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Abdominal hernia


Abdominal hernia - protrusion of the viscera from the abdominal cavity together with the covering wall of the peritoneum through the "weak" areas of the abdominal wall under the skin (external hernia) or into various pockets and bags of the peritoneum (internal hernia). abdominal cavity, the size of which for various reasons (weight loss, weakening of the ligament apparatus) has increased, or holes that have arisen at the site of a tissue defect, thinning of the postoperative scar, and others. The hernia consists of hernial the mouth is the opening through which the hernial protrusion exits, the hernial sac formed by the parietal peritoneum, and its contents (it can be any organ of the abdominal cavity).

Depending on the localization, inguinal, femoral, umbilical hernias, hernias of the white line of the abdomen, etc. are distinguished. According to the etiological factor, hernias are usually divided into congenital and acquired, traumatic, postoperative; by the nature of the flow - to complete and incomplete, reducible and unreducible, complicated and uncomplicated.

The most characteristic symptom of a hernia is the presence of swelling that occurs when straining and disappears when muscles are relaxed in the supine position or after a manual reduction. A swelling that is not susceptible to reposition is characteristic of an irreducible hernia.

In the initial stage of development, a hernia is detected when a finger is inserted into the hernial canal by the sensation of the hernial contents coming out at the moment of coughing or straining of the patient. If there is an intestinal loop in the hernial sac, a tympanic sound is determined during percussion, and a rumbling is determined during auscultation. Often patients suffer from pain in the field of hernial protrusion, nausea , belching , constipation , abdominal distention, and urination problems.

Inguinal hernia. Anatomical features of the groin area contribute to the formation of hernias. There are oblique and direct inguinal hernia. Oblique inguinal hernia through a deep inguinal ring enters the inguinal canal along the spermatic cord, penetrates the superficial inguinal ring and is located under the skin, often falling into the scrotum, and in women - into the labia majora. A straight inguinal hernia emerges from the abdominal cavity through the medial inguinal fossa opposite the superficial inguinal ring (the finger inserted into it goes straight, unlike the oblique hernia). Straight inguinal hernia is often bilateral. The contents of an inguinal hernia in most cases are the small intestine and the omentum, occasionally the cecum, the appendix, the bladder, the sigmoid colon, and the internal female genital organs.

Recognition of an inguinal hernia usually presents no difficulties, and only in the initial stage of development, when the hernia has not yet left the surface of the surface ring, doubts can arise. Then a finger is inserted along the inguinal canal, and if a push is felt when coughing and straining the patient, this indicates a hernia.

Femoral hernia ranks second in frequency after inguinal, it is more common in women 40 to 60 years. An increase in the size and weakness of the femoral ring (the region of the femoral vessels under the inguinal ligament) predisposes to the development of the femoral hernia. Femoral hernia usually contains the small intestine and omentum, very rarely other organs of the abdominal cavity (uterus, ureter, etc.). Patients complain of pain in the lower abdomen, in the groin and thigh, and nausea. The femoral hernia is defined below the inguinal ligament, in contrast to the inguinal hernia located above it. Often the femoral hernia is bilateral.

Umbilical hernia is more common in women; multiple pregnancies and childbirth contribute to its occurrence, weakening the abdominal wall and umbilical ring. The contents of the umbilical hernia are more often the small intestine and the omentum, but there may be a large intestine and a stomach. Umbilical hernia often causes pain, nausea and other complaints.

A hernia of the white line of the abdomen (epigastrium) occurs through the cracks and holes in the white line of the abdomen, into which preperitoneal fat first passes, gradually tightening the peritoneum behind it. Hidden hernias are observed when the hernial protrusion is thicker than white.

Pini without going beyond its limits. Often there are multiple hernia, located one above the other. The contents of the hernia are more often the epiploon, sometimes the small intestine and other organs. More often, these hernias are asymptomatic, but in some cases, patients complain of pain in the epigastric region, aggravated after eating, nausea, and even vomiting. Often these hernias are associated with peptic ulcer, gastric cancer, cholecystitis, etc.

Postoperative hernia is formed in the postoperative scar after appendectomy, midline laparotomy, after operations on the biliary tract, etc. The hernial ring in these hernias are slit-like or round, sometimes very large. They are formed by the edges of the muscles and aponeurosis. More often, the formation of postoperative hernia is associated with suppuration of the surgical wound. Symptoms of postoperative hernia - pain, sometimes nausea , vomiting , constipation . Recognition of hernias is based on the presence in the postoperative scar of protrusion that occurs during straining, coughing or when the patient is in an upright position.

Internal abdominal hernias are rare. They are formed as a result of the penetration of the abdominal organs into various intra-abdominal pockets (stuffing box, cecum, etc.). In many patients, the internal hernia does not manifest itself and is discovered by chance during any intra-abdominal operation. When a hernia is strangled, symptoms similar to those of intestinal obstruction occur. The diagnosis is usually made during surgery.

Complications. A terrible complication of hernia is infringement. Hernia infestation is associated with a sudden compression of its contents in the hernial ring, usually after weight lifting, strong straining, coughing. The reason for the infringement can be spastic contraction of the tissues surrounding the hernial ring, cicatricial constriction in the hernial bag. Often, the small intestine is infringed, at the site of compression of which the strangulation furrow (a sharp thinning of the intestinal wall) is formed by the restricting ring, and blood circulation in the strangulated part of the intestine occurs. Usually, the venous vessels of the mesentery are first compressed, as a result of which plasma flows into the intestinal wall and into the intestinal lumen. The volume of the strangulated part of the intestine increases, the arterial blood supply to the intestine is disturbed, and it undergoes necrosis. Plasma also sweats into the hernial sac, forming "hernial water", which becomes turbid when microorganisms penetrate into it. Necrosis of the intestine may be accompanied by perforation of its wall and the development of peritonitis. The clinical signs of bowel obstruction are the same as with intestinal obstruction. Severe pain usually occurs in the area of ​​the hernia, but in elderly patients it can be dull. Hernia becomes unreducible, tense, enlarged and very painful on palpation. Often there is vomiting at first, with an admixture of bile, and then caliciform, stool and gas discharge ceases. The pulse is weak and frequent, the extremities are cold, the tongue is dry, sometimes dizziness occurs.

In the diagnosis of strangulated hernia, a well-collected history is of great importance. However, with a small hernia size, the patient may not be aware of its existence, therefore, for abdominal pains, it is always necessary to examine all parts of the abdominal wall where the hernia can be formed. The appearance of severe pains with an unreducible hernia is a sign of its possible infringement, especially if they are accompanied by a delay in stool and gas, vomiting, abdominal distension. A patient with a strangulated hernia is immediately hospitalized in the surgical department (transportation should be carried out on a stretcher). An attempt to reduce the strangulated hernia is unacceptable, as is the appointment of painkillers and the use of heating pads.

Treatment of hernia operative. All patients who have a hernia, should be sent for surgery. The exceptions are patients with acute infections, dermatitis and eczema in the area of ​​hernia, pregnant women with late pregnancy, patients with severe diseases of the heart, lungs, kidneys, and liver. If the operation is impossible due to serious diseases, wearing a bandage is shown.

The surgery performed on the hernia (hernia repair) consists of removing the hernia sac, repositioning the viscera into the abdominal cavity and strengthening the weak portion of the abdominal wall in the area of ​​the hernia gate by plastics with local tissues. When a hernia is strangled, an emergency operation is indicated, since the risk of necrosis of strangulated organs increases with each passing hour.

Hernias in children are usually detected shortly after birth. More often inguinal and umbilical hernia.

An inguinal hernia develops when the vaginal process of the peritoneum does not open. When shouting, straining a child in the groin, a painless protrusion appears, easily prostrate in the prone position. Quite often cryptorchidism is combined with inguinal hernia - undescended testicle with its delay in the abdominal cavity or in the inguinal canal. A differential diagnosis of an inguinal hernia is performed with an edema of the testicle (see Hydrocele). Surgery for inguinal hernias is performed at the age of 6 months - 1 year. When a hernia is strangled, there are sudden severe pains in the area of ​​the hernial protrusion, its painful tension, while the hernia is unreducible. If the hernia is strangled, it is sent to the surgical hospital.

Umbilical hernias in children manifest in the form of swelling in the area of ​​the umbilical ring, which usually occurs with a cry, anxiety of the child and easily set in the abdominal cavity at rest. Infringement of an umbilical hernia in children is rarely observed. Treatment of umbilical hernia at the beginning is conservative - massage of the anterior abdominal wall, therapeutic exercises, proper nutrition. Usually against the background of this treatment, when the child reaches 3-5 years old, the umbilical ring is reduced in size and closes on its own. If this does not happen, the operation is shown.