such patients disorder of bowel loop patency, that is in a hernia sack, creates accumulation of excrement. Coprostasis mostly found at fecal hernia in older people, that suffer from intractable constipation. Clinically it develops gradually and slowly. The hernia swelling almost not painfully, some tense, a positive symptom of the “cough push”. Beginning of coprostasis is unconnected with physical tension. Application of cleansing siphon enema washed of excrement and liquidated coprostasis.
Unreal jamming of hernia. In clinical practice there are often such situation, when during the acute surgical diseases of organs of abdominal cavity free external abdominal hernia becomes irreducible, painfully and tense, and looks like incarcerated. This is the unreal jamming of hernia, which can be observed at the acute surgical diseases of organs of abdominal cavity, ascites. During examination of such patients it is necessary to remember, that at the unreal jamming abdominal pain, vomiting, worsening of the general condition and signs of the intestine obstruction come earlier, than changes in a hernia sack.
In addition, during the operation in patients with incarcerated hernia, it is needed to make sure, whether there is a strangulation furrow, or organ, that is in a hernia sack, fixed in a hernia gate. When these signs are absent, it is possible to consider that jamming is unreal.
The incarcerated femoral hernia must be differentiated with inguinal lymphadenitis, by varicose expansion of large hypodermic vein, varicose knot and their thrombophlebitis, tumor and abscess.
From such pathology without surgical procedure it is possible to differentiate only varicose expansion of veins (varicose knot), for which the positive Valsalv test — at horizontal position of patient with the leg heaved up a knot is empty.
The incarcerated inguinal hernia needs to be differentiated also with hydrocele and orchiepididymitis, cyst of deferent duct, cyst of round ligamentum of uterus, bartholinitis. Patients, who have with such diseases, a process usually does not spread higher external ring of inguinal channel. Also, absence of testicle in scrotum can be cryptorchiism sign.
The common clinical signs of the internal incarcerated hernia is abdominal pain and symptoms of the intestinal obstruction. A final diagnosis is set during the operation.
Tactics and choice of treatment method
The incarcerated hernia, regardless of time of its origin, localization and age of patient, must be operated on. However, if a patient is hospitalized already with the expressed symptoms of intestinal obstruction, than should be preoperative treatment. Such conservative therapy must be brief (1–1,5 hours), but always actively directed for correction of violations of metabolism and prophylaxis of possible pulmonary and cardiovascular complications. It is necessary also to conduct evacuation of the gastric contents and other preparatory procedures.
Patient with reduced hernia must be hospitalized and observed during 1–2 days. If a abdominal pain is contained or is growing, the signs of peritonitis and intoxication appear, than performed urgent laparotomy and necessary operation. If the symptoms of “acute” abdomen are not present, a patient examined and prepared for elective operation.
Operation at the incarcerated hernia is executed under the general anesthesia. A hernia sack is selected from surrounding tissue, cut it in the area of bottom and remove hernia water, defining its character and sending to bacterial inoculation. Retaining the damaged organs, a strangulated ring is cut. It is necessary to remember, that at the incarcerated femoral hernia ring cut up and some medially, because a femoral vein passes from a lateral side.
If a bowel is contents of hernia sack, we must estimate its viability. Remembering about possibility of the retrograde jamming, special attention must be paid to the state of strangulation furrow. About viability of the bowels testify: 1) renewal of its normal color; 2) presence or renewal of peristalsis; 3) renewal of pulsation of vessels of mesentery and bowel. If there are the certain doubting, a bowel is dipped on a holder in an abdominal cavity and in 15–20 minutes it is examined repeatedly. If one of the resulted signs of viability is absent even, it is necessary to conduct the resection of bowel. The resection is executed, receded from the strangulation furrow on a proximal loop 30–40 cm and distal — 15–20 cm. Anastomosis between proximal and distal loops it is better to impose “end-to-end”. The plastic of hernia gate are conducted depending on indications after one of the surgical methods.
When the necrosis elements of omentum or fatty pendants of colon are contents of hernia sack, they must be removed within the limits of healthy tissue.
There can be necrosis of wall of colon or urinary bladder at sliding hernia. In such cases it is needed to be limited to the minimum surgical procedure: to dip a necrosis area by sutures inside the bowel or use it for forming of colostomy or epicystostomy. These are the best to conclude operation.
In similar situations at the incarcerated parietal hernia in most patients it is possible to be limited to peritonization of displaced area of wall of bowel. If after the peritonization there is the threat of narrowing of bowel or necrosis goes outside of the strangulation furrow, it is needed to conduct the resection of bowel.
Because of insufficient blood floow of Meckel’s diverticulum and, permanent threat of it necrosis, at patients with Littre’s hernia it resection must be performed.
At the phlegmon of hernia sack operation is begun with herniotomy. If the incarcerated organ is damaged by necrosis, and in a hernia sack present pus, than there is a necessity for surgeon to perform laparotomy. After that incarcerated organ resected within the limits of healthy tissue (in the generally accepted limits —
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