Incarcerated hernia: classification, clinical picture, diagnosis, treatment. Symptoms of a strangulated hernia and methods of treatment Strangulated postoperative

A hernia is a disease accompanied by protrusion of parts of organs beyond their anatomical position. ICD code: K40-K46. The ventral hernial sac is formed in the abdominal cavity (ventrum - lat. cavity). One of the complications of a hernia is compression of parts of the internal organs, as a result of which the compressed tissues suffer from poor circulation, partial death of the epithelium occurs, which causes a strong inflammatory process. For timely treatment of a pinched abdominal hernia, it is important to recognize the symptoms of the complication in time.

How does pinching occur?

There are anatomically weak spots in the abdominal region through which internal organs can protrude for various reasons. Most often, pathology occurs in the area of ​​the umbilical ring, the groin area, the lumen of the white line of the abdomen, and the anatomical openings of the diaphragm.

Depending on the location of the protrusion, movable organs of the abdominal cavity can enter the hernial orifice, which is what the opening in the muscles is called: intestinal loops, part of the stomach, greater omentum.

A serious complication of the disease is the infringement of the internal organs located in the hernial sac. In the compression zone, an inflammatory focus forms, turning into gangrene, which spreads throughout the abdominal cavity.

Where compression may occur

Organ pinching can occur anywhere in the abdomen where a protrusion has formed. The weakest points of the peritoneal wall include:

1. Ring in ligaments in the navel area.
2. The linea alba is a vertical line running exactly in the middle: from the solar plexus to the pubis.
3. Inguinal canal on the left and right sides.
4. Pathological formations – femoral canals.
5. Scars after surgery.

The most commonly diagnosed injuries are in the groin, navel, and femoral fossa. Compression is less common with hernias of the white line of the abdomen and in the area of ​​postoperative sutures.

The structure of the hernia

Each hernia has the same structure. The protrusion consists of the following parts:

1. The pouch is an area of ​​skin and internal fascia of the abdomen surrounding the organs that have undergone protrusion.
2. The gate is an opening between the ligaments and muscles into which parts of the internal organs are pressed.
3. Contents: intestinal loops, omentum, stomach.

Externally, the hernia resembles a round formation, which can be small or quite large in size. At rest, the protrusion may be hidden from view; the volume of the formation increases with physical activity, while standing, running and walking.

Incarceration can occur regardless of the location and size of the protrusion. A complication can happen at any time, which is why a hernia in medical practice is called a time bomb.

Types of pathology

The clinical picture of the disease depends on the type of infringement and which organ was damaged due to compression. Infringements are classified according to location (internal, external), nature and degree of compression (retrograde, parietal, Littre's hernia), organs trapped in the hernial orifice (frequently impacted organs, rare types of compression). Compression can be primary or secondary.

According to the mechanism of development, infringement of the elastic and fecal nature occurs.

Elastic

If there is a protrusion, sudden compression of organs can occur under the influence of loads on the peritoneal area, when lifting weights, during severe coughing, sneezing and other types of stress. The consequence of muscle tension is a sharp expansion of the hernial orifice, which provokes the release of a significant part of the internal organ into the abdominal cavity. In this case, the pinched area is not reduced, since the gate closes and its contents are isolated. All this is accompanied by severe pain and muscle spasms.

Feces

The mechanism of fecal strangulation is different in that here the causes of compression are not the physical tension of the peritoneal muscles, but the gradual accumulation of feces in the intestinal loops trapped in the hernial sac. Most often, this type of pinching occurs in elderly patients and people with impaired gastric motility.

According to the nature of compression, they are distinguished:

• retrograde;
• wall,
• Littre's hernia.

Retrograde

It is characterized by impaired blood circulation in the area of ​​the intestinal loop, which is located not in the hernial sac, but inside the abdominal cavity. During an emergency operation, the surgeon examines the contents of the hernial sac and discovers that the strangulated end of the intestine is completely viable. Meanwhile, the damaged loop of intestine sinks deep into the abdominal cavity.

Parietal

The peculiarity is not the complete entry of the intestinal loop into the hernial orifice, but the compression of a certain part of it. Intestinal obstruction does not occur, but there is a high risk of death of one of the intestinal walls.

Littre hernia

This type of compression is very similar to parietal compression, with the difference that here the symptoms develop much faster. Necrosis and other complications may occur within the first hour of compression.

Regardless of the types of compression, the symptoms of the pathology are similar. Pinching is accompanied by severe pain, the inability to independently reduce the protrusion and dyspeptic disorders of the digestive system.

General signs of a strangulated abdominal hernia

When an organ is compressed, blood circulation is impaired, which entails the development of many negative symptoms. Signs of pathology can be divided into early and late manifestations of the disease.

Early symptoms

Immediately after compression of an organ, a person experiences sharp pain, and pain shock often develops. The intensity of the symptoms depends on which organ is being compressed. When the greater omentum is pinched, the clinical manifestations may be mild, the patient experiences aching, cramping pain.

If intestinal loops are compressed, the process may be accompanied by the following manifestations:

1. Sharp intense pain of a paroxysmal nature.
2. Repeated vomiting that does not bring relief.
3. Severe bloating, lack of gas discharge.
4. A decrease turning into a complete absence of intestinal motility.
5. Nausea, prolonged hiccups, belching, heartburn.

External signs of pinching are characterized by redness of the skin, increased temperature in the area of ​​the protrusion, the density of the hernia and its pain. An important symptom by which compression can be diagnosed is the absence of a symptom of a cough impulse.

Late signs

In the absence of necessary medical care, a strangulated ventral hernia may be accompanied by the following manifestations:

1. Skin hyperemia is a local blood flow to the affected area.
2. Severe increase in temperature.
3. Accumulation of exudate at the site of compression.
4. Weakness, apathy, chronic fatigue.

Often, patients experience purulent lesions (phlegmon) of the hernial sac, which can also be strangulated with subsequent melting of the wall of the intestinal loop.

Strangulation of internal hernias

Internal protrusions are rare and are diagnosed by chance during examination of other internal organs. Pathology occurs due to the weakness of the natural openings of the diaphragm. Manifestations of pathology are as follows:

1. Slight pain on palpation of the affected area.
2. Breathing problems.
3. Displacement of the heart is opposite to the pinched side.
4. The presence of peristaltic noise in the lower chest.

It is difficult to diagnose a pinched hiatal hernia. This type of pathology is often detected when it is significantly complicated, since the signs of the disease are similar to the symptoms of cardiac dysfunction, lung disease, and stomach function.

Symptoms of inguinal hernia strangulation

A strangulated inguinal hernia is often diagnosed when there is a protrusion in the area of ​​the inguinal ring. When elastic pinching occurs, the following signs appear:

• acute pain;
• inability to self-reduce;
• general deterioration of health.

When fecal compression occurs, the patient experiences the following symptoms:

• development of nausea, vomiting;
• lack of stool;
• flatulence.

When a right-sided inguinal hernia is strangulated, a differential diagnosis with acute appendicitis is necessary.

Signs of umbilical hernia compression

Pathology is more common in infants. A hernia in the navel area may not bother the child for a long time, but when pinching develops, the symptoms become more pronounced. These include:

• intense cramping pain at the site of compression;
• malfunction of the gastrointestinal tract;
• nausea, vomiting;
• constipation;
• intestinal obstruction;
• the presence of blood in the stool;
• inability to independently reduce the protrusion.

An increase in body temperature, signs of intoxication, and weakness are often associated.

Manifestations of a pinched femoral hernia

Compression of the hernial contents during femoral protrusion is accompanied by the following symptoms:

• tingling, cramping pain that intensifies with physical activity;
• feeling of pressure in the groin area;
• flatulence, nausea, vomiting;
• swelling and redness of tissue in the area of ​​protrusion;
• constipation, acute intestinal obstruction.

With the development of complications, such as necrosis and peritonitis, there may be a sharp increase in body temperature, general weakness, a sharp drop in blood pressure, confusion, respiratory and cardiac arrest.

Pinched hernia of the white line of the abdomen

With this type of hernia, intestinal obstruction is rare. The main signs of organ compression with such hernias are:

• pain syndrome;
• pallor of the patient;
• general deterioration of health;
• nausea, vomiting;
• fever;
• bloating.

Often the patient experiences a state of shock, which occurs against the background of severe pain, low blood pressure, and rapid heart rate.

Symptoms of compression of postoperative hernias

Postoperative hernias occur in areas of scars formed after surgical treatment. A complication of the disease is compression of the internal organs by the hernial orifice. The clinical picture of strangulated hernias after surgery includes the following symptoms:

• suddenly developing pain;
• increased sweating;
• tachycardia;
• nausea, vomiting;
• swelling and redness of the affected tissues;
• indigestion;
• bloating with inability to pass gas;
• local or general increase in body temperature.

Regardless of the type of compression, if the above symptoms occur, you should immediately seek medical help.

Complications of pathology

With the development of pathology, the risk of complications is quite high. Serious consequences can occur if the patient seeks medical help too late. The most common complications are:

1. Tissue necrosis.
2. Peritonitis.
3. Phlegmon of the hernial sac.

Necrosis

With the elastic type of pathology, necrosis occurs very quickly - tissue death due to disruption of the blood and lymph flow in them. First, the mucous layer of the organ and submucosal tissues are affected, then the process of death spreads to the muscular and serous layers.

Peritonitis

A serious complication that occurs in all types of injuries. With the development of pathology, the patient’s condition sharply worsens, the functioning of all organs and systems is disrupted. Signs of intoxication are observed - weakness, nausea, vomiting, fever, apathy. In many cases, it is not possible to save the patient even in a hospital setting.

Phlegmon

Due to necrosis of the intestine trapped in the hernial orifice, a severe inflammatory process develops, which over time affects all surrounding tissues and spreads to the peritoneal organs. Phlegmon develops in both elastic and fecal pathologies.

Diagnostics

Diagnosing the complication is not difficult. Pinching is easily detected by palpation. During a visual examination of the patient, the doctor pays attention to the following signs:

1. Hardness of the hernial protrusion, painful formation.
2. The hernia does not disappear when the patient’s body position changes.
3. Negative symptom of cough impulse.
4. Peristalsis is not audible.

Among instrumental methods, survey radiography is used, less often ultrasound and computed tomography.

After making a diagnosis, the doctor decides on the urgency of surgical intervention and other necessary manipulations to normalize the patient’s condition.

Features of surgical treatment

Surgical intervention in case of organ strangulation is carried out on an emergency basis and consists of the following:

1. Elimination of strangulation and release of the organ by cutting tissue in the area of ​​the hernial orifice.
2. Examination of the affected organ, making a decision on its excision if necessary.
3. Resection (removal) of tissues that have undergone necrosis.
4. Repositioning the organ into the abdominal cavity.
5. Plastic surgery of hernial orifices.

After the operation, the patient undergoes a rehabilitation period, which consists of taking medications to prevent tissue infection, following a diet (proper nutrition), and wearing a special bandage.

With timely treatment and compliance with preventive measures, the prognosis for recovery is favorable. Relapses of the disease are rare and the patient soon returns to normal activities.

From the point of view of the mechanism of occurrence of this complication of hernias, there are two fundamentally different types of strangulation: elastic and fecal.

Elastic entrapment occurs after the sudden release of a large volume of abdominal viscera through a narrow hernial orifice at the moment of a sharp increase in intra-abdominal pressure under the influence of strong physical stress. The removed organs do not move back into the abdominal cavity on their own. Due to compression (strangulation) in the narrow ring of the hernial orifice, ischemia of the strangulated organs occurs, which leads to severe pain. In turn, it causes persistent spasm of the muscles of the anterior abdominal wall, which aggravates the infringement. Unliquidated elastic strangulation leads to rapid (within several hours, minimum 2 hours) necrosis of the hernial contents.

At fecal impaction compression of the hernial contents occurs as a result of a sharp overflow of the adductor section of the intestinal loop located in the hernial sac. The outlet section of this loop sharply flattens and is compressed in the hernial orifice along with the adjacent mesentery. Thus, a pattern of strangulation eventually develops, similar to that observed with elastic entrapment. However, the development of intestinal necrosis due to fecal strangulation requires a longer period (several days).

An indispensable condition for the occurrence of elastic strangulation is the presence of a narrow hernial orifice, while fecal strangulation often occurs with a wide hernial orifice. In the case of fecal strangulation, physical force plays a lesser role than with elastic strangulation; much more important is the disturbance of intestinal motility and slowing of peristalsis, which is often found in old and senile age. Along with this, with fecal strangulation, kinks and twisting of the intestine located in the hernia and its fusion with the walls of the hernial sac play a significant role. In other words, fecal strangulation usually occurs as a complication of a long-standing irreducible hernia.

Various organs that are hernial contents can be injured. Most often, the small intestine or a section of the greater omentum is strangulated, less often the large intestine. Very rarely, organs located mesoperitoneally are strangulated: the cecum, bladder, uterus and its appendages, etc. The most dangerous is strangulation of the intestine, since it can become necrosis and develop severe strangulation intestinal obstruction, which, along with painful shock, causes progressive intoxication.

Pathogenesis (what happens?) during a strangulated hernia

At the moment of strangulation, a closed cavity is formed in the hernial sac containing an organ or organs in which the blood supply is impaired. At the site of compression of the intestinal loop, omentum and other organs, a so-called strangulation groove, which remains clearly visible even after the infringement is eliminated. It is usually clearly visible both in the area of ​​the adductor and efferent sections of the intestine, and in the corresponding areas of the mesentery.

Initially, as a result of impaired blood supply in the intestine, venous stasis occurs, which soon causes swelling of all layers of the intestinal wall. At the same time, diapedesis of the formed elements of blood and plasma occurs both inside the lumen of the strangulated intestine and into the cavity of the hernial sac. In the closed lumen of the ischemic intestine, the process of decomposition of intestinal contents begins, characterized by the formation of toxins. Strangulated loop of intestine quite quickly, within a few hours (with elastic entrapment), undergoes necrosis,which begins with the mucous membrane, then it affects the submucosal layer, the muscular layer and, lastly, the serous membrane. This must be remembered when assessing its viability.

The fluid that accumulates during strangulation in the closed cavity of the hernial sac (due to trans- and exudation) is called hernial water. At first it is transparent and colorless (serous transudate), but as the formed elements sweat, the hernial water acquires a pink and then red-brown color. The necrotic intestinal wall ceases to serve as a barrier to the passage of microbial flora beyond its boundaries, as a result of which the exudate ultimately becomes purulent in nature with a colibacillary odor. Such purulent inflammation, which developed in the late stages of strangulation, spreading to the tissue surrounding the hernia, received an ingrained, but not entirely accurate name "Phlegmon of the hernial sac."

When strangulated, not only the part of the intestine located in the hernial sac suffers, but also its adductor section, located in the abdominal cavity. As a result of the development of intestinal obstruction, intestinal contents accumulate in this section, which stretches the intestine, and its wall becomes sharply thinner. Then all the disorders characteristic of this pathological condition arise.

Arising as a result of strangulation, strangulation obstruction is known to be one of the most severe types of intestinal obstruction, especially when the small intestine is strangulated. In this case, early repeated vomiting quickly leads to dehydration of the body, loss of vital electrolytes and protein ingredients. In addition, compression of the nerve elements of the mesentery leads to severe pain shock until necrosis of the intestine and the strangulated part of the mesentery occurs. These changes and damage to the adductor intestine are associated with the risk of developing not only phlegmon of the hernial sac, but also purulent peritonitis.

The listed factors determine the high mortality rate that persists in strangulated hernias, which indicates the need not only for early surgical intervention, but also for vigorous corrective postoperative therapy.

As special types of infringement distinguish between retrograde (W-shaped) and parietal (Richter) strangulation, Littre's hernia.

Retrograde entrapment characterized by the fact that in the hernial sac there are at least two intestinal loops in a relatively good condition, and the third loop connecting them, which is located in the abdominal cavity, undergoes the greatest changes. She is in worse conditions of blood supply, since her mesentery is bent several times, entering and exiting the hernial sac. This type of strangulation is observed infrequently, but it is much more severe than usual, since the main pathological process develops not in a closed hernial sac, but in the free abdominal cavity. In this case, there is a significantly greater risk of peritonitis. In case of retrograde strangulation, the surgeon must examine the loop of intestine located in the abdominal cavity during the operation.

Parietal infringement also known in the literature as Richter's hernia. With this type of infringement, the intestine is not compressed to the full extent of its lumen, but only partially, usually in the area opposite its mesenteric edge. In this case, mechanical intestinal obstruction does not occur, but there is a real danger of necrosis of the intestinal wall with all the ensuing consequences. At the same time, diagnosing such infringement is quite difficult, due to the absence of severe pain (the mesentery of the intestine is not infringed). The small intestine is most often affected by parietal strangulation, but cases of parietal strangulation of the stomach and large intestine have been described. This type of strangulation never occurs with large hernias; it is typical for small hernias with narrow hernial orifices (femoral, umbilical hernia, hernia of the white line of the abdomen).

Littre hernia - This is a strangulation of Meckel's diverticulum in an inguinal hernia. This pathology can be equated to a normal parietal strangulation, with the only difference being that due to worse blood supply conditions, the diverticulum undergoes necrosis more quickly than the normal intestinal wall.

Symptoms of a strangulated hernia

If you complain of sudden abdominal pain (especially if they are accompanied by symptoms of intestinal obstruction), it is always necessary to exclude strangulated hernia. That is why, when examining any patient with suspected acute abdomen, the anatomical areas of possible hernia should be examined.

There are four signs of infringement:

1) sharp pain in the hernia area or throughout the abdomen;

2) irreducibility of the hernia;

4) absence of transmission of the cough impulse.

Pain is the main symptom of infringement. It occurs, as a rule, at a moment of strong physical stress and does not subside, even if it stops. The pain is so severe that it becomes difficult for the patient to refrain from moaning and screaming. His behavior is restless, the skin turns pale, and symptoms of real painful shock often develop with tachycardia and a decrease in blood pressure.

Pain most often radiates along the course of the hernial protrusion; when the intestinal mesentery is pinched, irradiation is observed in the center of the abdomen and epigastric region. In the vast majority of cases, the pain remains very severe for several hours until the moment when necrosis of the strangulated organ occurs with the death of intramural nerve elements. Sometimes the pain can become cramping, which is associated with the development of intestinal obstruction.

Irreversible hernia - a sign that can only be significant when a free, previously reducible hernia is strangulated.

Hernia tension and some increase in its size is accompanied by strangulation of both reducible and irreducible hernia. In this regard, this sign is more important for recognizing strangulation than the irreducibility of the hernia itself. Usually the protrusion becomes not only tense, but also sharply painful, which is often noted by patients themselves when they feel the hernia and try to perform a reduction.

Lack of transmission of cough impulse in the area of ​​hernial protrusion - the most important sign of strangulation. It is due to the fact that at the moment of strangulation, the hernial sac is disconnected from the free abdominal cavity and becomes, as it were, an isolated formation. In this regard, the increase in intra-abdominal pressure that occurs at the time of coughing is not transmitted to the cavity of the hernial sac (a negative symptom of a cough impulse). This symptom is difficult to assess in large ventral hernias, which contain a significant part of the abdominal organs. In such situations, when coughing, it is difficult to determine whether the cough impulse is transmitted to the hernia, or whether it shakes along with the entire abdomen. To correctly interpret this symptom in such cases, you do not need to place your palm on the hernial protrusion, but grasp it with both hands. In the case of a positive cough impulse symptom, the surgeon feels an enlargement of the hernia.

Percussion over a strangulated hernia, dullness due to hernial water is usually determined (if the hernial sac contains intestine, then tympanitis is heard in the first hours of strangulation).

Strangulation is often accompanied by a single vomiting, which at first is of a reflex nature. Subsequently, as intestinal obstruction and intestinal gangrene develop, it becomes permanent. The vomit becomes greenish-brown in color with an unpleasant odor. Since intestinal strangulation (excluding Richter's hernia) is complicated by acute intestinal obstruction, it is accompanied by all the characteristic symptoms.

Partial strangulation of the large intestine, for example the cecum in a sliding inguinal hernia, does not cause obstruction, but soon after strangulation, along with pain, a frequent false urge to defecate (tenesmus) appears. Parietal entrapment of the bladder in a sliding hernia is accompanied by dysuric disorders: frequent painful urination, hematuria.

In elderly patients who have suffered from a hernia for many years, in cases of long-term use of a bandage, a certain addiction to painful and other unpleasant sensations in the hernia area develops. In such patients, if infringement is suspected, it is important to identify changes in the nature of the pain syndrome, the moment of onset of intense pain and other unusual symptoms.

Prolonged strangulation, as already mentioned, leads to the development of phlegmon of the hernial sac. Clinically, this is manifested by a systemic inflammatory response syndrome and characteristic local signs: swelling and hyperemia of the skin, severe pain and fluctuation over the hernial protrusion.

Ultimately, long-term strangulation ends, as a rule, with the development of diffuse peritonitis due to the transition of the inflammatory process to the abdominal cavity, or due to perforation of the sharply distended and thinned adductor section of the strangulated intestine.

The picture described above is inherent mainly to elastic infringement. Fecal strangulation has the same patterns of development, but it proceeds less violently. In particular, with fecal strangulation, the pain syndrome is not so pronounced, intoxication phenomena develop more slowly, and necrosis of the strangulated intestine occurs later. However, fecal strangulation is just as dangerous as elastic strangulation, since the final outcome of these two types of strangulation is the same, therefore the treatment tactics for them are the same.

Certain types of strangulated hernias

Strangulated inguinal hernia. Inguinal hernia strangulation occurs in 60% of cases in relation to the total number of strangulations, which corresponds to the highest frequency of inguinal hernia in surgical practice. Indirect inguinal hernias are more often subject to strangulation, since they pass along the entire length of the inguinal canal, while direct hernias pass only through its distal part.

The clinical picture of a strangulated inguinal hernia is quite typical, since all signs of strangulation are easily noticeable. Difficulties occur only when a canal hernia is strangulated in the deep inner ring of the inguinal canal, which can only be identified with a very careful examination. Usually, in this case, in the thickness of the abdominal wall, according to the localization of the lateral inguinal fossa, it is possible to palpate a dense, rather painful small formation, which helps to establish the correct diagnosis.

It is necessary to differentiate strangulated inguinal hernia from inguinal lymphadenitis, acute orchiepididymitis, tumor and hydrocele of the testicle or spermatic cord and strangulated femoral hernia. In the first two cases, there is usually no anamnestic indication of a previous hernia, there is no pronounced pain syndrome and vomiting, and the pain is most often accompanied by an early increase in body temperature. Establishing the correct diagnosis is helped by a routine physical examination, during which it is possible to determine the unchanged outer ring of the inguinal canal, the presence of abrasions, scratches, ulcers of the lower limb or prostatitis, proctitis, phlebitis of the hemorrhoidal node, which are the causes of concomitant lymphadenitis. In cases of epididymitis orchiepididymitis, it is always possible to determine the presence of an enlarged, painful testicle and its epididymis.

Oncological diseases of the testicle and spermatic cord are not accompanied by the sudden appearance of clinical symptoms indicating a strangulated inguinal hernia. A thorough digital examination of the inguinal canal can exclude this pathological condition. The testicular tumor is dense to palpation, often tuberous. Palpation of hydrocele and funiculocele is painless, unlike a strangulated hernia.

In women, it is not always easy to distinguish a strangulated inguinal hernia from a femoral hernia, especially with a small hernial protrusion. Only with a very careful and careful examination can it be established that the femoral hernia comes from under the inguinal ligament, and the external opening of the inguinal canal is free. However, an error in the preoperative diagnosis is not decisive here, since in both cases urgent surgery is indicated. Having found out during the intervention the true localization of the hernial orifice, the appropriate method of repair is chosen.

If difficulties arise in the clinical verification of a uterine round ligament cyst, the patient must undergo emergency surgery, since in such a difficult diagnostic situation a strangulated inguinal hernia can be missed.

In case of strangulation of an inguinal hernia, after dissecting the skin and subcutaneous fat (the projection of the incision is 2 cm above and parallel to the Pupart ligament), the hernial sac is isolated in the bottom area. Its wall is carefully opened. You should not dissect the hernial sac near the site of incarceration, since here it can be fused with the hernial contents.

Thickening of the outer wall of the hernial sac in patients with right-sided strangulation may indicate the presence of a sliding hernia. To avoid injury to the cecum, the thinnest part of the hernial sac on its anteromedial surface should be opened.

If during surgery muscle fibers are found in the inner wall of the hernial sac, bladder entrapment should be suspected. The presence of dysuric symptoms in the patient reinforces this suspicion. In such a situation, it is necessary to open the thin-walled lateral part of the hernial sac to avoid iatrogenic damage to the bladder.

Having opened the hernial sac, the transudate is aspirated and a culture is taken. Fixing the hernial contents with your hand, cut the pinching ring. Usually it is the external opening of the inguinal canal. Therefore, along the fibers, the aponeurosis on the external oblique abdominal muscle is dissected using a grooved probe in the outer direction (Fig. 6.6). If an incarceration is found in the internal opening of the inguinal canal, the incarcerating ring is also dissected lateral to the spermatic cord, remembering that the lower epigastric vessels pass from the medial side.

If necessary, in particular, to perform resection of the small intestine or greater omentum, a herniolaparotomy is performed - the posterior wall of the inguinal canal is dissected and the tendon part of the internal oblique and transverse muscles is crossed. In most patients, this access is sufficient to bring out a sufficient portion of the small intestine and greater omentum for the purpose of inspection and resection.

It is necessary to make an additional midline incision of the abdominal wall in the following situations:

1) there is a pronounced adhesive process in the abdominal cavity, which interferes with the removal of parts of the intestine necessary for resection through the available access in the groin area;

2) it is necessary to resect the terminal ileum with the application of ileotransverse anastomosis;

3) necrosis of the cecum and sigmoid colon was detected;

4) phlegmon of the hernial sac was detected;

5) diffuse peritonitis and/or acute intestinal obstruction are diagnosed.

Having completed the stage of hernia repair, after isolating, ligating and removing the hernial sac, they begin the plastic part of the operation. Regardless of the type of strangulated inguinal hernia (oblique or direct), it is better to perform plastic surgery of the posterior wall of the inguinal canal. This tactical approach to the choice of surgical intervention is pathogenetically correct and justified, since the development of any inguinal hernia is based on the structural failure of the transverse fascia. In emergency surgery, the simplest and most reliable methods of hernial orifice repair should be used. Meets these conditions Bassini method(Fig. 6.7). Under the elevated spermatic cord, the first three sutures fix the edge of the sheath of the rectus abdominis muscle and the connected muscle tendon to the periosteum of the pubic tubercle and Cooper's ligament, which is located on the upper surface of the symphysis. Then the edges of the internal oblique and transverse muscles are sutured, grasping the transverse fascia to the Pupart ligament. Non-absorbable suture material is used. The swabs are placed at a distance of 1 cm from each other. Tissue tension in the plastic area with a high inguinal gap is eliminated by dissecting the anterior wall of the rectus abdominis vagina over several centimeters. The cord is placed over the applied sutures on the newly created posterior wall. Then the dissected sheets of the aponeurosis of the external oblique muscle are sutured edge to edge. At the same time, the external opening of the inguinal canal is formed so that it does not compress the spermatic cord.

In cases of significant “destruction” of the posterior wall of the inguinal canal, the use of a modified Bassini operation is justified - techniquesPostempsky. The internal oblique and transverse muscles are dissected in the lateral side of the deep opening of the inguinal canal in order to move the spermatic cord to the superolateral corner of this incision. Under the elevated spermatic cord on the medial side, the connected tendon of the internal oblique and transverse muscles and the edge of the rectus sheath are sutured to the pubic tubercle and the superior pubic ligament of Cooper. Not only the overhanging edge of the muscles and the transverse fascia, but also the superomedial layer of the aponeurosis are fixed to the inguinal ligament with sutures using Kimbarovsky sutures (Fig. 6.8). The spermatic cord is transferred under the skin into the thickness of the subcutaneous fat, forming a duplicator underneath it from the inferolateral layer of the aponeurosis. With this type of plastic surgery, the inguinal canal is eliminated.

Plastic surgery of the inguinal canal in women is carried out using the same techniques listed above. They strengthen the posterior wall under the round ligament of the uterus or, which is quite justified, by capturing it in sutures. A releasing incision on the anterior wall of the rectus sheath is most often not necessary, because the inguinal space is slightly expressed, the internal oblique and transverse muscles are closely adjacent to the Pupart ligament. The external opening of the inguinal canal is closed tightly.

In cases of strangulation of recurrent hernias and structural “weakness” of natural muscular-fascial-aponeurotic tissues, a synthetic mesh patch is sewn in to strengthen the posterior wall of the inguinal canal.

Strangulated femoral hernia occurs on average in 25% of cases in relation to all strangulated hernias. Differential diagnosis is made between acute femoral lymphadenitis, strangulated inguinal hernia and thrombophlebitis of aneurysmal dilatation of the mouth of the great saphenous vein.

Establishing a diagnosis of acute lymphadenitis is helped by anamnestic data indicating the absence of a hernia and the results of an objective examination. You should pay attention to the presence of abrasions, ulcers and ulcers on the lower extremities, which served as entry points for infection. However, sometimes lymphadenitis is correctly diagnosed only during intervention, when in the area of ​​the subcutaneous ring of the femoral canal (oval fossa) not a hernial protrusion is found, but a sharply enlarged, hyperemic Rosenmuller-Pirogov lymph node. In these cases, the inflamed lymph node should not be excised in order to avoid prolonged lymphorrhea and impaired lymph circulation in the limb. The intervention is completed by partial suturing of the wound.

A routine, thorough physical examination of the patient helps identify a strangulated femoral hernia rather than an inguinal hernia. An error in diagnosis, as noted above, is not fundamental, since the patient is one way or another indicated for emergency surgery. The presence of intestinal obstruction, which develops when the intestine is strangulated, and dysuric disorders caused by bladder strangulation should be taken into account.

The diagnosis of varicothrombophlebitis at the level of the saphenofemoral junction in most cases does not cause significant difficulties. It is necessary to take into account the presence of local signs of a thrombotic process in the underlying saphenous veins (hyperemia, pain and cord-like cord). The contours and dimensions of the palpable infiltrate do not change when the patient is transferred from a vertical to a horizontal position, the cough impulse is negative. For the purpose of accurate topical diagnosis, ultrasound duplex angioscanning with color mapping of blood flow is used.

Surgery for a strangulated femoral hernia is one of the most technically difficult interventions due to the narrowness of surgical access to the neck of the hernial sac and the proximity of important anatomical structures: femoral vessels, inguinal ligament.

Elimination of the infringement is possible almost only in the medial direction due to dissection of the lacunar (gimbernate) ligament. However, here you need to be extremely careful, since in 15% of cases the lacunar ligament is pierced by the large obturator artery, which abnormally arises from the inferior epigastric artery. This anatomical variant in old manuals was called the “crown of death”, since when an artery was accidentally injured, severe bleeding occurred, which was difficult to cope with.

Careful and attentive dissection of the ligament strictly under visual control avoids this extremely unpleasant complication. If, nevertheless, an injury to the anomalous artery occurs, then it is necessary to press the bleeding area with a tampon, cross the inguinal ligament, isolate the inferior epigastric artery and ligate either its main trunk or the obturator artery immediately at its origin. Dissection of the inguinal ligament is also resorted to in cases where it is not possible to eliminate the infringement by cutting the lacunar ligament alone.

Many surgeons, when operating on patients with strangulated femoral hernia, give preference to femoral methods of performing hernia repair and repair. These techniques are characterized by approaching the femoral canal from its external opening. Of the many proposed methods, only one is practically acceptable Bassini method, which is as follows. After excision of the hernial sac, the inguinal ligament is sutured with two or three sutures to the superior pubic (Cooper) ligament, i.e., to the thickened periosteum of the pubic bone. Thus, the internal opening of the femoral canal is closed. The use of more than three sutures is not recommended, as this may lead to compression of the outwardly lying femoral vein.

The main disadvantages of the Bassini method are: the difficulty of isolating the neck of the hernial sac, which leaves a long stump; technical difficulties at the stage of eliminating the femoral canal and, especially, bowel resection. All these negative consequences can be avoided by using the inguinal approach.

We believe it is advisable to use more often Ruji-Par methodLavecchio, primarily in case of prolonged strangulation of the intestine, when the need for its resection is very likely. The incision is made, as for an inguinal hernia, or in the form of a hockey stick, moving to the thigh, which makes it easier to isolate the hernial sac. The latter is opened and the strangulated organ is fixed. The external opening of the femoral canal is dissected on the thigh, the lacunar ligament from the side of the opened inguinal canal. Having immersed the insides in the abdominal cavity, the isolated hernial sac is transferred to the inguinal canal, passing it under the Pupart ligament. The hernial sac is excised after isolation and ligation of the neck. Sutures are placed, moving away from the femoral vein, between the pubic and pupart ligaments. Plastic surgery of the inguinal canal and suturing of the wound are performed. For bowel resection, laparotomy is performed through the inguinal canal.

Strangulated umbilical hernia occurs in surgical practice in 10% of cases in relation to all strangulated hernias.

The clinical picture of strangulation that occurs against the background of a reducible hernia is so characteristic that it is almost difficult to confuse it with another pathology. Meanwhile, it is necessary to take into account that umbilical hernias are most often irreducible, and the presence of an adhesive process in this area can cause pain and the phenomenon of adhesive intestinal obstruction, which is sometimes incorrectly regarded as a strangulated hernia. The only distinguishing diagnostic sign is the presence or absence of transmission of a cough impulse.

With small umbilical hernias, Richter's strangulation is possible, which presents certain difficulties for recognition, since parietal strangulation of the intestine is not accompanied by symptoms of acute intestinal obstruction.

They use surgical access with excision of the navel, because There are always pronounced skin changes around it. Two bordering incisions are made around the hernial protrusion. In this regard, the hernial sac is opened not in the area of ​​the dome-shaped bottom, but somewhat to the side, i.e., in the body area. The aponeurotic ring is dissected in both directions in a horizontal or vertical direction. The latter is preferable, since it allows you to switch to a full-fledged midline laparotomy to perform any required surgical procedure.

For phlegmon of the hernial sac, the Grekov operation is performed (Fig. 6.9). The essence of this method is as follows: the bordering skin incision is continued, somewhat narrowing, through all layers of the abdominal wall, including the peritoneum, and thus the hernia is excised as a single block along with the pinching ring within the healthy tissue. Having entered the abdominal cavity, they cross the strangulated organ proximal to the strangulation and remove the entire hernia without releasing its contents. If the intestine has been strangulated, then an anastomosis is performed between its afferent and efferent sections, preferably “end to end.” If the omentum is strangulated, a ligature is applied to its proximal part, after which the hernia is also removed en bloc.

Of the methods for plastic surgery of the aponeurosis of the anterior abdominal wall, either the Sapezhko method or the Mayo method is used. In both cases, a duplicative aponeurosis is created by applying U-shaped and interrupted sutures.

Strangulated hernia of the white line of the abdomen. Classic strangulation of hernias of the white line of the abdomen is quite rare in surgical practice. Much more often, incarceration of preperitoneal fatty tissue, which protrudes through slit-like defects in the aponeurosis of the white line of the abdomen, is mistaken for a strangulated hernia. However, there are also true strangulations with the presence of a loop of intestine in the hernial sac, most often of the Richter hernia type.

In this regard, during surgical intervention for a suspected strangulation of a hernia of the linea alba, it is necessary to carefully dissect the preperitoneal fatty tissue protruding through the defect of the linea alba. If a hernial sac is detected, it should be opened, the organ located in it should be inspected, and then the hernial sac should be excised. If there is no hernial sac, a stitching ligature is applied to the base of the lipoma and cut off. For plastic closure of the hernial orifice, simple suturing of the aponeurosis defect with separate sutures is usually used. Rarely, in the presence of multiple hernias, plastic surgery of the white line of the abdomen is used according to the Sapezhko method.

Strangulated postoperative ventral hernia is relatively rare. Despite the large hernial orifice, strangulation can occur in one of the many chambers of the hernial sac through the feces or, which is much less common, through the elastic mechanism. Due to the existing extensive adhesions, kinks and deformations of the intestine, acute pain and the phenomenon of adhesive intestinal obstruction often occur in the area of ​​postoperative hernias, which are regarded as the result of a strangulated hernia. Such an error in diagnosis is not of fundamental importance, since in both cases it is necessary to resort to emergency surgery.

Surgery for a strangulated postoperative hernia is usually performed under anesthesia, which allows for a sufficient inspection of the abdominal organs and suturing of the abdominal wall defect.

The skin incision is made bordering, since it is sharply thinned over the hernial protrusion and is directly fused with the hernial sac and the underlying intestinal loops. After opening the hernial sac, the incarcerating ring is dissected, its contents are inspected and viable organs are immersed in the abdominal cavity. Some surgeons do not isolate the hernial sac due to the significant traumatic nature of this manipulation, but suture the hernial orifice inside it with separate sutures. For small defects, the edges of the aponeurosis or muscles are sutured “edge to edge.” For huge ventral hernias, which include most of the contents of the abdominal cavity, especially in the elderly, the hernial orifice is not sutured, but only skin sutures are placed on the surgical wound. Complex methods of plastic surgery, especially with the use of alloplastic materials, are not used so often in such cases, since they greatly increase the risk of surgical intervention in this difficult group of patients.

You can count on the success of alloplasty only by strictly observing the rules of asepsis. The synthetic “mesh,” if possible, is fixed in such a way that the edges of the aponeurosis are sutured over it (the intestine must be “fenced off” from the synthetic material by part of the hernial sac or the greater omentum). If this is not possible, the “patch” is sewn to the outer surface of the aponeurosis. It is mandatory to drain the postoperative wound (with active aspiration for 2-3 days). All patients are prescribed broad-spectrum antibacterial drugs.

In his work, a surgeon may encounter infringement hernia spige Lie (lunar) line. The hernial orifice is localized on the line connecting the navel with the anterior superior axis of the ilium near the outer edge of the rectus abdominis sheath. The hernial sac can be located either subcutaneously or interstitially between the internal oblique muscle and the aponeurosis. Surgical correction of such a hernia is performed through an oblique, pararectal or transverse approach.

Strangulation of lumbar, obturator, sciatic hernias, etc. is extremely rare. The principles of their surgical treatment are set out in special guidelines.

Strangulated internal hernias occupy a modest place in emergency surgery. Compression of organs can occur in the folds and pockets of the peritoneum near the cecum, in the intestinal mesenteries, at the ligament of Treitz, in the lesser omentum, in the area of ​​the broad ligament of the uterus, etc. With a diaphragmatic hernia, the intra-abdominal viscera are pinched in the openings of the diaphragm of congenital or traumatic origin. More often, such a hernia is “false” in nature, since there is no hernial sac.

A strangulated internal hernia may manifest itself as symptoms of acute intestinal obstruction (with abdominal pain, vomiting, stool and gas retention, and other clinical and radiological symptoms). Preoperative diagnosis of parietal entrapment of hollow organs is extremely difficult. Radiologically, a strangulated diaphragmatic hernia is recognized by the presence of part of the stomach or other organ in the chest cavity above the diaphragm.

As a rule, this type of strangulation is discovered during an examination of the abdominal cavity, when operating on a patient for intestinal obstruction. The scope of surgical intervention in this case is determined by the specific anatomical “situation” and the severity of pathological changes in the strangulated organ. Any disruption of the integrity of the diaphragm must be repaired. Small holes are sutured through a transabdominal approach, connecting their edges with interrupted sutures. Extensive defects in the diaphragm are “closed” with various grafts from the side of the pleural cavity.

Postoperative management of the patient

Postoperative period with a strangulated hernia, it requires significantly more attention than with planned hernia repair. This is due to the fact that, on the one hand, patients are admitted in a fairly serious condition, and on the other hand, due to the advanced age of most patients. In this regard, in addition to the usual painkillers and cold applied to the surgical area, patients are prescribed the necessary cardiotropic and other drugs. Adequate detoxification therapy and necessary measures are carried out to combat disturbances in water-electrolyte and acid-base balance. In case of intestinal resection, patients are transferred to total parenteral nutrition for 2-3 days. Antibiotics are prescribed according to indications. It is extremely important to restore intestinal peristaltic activity.

To prevent venous thromboembolic complications, anticoagulants and drugs that improve the rheological properties of blood are used. The patient should get out of bed as early as possible, after putting on a bandage. Active motor mode is necessary already on the day of surgery.

Treatment of developed complications is carried out in accordance with their nature. After operations performed without hernial orifice repair, repeated planned interventions are performed after 3-6 months.

Concluding this chapter, it should be recognized that only timely surgical repair of hernias in a planned manner will reduce the number of emergency interventions. A complicated hernia must be operated on as soon as possible from the moment of strangulation. Adequate surgical tactics and correct technique for performing all stages of the operation help reduce postoperative complications, provide a good functional result and prevent relapse of the disease.

Diagnosis of strangulated hernia

Diagnosis of strangulated hernia in typical cases it is not difficult. It is necessary, first of all, to take into account the medical history, from which it is possible to identify the presence of a hernia in the patient, which was reducible and painless before the onset of pain. It should also be taken into account that the moment of infringement is usually preceded by strong physical stress: lifting weights, running, jumping, defecation, etc.

The physical examination of the patient must be very careful, since the initial picture of strangulation has similar features to some other acute diseases of the abdominal organs. In this regard, in case of abdominal pain, first of all, it is necessary to examine all those “weak” places of the abdominal wall that can serve as a hernial orifice. The urgent need for such an inspection arises because sometimes there are so-called primary strangulated hernias. This concept includes hernias that are strangulated immediately at the time of their initial appearance, without a previous hernia history. Especially often, hernias of rare localizations are subject to primary infringement: the Spigelian (lunate) line, lumbar regions, obturator canal, etc.

Upon examination, the hernial protrusion is usually clearly visible; it does not disappear and does not change shape when the patient’s body position changes. On palpation, the protrusion is sharply tense and painful, especially in the area of ​​the hernial orifice. There is no transmitting cough impulse. Percussion of the protrusion in the early stage of intestinal strangulation can reveal tympanitis, but later, due to the appearance of hernial water, tympanitis is replaced by a dull percussion sound. During auscultation over a strangulated hernia, peristalsis is not heard, but over the abdominal cavity it is often possible to detect increased peristalsis of the adductor section of the strangulated intestine. When examining the abdomen, it is sometimes possible to note a splashing noise, Val's sign and other symptoms of intestinal obstruction. The presence of the latter in the case of a strangulated hernia can also be determined by plain fluoroscopy of the abdominal cavity, in which fluid levels in the intestinal loops with gas accumulation above them (Kloiber cups) are usually clearly visible.

Differential diagnosis when a hernia is strangulated, it is necessary to deal with a number of pathological conditions associated both with the hernial protrusion itself and those not directly related to it. Of course, in typical cases, the diagnosis of strangulation is simple, but sometimes, due to a number of circumstances (primarily strangulated hernia, the presence of concomitant pathology of the abdominal organs, etc.), its recognition presents great difficulties.

First of all, it is necessary to differentiate strangulated hernia from non-reducible. The latter, as a rule, is not tense, is not painful, and transmits the cough impulse well. In addition, completely irreducible hernias are rare; usually, part of the hernia contents can still be reduced. Particular difficulties in differential diagnosis may arise in the case of a multi-chamber hernia, when strangulation occurs in one of the chambers. Nevertheless, in this case, the obligatory signs of infringement are observed: pain, tension and lack of transmission of the cough impulse.

In practical surgery, sometimes it becomes necessary to differentiate strangulated hernia from coprostasis. The latter condition occurs mainly with irreducible hernias in elderly people who have a physiological slowdown in peristalsis and a tendency to constipation. This leads to stagnation of the contents in the intestinal loop located in the hernial sac, but unlike fecal strangulation, with coprostasis there is never compression of the intestinal mesentery. Clinically, coprostasis increases gradually without previous physical stress with the slow development of pain. The pain is never intense, the first place is retention of stool and gases, the tension of the hernial protrusion is not expressed, the cough impulse symptom is positive. Coprostasis does not require surgical treatment; a conventional siphon enema is used to eliminate it. Meanwhile, it is worth keeping in mind that unresolved caprostasis can lead to fecal strangulation of the hernia.

In clinical practice there are situations that are usually designated by the term false infringement. This concept includes a symptom complex that resembles a picture of strangulation, but is caused by some other acute disease of the abdominal organs. This symptom complex causes an erroneous diagnosis of a strangulated hernia, while the true nature of the disease remains hidden. Most often, diagnostic errors occur with strangulation intestinal obstruction, hemorrhagic pancreatic necrosis, peritonitis of various natures, hepatic and renal colic. An incorrect diagnosis leads to incorrect surgical tactics, in particular to hernia repair instead of the necessary wide laparotomy or unnecessary hernia repair for urolithiasis or biliary colic. The only guarantee against such an error is a careful examination of the patient without any omissions. Particular attention should be paid to pain outside the hernia.

The clinician may also encounter a situation where a strangulated hernia, as the true cause of intestinal obstruction, remains unrecognized, and the disease is regarded as a consequence of intestinal strangulation in the abdominal cavity. The main reason for this error is inattentive examination of the patient. It should be remembered that a strangulated hernia does not always look like a clearly visible protrusion on the anterior abdominal wall. In particular, with an initial inguinal hernia, strangulation occurs in the internal ring of the inguinal canal. In this case, external examination, especially in obese patients, does not give any results; Only with careful palpation in the thickness of the abdominal wall, slightly above the inguinal ligament, can a dense, painful formation of a small size be detected. We should also not forget about the possibility of strangulation of rare hernias: obturator canal, Spigelian line, lumbar, perineal, etc., which, when strangulated, most often give a picture of acute intestinal obstruction. Here it is appropriate to recall the statement of the famous French clinician G. Mondor: "When notbowel movement, the hernial orifice should first be examinedand look for a strangulated hernia.”

It is indisputable that if there are any doubts regarding the diagnosis, they should be resolved in favor of a strangulated hernia. Surgeons who have extensive experience in treating hernias formulate this attitude as follows: “In doubtful cases, it is much more correct to lean towards strangulation and urgently operate on the patient. It is less dangerous for a patient to recognize an impairment where there is none than to mistake the impairment for some other disease.

During the prehospital and inpatient stages, the following actions should be performed.

Pre-hospital stage:

1. In case of abdominal pain, a targeted examination of the patient for the presence of a hernia is necessary.

2. If a hernia is strangulated or is suspected of strangulation, even if it is spontaneously reduced, the patient is subject to emergency hospitalization in a surgical hospital.

3. Attempts to forcibly reduce strangulated hernias are dangerous and unacceptable.

4. The use of painkillers, baths, heat or cold for patients with strangulated hernias is contraindicated.

5. The patient is taken to the hospital on a stretcher in a supine position.

Stationary stage:

1. The basis for the diagnosis of a strangulated hernia are:

a) the presence of a tense, painful and self-reducing hernial protrusion with a negative cough impulse;

b) clinical signs of acute intestinal obstruction or peritonitis in a patient with a hernia.

2. Determine: body temperature and skin temperature in the area of ​​the hernial protrusion. If signs of local inflammation are detected, a differential diagnosis is made between phlegmon of the hernial sac and other diseases (inguinal adenophlegmon, acute thrombophlebitis of the aneurysmally dilated mouth of the great saphenous vein).

3. Laboratory tests: general blood test, blood sugar, general urine test and others as indicated.

4. Instrumental studies: chest radiography, ECG, plain radiography of the abdominal cavity, if indicated - ultrasound of the abdominal cavity and hernial protrusion.

5. Consultations with a therapist and anesthesiologist, and, if necessary, with an endocrinologist.

Treatment of strangulated hernia

Surgical tactics clearly indicates the need for immediate surgical treatment of a strangulated hernia, regardless of the type of hernia and the period of strangulation. The only contraindication to surgery is the agonal state of the patient. Any attempt to reduce a hernia at the prehospital stage or in the hospital seems unacceptable due to the danger of moving an organ that has undergone irreversible ischemia into the abdominal cavity.

Of course, there are exceptions to this rule. We are talking about patients who are in an extremely serious condition due to the presence of concomitant diseases, for whom no more than 1 hour has passed since the moment of infringement that occurred in front of a doctor. In such situations, surgery poses a significantly greater risk to the patient than attempting to repair the hernia. Therefore, you can do it carefully. If little time has passed since the moment of strangulation, then reduction of the hernia is also permissible in children, especially young children, since their muscular-aponeurotic formations of the abdominal wall are more elastic than in adults, and destructive changes in the strangulated organs occur much less often.

In a number of cases, patients themselves, who have some experience in repairing their hernia, due to fear of the upcoming operation, make repeated and often quite crude attempts to reduce the strangulated hernia at home. As a result, a condition called so-called imaginary reduction which is one of the extremely severe complications of this disease. Much less often, imaginary reduction is the result of physical influence from a doctor. Let us list the options for “imaginary reduction”:

1. In a multi-chamber hernial sac, it is possible to move the strangulated viscera from one chamber to another, which lies deeper, most often in the preperitoneal tissue.

2. You can separate the entire hernial sac from the surrounding tissues and place it, along with the strangulated viscera, into the abdominal cavity or preperitoneal tissue.

3. There are known cases of the neck being torn off both from the body of the hernial sac and from the parietal peritoneum. In this case, the restrained organs are “reduced” into the abdominal cavity or preperitoneal tissue.

4. The consequence of rough reduction may be rupture of the strangulated intestine.

Typical clinical symptoms of a strangulated hernia after “imaginary” reduction are no longer detectable. Meanwhile, the presence of sharp pain when examining the location of the hernia and abdomen, combined with anamnestic information about attempts at forced reduction, allows us to establish the correct diagnosis and subject the patient to emergency surgery.

In doubtful cases (irreducible hernia, multilocular incisional hernia), the issue should be resolved in favor of emergency surgery.

In case of false strangulation syndrome caused by another acute surgical disease of the abdominal organs in patients with a hernia, the necessary operation is performed, and then hernioplasty, if there are no signs of peritonitis.

Let us especially focus on surgical tactics in the case of spontaneous reduction of a strangulated hernia. If it occurred before hospitalization: at home, in an ambulance on the way to the hospital, or in the emergency room, then the patient should nevertheless be hospitalized in the surgical department.

The existing irrefutable fact of strangulation with a disease duration of more than 2 hours, especially in cases of acute intestinal obstruction, serves as an indication for emergency surgery (performed by midline laparotomy) or diagnostic laparoscopy. The injured organ must be found and its viability assessed.

In all other cases of spontaneous reduction: 1) the period of infringement is less than 2 hours; 2) if there is doubt about the authenticity of the infringement that has taken place, dynamic monitoring of the patient’s condition is necessary. In those situations where the condition of the abdominal cavity in the next 24 hours after strangulation does not cause alarm: there is no pain or signs of intoxication, the patient can be left in the hospital and, after the necessary examination, undergo a planned hernia repair.

If during observation the patient’s body temperature rises, pain in the abdomen persists and symptoms of peritoneal irritation appear, an emergency midline laparotomy is performed and the organ that has been strangulated and necrosed is resected. Spontaneous reduction of the hernia can occur on the way to the operating room, during induction of anesthesia or the start of local anesthesia . Despite this, the operation begins. After opening the hernial sac (if necessary, a herniolaparotomy is performed), nearby organs are examined. Having discovered an organ that has been pinched, it is removed into the wound and its viability is assessed. If it is difficult to find the strangulated organ, they resort to laparoscopy through the mouth of the opened hernial sac. Then the operation is continued and completed according to the generally accepted rules for a strangulated hernia.

Preoperative preparation Before surgery for a strangulated hernia, the procedure is most often minimal: the patient is asked to urinate or the urine is removed using a catheter, the area of ​​the surgical field is shaved and it is hygienically prepared. If necessary, empty the stomach using a tube.

Patients with long periods of impairment, with symptoms of severe intoxication and with severe concomitant diseases are subject to hospitalization in an intensive care unit for appropriate correction of disturbed homeostasis indicators for 1.5-2 hours (or it is carried out on the operating table), after which surgery is performed. The issue of the need for special preparation of the patient for surgery is decided jointly by the senior surgeon and anesthesiologist. Particular attention should be paid to elderly and senile patients with serious pathology of the cardiovascular system. Regardless of the nature of the preparation, the operation must be performed as quickly as possible (no later than the first 2 hours after hospitalization), since with each subsequent hour the danger of intestinal necrosis increases. Delaying the operation due to expanding the scope of examination of the patient is unacceptable.

Anesthesia. Many surgeons prefer local anesthesia. It is believed that it does not lead to unwanted hernia reduction. Meanwhile, experience shows that this danger is clearly exaggerated. For any location of a strangulated hernia, preference should undoubtedly be given to epidural (spinal) anesthesia or intubation endotracheal anesthesia.

The latter is urgently necessary in cases of expanding the scope of surgical intervention due to intestinal obstruction or peritonitis.

Features of surgical intervention. Emergency surgery for a strangulated hernia has a number of fundamental differences from planned hernia repair. It should be remembered that the surgeon’s primary task in this case is to expose and fix the strangulated organ as quickly as possible in order to prevent it from slipping into the abdominal cavity during subsequent manipulations in the area of ​​the hernial orifice and elimination of the strangulation. The incision is made directly above the hernial protrusion in accordance with the location of the hernia. The skin and subcutaneous fatty tissue are dissected and, without completely isolating the hernial sac, its bottom is dissected. Usually, yellowish or dark brown hernial water pours out. In this regard, before opening the hernial sac, it is necessary to isolate the wound with gauze pads. Immediately after opening the hernial sac, the assistant takes the strangulated organ (most often a loop of the small intestine) and holds it in the wound. After this, you can continue the operation and cut the pinching ring, that is, the hernial orifice (Fig. 6.3). They do this in the safest direction in relation to surrounding organs and tissues. The strangulated organ can be freed in two ways: dissection of the aponeurosis begins either directly from the side of the hernial orifice, or goes in the opposite direction from the unchanged aponeurosis to the scar tissue of the strangulated ring. In both cases, in order to avoid damage to the underlying organ, the aponeurosis must be dissected by placing a grooved probe under it.

Let us remind you once again about the possibility of retrograde infringement. Due to this, if there are two or more loops of intestine in the hernial sac, thenit is necessary to remove and inspect the intermediate loop, which is located in the abdominal cavity.

Having freed the strangulated intestine, its viability is assessed according to the following criteria:

1) normal pink color of the intestinal wall;

2) the presence of peristalsis;

3) determination of pulsation of mesenteric vessels involved in strangulation.

If all these signs are present, then the intestine can be considered viable and immersed in the abdominal cavity. In doubtful cases, 100-150 ml of a 0.25% novocaine solution is injected into the intestinal mesentery and the pinched area is warmed for 10-15 minutes with napkins moistened with a warm isotonic sodium chloride solution. If, after this, at least one of the above signs is absent and doubts remain about the viability of the intestine, then this serves as an indication for its resection within healthy tissue, which in most cases is performed through a herniolaparotomy access.

In addition to the strangulated loop, 30-40 cm of the adductor part of the intestine (above the strangulation) and 15-20 cm of the efferent part of the intestine (below it) must be removed. The longer the infringement, the more extensive the resection should be. This is due to the fact that with intestinal strangulation, which is essentially one of the types of strangulation obstruction, the adductor section, which is located above the obstacle, suffers to a much greater extent than the abducent section. In this regard, the imposition of an intestinal anastomosis near the strangulation groove is associated with the risk of its failure and the development of peritonitis.

Resection of the strangulated small intestine is carried out according to general surgical rules; first, the mesentery is dissected step by step and ligatures are applied to its vessels, and then the mobilized part of the intestine is excised. It is preferable to perform anastomosis between the afferent and efferent sections “end to end”. If there is a sharp discrepancy between the diameters of the afferent and efferent sections of the intestine, they resort to a side-to-side anastomosis.

If the distal border during resection of the ileum is located less than 10-15 cm from the cecum, ileoascendo- or ileotransverse anastomosis should be applied.

In some cases, the strangulated intestine itself appears to be quite viable, but has pronounced strangulation grooves, in place of which local necrosis can develop. In such a situation, they resort to circular immersion of the strangulation groove with interrupted seromuscular silk sutures, with mandatory control of intestinal patency. If there are deep changes in the area of ​​the strangulation groove, the intestine should be resected.

It must be remembered that in a strangulated loop of intestine, the mucous membrane and submucosal layer are primarily affected, which are not visible from the serous membrane, and the damage to which can be judged only by indirect signs. The literature describes cases of ulceration of the mucous membrane and perforation of ulcers of the small intestine that have been strangulated. Cicatricial stenosis of the small intestine after strangulation, its adhesion to surrounding organs, which subsequently led to intestinal obstruction, have also been described.

The situation is much simpler with necrosis of the strangulated omentum. In this case, its necrotic part is removed, and the proximal part is reduced into the abdominal cavity. If the fat suspension is pinched, the nutrition of the corresponding part of the intestine may be disrupted. Therefore, when resecting it, it is necessary to carefully examine the adjacent intestinal wall and assess its viability.

The surgeon's tactics in cases of infringement of other organs (fallopian tube, appendix, etc.) are determined by the severity of morphological changes in these anatomical formations. For example, when operating on a patient with necrosis of the sigmoid colon, it is necessary to significantly expand the scope of surgical intervention and perform the Hartmann procedure from an additional midline laparotomy approach.

Having immersed a viable or resected organ that has been strangulated into the abdominal cavity, the hernial sac is completely isolated from the surrounding tissue, bandaged at the neck and excised. Excision of the hernial sac is not used for large hernias, in elderly people, those with concomitant diseases and in children. In these cases, the hernial sac at the neck is only bandaged and crossed, and its inner surface is lubricated with alcohol in order to cause adhesion of the peritoneal layers.

Subsequently, depending on the type of hernia, they begin plastic surgery of hernial orifices. From this point on, the operation is not fundamentally different from planned hernia repair, with the exception that in case of a strangulated hernia it is necessary to use the simplest, least traumatic methods of hernioplasty, which do not significantly complicate or burden the surgical intervention. To date, tension-free methods of hernioplasty using various allografts have been developed. In emergency surgical practice, they are rarely used, usually in patients with strangulated hernias who have large hernial orifices (recurrent inguinal, umbilical, postoperative, etc.).

Primary plastic surgery of the abdominal wall cannot be performed in case of phlegmon of the hernial sac and peritonitis (due to the severity of the patients’ condition and the danger of purulent complications), large ventral hernias that have existed in patients for many years (the development of severe respiratory failure is possible). In these cases, after suturing the peritoneum, the surgical wound should only be partially sutured and sutures placed on the skin.

The volume and sequence of surgical intervention for a strangulated hernia, which led to the development of acute intestinal obstruction, are determined by the characteristics and severity of the clinical situation.

Separately, we should dwell on the principles of surgical intervention for special types of strangulated hernia. Having discovered an infringement sliding hernia, the surgeon must be especially careful when assessing the viability of the strangulated organ in that part that does not have a serous cover. Most often, the cecum and bladder “slip” and are pinched. In case of necrosis of the intestinal wall, a median laparotomy and resection of the right half of the colon are performed with ileotransverse anastomosis. After this stage of the operation is completed, plastic closure of the hernial orifice begins. In the case of necrosis of the bladder wall, the operation is no less difficult, since it has to be resection with the imposition of an epicystostomy.

With a restrained Littre's hernia Meckel's diverticulum should be excised in any case, regardless of whether its viability is restored or not. The need to remove a diverticulum is caused by the fact that this rudiment, as a rule, lacks its own mesentery, comes from the free edge of the small intestine and has a poor blood supply. In this regard, even short-term infringement is associated with the danger of necrosis. To remove a diverticulum, either a ligature-purse string method, similar to an appendectomy, is used, or a wedge-shaped resection of the intestine, including the base of the diverticulum, is performed.

In case phlegmon of the hernial sac The operation is carried out in 2 stages. First, a median laparotomy is performed under general anesthesia. With this complication, the strangulated organ is so firmly welded to the hernial orifice that there is practically no danger of it slipping into the abdominal cavity. At the same time, the presence of purulent inflammation in the hernia area creates a real danger of infection of the abdominal cavity if the operation is started in the usual way by opening the hernial sac.

Having performed a laparotomy, they approach the strangulated organ from the inside. If the intestine is strangulated, then it is mobilized within the limits indicated above. The ends of the strangulated part of the intestine to be removed are also cut off, leaving small stumps that are sutured tightly. An anastomosis is performed between the afferent and efferent sections of the viable intestine with a single-row intranodular suture. The question of how to complete the colon resection is decided individually. As a rule, obstructive resection is performed with a colostomy.

After the formation of the interintestinal anastomosis, a purse-string suture is placed on the peritoneum around the strangulated ring (the intestinal stumps are first immersed under the peritoneum), thereby delimiting the abscess from the abdominal cavity. Then the laparotomy wound is sutured and proceed to the 2nd stage of the intervention directly in the area of ​​the hernial protrusion. The skin and subcutaneous fatty tissue are dissected, the bottom of the hernial sac is opened, and then the hernial orifice is incised just enough so that the strangulated organ can be removed and removed, including the blind ends of the intestine left outside the peritoneum. After this, the necrotic intestine is removed, the abscess cavity is drained and plugged. In these cases, there can be no talk of any plastic surgery of the hernial orifice.

Naturally, refusal to repair the hernia orifice leads to recurrence of the hernia, but it is always necessary to remember that the primary task of the surgeon is to preserve the life of the patient, and surgery for a recurrent hernia can then be performed as planned. The specified surgical tactics are used in almost all cases of phlegmon of the hernial sac, with the exception of purulent inflammation of a strangulated umbilical hernia, in which a circular through method of hernia repair, proposed by I.I., is used. Grekov. The essence of this method is outlined below in the section on umbilical hernias.

In patients who are in an extremely serious condition, which does not allow a wide laparotomy to be performed, it is permissible to resort to the so-called exteriorization of the strangulated organ. In these cases, the hernial sac and the strangulating hernial orifice are dissected under local anesthesia, after which the strangulated necrotic intestine is removed and fixed outside the hernial sac. It is also permissible to excise the necrotic part of the intestine and fix the ends of the intestine around the wound according to the type of double-barreled stoma.

25.04.2019

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The pathology is not rare, however, it can be life-threatening. A strangulated hernia often leads to deterioration in the functionality of internal organs. Naturally, there may be other serious complications.

The pathological condition is compression of the hernial sac at the hernia gate. In this case, blood circulation in the tissues is disrupted, and necrosis begins in those parts of the organs that form it. That is, strong tension in the abdominal wall expands the hernial orifice and provokes organ prolapse. After this, the muscles contract and the entire contents are clamped.

A strangulated hernia requires immediate surgical intervention, as it is an acute surgical condition. It is considered no less dangerous than appendicitis. Any abdominal hernia can be strangulated. The main danger of this pathology is that the patient develops intestinal obstruction, as well as acute peritonitis.

The infringement is always sudden:

1. The patient experiences sharp, severe pain that persists after relaxing the abdominal muscles.
2. The hernia cannot be set back; it is tense.
3. The patient's condition rapidly deteriorates: arrhythmia appears and blood pressure decreases.

The first symptoms of tissue necrosis may appear after 7 hours. If you do not consult a doctor in advance, the patient may die. However, timely surgical intervention allows you to quickly eliminate the problem with minimal harm to the body.

Primary and secondary infringement

Primary strangulation of a hernia is quite rare. It appears as a result of very strong physical simultaneous stress, if a person is predisposed to the appearance of such a protrusion. That is, as a result of such effort, a person simultaneously develops a hernia and is strangulated.

Diagnosing a strangulated hernia is quite difficult. This can only be done by an experienced doctor who does not forget about the possibility of its occurrence. This is the danger of this insidious disease. The patient is simply not able to understand what is happening to him, and may miss precious time. As a result, peritonitis begins, tissue death of internal organs, as well as severe intoxication.

Secondary strangulation of the hernia is detected much faster, since it develops against the background of an existing protrusion. That is, the patient can already explain the situation to the emergency doctor.

Types of pathological conditions

There is the following classification of types of hernia strangulation:

1. According to the location of the protrusion:

• external: inguinal, umbilical, femoral, and also more rare - hernia of the lumbar triangle and Spigelian line;
• internal: supradiaphragmatic, subdiaphragmatic, intraperitoneal, epigastric, pelvic floor hernia.

1. According to which organ suffers from infringement:

• oil seal;
• bladder;
• cecum and colon;
• small intestine;
• in rare cases, the lower esophagus, spermatic canal, uterus, and stomach fall out.

1. By the nature of the infringement:

• antegrade, in which only one loop of the intestine or other internal organ is compressed;
• retrograde, in which 2 loops fall out, while the connecting one remains inside and is pinched the most;
• wall;

1. According to the degree of organ damage:

• incomplete;
• complete.

1. According to the mechanism of infringement:

• fecal;
• elastic.

The fecal mechanism is characterized by the fact that the adductor loop of the intestine, captured by the hernial sac, is suddenly filled with feces. The condition develops only if the patient has irreducible hernias for a long time. The hernial orifice in this case is quite wide.

The elastic mechanism is characteristic of the sharp simultaneous entry of large hernial contents into the gate. At the same time, the internal organs cannot straighten themselves. The hernial orifice in this case is narrow.

In order to determine what type of hernia strangulation is present in the patient, the doctor must listen and analyze the patient’s complaints.

Reasons for development

Naturally, the presented pathology does not appear on its own. Pinching can occur in almost any person who has this protrusion. To do this, it is enough to perform some action that provokes tension in the abdominal muscles.

There are certain reasons that lead to strangulated hernia:

• abruptly lifting an object that is too heavy with a jerk;
• pushing off the ground during a high jump;
• indomitable severe cough;
• tension in the abdominal muscles due to constipation;
• prostate adenoma;
• weakness of the abdominal muscle corset;
• intestinal atony, characteristic of older people

In addition, there are other factors that can provoke a strangulated hernia: periodic difficult childbirth, too rapid weight loss, abdominal wall injury, too much physical activity.

Symptoms of pathology

The most important sign of a strangulated hernia is sharp, severe pain and its intensity, which may vary depending on its location, compression force and type. In this case, the pain syndrome can be felt only in the area of ​​protrusion or spread throughout the entire abdominal cavity.

Unpleasant sensations often radiate to the thigh, groin and other parts of the abdomen. The patient's discomfort does not go away, even if he lies and does not move. Over time, the pain becomes severe until necrosis reaches the nerves.

If a patient has a strangulated hernia, the symptoms are as follows:

1. Very frequent, erratic heartbeat (pulse reaches 120 beats per minute).
2. Rapid drop in blood pressure.
3. Paleness of the skin.
4. The low intensity of symptoms may indicate that a strangulated hernia appeared due to the accumulation of feces.
5. Intestinal obstruction, which is characterized by uncontrollable constant vomiting with a gradually increasing odor of feces.
6. If the pinching is parietal, then the patient will not show signs of intestinal obstruction.
7. The protrusion greatly increases in size and also becomes tense.
8. Absence of the “cough impulse” symptom.
9. Increased anxiety and restless behavior appears.

With a strangulated hernia, the symptoms appear very clearly, so diagnosing the pathology is not so difficult.

Diagnostic features

Diagnosis of a strangulated hernia involves an external examination of the affected area. The doctor pays attention to the presence of a protrusion, which is painful and tense. Moreover, when changing position it does not disappear.

In addition, the doctor checks the cough impulse, which is absent when pinched. Peristalsis over the hernia cannot be heard. Often the symmetry of the abdomen is broken. You may also need an x-ray of the abdominal cavity - it makes it possible to diagnose intestinal obstruction.

For differential diagnosis, ultrasound examination of the internal organs of the peritoneum is performed.

Features of treatment

Strangulated hernias must be treated only with surgery. Moreover, it must be urgent and carried out “for health reasons.” That is, having felt the first sign of an obvious strangulation of the hernia, the patient urgently needs to call an ambulance. Before she arrives, the patient needs to lie down with a small pillow under the pelvis.

If the pain is too strong, then you can apply an ice compress to the affected area. You can't do anything else, not even take painkillers. In addition, it is prohibited:

• take a bath, especially a hot one;
• use warm compresses that activate blood circulation and only worsen the process;
• drink antispasmodics;
• independently engage in reduction of the protrusion.

The fact is that such actions can cause rupture of blood vessels with the appearance of hemorrhage into the hernial sac. The hernia membrane may also burst, in which case dead tissue will enter the abdominal cavity.

This pathology can only be cured through surgery. However, before doing so, the surgeon must know whether the patient has a serious cardiac condition or has had a recent heart attack.

You have to prepare for surgery very quickly, since necrosis does not wait. During the procedure, the doctor is obliged not only to detect the pinched part and fix it, but also to release the pinched tissues from the hernial sac, assess their condition, and then remove the body of the hernia and dead parts of the organs.

What types of operations exist

So, surgical intervention is necessarily performed using local, spinal anesthesia or general anesthesia. There are these types of operations:

1. Traditional. It is done like this: the skin is cut over the hernia, and then the wall of the hernial sac is dissected. At this stage, the surgeon must quickly assess the condition of the protrusion. Next, the clamped organ needs to be fixed, and the hernial orifice must be cut. If the tissues are not damaged and are in satisfactory condition, then they can be inserted back into the abdominal cavity. If an organ is damaged, these areas must be removed. To perform hernial orifice repair, either your own tissue or a special mesh is used.
2. Laparoscopy. This is a minimally invasive operation that does not require a long recovery period. However, this procedure requires general anesthesia. Laparoscopy is used if: the protrusion is small in size, the patient has no concomitant pathologies, no more than 3 hours have passed since tissue clamping, and there is no general intoxication of the body or peritonitis. Laparoscopy should not be used if the patient is pregnant, severely obese, or if there are symptoms of intestinal obstruction.

The second method of performing the operation has some advantages:

• the patient does not develop postoperative scars;
• the risk of complications is reduced;
• the surrounding tissues are practically not injured.

Laparoscopy is performed as follows: first, small punctures are made in the area of ​​the protrusion, through which special miniature instruments equipped with a video camera are inserted. The entire progress of the operation is shown on monitors. For plastic surgery of the hernia gate, a special stapler is used.

Prognosis and prevention

It has long been known that strangulated hernias are quite dangerous to human health and life. For example, as a result of the development of such a pathological condition, 10% of patients who have reached old age may die. Statistics show this.

If a person seeks medical help too late, this greatly complicates treatment. And attempts to relieve pain and repair the hernia on your own will lead to a worsening of the patient’s condition and difficulty in diagnosis.

The most dangerous complication of the disease is considered to be the necrosis of a compressed intestinal loop, which leads to its obstruction. In this case, peritonitis may begin and you will have to undergo a more serious operation, the recovery period after which is long and difficult.

As for the prevention of pathology, it provides:

1. Timely treatment of abdominal hernias.
2. Avoiding all activities that can cause severe tension in the abdominal muscles.

The treatment of this pathology is carried out by a gastroenterologist and surgeon. Timely surgery not only saves the patient’s life, but also preserves health. Within a few days after the operation, the patient can get up and try to walk. The rehabilitation process does not take much time, but it is necessary to restore normal functionality of the body.

Strangulated hernia- this is a sudden compression of the contents of the hernia in the hernial orifice or in the neck of the hernial sac, leading to disruption of the blood supply and necrosis of the strangulated organ. Both external (in various crevices and defects in the walls of the abdomen and pelvic floor) and internal (in the pockets of the abdominal cavity and openings of the diaphragm) hernias can be strangulated. According to statistics, strangulation occurs in 8-10% of patients with hernias of any age group, somewhat more often in middle-aged people who engage in heavy physical labor.

A sharp increase in intra-abdominal pressure, narrow hernial orifices, inflammatory processes and cicatricial changes in the area of ​​the neck of the hernial sac contribute to the occurrence of strangulation.

A distinction is made between true and false strangulation (Broca's hernia). With true strangulation, compression of the hernia contents occurs in the hernial orifice (20-40% of cases) or in the neck of the hernial sac (66-80%) with impaired circulation of the strangulated organ and the appearance of severe ischemic pain. In case of false strangulation, pain in the hernia occurs due to the entry of affected abdominal organs into the hernial sac during acute surgical diseases or infected effusion (with a perforated ulcer of the stomach and duodenum, acute appendicitis, acute cholecystitis, acute pancreatitis, etc.) without compression of the contents of the hernia in its neck and, therefore, without the presence of a strangulation groove, which is the main diagnostic sign for differentiating a false strangulation from a true one.

Classification of strangulated hernias

1. According to the mechanism of infringement:

• elastic;
• fecal

2. By localization:

• external abdominal hernias: inguinal, femoral, umbilical, linea alba, postoperative, rare (lunate line, xiphoid process, perineal, obturator, sciatic, lumbar, etc.);
• internal abdominal hernias: diaphragmatic, omental or mesenteric defect, abdominal pouches.

3. For the injured organ:

• large oil seal;
• organs of the gastrointestinal tract (stomach, small intestine, colon, appendix, Meckel's diverticulum);
• uterus and its appendages;
• bladder.

4. Clinical types of infringement:

• antegrade;
• retrograde, or W-shaped infringement (Maidl);
• mixed;
• parietal (Richter's) strangulation - Richter's hernia;
• strangulation of Meckel's diverticulum (Littre's hernia);
• false impingement (Broca's impingement).

5. Complications of infringement:

• acute intestinal obstruction;
• peritonitis;
• fecal phlegmon of the hernial sac.

Elastic entrapment occurs in patients with a narrow hernial orifice after a large volume of abdominal organs enters the hernial sac at the time of a sudden increase in intra-abdominal pressure (Fig. 2.7a).

Fig 2.7a - Elastic entrapment:
1 - outlet loop;
2 - adducting loop;
3 - strangulated loop (hernial contents);
4 - pinching ring;
5 - hernial sac;

Elastic strangulation is based on impaired blood circulation in the strangulated organ (strangulation), which leads to severe pain. The pain causes persistent spasm of the muscles of the anterior abdominal wall, which aggravates the infringement. Unliquidated elastic strangulation leads to rapid (within several, at least 2 hours) necrosis of the hernial contents.

At fecal impaction intestines, compression of the hernial contents occurs as a result of a sharp overflow of the intestinal contents of the adductor section of the intestinal loop located in the hernial sac (Fig. 2.7b).

Fig 2.7b Fecal strangulation of hernia

The abducent section of such a loop is compressed in the hernial orifice along with the adjacent mesentery, as a result of which strangulation develops, similar to elastic strangulation. However, a longer period is required for the development of intestinal necrosis due to fecal strangulation. For the development of fecal impaction, the fact of physical tension is less important than for elastic; much more important is the slowdown of peristalsis, the kinking of the intestine in the hernial sac with an irreducible hernia.

At the moment of strangulation, a closed cavity is formed in the hernial sac containing an organ or organs whose blood supply is impaired. At the site of compression of the intestine, omentum or other organs, a strangulation groove is formed, which is clearly visible even after the compression is eliminated. Venous stasis occurs, the permeability of the vein walls is disrupted, which causes swelling of the intestinal wall. At the same time, plasma sweating and diapedesis of blood cells occurs both into the cavity of the hernial sac and into the lumen of the strangulated intestine or imbibition of the omentum. The fluid that accumulates in the hernial sac (due to transudation and exudation) is called hernial water.

At first it is transparent and colorless (serous transudate); As blood cells enter and are destroyed, the hernial water acquires a pink and then brown color. The consequence of microcirculatory disorders in the intestinal wall is the translocation of microflora beyond its boundaries, as a result of which the hernial water becomes infected and becomes purulent in nature with an unpleasant odor. Such purulent inflammation, spreading to the tissue surrounding the hernia, has received the established name “phlegmon of the hernial sac.”

In the strangulated part of the intestine, three segments are distinguished: the afferent loop, the central segment and the efferent loop. The most pronounced morphological changes occur in the central segment of the intestine, somewhat less in the afferent loop, and even less in the efferent loop.

With increasing edema, compression of the intestine and its mesentery increases, which causes disruption of arterial circulation with the development of arterial stasis in the strangulated loop of intestine, and its necrosis develops. Morphological changes in the intestinal wall begin with the mucous layer, where the vessels are located that provide trophism to the intestinal wall and transport oxygen. In the future, perforation of the intestine may occur with the development of phlegmon of the hernia. In the initial stages of strangulation, infection of the hernia contents is limited to the hernial sac. With the development of necrosis of the afferent loop, the abdominal cavity becomes infected with the development of peritonitis.

In the afferent loop of the intestine, due to increased peristalsis and muscle spasm, as well as the accumulation of large amounts of contents and gases, blood circulation is also disrupted and morphological changes develop in its wall. The segment of the adductor loop, which is located next to the hernial orifice, suffers the most. Necrotic changes also begin from the mucous membrane and spread to all layers of the intestinal wall, including the serosa. This must be taken into account when intraoperatively assessing the viability of the strangulated segment of the intestine and determining the boundaries of its resection. If it is necessary to perform intestinal resection, it is necessary to remove at least 50 cm of the afferent loop (Kocher's rule) (Fig. 2.8).

In the outflow loop, changes are limited to minor swelling and venous stagnation without the formation of blood clots and significant circulatory impairment. These changes occur in a small section of the intestine, next to the hernial orifice. Taking this into account, when resection of a necrotic segment of the intestine, it is enough to remove 15-20 cm of the efferent loop.

Experimental studies have proven that with a complete cessation of blood circulation, irreversible morphological changes in the intestinal wall occur after 3.5-4 hours. That is why, in the case of a strangulated hernia, the sooner surgical intervention is performed, the lower the risk of intestinal necrosis and the better the immediate and long-term results of treatment will be.

Clinical picture of strangulated hernia

Classic clinical signs of a strangulated hernia are:

• sudden severe pain in the area of ​​the hernial protrusion or in the abdominal cavity;
• irreducibility of a previously reducible hernia;
• rapid increase and tension of the hernial protrusion;
• inability to determine the hernial orifice;
• negative symptom of “cough impulse”;
• the appearance and increase of dyspeptic disorders (nausea, vomiting, heartburn) and the clinic of acute strangulating mechanical intestinal obstruction (with strangulation of a loop of intestine).

The clinical picture of strangulation largely depends on the period of time that elapsed from the moment of strangulation to the examination of the patient. When a loop of intestine is strangulated, a clinical picture of acute strangulation intestinal obstruction develops. If the contents of the hernial sac are strangulated small intestine, the clinical picture of acute intestinal obstruction develops quickly; When the colon is strangulated, the symptoms of intestinal obstruction usually develop gradually and are of increasing nature. The patient's condition becomes serious in the first minutes. The patient's behavior is restless, the tongue is dry, the skin is pale, the pulse is soft, tachycardia. Subsequently, the patient's condition progressively worsens. If there is a delay in the operation, intestinal necrosis, perforation, fecal phlegmon of the hernia, widespread peritonitis may occur, which determine the clinical manifestations of the disease. The described clinical picture is inherent in elastic entrapment.

Fecal strangulation has the same patterns of development, but it proceeds less violently, the pain syndrome is not so acute, intoxication develops more slowly, and necrosis of the strangulated intestine occurs later. However, fecal strangulation is just as dangerous as elastic strangulation, since, ultimately, the degree of morphological changes in the intestinal wall with these types of strangulation is the same, which is why the treatment tactics for them are identical.

Isolated strangulation of the omentum is manifested by local pain and the absence of acute intestinal obstruction, which is characteristic of intestinal strangulation.

Clinical types of strangulated hernia

Retrograde entrapment (W-shaped, Maidl) occurs when two or more loops of intestine enter the hernial sac. In this case, the loop located in the abdominal cavity undergoes the most pronounced morphological changes, which necessitates a thorough assessment of its condition during the operation. The diagnosis of retrograde strangulation can only be made during surgery, although this type of strangulation can be suspected based on clinical manifestations. The patient's condition is usually more severe than with antegrade strangulation, since the destructive process in the strangulated intestine develops in the free abdominal cavity, and not in a delimited space (in the hernial sac) (Fig. 2.9).

Parietal strangulation occurs with initial hernias. In this case, not the entire intestine is infringed, but only its wall, opposite to the mesenteric edge (Fig. 2.10).

Surgeons call this type of strangulation “insidious”, since due to the preservation of the intestinal lumen there is no clear, classic clinical picture of a strangulated hernia, which often leads to diagnostic errors. Partial infringement of the wall of the colon with a sliding inguinal hernia, in the absence of clinical signs of intestinal obstruction, is manifested by pain and frequent false urge to defecate (tenesmus). Parietal entrapment of the bladder in a sliding hernia is accompanied by frequent painful urination and hematuria; sometimes, on the contrary, there may be urinary retention. The main feature of parietal strangulation is the complete absence of symptoms of acute intestinal obstruction.

Diagnosis of strangulated hernia

Diagnosing a strangulated hernia in most patients is not difficult. The presence of the above classical signs of infringement allows us to make the correct diagnosis.

Depending on the severity of destructive changes in the strangulated organ and the presence of complications in the general blood test, leukocytosis, a shift in the leukocyte formula to the left, may be noted. At the same time, the absence of these signs in a number of patients for several hours immediately after strangulation does not exclude the presence of this complication, especially in case of fecal strangulation.

Of the additional examination methods, the most informative are ultrasound, x-ray examination of the abdominal organs (panoramic fluoroscopy and graphy) and others. Ultrasound reveals a fixed loop of intestine or a strand of omentum in the hernial sac against the background of hernial water; the intestinal wall and its lumen become visible with the presence of liquid and gas. The omental strand is defined as an additional formation of increased echogenicity with uneven contours and the absence of gas. The state of blood supply to the strangulated organ can be determined using Dopplerography. An ultrasound can distinguish a strangulated hernia from inflammatory or malignant tumors of the abdominal wall, thrombosis of the venous node at the mouth of the great saphenous vein, which often imitates a strangulated femoral hernia.

The main radiological sign of strangulation of the small intestine is the accumulation of gas and fluid in the intestinal loop located in the hernia and in the afferent loops; Kloiber's bowls appear after 2-4 hours and at a later date.

Differential diagnosis of strangulated hernia

Differential diagnosis of strangulated hernias must be carried out with diseases that are localized at the site of the hernia and have an acute onset.

A strangulated inguinal hernia should be differentiated from orchitis, epididymitis, lymphadenitis, a femoral hernia should be differentiated from lymphadenitis of the femoral lymph nodes, tuberculous leaks, thrombophlebitis of the great saphenous vein of the thigh at its junction with the deep vein; umbilical - with omphalitis, tumor metastases in the navel. In all of these diseases, there is no history of a hernia or classic signs of strangulation.

A strangulated hernia must also be differentiated from inflammation of the hernia and coprostasis, in which the pain is moderate; the hernia can be partially reduced and the hernial orifice can be palpated; the symptom of a “cough impulse” is positive.

In cases where it is impossible to establish a diagnosis, after assessing subjective and objective signs and the results of special examination methods, it is necessary to lean toward the diagnosis of strangulation and urgently operate the patient, since expectant management can lead to intestinal necrosis or perforation with the development of peritonitis.

The diagnosis of strangulated and irreducible hernia often causes certain difficulties. However, pain with an irreducible hernia is constant, less intense than with strangulation; the hernia is not tense and decreases in size when trying to reduce it into the abdominal cavity. In this case, it is possible to identify the hernial orifice, its edges, and the positive symptom of a “cough impulse.” Characteristic is the absence of a clinical picture of acute intestinal obstruction.

Treatment of strangulated hernias

The instruction of A.P. Krymov (1929): “It is necessary to remember that it is better for the patient, if he is given the right medical care, to accept the infringement where it is not, rather than to overlook it where it is,” remains undeniable today.

When determining treatment tactics for strangulated hernias, it is necessary to remember that
There are no contraindications to surgery for a strangulated hernia in any patient, because the older the patient, the faster circulatory disorders occur in the strangulated organ and the more decisively the surgeon must act. The only contraindication to surgery is the pre- or agonal state of the patient (death in such cases, even without surgical intervention, occurs within 1-4 hours from the moment of hospitalization in the surgical hospital).

A patient with a spontaneously reduced strangulated hernia (at home or during transportation to a medical institution) should be hospitalized in the surgical department, since a previously reduced strangulated organ and hernial water can be a source of peritonitis or intraintestinal bleeding. The surgeon’s tactics should be clear: hospitalization of the patient for dynamic observation.

In case of spontaneous reduction of a strangulated hernia in a patient in a surgical hospital, in the absence of absolute contraindications to the operation (extremely high degree of surgical risk), surgical intervention is also indicated, especially for patients of older age groups, in whom necrosis of the wall of the strangulated intestine can occur within 2 days. 3 hours from the moment of infringement (the most pronounced changes occur in the area of ​​the strangulation groove). In such cases, there is a real threat of developing peritonitis, which significantly worsens the immediate results of surgical interventions performed at a later date (high rates of postoperative complications, mortality).

If, during examination of a patient at the time of admission to the surgical department or during dynamic observation, peritonitis or intraintestinal bleeding is diagnosed, the patient is urgently subjected to surgical intervention. If peritonitis is suspected, diagnostic laparoscopy (where possible) or laparocentesis with insertion of a “groping catheter” is indicated. When forcibly reducing a hernia by the patient himself, the doctor’s tactics should be the same. Forcible reduction of a hernia by doctors is unacceptable and prohibited, since this can cause damage to the hernial sac and hernia contents, including rupture of the strangulated intestinal loop with the development of peritonitis and intra-abdominal bleeding. With forced reduction, the hernial sac with its contents can be displaced into the preperitoneal space (“imaginary” or “false” reduction), which quickly leads to the development of intestinal obstruction and retroperitonitis (Fig. 2.11).

If the course of the disease is favorable after self-reduction of the hernia, the patient should be offered a planned operation after additional examination.

For small postoperative hernias in patients without severe general disorders, surgical intervention is performed without intensive preoperative preparation. Conversely, in the presence of large strangulated hernias in elderly and senile patients with severe concomitant pathology, intensive preoperative preparation is indicated.

Preparing for surgery should be short-term (up to 1-2 hours) and aimed primarily at improving the general condition of the patient and correcting metabolic, hemodynamic and other vital disorders. In subcompensated and decompensated states of the body, correction of disturbances in homeostasis and the functional state of vital organs and systems is carried out with the participation of an anesthesiologist and related specialists (in the intensive care unit or directly in the operating room). The short duration of preoperative preparation in such cases is due to the rapidly increasing development of necrotic changes in the strangulated organ. Based on this situation, it is advisable to perform an operation in combination with simultaneous intensive corrective therapy. Delaying the operation by expanding the scope of the patient's examination is unacceptable.

Anesthesia: endotracheal anesthesia, sometimes local anesthesia.

Operation with a strangulated hernia, it has its own characteristics, which consist in the strict sequence of its stages. After incision of the skin, the hernial sac is immediately opened and its contents are sanitized, which allows one to prevent, as a rule, infected hernial water from entering the abdominal cavity and to avoid self-reduction of the strangulated organ, which must be carefully examined to determine its viability. Only after this is the pinched ring cut (after preliminary capture and retention of the pinched organ).

In case of strangulated inguinal hernias (usually the strangulation occurs in the outer ring of the inguinal canal, extremely rarely in the inner ring), the strangulating ring is dissected to the lateral side of the spermatic cord. If the strangulation has occurred in the internal (deep) opening of the inguinal canal, then, by introducing and moving deep into the Kocher probe between the strangulating ring and the neck of the hernial sac in the region of the superolateral area (avascular zone), carefully dissect the strangulating ring upward with a scalpel or scissors, remove the strangulated loop of intestine and examine her.

When a femoral hernia is strangulated (with a femoral approach), the strangulating ring is cut inward - through the lacunar ligament. However, you should be extremely careful, since in 15% of cases the lacunar ligament is pierced by the obturator artery, which abnormally arises from the inferior epigastric artery. This anatomical variant is called the “crown of death”, since when an artery is accidentally injured, severe bleeding occurs, which is difficult to cope with. Careful and attentive dissection of the ligament strictly under visual control allows you to avoid this extremely unpleasant and life-threatening complication for the patient. If an injury to the artery does occur, then it is necessary to press the bleeding area with a tampon, grasp the bleeding vessel with clamps and bandage both ends. If the bleeding cannot be stopped in this way, it is necessary to cross the inguinal ligament, isolate the inferior epigastric artery and ligate either its main trunk or the obturator artery immediately at its origin. Dissection of the inguinal ligament is also used in cases where it is not possible to eliminate the infringement by cutting only the lacunar ligament. If an anomalous vessel (“crown of death”) is detected, it should be sutured, ligated and crossed between two ligatures.

With inguinal access for a strangulated femoral hernia, it is much easier to detect and ligate an abnormally located vessel. With this method, there is another method of cutting the pinching ring - in the upper-outer direction above the vessels without cutting the inguinal ligament.

In case of strangulated umbilical hernias, dissection of the strangulating ring can be performed both longitudinally and transversely, after which it is necessary to assess the condition of the strangulated organ held by the fingers before dissection.

A segment of a strangulated loop of intestine is limited by a strangulation groove, which may be barely noticeable or necrotically changed. The viable intestine has a bluish-red color, which, after eliminating the infringement, gradually changes to pink; its serous membrane is smooth, shiny, without damage; intestinal peristalsis and pulsation of the direct vessels of the mesentery are preserved. The nonviable intestine is dark bluish in color with dirty green patches, the serous membrane is dull, desquamated in places, there is no peristalsis and pulsation of the mesenteric vessels. When determining the viability of intestinal loops, it is important to know and remember that intestinal necrosis begins from the mucous membrane. From the side of the serous membrane, these phenomena appear much later. The viable intestine is reduced into the abdominal cavity, and its nonviable segment is resected taking into account Kocher's rule. The further stages of the operation are performed as standard, as with an uncomplicated hernia. Doubts about the viability of the intestine serve as an indication for resection of its strangulated segment as non-viable. The same tactics should be used in cases of parietal (Richter) strangulation of the intestine and in case of doubts about the viability of this area. With this type of incarceration, the altered area should not be immersed into the intestinal lumen, as this creates a mechanical obstacle and contributes to the occurrence of insufficiency of the immersion sutures.

If a sliding hernia is strangulated, the viability of a part of the sliding organ should be carefully determined. If necrosis of the intestinal wall is detected, resection of the ileocecal angle or the right half of the colon is performed with the imposition of an ileotransversoanastomosis. In case of necrosis of the bladder wall, the necrotic part is resected and an epicystostomy is applied. The strangulated areas of the omentum are resected in all cases. The vermiform appendix located in the hernial sac is also removed. If Meckel's diverticulum is strangulated (Littre's hernia), it is removed regardless of whether it is viable or not (Fig. 2.12).

This tactic is due to the fact that Meckel’s diverticulum, without its own mesentery, has a poor blood supply, which is why even short-term infringement carries the risk of necrosis. When a fatty deposit is strangulated, the nutrition of the corresponding section of the intestine may be disrupted, which is why during its resection it is necessary to carefully examine the adjacent sections of the intestinal wall and assess their viability.

In case of false Brocca's incarceration, it is necessary to conduct a complete intraoperative examination of the abdominal organs to identify an acute inflammatory process that led to false incarceration.

In case of hernia phlegmon, surgical intervention begins with laparotomy, followed by resection of the strangulated intestine, restoration of the patency of the intestinal tract due to the formation of an intestinal anastomosis, drainage of the abdominal cavity and suturing of the laparotomy wound. After opening the hernial sac, the previously resected intestine is removed (Fig. 2.13).

1 - lower median laparotomy and intra-abdominal stage;
2 - opening of the hernial sac and removal of the resected organ

Hernial orifice plastic surgery is not performed. Naturally, refusal to repair the hernial orifice leads to recurrence of the hernia. However, it is always necessary to remember that the primary task of the surgeon in such cases is to preserve the life of the patient, and surgery for a recurrent hernia can be performed subsequently as planned.

For a strangulated hernia complicated by peritonitis, the operation is performed in the following stages: laparotomy, resection of a segment of non-viable intestine to areas with normal vascularization and unchanged mucosa, restoration of the integrity of the intestinal tube, nasogastric intubation of the small intestine, sanitation of the abdominal cavity. In case of widespread fibrinous, fibrinous-purulent peritonitis, laparostomy with subsequent planned (staged) sanitation is indicated. Primary plastic surgery of the abdominal wall in case of peritonitis, as well as in case of phlegmon of the hernial sac, should not be performed due to the severity of the patient’s condition and the risk of developing purulent complications. In these cases, after suturing the peritoneum, the surgical wound should only be partially sutured with the application of rare sutures to the skin, which allows for staged planned sanitation of the abdominal cavity.

Laparoscopic hernioplasty, as a method of surgical treatment of strangulated hernias, is increasingly being introduced into everyday practice and gives good immediate and long-term results. A positive aspect of laparoscopy for a strangulated hernia is the possibility of revision of all abdominal organs, which eliminates the risk of undetected retrograde or false strangulation.

Complications that may arise during surgery for a strangulated hernia:

• damage to strangulated organs (bladder, intestines);
• injury to blood vessels during dissection of the hernial orifice (femoral, obturator artery and vein - “crown of death”).

The most common postoperative complications are:

• suppuration of a postoperative wound;
• pulmonary embolism.

Prevention of complications. To prevent wound suppuration, it is necessary to carry out thorough hemostasis and repeated sanitation of the wound, treat tissues with care during surgery, and use antibiotics in the postoperative period.

Prevention of thromboembolic complications involves early activation of the patient, performing breathing exercises, and prescribing direct and indirect anticoagulants.

Literature: Surgery: / [M.P. Zakharash, N.D. Kucher, A.I. Poyda, etc.] ed. M.P. Zakharash. - Vinnitsa: Nova Kniga, 2014. -688 p. pp. 55-64 - (Zakharash M.P., Zaverny L.G., Stelmakh A.I.).

– compression of the hernial sac in the hernial orifice, causing disruption of the blood supply and necrosis of the organs forming the hernial contents. A strangulated hernia is characterized by sharp pain, tension and soreness of the hernial protrusion, and irreducibility of the defect. Diagnosis of a strangulated hernia is based on anamnesis, physical examination, and plain radiography of the abdominal cavity. During hernia repair for a strangulated hernia, resection of necrotic intestine is often required.

General information

Strangulated hernia is the most common and serious complication of abdominal hernias. Strangulated hernias are an acute surgical condition requiring emergency intervention, and are second in incidence only to acute appendicitis, acute cholecystitis and acute pancreatitis. In operative gastroenterology, strangulated hernia is diagnosed in 3-15% of cases.

A strangulated hernia is associated with sudden compression of the contents of the hernial sac (omentum, small intestine, etc.) in the hernial orifice (defects of the anterior abdominal wall, openings of the diaphragm, abdominal pockets, etc.). Any abdominal hernia can be strangulated: inguinal (60%), femoral (25%), umbilical (10%), less often - hernia of the white line of the abdomen, hiatus, postoperative hernia. A strangulated hernia is associated with the risk of developing necrosis of compressed organs, intestinal obstruction, and peritonitis.

Types of strangulated hernia

Depending on the organ compressed in the hernial orifice, hernias with strangulation of the intestines, omentum, stomach, bladder, uterus and its appendages are distinguished. The degree of overlap of the lumen of a hollow organ when a hernia is strangulated can be incomplete (parietal) or complete. In some cases, for example, with strangulation of Meckel's diverticulum or the appendix, blockage of the organ lumen is not observed at all. According to the developmental features, antegrade, retrograde, false (imaginary), sudden (in the absence of a hernia history) strangulated hernia are distinguished.

There are two mechanisms of hernia strangulation: elastic and fecal. Elastic strangulation develops when a large volume of hernial contents emerges simultaneously through a narrow hernial orifice. The internal organs enclosed in the hernial sac cannot move into the abdominal cavity on their own. Their strangulation by a narrow ring of the hernial orifice leads to the development of ischemia, severe pain, persistent muscle spasm of the hernial orifice, which further aggravates the strangulation of the hernia.

Fecal strangulation develops when the afferent loop of intestine, trapped in the hernial sac, suddenly overflows with intestinal contents. In this case, the efferent section of the intestine is flattened and pinched in the hernial orifice along with the mesentery. Fecal strangulation often develops with long-standing irreducible hernias.

A strangulated hernia can be primary or secondary. Primary strangulation is less common and occurs against the background of a one-time extreme effort, as a result of which the simultaneous formation of a previously non-existent hernia and its compression occur. Secondary strangulation occurs against the background of a previously existing abdominal wall hernia.

Causes of strangulated hernia

The main mechanism of strangulation of a hernia is a sharp simultaneous or periodically repeated increase in intra-abdominal pressure, which can be associated with excessive physical effort, constipation, cough (with bronchitis, pneumonia), difficulty urinating (with prostate adenoma), difficult childbirth, crying, etc. Development and Incarceration of a hernia is facilitated by weakness of the muscles of the abdominal wall, intestinal atony in older people, traumatic injuries to the abdomen, surgical interventions, and weight loss.

After normalization of intra-abdominal pressure, the hernial orifice decreases in size and infringes on the hernial sac that extends beyond its limits. Moreover, the likelihood of developing strangulation does not depend on the diameter of the hernial orifice and the size of the hernia.

Symptoms of a strangulated hernia

A strangulated hernia is characterized by the following symptoms: sharp local or diffuse pain in the abdomen, inability to reduce the hernia, tension and pain in the hernial protrusion, and the absence of the “cough impulse” symptom.

The main signal of a strangulated hernia is pain that develops at the height of physical effort or tension and does not subside with rest. The pain is so intense that the patient often cannot stop groaning; his behavior becomes restless. The objective status shows pallor of the skin and symptoms of painful shock - tachycardia and hypotension.

Depending on the type of strangulated hernia, pain can radiate to the epigastric region, center of the abdomen, groin, and thigh. When intestinal obstruction occurs, the pain becomes spastic. The pain syndrome, as a rule, is expressed for several hours, until necrosis of the strangulated organ develops and death of the nerve elements occurs. With fecal impaction, pain and intoxication are less pronounced, and intestinal necrosis develops more slowly.

When a hernia is strangulated, one-time vomiting may occur, which initially has a reflex mechanism. With the development of intestinal obstruction, vomiting becomes constant and acquires a fecal character. In situations of partial strangulation of the hernia, obstruction, as a rule, does not occur. In this case, in addition to pain, tenesmus, gas retention, and dysuric disorders (frequent painful urination, hematuria) may be bothersome.

Long-term strangulation of a hernia can lead to the formation of phlegmon of the hernial sac, which is recognized by characteristic local symptoms: swelling and hyperemia of the skin, pain in the hernial protrusion and fluctuations over it. This condition is accompanied by general symptoms - high fever, increased intoxication. The outcome of an unresolved hernia strangulation is diffuse peritonitis, caused by the transfer of inflammation to the peritoneum or perforation of a distended section of the strangulated intestine.

Diagnosis of strangulated hernia

If you have a hernia history and a typical clinical picture, diagnosing a strangulated hernia is not difficult. During a physical examination of the patient, attention is paid to the presence of a tense, painful hernial protrusion that does not disappear when changing body position. A pathognomonic sign of strangulated hernia is the absence of a transmitting cough impulse, which is associated with complete delimitation of the hernial sac from the abdominal cavity by a strangulating ring. Peristalsis over the strangulated hernia is not heard; Sometimes there are symptoms of intestinal obstruction (Val's sign, splashing noise, etc.). Abdominal asymmetry and positive peritoneal symptoms are often observed.

In the presence of intestinal obstruction, plain radiography of the abdominal cavity reveals Kloiber's cups. For the purpose of differential diagnosis, an ultrasound of the abdominal organs is performed. Incarceration of femoral and inguinal hernia should be distinguished from local tissue or synthetic prostheses).

The most crucial moment of the operation is to assess the viability of the strangulated intestinal loop. The criteria for the viability of the intestine are the restoration of its tone and physiological color after release from the strangulating ring, the smoothness and shine of the serous membrane, the absence of a strangulation groove, the presence of pulsation of the mesenteric vessels, and the preservation of peristalsis. If all these signs are present, the intestine is considered viable and is immersed in the abdominal cavity.

Otherwise, if a hernia is strangulated, a resection of a section of the intestine with an end-to-end anastomosis is required. If it is impossible to perform resection of the necrotic intestine, an intestinal fistula (enterostomy, colostomy) is performed. Primary abdominal wall repair is contraindicated in case of peritonitis and phlegmon of the hernial sac.

Prognosis and prevention of strangulated hernia

Mortality due to strangulated hernia among elderly patients reaches 10%. Late seeking medical help and attempts to self-treat a strangulated hernia lead to diagnostic and tactical errors and significantly worsen treatment results. Complications of operations for a strangulated hernia may include necrosis of a modified intestinal loop with an incorrect assessment of its viability, failure of the intestinal anastomosis, and peritonitis.

Prevention of strangulation consists of routine treatment of any identified abdominal hernias, as well as the exclusion of circumstances conducive to the development of a hernia.