HERNIAS OF ABDOMEN
External hernias of abdomen (herniaе abdominalis externae) – Are those hernias where in the contents are
covered by the skin followed by the layers of the abdominal wall and the
parietal layer of the peritoneum through various defects of the abdominal wall.
V.N.Sels gave classical definition of the hernia, as protrusion of the abdominal viscera through acquired and congenital
hiatus.
Internal
hernias (herniae abdominalis internae) - is the protrusion of abdominal viscera
and contents into the pouches and folds of the peritoneum or into the thoracic
cavity through the natural or acquired hiatus and clefts of a diaphragm.
The hernias remain the most
wide-spread surgical pathology and occupy the second place after an acute
appendicitis. The hernias occur at the rate of 50 per 10.000 populations (А.V.Protosov
and Soavt. 1999 y.).
In USA
more than 700.000, Russia -
200.000, France - 110.000
and Great Britain
In Ukraine Ukraine
The mortality after scheduled herniotomies in Ukraine
Hernias
are known from old times and occur in various stages of life from embryonic
development up to old age.
The hernias are much more often seen in males
(80-85% inguinal hernias); other kinds of hernias are more often in females.
Contents of hernia - Components of external hernias are
the hernial hiatus, hernial sac and its contents.
Hernial orifice / Ring is, first of all, weaknesses in
the musculoaponeurotic abdominal wall through which the internal organs with
the parietal peritoneum out of the abdominal cavity. Form hernial orifice is
oval, round, slit, triangular, and uncertain.
Postoperative and traumatic hernias more frequently occur in irregular
shaped hernial orifice. The dimensions of hernial hiatus are highly variable -
from a few centimeters in diameter to 30 cm or more.
The
margins of hernial hiatus initially are pliable and elastic, and then roughen,
become rigid due to scarring. Exceptions and properties form neuropathogenic hernias - where there
is no expressed hiatus, over a
large area of the abdominal wall muscles atrophies and lose their tone, and
full-aponeurotic tissues are not available, then this part of the wall begins
to bulge (an example - relaxation of the diaphragm or abdominal muscle atrophy
due to surgical trauma innervating their nerve fibers).
The
hernial sac is a part of the peritoneum which passes through hernial
hiatus. Divided into mouth or
opening (ostium), neck, body and fundus (or apex) hernial sac.
The
ostium is a part of the hernial sac,
margined with abdominal cavity. The neck
is the part passing through the hernial hiatus. The body is the widest part of the sac lying under the skin. And the
fundus is the distal part of the hernial sac. The hernial sac can be unicameral
(unilocular) or multi chambered and in various dimensions.
Anatomical features of sliding hernias.
Sometimes the wall of the
hernial sac may be a body partially covered with abdomen or retroperitoneal
located. Most often it is the bladder, kidney, caecum or ascending colon, most
often sigmoid colon. This is called a sliding
hernia.
Hernial contents Hernial contents can be any organ of the abdominal cavity, but mostly it
is the omentum of small and large intestine. If the contents of hernial sac is
a loop of ileum with a Meckel diverticulum – Liters Hernia.
The
international classification of hernias
By origin are divided into two groups: congenital (hernia congenitalis) and acquired (hernia acquisita).
Congenital hernia - umbilical, inguinal, white line of the abdomen,
umbilical cord hernias, gastroschisis (from the Greek. - splitting of the
abdomen).
Acquired hernias are divided into groups depending on etiology, which lead to
genesis defect of abdominal wall.
1. Predestined hernia (hernia prеfomata). They arise in the typical
"weak" places the abdominal wall. It inguinal canal, femoral and
umbilical ring, the gap in the white line, semilunar and arcuate (Douglas)
lines, triangle Petit, gap Grünfeld-Lecgraft, the obturator canal, perineum,
holes and cracks in the diaphragm.
2. Postoperative hernia
(hernia postoperative).
3. Recurrent hernia (hernia
recidivus).
4. Traumatic hernia (hernia
traumatica).
5. Neuropathic hernia (hernia
neuropathica).
6. Artificial rupture (hernia
artificialis).
By
localization (anatomical classification)
There are inguinal, femoral, umbilical, white lines of
the abdomen.
Less
common hernias semilunar and Douglas line, metasternum, lumbar, ischiadic, perineal,
diaphragmatic, obturator.
Clinical (by run of the disease) classification
1. Free
(reducible) hernia (hernia reponibilis).
2. Irreducible hernia (hernia irreponibilis).
3. Strangulated hernia (hernia incarcerata).
4. Coprostasis of the hernia
5.
Inflammation of the hernia.
6. Traumatic hernia.
The internal hernias are classified into
the following:
1. Preperitoneal internal hernias:
а) epigastricс;
b) supravesical
c) Paravesical.
2. Post peritoneal internal hernias:
а) Treitz's hernia
b) paracecal;
c) Intersigmoidal; d)
Ileo-subfascial.
3. Intraperitoneal internal hernias:
а) Mesenteric-Parietal; b)
foramen of Winslow;
c) Through colo- mesenteric a hernia of the
omental bursa;
d) Hernia in omental openings, mesentery of a
small bowel and appendix, gastrocolic ligament, falciform ligament of liver, hernia of Douglas
pouch.
The internal hernias are usually found out
during operation concerning an acute intestinal obstruction and post-mortem
period.
Diaphragmatic hernia diagnosed by
contrasting of the gastrointestinal tract.
The concepts of eventration and prolapse come
near to concept of hernia.
Eventration
- is acute developing defect in the peritoneum and the abdominal wall with
protrusion of the viscera (omentum/intestine) through this defect. The
eventrations are of three types congenital, traumatic and postoperative.
Evagination (evaginatio) – Is protrusion of some part or the whole
organ from its normal position through a stroma (artificial opening).
Prolapse- the partial or complete falling,
sinking, or sliding of an organ from its normal position or location in the
body. example: prolapse of the uterus through a vagina, uterus or rectal
prolapse.
When collecting anamnesis of hernia should
find favorable and producing factors. Risk/Favorable factors: heredity,
age, sex, weight loss, obesity.
Producing factors: traumatic injuries of the abdominal wall,
the presence of scars, increased intraperitoneal pressure, constipation, cough,
short urethra, difficult/prolonged labour/childbirth, weight lifting, Benign
prostatic hyperplasia.
Etiology and
pathogenesis
The fact that various congenital anomalies can
lead to hernias confirmed their appearance immediately after birth or in the
newborn period. So children blacks 20% and 5% of children of Caucasian peoples
are congenital umbilical hernia. The same regularity is marked with oblique
inguinal hernia, which occurs as a result of disorder of vaginal obliteration
of the processus vaginalis, that’s why there is communication between the
abdominal cavity and the scrotum in men and Nuck’s canal in women. Found that
in 50% male processus vaginalis is not developed.
At autopsy in 20% in total was
found vaginal processes without any clinical signs of herniation in life (W.
Hughson, 1995). Also found in 5% of young women exposed to herniography after
hysterosalpingography, processus vaginalis of peritoneum – Nuck’s diverticulum
(A. Cullmo, 1984.), But they had no clinical signs of herniation.
From this it follows that the occurrence of hernia due to various
reasons: the repeated local trauma, degenerative changes in aponeurosis due to
increased intra abdominal pressure and a disorder of the synthesis of collagen.
Conduct
biochemical studies led to the discovery of molecular and cellular structures
in the fascia, which normally prevent the appearance of hernia. Collagen - the main element of the
fascia and aponeurosis. Its formation and the destruction are in a state of
equilibrium. Processes of destruction of collagen on the side of the hernial
protrusion is more expressed. The assumption that the anomalies in the
structure of collagen molecules are the factors predispose to the development
of hernias, has been confirmed in studies of hydroxyproline (acid, which is the
basis of collagen), which was taken from the aponeurosis in patients with
hernia and healthy persons.
It was also discovered a large number of randomly arranged microfibrils,
which confirms the view of the role of structural abnormalities of collagen in
the occurrence of hernias. Several centuries ago, doctors noticed that the
sailors long at sea. Developed scurvy. Together with, bleeding gums, periosteal
pain, general weakness, and much hernia occurred, run out of old scars. Later
proved the role of vitamin C in the synthesis of collagen, allowed to explain
the above symptoms.
It follows that individuals have a "breakage" in the synthesis
of the protein collagen, more likely to suffer recurrences of hernias. In the
etiology of hernias, there are other factors. Thus, the example of persons with
alcoholic cirrhosis and ascites increased intraperitoneal pressure and the
common umbilical and inguinal hernias.
In persons subjected to considerable physical exertion (athletes,
working foundries, etc.) also often occur hernia. Pathogenesis of hernia same -
congenital predisposing factors plus the generating factor in increasing the
intraabdominal pressure during physical exertion.
By generating factors are also difficult delivery, difficulty urinating
during phimosis, urethral stricture, prostate cancer, prolonged cough
(tuberculosis, bronchitis), constipation, diarrhea and other pathological
conditions accompanied by increased intra-abdominal pressure.
A certain percentage of hernias due to iatrogenic factors. For instance
when appendectomy may be damaged branches infracostal nerve, iliac-hypogastric
and iliac-inguinal nerve, which leads to atrophy of muscles and aponeurosis. As
a result, can herniate.
In general, referring to postoperative hernia, it should be noted that
there exists a direct correlation between the size of laparotomy and the
probability of postoperative hernia.
In the development of external
abdominal hernias (especially inguinal) can
distinguish 4 stages.
Most hernia appears gradually, gradually increasing in size. Fewer
hernias occur acutely, when a sharp rise in intra-abdominal pressure in the
presence of anatomical weakness of the abdominal wall rupture occurs inguinal
canal with subsequent formation of hernia.
І stage. Initially formed hernial orifice. Starting hernia (at the time of coughing in
the hiatus is determined by pushing motion of parietal peritoneum).
II stage. Hernia has all the constituent parts, but the hernial sac does not
extend through the thickness of the abdominal wall. Hernia occurs only on
exertion and disappears after removal of exertion. Incomplete hernia.
III stage. Full hernia. Hernias go beyond the abdominal wall, causes a change
in the abdomen (bulging) that appear when standing up and at the slightest
physical exertion.
IV stage. Are pertain largeness hernias
- huge hernias
Complications of hernial disease
Under the influence of permanent injury to the inner surface of the
hernia sac develops aseptic inflammation and adhesive process, which prevents
the occurrence of hernia contents into the abdominal cavity - there comes a
partial or complete irreducible hernia.
Most irreducible hernias are umbilical, femoral and epigastrocele of abdomen.
When the contents are so constricted as to interfare with their blood
supply this type of hernia is known as a
strangulated hernia(Fig.3.3) - a dangerous complication requiring immediate
surgical intervention. The incarceration may be in the body, and in the bottom
of the hernial sac. Incarcerated may be any organ, but the most dangerous is
the incarceration of the intestine. Strangulated hernia occurs with a sudden
rise in intraabdominal pressure, which may be by coughing, sneezing,
weight-lifting. Thus there is a hyperextension of hernial orifice and in the
hernial sac goes more contents than usual and becomes incarcerated on returning
through hernial orifice to its former condition. Such incarceration is known to
be elastic
Other types are "fecal”
incarceration), which occurs because of dysperistalsis, especially in the
elderly. Falling into herniating sac intestinal contents also pour into the
hernial sac and does not reduce along with the intestine getting struck causing
incarceration of fecal matter.
Third type of strangulation - partial
enterocele (hernia Richter) (Fig.3.6). In the hernial sac only a part of
the wall of the gut (opposite to mesenteric edge) is involved. Difficulties in
the diagnosis of this type of strangulation related to the fact that the
hernial protrusion is small and it is not always possible to find, especially
in obese patients and if a surgeon misses the strangulated loop during surgery.
In the reverse (retrograde,
W-shaped, hernia Maydl) strangulation in the hernial sac is two bowel loops, and connecting the third loop is located in the abdominal
cavity and can be strangulated.
Strangulation may be different from the minor, when the blocks a gut to
pronounced strangulation with impairment of arterial blood supply and rapid
development of necrosis organs. Strangulation of bowel causing bowel
obstruction with all the consequences.
Developed venous congestion in
strangulated organs, following accumulation of fluid in the hernial sac. With
an increase in impairment of circulation associated with inflammation and necrosis.
If such a patient is not timely operated- he may die from intestinal
obstruction, peritonitis.
Common symptoms, diagnosis
Hernias usually develop slowly and gradually with increase in the
characteristic symptoms. With heavy physical work, running, jumping patient
feels dull or lancinating pain on the site formed
hernias (usually in the groin area, below the inguinal ligament, in the navel
or postoperative scar). Pain in the
beginning is dull, with a mild trouble to the patient, and then increases with
physical work, and even walking fast. Then in place of pain appears protrusion,
which appears during physical exertion and disappears during rest. Protrusion gradually increased,
becoming a rounded shape. With the increase in hernial protrusion pain can increase
or disappear altogether, and sometimes the patient notices only the protrusion.
Hernias can reach large sizes (if they do not operate in a timely manner).
The main symptom of hernia is a protrusion,
which appears at the exertion and the self disappears at rest, horizontal
position or at the light pressing his hand. These classic manifestations of the
external abdominal hernias can make a diagnosis before the examination of the
patient. An objective study conducted on the local status of the scheme: observation,
palpation, percussion, auscultation, and special methods of investigation.
On examination, the patient in a horizontal position you can not find
signs of herniation. For large hernia bulge can be seen, the relevant
provisions of hernial orifice. In small uncomplicated hernias skin of
protrusion has the usual form. For large & long-standing hearnias the skin
is stretched, flabby, with areas of scar changes and expanded veins. When coughing, straining or on active movements the protrusion appears. On termination of active movements, it disappears
right away. In large hernias one can see the peristalsis of intestine through the
thinning of the skin.
Percussion of hernial protrusion gives
tympanic sound if the bowel is the content of the hernia sac and dullness when omentum
or other organ is the part of hernial sac.
Auscultation of hernias are
rarely done (e.g., for suspected aneurysm of femoral artery, when on auscultation
we get systolic noise).
The special methods of
investigation include the determination of hernial orifice and the cough
impulse. Fingers are penetrated into the depth of the abdominal wall and the borders
of hernial ring is felt (form, size, feature of their edges and surrounding
tissue). While patient is coughing the
doctor feels the thrust bulging of the peritoneum and adjacent organs on the
tip of his finger (cough impulse).
Some authors for the accurate diagnosis of inguinal hernia, especially
in infants, produce herniography –
X-Ray after administration of contrast material (diatrizoate - 2 ml per 1 kg)
in the abdominal cavity. Transcending contrast material beyond the peritoneal
cavity indicates the presence of hernia.
NOTE: Laboratory and other research
methods are applied only for getting a more complete picture of the general
condition of the patient.
In case of irreducible hernia- as a rule the pain becomes constant,
and is intensifying during physical exertion. Hernial protrusion does not
change its shape and size, and decreases slightly in the horizontal position.
Irreducible hernia often tends to strangulation.
Symptoms of strangulated hernia
-
sudden-onset of pain in the hernial site, increase, irreducible, severe tenderness
and soreness of protrusion. These symptoms associated with clinic of acute
intestinal obstruction: abdominal pain, cramping, vomiting, delayed stool and
gas. The patient is restless, moaning, tossing, cry for help. Сlinical picture less expressive in the
infringement of the omentum. In old people picture of strangulated hernia is
sluggish and possibly can be overlooked as a complication.
Sometimes it is difficult to differentially diagnose the irreducible and
strangulated hernia, which must be decided quickly according to law of
emergency surgery - suspicion in the diagnosis of acute abdominal pathology
surgical intervention is necessary.
Basic principles of treatment
of abdominal hernias
The basic method of treatment of external abdominal hernia is
operational. In the presence of contraindications for surgery patients it is
recommended, to carry bandage. It is allowed even wearing bandage temporarily,
during the preoperative preparation for large ventral hernia. If irreducible
hernia bandage is contraindicated. Wearing a truss for persons who has no contraindication for operation is contraindicated since Under the truss
is noticed skin irritation, there are scratches, folds, maceration,
lymphadenitis. Under the influence of trauma, hernial sac undergoes scar’s
degeneration, there are adhesions to abdominal organs, and atrophy of the
tissues occurs in the abdominal wall.
Contraindications to surgery in
uncomplicated hernia:
Old age
(above 75 years), decompensated cardiac anomaly, active tuberculosis, malignant
tumors, stricture urethra, adenoma prostate, pustular disease, and others which
make herniotomy life-threatening.
The basic principle of surgical treatment of abdominal hernia is an individual
decesion, a differentiated approach to the selection method of herniotomy.
Operation for hernia should be very simple and minimally invasive, technically
executed flawlessly and providing radical treatment.
General principles of operation for
uncomplicated hernias:
1) Dissection of the
tissues over the hernia;
2) The separation of
hernial sac;
3) Opening it;
4) Reducing content in
the abdominal cavity;
5) Ligation of hernial
sac from the neck;
6) Cutting it off ;
7) Suturing the abdominal
wall defect (plasty).
Reducible
uncomplicated hernias do not require urgent surgical treatment. But operation
should not be delayed for a long time with non-reducible hernia. Strangulated hernia requires immediate
surgical treatment. There are no contraindications for surgery of
strangulated hernia, except for morbid state.
The peculiarity of the operation in
strangulated hernia is a need before dissection of the ring opening of hernial sac, fixation
of incarcerated organs (herniated sing) or otherwise they can slide away into
the abdominal cavity, which requires a laparotomy for revision. After opening
the bag and cutting the ring inspect the contents in the intestine mesentery by
introducing 0, 25% sol. Of Novocain and intestine should be warmly draped &
dampened with warm saline. If the intestine is viable it is put back into the
abdominal cavity, whereas in case of necrosis we resect the intestine. Determining
the amount of resection is not always easy. Therefore it is a rule to resect the
intestine from the border of necrosis in the proximal direction upto 30-40 cm,
and 20 cm distally. The operation ends with plasty.
Forced reducing of strangulated
hernia is contraindicated (either patients or their relatives or health professional). It should
be kept in mind that some patients because of fear of surgery reduce a
strangulated hernia. In this case there is a risk of strangulation of incarcerated
organ and imaginary (false) reducing.
Possible variants imaginary
reducing:
1) Separation of hernial sac from the surrounding tissue and reducing
with the into the abdomen or preperitoneal cellular tissue;
2) Detachment of
the neck and reducing with the incarcerated organ in the abdominal cavity;
3) Complete detachment of the neck from the body, and from the parietal
peritoneum and reducing in the
abdominal cavity;
4) The movement of strangulated part from one wall of hernial sac to
another. It is important to detect all that timely with a picture of
peritonitis and acute intestinal obstruction.
Tactics of the surgeon at
spontaneous reducing of strangulated hernia.
Spontaneous reducing of strangulated hernia can be at any stage of the
preoperative period. What to do? Tactics must be individualized. In the
presence of tachycardia, leukocytosis, abdominal pain, vomiting, hernial
history, the patient should be operated immediately, using mid line incision.
In doubtful cases, a more rational laparoscopy. If after the spontaneous
reducing of strangulated hernia patient feels well, no complaints, no alarming
symptoms of the abdomen, then emergency surgery is not indicated. The patient
should remain in the hospital under constant observation. If peritoneal
symptoms appear, the patient should be operated on emergency basis and with satisfactory
condition of patient, has to be operated on routine basis over 3-5 days.
Strangulated of sliding
hernias. When
necrosis is in the cecum - right hemicolectomy followed by plasty of hernial
orifice. When necrosis is in the bladder wall - resection of the bladder with
epicystotomy.
In case of hernial sac phlegmon
– operation starts with
laparotomy, the intersection of strangulated bowel loop at the mouth of a purse
string suture on the orifice of hernial sac for the purpose of that the pus
shouldn’t fall into the abdominal cavity. Is superimposed on entero
enteroanastomosis and laparotomy wound is sutured. Then a cut above the hernia
dissect tissue with hernial sac, identify hernial hiatus derive strangulated loop. Sanitize purulent cavity and drain. Mortality in
this group of patients is above 50%. In the case of recovery and the presence
of granulation of wound, the patient is reoperated by excision of the wound
with the remnants of hernial sac. Followed by hernioplasty.
There are five basic methods of plasty
of hernias:
1) aponeurotic
fascial;
2)
Musculoaponeurotic;
3) Musculo-muscular;
4) Plasty
with additional biological or synthetic materials (alloplasty, explantation);
5)
combined (using auto and foreign tissue).
The advantage of fascial-aponeurotic
plasty is that this method is implemented the principle of the connection
of homogeneous tissue, as a result of which is the reliability of their
adherence. Operation is least traumatic. However, their reliability depends on
the size of hernia defect, the degree of tension in the tissues and strength
qualities of fascia and aponeurosis. In cases where the tissue is thinned,
atrophic or separated tissues at large (more than 10 cm) distance between the
edges of the hernial defect, the use of fascial-aponeurotic plasty leads to
frequent relapses (from 14 to 53%).
Currently, the main method of plasty abdominal hernia is
musculoaponeurotic plasty. With this method, the strengthening of the abdominal
wall defect is caused not only the aponeurosis, and muscle.
The major advantage of this method is that the defect in the abdominal
wall strengthening muscle tissue, capable of providing an active dynamic
resistance fluctuations in intra-abdominal pressure, due to her characteristic
of contractility and elasticity. Using this method leads to a very good late
results of treatment of ventral hernias. At the same time, the use of this
method in large and giant hernial defects gives up to 35% of recurrences (KT Toskin
et al., 1994).
To
apply the method of plasty with
additional biological and synthetic materials there are some indications:
1) Recurrent, especially multiple times recurrent hernias;
2) The primary hernia of large size when flaccid abdominal wall due to
atrophy of muscles, fascia and aponeurosis;
3) Postoperative hernia with multiple hernial rings when herniorrhaphy
does not give full confidence in their substantiality;
4) Huge hernias the size of the defect of the abdominal wall more than
10x10 cm,
5) "Difficult" inguinal hernia (large straight, slanting with
the direct channel, the sliding and combined), with marked atrophy of muscles,
separated tissues aponeurosis, hypoplasia ligaments.
Transplants, depending on their
origin are divided into:
1) Autologous (taken within
the same organism), these include - auto fascia, skin autotransplantation;
2) Allogeneic (taken from the
body of the same species as the body of the recipient), these include -
allogeneic fascia, allogenic pericardium, allogeneic dura mater;
3) Xenogeneic (taken in the
body of another species);
4) Explants (tissue or organ
were incubated out of organism);
5) Composite grafts.
The most important stage of development of surgery of abdominal hernial
plasty is associated with the synthesis of high molecular polymers. The most
common today synthetic material is: Marlex, Dacron, polypropylene, Mersilene, Teflon. Studies of remote
results indicate that the use of mesh prostheses can dramatically reduce the
number of relapses.
Hernias of midline of abdomen
(epigastrocele):
White line (linea Alba) -
aponeurotic part of the anterior abdominal wall (width from 1-2 mm to 2-3 cm),
coming from the xiphoid process to lacunar articulation between the rectus
muscles. Between the bundles of fibrous filaments are cracks and depressions,
which may be predisposing factors in the formation of hernias. Hernias develop
slowly, often without clinical manifestations. Initially through the hernial
orifice bulges preperitoneal fat, and then formed hernial sac. Epigastrocele
rarely large, Hernial sac can be delayed in the thick white line and hernial
protrusion is not defined, these are called hidden hernia (hernia occulta).
Clinic- epigastrocele consists of two symptoms - pain and palpable protrusion. Pain in the field
of hernia may cause pyloric spasm and increased secretion. We have to carry out
differential diagnosis of peptic ulcer, chronic cholecystitis.
Epigastrocele
incarcerated frequently - a sharp increase in pain, can appear symptoms of
intestinal obstruction. Expansion of the white line of the stomach called diastase recti: I st. - up to 5-7 cm,
stage II - 7-10 cm, III stage - 10 cm or more. Selecting operation depends on
the size of hernia, the degree of diastasis, severity of the clinic, the patient's
condition and age.
Anesthesia
both local and general.
At small hernia defect in the aponeurosis stitched in the longitudinal
direction of the interrupted stitches.
Hernias medium and large sizes are operated on Sapezhko and Mayo. When combined hernia with diastase muscles
aponeurotic plasty by Napalkov or
Martynov is used.
Plasty by Napalkov - after removal of hernial sac
edge of aponeurosis is sewed by interrupted stitches. Then, at the medial edge
make two parallel cuts anterior wall of vagina with rectus muscles. Inner edge
joined, and the first layer stitches are embedded. Then also sewed is the outer
edge of the cut wall to aponeurotic sheath.
Plasty by Martynov - the elimination of diastase
follows - on the medial edge of one of the lines cut through the muscles of the
front wall of the vagina throughout the diastasis. Then the medial edges of
vagina and rectus muscle are sutured. The line of stitches strengthens layer of
aponeurosis of the anterior wall of the vagina previously dissected.
Then used and implemented is the practice of plasty "no
tension" with the use of synthetic mesh.
Umbilical hernia in adults
(hernia umbilicalis adultorum)
More common in women, causes - defect in anatomical structure of
umbilical ring, on the other - the factors predisposing increase in the
intra-abdominal pressure (pregnancy, obesity). Clinical manifestations depend
on the size of hernia, severity of adhesions, and the presence of
complications.
Results of
treatment of umbilical hernia are worse than in inguinal and femoral (often up
to 15-40% of relapses and complications more).
Used are
two ways of operations.
Method Mayo. Anesthesia general. Hernia is
surrounded by two cross convergent arch forming cuts. Reveal the hernial sac,
take out the adhesion, adherent omentum separated and internal organs are
reduced to the abdominal cavity. Bag excised and the edges sutured in the
transverse direction. Hernial orifice is expanded by two transverse incisions
to internal edges of the muscles. Then apply U-shaped stitches (bottom flap
under the top). The second series of sutures (upper flap to the bottom forming
duplicate).
Method Sapezhko. Produce two longitudinal curved
incisions with excision of loose skin and umbilical button. Scared edges
excised. Peritoneum from the posterior surface of one muscle detach at 2-4 cm.
Stitch on the peritoneum. Then it created is duplicate in the longitudinal
direction of 2-4 cm in width (edge aponeurosis on the one hand sutured to the posteromedial
part of the vaginal rectus muscle, which was the preparated peritoneum. The
second layer stitched by duplicating). Method Sapezhko is more physiological
(reduced width of the white line, straightened the course of rectus muscle
fibers).
Due to
unsatisfactory results of plasty umbilical hernia, developed and implemented in
the practice of plasty using knitted polypropene mesh, which is fixed to the
aponeurosis by polypropylene mono-filament sutures.
Inguinal hernia
ANATOMY
More common than other,
Anatomically, are of two types: indirect
and direct. Indirect are congenital and acquired. In addition to
these classical forms is practically important to know their variants, although
they are rare. The Indirect hernias with a direct channel inside the wall
(preperitoneal, intermuscular, subcutaneous), encysted, parainguinal,
supravesical and combined.
Acquired indirect inguinal hernia. Protrusion of parietal peritoneum in the
internal inguinal ring (fovea inguinalis lateralis), which is implemented in
the anulus inguinalis profundus, passes the entire inguinal canal and exits
through the external inguinal ring (anulus inguinalis superficialis). Internal
inguinal ring is the hernial orifice. The walls of this ring are strengthened by
transverse muscle (above and outside) and Hesselbach's ligament (from the
bottom and inside). Elements of the spermatic cord are scattered on hernial
sac.
Direct inguinal hernia. Protrusion of the peritoneum in the fovea
inguinalis medialis and enters the inguinal canal outside of the spermatic cord
through the inguinal gap, hernial orifice is the inguinal gap, which in this
case is the "weak point". Inguinal gap increases and the valve
function of muscles are absent. Hernial sac is covered with a layer of preperitoneal
fat and dramatically extended to the transverse fascia.
Supravesical inguinal hernia. Protrusion of the peritoneum
through the medial gap.
Combined inguinal hernia. 2-3 individual hernial sacs.
Sliding inguinal hernia (hernia
inguinalis labentes). In the formation of hernial sac is involved not only has the parietal
layered of the peritoneum. One of the walls of the hernial sac is formed by
surrounding organ, located retroperitoneally. There may be sliding inguinal
hernias of the urinary bladder, cecum, ovaries, tubes, uterus, sigmoid colon,
ureters and kidneys.
Recurrent inguinal hernias occur up to
10%.
Causes of recurrent inguinal hernias:
1) Late surgery in the
presence of significant changes in tissues of the groin;
2) Old age;
3) The wrong choice
method of operation;
4) Gross mistakes in
operational technology;
5) Inflammatory
complications from the surgical wound;
6) Early weight lifting after
operation not yet formed a scar;
7) Heavy physical load in
the late postoperative periods.
D/D of inguinal hernia
A) In male
1)Femoral hernia
2)Vaginal hydrocele.
3)Encysted hydrocele of
cord.
4)Spermatocele
5)Undecended testis
6)Lipoma of cord
B) In female
1)Femoral hernia
2)Hydrocele of nuck’s
canal.
Nyhus's classic parasagittal diagram of the right midinguinal region
illustrating the muscular aponeurotic layers separated into anterior and
posterior walls. The posterior laminae of the transversalis fascia have been
added, with the inferior epigastric vessels coursing through the abdominal wall
medially to the inner inguinal canal.
Classification (Nyhus) (Fig.3.10).
I type - indirect inguinal hernia. Internal ring not dilated, hernial contents are situated in inguinal
canal (canals inguinal hernia).
II type - indirect inguinal hernia by large widening inguinal
ring.
III type: А - all form direct inguinal hernia. There is weakness
transverse fascia
В - indirect inguinal
hernia large size (inguinal-scrotal) ; С - femoral hernia
IV type - recurrent hernia: А - direct recurrent; В - indirect recurrent; С - femoral recurrent; D - combination
recurrent direct, indirect and femoral hernias
Diagnosis of inguinal hernias in women is different in that the introduction of the
finger in the external inguinal ring is not possible. Limited to inspection and
palpation. In a direct - located above the inguinal ligament, and in case of
indirect hernia slides down to external genital labia.
Surgery of inguinal hernias
Anesthesia.
At
present, the following methods of anesthesia in herniotomy:
1) The
local infiltration and block anesthesia;
2) Multicomponent
intravenous general anesthesia with spontaneous breathing;
3)
Multicomponent intravenous general anesthesia with artificial pulmonary
ventilation;
4)
Peridural anesthesia;
5)
Peridural anesthesia in combination with intravenous anesthesia;
6)
Peridural anesthesia in combination with intravenous anesthesia and
ventilation.
Stages of herniorrhaphy:
1) Formation of access;
2) Separation from the surrounding tissues and removal of hernial sac
(moving the hernial stump from hernial sac by Krasintsev-Barker in direct
inguinal hernia);
3) suturing the deep inguinal orifice: Ioffe’s method to the upper and
lower edge of medial deep inguinal orifice (the edge of the transverse fascia)
impose forceps, then encircling suturing the opening up to 0,6-0,8 cm);
4) Plasty of inguinal canal
Methods of Girard, Spasokukotsky, Kimbarovsky, Martynov, Bassini,
Postempsky.
Bassini - Nyhus - cut through the transverse
fascia, detach it. Put the stitches on the mobilized layer of transverse
fascia. Herniotomy with approximation of posterior wall of the
inguinal canal by suturing the conjoined tendon above to the inguinal ligament
below, by using interrupted, nonabsorbable suture material like nylon or
polypropylene .
Bassini’s herniorrhaphy
The method of plasty of the
inguinal canal by Shouldice is in large enough popularity practice is
enjoyed in Western Europe, the United
States
Features of plasty: the author proposes dissection of cremasteric
muscle, further dissection of the transverse fascia from the inner ring to
lacunar tubercle. Surplus fascia can be dissected. For the reconstruction of
posterior wall of the inguinal canal using atraumatic monofilament material’s
are used (polypropylene, RDS, etc.).By disecting the transversalis fascia we
get two flaps upper and lower the lower one is sutured to the undersurface of
the upper and the upper one is sutured to the inguinal ligament.Sutures extend
to lacunar tubercle, where both ends of the threads are tied. By the formation
of the inguinal canals posterior wall in two-layers (double breasting) this
method ends. Followed by traditional closure.
Plasty of the inguinal canal by
Shouldice.Plasty of inguinal hernias with mesh allografts. Since 1984, the clinic Liechtenstein
began to apply a new technique for plasties "without tension"(“Tension
free"). The key point of this method was the application alloplasty.
Currently, the method Lichtenstein (Fig.3.13) became one of the best modern
methods of treatment of inguinal hernias.
When
indirect inguinal hernia after removal of hernial sac reconstructed is deep
inguinal ring and the transverse fascia is sutured. In direct hernia, the
transverse fascia is cut just above the hernial sac, and if possible is reduced of hernial
sac without
cutting, and then sutured in continuous suture to transverse fascia. From
polypropylene mesh is cut patch of 6X12 cm that put under the spermatic cord.
The rounded lower end of the mesh is fixed with 2-3 sutures to lacunar tubercle
along with lacunar (Cooper) ligaments. To inguinal ligament is fixed the mesh
with 4-5 interrupted or continuous polypropylene sutures, at the level of
internal ring sparing the spermatic cord. Upper medial edge of mesh sutured to
the internal oblique muscle, transverse muscle and to the rectus abdominis
muscle. Suture the external oblique muscle aponeurosis.
Plasty of inguinal hernias with mesh allografts by Liechtenstein
Femoral Hernias: Herniation
of intra-abdominal contents through the femoral canal is described as femoral hernia. Hernias go through the femoral
ring below the inguinal ligament. Under the inguinal ligament located space
that is divides the iliac-pectinate ligament into two gaps: the muscular and
vascular.
Laterally placed muscle gap is Iliopsoas muscle (m. iliopsoas) and
femoral nerve (n. femoralis). Medially in the vascular lacuna is located
femoral artery, femoral vein, nerves (n. genitofemoralis ET n lumboinguinalis),
and lymphatic vessels. Inner third of the vascular lacuna between the vein and
the lacunar ligament is called the femoral ring. It holds a spongiose fatty
tissue, lymph vessels and lymph node Rosenmüller- Pirogov.
The boundaries of the femoral rings: anterior - inguinal ligament,
posterior - pectineal ligament, medial - lacunar ligament (lig. lacunare
Gimbernati), lateral - femoral Vein.
Femoral canal normally is absent. In the case
of bulging out of the interior organs through femoral ring is formed femoral canal with a
length of 2 cm.
Margins of which are:
Anterior – posterio-inferior surface of
the inguinal ligament, superficial layer of broad femoral fascia,
Posterior - pectineal ligament (Cooper
ligament) and pectineal muscles fascia,
Medial - Lacunar ligament,
Lateral - fascial sheath of femoral
vein.
Internal foramen of femoral canal is the femoral ring and the outer -
oval fossa - an orifice in the broad fascia of the femur through which passes
is the large subcutaneous femoral Vein. "Corona
Depending on the outlet of the hernia
femoral hernias are of following types:
1) Typical femoral hernia - going through
the vascular lacuna medially from the femoral vein;
2) External - outside from the femoral
artery;
3) Before vascular hernia (medium) - goes
over the vessels;
4) musculo-lacunary hernia (Hesselbach's
hernia) - goes through the muscular lacuna;
5) Femoral
hernia of lacunar ligament.
Femoral hernia.
Causes for femoral hernia
Femoral hernia is never congenital.
1. Pregnancy: increased
abdominal pressure due to repeated pregnancies is one of the chief factors
responsible for femoral hernias. The maximum incidence is around 30-40 years of
age.
2. Wide femoral canal.
Clinics. More commonly women suffer.
Complaints of pain in the groin, lower abdomen, upper portions of the thigh. To
start with, there is a small swelling below the inguinal ligament, which goes unnoticed very often. Characteristic signs - the
presence of hernial protrusion in the femoro-inguinal fold, positive symptom of
"cough impulse”.
The differential diagnosis is carried out with inguinal hernia,
lymphadenitis, tumors, aneurysms, congestive abscess, cysts, and varicose
disease.
Treatment - surgical.
There are many methods of hernioplasty. Among them there are two basic
methods: femoral and inguinal.
Low (Lockwood) Operation: Sac is dissected out below
inguinal ligament via a groin-crease incision.
High (McEvendy) Operation: Vertical incision is made
over the femoral canal and continued upwards above above the inguinal ligament.
Lotheissen’s operation: Inguinal canal is opened as
for inguinal herniotomy.
Femoral method - Bassini: hernial ring is closed by sutures: the first layer -
inguinal ligament and pectineal ligament (Cooper ligament) and the second
series of stitches - between the semilunar edge of the broad fascia of the
thigh and pectineal fascia.
Inguinal method - Rudi-Parlavechcho. Open the inguinal canal, mobilize the spermatic
cord. Dissect the transverse fascia and enter into the preperitoneal space,
where is found hernial sac neck. Pulled hernial sac from the femoral canal, the
hernial sac is opened, the revision is performed, and then hernial sac is
removed. Femoral ring is closed by stitching pectineal ligament and inguinal
ligament - (Rudi). The second layer of stitches (Parlavechcho) internal oblique
and transverse muscle sutured to the inguinal ligament.
Reich (1911) suggested a one layer of stitches to sew the
internal oblique, transverse muscles, Cooper's ligament and inguinal ligament.
Then reconstructing inguinal canal.Patients with femoral hernias and patients
with symptoms of atrophy of musculoaponeurotic and ligamentous apparatus the
method of choice is plastic with polypropylene mesh.
Postoperative ventral hernia
Surgical
treatment of postoperative ventral hernia - the issue of the day in abdominal
reconstructive and cosmetic surgery. Postoperative hernia poly etiologic
disease is regarded as a complex disease, entailing numerous disturbances in
the activity of internal organs. Number of patients with postoperative hernias
continues to grow.
CLASSIFICATION VENTRAL HERNIA SWR (J.P.Chevrel, A.M.
Rath)
Localization
M
(medianus): М1- supraumbilical L (lateralis): L1- subcostal
M2- paraumbilical L2- transversal
M3
infraumbilical L3- ileac
M4
xiphoid-pubic L4-
lumbar
W (wideness hernial orifice) W1 until 5
cm
W2
(5-10 cm )
W3 (10-15 cm )
W4 (more 15 cm )
Recurrence (number recurrence) R1 (first recurrence)
R2 (second recurrence)
The method of surgical
treatment of ventral hernias depends on the size of hernia, condition of the
anterior abdominal wall, and on the functionality of a particular patient.
Principle
treatment is autoplastic methods of plasty of postoperative ventral hernias
based on the closing of the anterior abdominal wall defect with mobilized
musculoaponeurotic edges of the hernial ring, which are stitched together by
duplicating layers. Significant tension can lead to relaxed cutting of the
anterior wall of the rectus muscle. Plasty of ventral hernia using the own
tissue of anterior abdominal wall is very difficult and lead to recurrence in
more than 50% of cases. To strengthen the lines of stitches a number of authors
used auto dermal skin flaps. Experience of the world's leading clinics confirms
the world’s tendency towards increased use of alloplastic treatment of
postoperative hernias.
Methodology of synthetic meshes can be divided into
three groups: 1)Strengthening
the anterior abdominal wall through fixing of mesh transplant to the
aponeurosis over the hernial defect).on lay mesh plasty.
2) The
strengthening of the anterior abdominal wall by placing mesh under the
preperitoneal musculoaponeurotic layer (in
lay mesh plasty).in lay mesh plasty.
3) Laparoscopic mesh plasty (Sub lay) intervention in which the mesh graft is fixed
inside the abdominal cavity, closing in the form of a patch hernial ring.Laparoscopic mesh plasty.
