Intestinal strangulation. Types of strangulated abdominal hernias and their manifestations

• Question 1: Hernias. Definition of the concept, etiology, pathogenesis. Elements of abdominal hernias. Anatomical features of sliding hernias. Prevention of hernias.
• Question 2: Classification, general symptomatology of free abdominal hernias. Diagnostics. Indications and contraindications for surgery. Treatment results. Causes of relapses.
• Question 3: Irreversible hernia. Reasons. Clinic, diagnosis, treatment. Preparing patients for surgery. Management of the postoperative period. Prevention.
• Question 4: Postoperative hernia. Causes of occurrence. Clinic. Diagnostics. Prevention. Methods of operations. Postoperative hernias form in the area of ​​the postoperative scar.
• Symptoms
• Treatment of postoperative hernia
• Question 5: Strangulated hernia. Clinic. Diagnostics, differential diagnosis. False infringement. Features of operational technology.
• Question 7: Surgeon’s tactics in case of a doubtful diagnosis of a strangulated hernia, with spontaneous reduction. Complications of forced reduction.
• Question 8: Inguinal hernias. Anatomy. Direct and oblique inguinal hernia. Congenital inguinal hernia. Diagnosis and differential diagnosis. Prevention. Methods of operations.
• Question 9: Femoral hernias. Anatomy of the femoral canal. Clinic. Diagnostics. Differential diagnosis. Prevention. Methods of operations.
• Question 10: Umbilical hernias and hernias of the white line of the abdomen. Anatomical data. Clinic and diagnosis of umbilical hernias in childhood.
• Question 11: Strangulated hernia. Types of strangulation (fecal, elastic, retrograde, parietal), pathological changes in the strangulated organ and general changes in the body with strangulated hernia.
• Question 12: Anatomical and physiological information about the cecum and appendix. The influence of variants of the location of the appendix on the clinical picture of the disease.
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• 42. Intestinal obstruction. Classification. Methods of examining patients.
• 43. Intestinal obstruction. Clinic. Diagnostics. Differential diagnosis.
• 44. Mechanical intestinal obstruction. Classification. Clinic. Diagnostics. Treatment.
• 45. Mechanical intestinal obstruction. Features of water-electrolyte balance and acid-base status, depending on the level and type of intestinal obstruction.
• 50. Strangulation intestinal obstruction (volvulus, nodulation, strangulation). Features of pathogenesis. Clinic. Diagnostics. Differential diagnosis. Treatment. Indications for intestinal resection.
• Types by localization
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• A strangulated hernia is understood as sudden or gradual compression of any abdominal organ in the hernial orifice, leading to disruption of its blood supply and, ultimately, to necrosis. 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.

  Elastic entrapment occurs when there is a sudden increase in intra-abdominal pressure during physical activity, coughing, or straining. In this case, overstretching of the hernial orifice occurs, as a result of which more internal organs come out into the hernial sac than usual. The return of the hernial orifice to its previous state leads to strangulation of the contents of the hernia. With elastic strangulation, compression of the organs that have entered the hernial sac occurs from the outside.

  Fecal impaction more often observed in older people. Due to the accumulation of a large amount of intestinal contents in the afferent loop of the intestine located in the hernial sac, compression of the efferent loop of this intestine occurs, the pressure of the hernial orifice on the contents of the hernia increases and elastic is added to the fecal strangulation. This is how a mixed form of infringement arises.

  Retrograde entrapment. More often, the small intestine is strangulated retrogradely when two intestinal loops are located in the hernial sac, and the intermediate (connecting) loop is located in the abdominal cavity. The connecting intestinal loop is affected to a greater extent. Necrosis begins earlier in the intestinal loop located in the abdomen above the strangulating ring. At this time, the intestinal loops located in the hernial sac may still be viable.

  Parietal infringement occurs in a narrow pinching ring, when only the part of the intestinal wall opposite the line of attachment of the mesentery is pinched; observed more often in femoral and inguinal hernias, less often in umbilical hernias. Disorder of lymph and blood circulation in the strangulated area of ​​the intestine leads to the development of destructive changes, necrosis and perforation of the intestine.

  Pathological picture. In the strangulated organ, blood and lymph circulation are disrupted; due to venous stasis, fluid transudates into the intestinal wall, its lumen and the cavity of the hernial sac (hernial water). The intestine becomes cyanotic in color, the hernial water remains clear. Necrotic changes in the intestinal wall begin with the mucous membrane. The greatest damage occurs in the area of ​​the strangulation groove at the site of compression of the intestine by the pinching ring.

  Over time, pathomorphological changes progress, and gangrene of the strangulated intestine occurs. The intestine becomes blue-black in color, and multiple subserous hemorrhages appear. The intestine is flabby, does not peristalt, and the mesenteric vessels do not pulsate. Hernial water becomes cloudy, hemorrhagic with a fecal odor. The intestinal wall may undergo perforation with the development of fecal phlegmon and peritonitis. Intestinal strangulation in the hernial sac is a typical example of strangulation intestinal obstruction.

  Intestinal strangulation is accompanied by significant changes in its afferent loop, in which a lot of intestinal contents accumulate. It stretches the intestine, compresses the intrawall vessels, disrupting blood and lymph circulation, which causes damage to the mucous membrane. At the same time, disruption of blood and lymph circulation occurs in the efferent part of the strangulated intestine. Toxins accumulated as a result of decomposition are absorbed into the blood, causing intoxication of the body. Reflex vomiting that occurs during strangulation contributes to the rapid development of water and microelements deficiency. The progression of intestinal necrosis, phlegmon and hernial sac leads to purulent peritonitis.

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 to the center of the abdomen and epigastric region is observed. 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 take on a cramping nature, 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. Later, 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 stretched 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 cut the hernial sac near the site of infringement, 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. This is usually 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 detected 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 (lunate) 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 hernia of the diaphragm 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 notintestinal patency, 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 with extensive experience in the treatment of 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 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 extracted 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 described 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, under local anesthesia, the hernial sac and the strangulating hernial orifice are dissected, 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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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 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 accidentally 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 discovered 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.

Often accompanied by increased body temperature, signs of intoxication, and weakness.

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. There are signs of intoxication - 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 the 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.

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Strangulated hernia. This is a hernia in which an organ is strangulated in the hernial sac. A strangulated hernia is usually the result of sudden compression of the hernial contents either at the gate of the hernial sac, or among adhesions in the hernial sac, or at the entrance to a natural or acquired pocket in the abdominal cavity. Intestinal loops, the omentum, the walls of the hernial sac, hernial membranes, and sometimes only the free edge of the intestinal loop in the form of “parietal” or “Richterian” strangulation are affected.

Approximately the same is the infringement of the sedentary parts of the circulatory system, in particular the blind, with a normal and with a “sliding” hernia. Sometimes only the mesentery is infringed. Then circulatory disorders develop over a long distance in the intestinal loop, located in the abdominal cavity and invisible in the sac (retrograde strangulation). A strangulated hernia is characterized by sudden severe pain at the site of the hernial protrusion and an increase in the volume of the hernia. Strangulation is the most common and dangerous complication of a hernia. With this complication of a hernia as a result of strangulation of a loop of intestine, a picture of strangulation NK develops.

With Richter (parietal) strangulation of the intestinal loop, there are only local symptoms - pain or irreducibility of the hernia; there are no signs of NK, but in the later stages the strangulated hernia can become elastic if intestinal loops or another organ are suddenly introduced into the hernial sac through a narrow internal opening; fecal, when the intestinal loops located in the hernial sac are gradually filled with abundant fecal contents.

With elastic entrapment, there is compression of an organ by a contracted hole, which, during its sudden initial expansion, let through a section of the viscera that does not correspond to its size. With fecal strangulation, the afferent part of the intestinal loop stretches and, increasing in size, can compress the efferent end of the intestine in the hernial orifice. When new portions of contents enter the afferent limb of the intestine, it stretches even more and begins to compress not only the afferent end of the intestine, but also the feeding vessels. In this way, strangulation can occur even in a wide hernial orifice.

There are also direct strangulation of the intestinal loop in the hernial sac; retrograde strangulation, when two loops are in the hernial sac, and the third (middle loop), located in the abdominal cavity, is strangulated. Combined infringement also occurs. A significant danger is posed by parietal incarceration of the intestinal loop - Richter's hernia(Figure 1).

When strangulated, the organs released into the hernial sac are subjected to compression. More often it occurs at the level of the neck of the hernial sac in the hernial orifice. Infringement of organs in the hernial sac is possible in one of the chambers of the sac itself, in the presence of scar cords compressing the organs, when the organs are fused with each other and with the hernial sac.

Figure 1. Parietal strangulation (Richter's hernia)

The latter often occurs with irreducible hernias. Infringement of a hernia more often occurs in elderly and senile people.

Femoral hernias are strangulated 5 times more often than inguinal and umbilical hernias. More often, small hernias with a narrow and scarred neck of the hernial sac are strangulated. With reducible hernias, this occurs relatively rarely. Strangulation does not occur when a hernia occurs. Incarceration occurs in inguinal hernias (43.5%), postoperative hernias (19.2%), umbilical hernias (16.9%), femoral hernias (1b%), hernias of the white line of the abdomen (4.4%) (M. I. Kuzin, 19871. The TC and greater omentum are infringed, but any organ can be infringed (bladder, ovary, choroid, Meckel’s diverticulum).

Elastic entrapment occurs suddenly, at the moment of a sharp increase in intra-abdominal pressure, during physical activity, coughing, straining and in other situations. In this case, more intra-abdominal organs enter the hernial sac than usual. This occurs as a result of overstretching of the hernial orifice. Returning the hernial orifice to its previous position leads to strangulation of the contents of the hernia (Figure 2). With elastic strangulation, compression of the organs that have entered the hernial sac occurs from the outside.

Figure 2. Types of intestinal strangulation:
a - elastic infringement; b - fecal impaction; c — retrograde infringement of the TC

Pathological anatomy. Most often, the intestinal loop is strangulated. In a strangulated loop of intestine, there are three sections that undergo uneven changes: the central section, the adductor knee and the abductor knee. The greatest changes occur in the strangulation groove, the loop lying in the hernial sac, and in the adductor knee; in the abductor knee they are less pronounced.

The main violations occur in the CO. This is due to the fact that the vessels supplying the intestinal wall pass through the submucosal layer. In the serous layer, pathological changes manifest themselves to a lesser extent and usually occur later. In the adductor knee, pathological changes in the intestinal wall and CO are observed over a distance of 25-30 cm, in the abducent limb - at a distance of about 15 cm. This circumstance must be taken into account when determining the level of resection of the afferent loop. A strangulated hernia is essentially one of the types of acute strangulation NK.

With severe and prolonged strangulation and complete cessation of blood circulation in the arteries and veins, irreversible pathomorphological changes occur in the strangulated organ. When the intestine is strangulated, venous stasis occurs, resulting in transudation into the intestinal wall, into its lumen and into the cavity of the hernial sac (hernial water). With rapid compression of the veins and arteries of the mesentery of the intestine located in the hernial sac by a pinching ring, dry gangrene can develop without the accumulation of hernial water.

At the beginning of strangulation, the intestine is cyanotic, the hernial water is clear. Pathomorphological changes in the intestinal wall gradually progress over time. The strangulated intestine becomes blue-black, the serosa becomes dull, and multiple hemorrhages occur. The intestine becomes flabby, there is no peristalsis, the mesenteric vessels do not pulsate. Hernial water becomes cloudy, with a hemorrhagic tint, and a fecal odor is noted. Emerging necrotic changes in the intestinal wall can be complicated by perforation with the development of fecal phlegmon and peritonitis.

As a result of NK, intraintestinal pressure increases, the intestinal walls are stretched, the intestinal lumen is filled with intestinal contents, which further aggravates the already impaired blood circulation. As a result of CO damage, the intestinal wall becomes permeable to microbes. Penetration of microbes into the free abdominal cavity leads to the development of peritonitis.

Intestinal strangulation like Richter's hernia is dangerous because at first there is no NK, and therefore the clinical picture develops more slowly, according to a different plan. Because of this, the diagnosis is made more difficult and later, which is fraught with catastrophic consequences for patients.
Retrograde strangulation of the hernia also poses a certain danger (Figure 3).

A strangulated hernia can be complicated by phlegmon of the hernial sac, and after reduction - by intestinal bleeding, and in the later stages - by the development of scarring intestinal strictures.

Figure 3. Retrograde entrapment

Clinic and diagnostics. The clinical symptoms of a strangulated hernia depend on the form of strangulation, the strangulated organ, and the time that has passed since the strangulation. The main clinical signs of strangulation are sudden pain at the site of a sharply tense and painful hernial protrusion, a rapid increase in the size of the hernial protrusion, and the irreducibility of a hernia that was previously freely reduced. Pain varies in intensity. Sharp pain can cause collapse and shock.

When a loop of intestine is strangulated, a picture of strangulation NK develops, and often diffuse peritonitis, especially in cases where a necrotic loop of intestine moves away from the strangulated ring.

The clinical picture has its own characteristics when the bladder, ovary, omentum and other organs are strangulated.

When examining the patient, a sharply painful hernial protrusion of dense elastic consistency is discovered, which does not reduce into the abdominal cavity.

It should be noted that in the case of long-irreparable hernias, the symptom of a suddenly disappeared possibility of reducing the hernia may be obscured. The strangulated intestine can suddenly move from the strangulating ring into the free abdominal cavity, being no longer viable; with persistent attempts to reduce a strangulated hernia, there may be mixing deep into the entire hernial protrusion with continued compression of the contents in the uncut strangulating ring. Such “false” reduction is extremely dangerous; necrosis of the hernia contents progresses, and vascular thrombosis and peritonitis may occur. Following the appearance of the listed signs of infringement, a picture of NK develops with its characteristic signs.

It should be borne in mind that sometimes local changes in the area of ​​hernial protrusion may be insignificant and will not attract the attention of either the patient or the doctor. It would be a serious mistake for a doctor if, observing only general symptoms, he does not examine all the locations of external hernias in the patient.

There is no symptom of cough impulse. When percussing the area of ​​the hernial protrusion, dullness is revealed if the hernial sac contains an omentum, bladder, and hernial water. If there is an intestine containing gas in the hernial sac, then the percussion sound is tympanic.

With elastic strangulation, sudden, severe and constant pain in the area of ​​the hernial protrusion is caused by compression of the vessels and nerves of the mesentery of the strangulated intestine.

Incarceration is manifested by signs of NK: cramping pain associated with increased intestinal motility, retention of stool and gases, vomiting. When auscultating the abdomen, increased bowel sounds are heard. A survey fluoroscopy of the abdomen reveals distended loops of intestine with horizontal levels of liquid and gas above them (“cups” of Kloiber). Somewhat later, signs of peritonitis appear.

There are three periods of the clinical course of a strangulated hernia. The first period is pain or shock, the second period is imaginary well-being, the third period is diffuse peritonitis. The first period is characterized by acute pain, which often causes shock. During this period, the pulse becomes weak and frequent, blood pressure decreases, breathing is frequent and shallow. This period is more pronounced with elastic infringement.

During the period of imaginary well-being, intense pain subsides somewhat, which can mislead the doctor and the patient about the supposed improvement in the course of the disease. Meanwhile, the decrease in pain is explained not by an improvement in the patient’s condition, but by the necrosis of the strangulated loop of intestine.

If assistance is not provided to the patient, his condition sharply worsens, diffuse peritonitis develops, i.e. the third period begins. At the same time, the body temperature rises and the pulse quickens. Abdominal bloating and vomiting with a fecal odor appear. In the area of ​​the hernial protrusion, swelling develops, skin hyperemia appears, and phlegmon occurs.

Diagnostics in typical cases it is not difficult and is carried out on the basis of characteristic signs: acute, sudden pain and irreducibility of a previously reducible hernia. When examining a patient in the groin area, a painful, tense, irreducible hernial protrusion is revealed (at the external opening of the inguinal canal). When a loop of intestine is strangulated, the symptoms of strangulation NK are added to these symptoms.

You should also think about the possibility of incarceration in the internal opening of the inguinal canal (parietal incarceration). In this regard, in the absence of a hernial protrusion, it is necessary to perform a digital examination of the inguinal canal, and not be limited to just examining the external inguinal ring. With a finger inserted into the inguinal canal, it is possible to palpate a small painful lump at the level of the internal opening of the inguinal canal. Mistakes are often made in diagnosing strangulated hernias. Sometimes genitourinary diseases (orchitis, epididymitis), inflammatory processes in the inguinal and femoral lymph nodes or tumor metastases to these nodes, edema abscesses in the groin area, etc. are mistaken for infringement.

Retrograde entrapment(see Figure 3). TC is more often subject to retrograde infringement. Possible retrograde strangulation of the colon, greater omentum, etc.

Retrograde strangulation occurs when several intestinal loops are located in the hernial sac, and the intermediate loops connecting them are located in the abdominal cavity. In this case, the strangulated intestinal loop lies not in the hernial sac, but in the peritoneal cavity, i.e. The connecting intestinal loops located in the abdominal cavity are more susceptible to infringement. Necrotic changes develop to a greater extent and earlier in these intestinal loops located above the strangulated ring.

The intestinal loops located in the hernial sac may still be viable. With such strangulation, the strangulated intestinal loop is not visible without additional laparotomy. Having eliminated the strangulation, it is necessary to remove the intestinal loop, make sure that there is no retrograde strangulation, and if in doubt, dissect the hernial orifice, i.e. perform a herniolaparotomy.

Diagnosis it is impossible to determine before surgery. During the operation, the surgeon, having discovered two intestinal loops in the hernial sac, must, after dissecting the strangulated ring, remove the connecting intestinal loop from the abdominal cavity and determine the nature of the changes that have occurred in the entire strangulated intestinal loop.

If retrograde strangulation remains unrecognized during surgery, the patient will develop peritonitis, the source of which will be a necrotic connecting loop of the intestine.

Parietal infringement(see Figure 1). Such pinching occurs in a narrow pinching ring. In this case, only the part of the intestinal wall opposite the line of attachment of the mesentery is infringed.

Parietal entrapment of the small intestine is more often observed with femoral and inguinal hernias, less often with umbilical hernias. As a result of the advancing disorder of blood and lymph circulation in the strangulated area of ​​the intestine, destructive changes, necrosis and perforation of the intestine occur.

Diagnostics presents great difficulties. Parietal intestinal strangulation is clinically different from intestinal strangulation with its mesentery. With parietal entrapment, shock does not develop. Symptoms of NK may be absent, since intestinal patency is not impaired. Sometimes there is diarrhea. There is constant pain at the site of the hernial protrusion. Here you can feel a small, painful, dense formation. The pain is not severe, since the mesentery of the strangulated area of ​​the intestine is not compressed.

Diagnostic difficulties arise especially when strangulation is the first clinical manifestation of a hernia. In obese patients (especially women), it is not easy to feel the small swelling under the inguinal ligament.

If the general condition of the patient initially remains satisfactory, then it progressively worsens due to the development of peritonitis, phlegmon of the tissues surrounding the hernial sac.

The development of inflammation in the tissues surrounding the hernial sac in patients with an advanced form of parietal strangulation can simulate acute inguinal lymphadenitis or adenophlegmon.

Thrombosis of a varicose node of the great saphenous vein at the point where it flows into the femoral vein can simulate strangulation of a femoral hernia. With thrombosis of this node, the patient experiences pain and a painful seal under the inguinal ligament is detected, and there are varicose veins of the lower leg.

Sudden appearance and strangulation of hernias. A similar condition occurs when a protrusion of the peritoneum (a pre-existing hernial sac) remains on the abdominal wall in areas typical for the formation of hernias after birth. Most often, such a hernial sac in the groin area is the unfused vaginal process of the peritoneum.

The sudden appearance of a hernia and its strangulation can occur as a result of a sharp increase in intra-abdominal pressure during physical stress, severe coughing, straining, etc.

Patients have no history of indications of pre-existing hernias, protrusions, or pain in the characteristic locations of hernias. The main symptom of suddenly occurring strangulated hernias is acute pain in the typical places where the hernias emerge. When examining a patient with such pain, it is possible to determine the most painful areas corresponding to the hernial orifice. The hernial protrusion is small in size, dense in consistency, and painful.

Differential diagnosis. A strangulated hernia is differentiated from inflammation of the lymph nodes, a tumor of the ovary and spermatic cord, volvulus, cases of “false” strangulation, when inflammatory exudate accumulates in the hernial sac during peritonitis; tumor metastases. Differential diagnosis in the latter case is especially important, since “a diagnosed disease of the abdominal organs can lead to erroneous surgical tactics and death of the patient. In doubtful cases, during the operation the abdominal cavity is examined using a laparoscope inserted through the hernial sac.

Phlegmon of the hernial sac. Develops with severe strangulated hernia. It is observed mainly in elderly and senile patients who visit a doctor late. Phlegmon of the hernial sac can be serous, putrefactive or anaerobic in nature.

Inflammation engulfs the walls of the hernial sac and then spreads to the tissue of the abdominal wall. With this complication, there is pain in the area of ​​the hernia, the skin over the hernia is swollen, infiltrated, hot to the touch, and cyanotic. Edema and hyperemia spread to the surrounding tissues, regional lymph nodes enlarge. The general condition may suffer significantly. There are signs of purulent intoxication: high body temperature, tachycardia, general weakness, loss of appetite.

In the area of ​​the hernial protrusion, hyperemia of the skin is determined; upon palpation, a tumor of dense elastic consistency, tissue swelling, and enlarged regional lymph nodes are detected.

Fecal stagnation and fecal strangulation. This complication often occurs in obese elderly and senile patients with a tendency to constipation. Fecal stagnation (coprostasis) is a complication of a hernia that occurs when the contents of the hernial sac are OK. Develops as a result of a disorder of motor function, weakening of intestinal motility associated with a decrease in the tone of the intestinal wall.

Fecal strangulation occurs due to the accumulation of a large amount of intestinal contents in the intestine located in the hernial sac. As a result, compression of the efferent loop of this intestine occurs (see Figure 2).

Elastic strangulation is also associated with fecal strangulation. Thus, a combined form of infringement occurs.

Coprostasis is promoted by the irreducibility of the hernia, a sedentary lifestyle, and abundant food. Coprostasis is observed in men with inguinal hernias, in women with umbilical hernias. In this form of strangulation, as the OC fills with feces, the hernial protrusion is almost painless, slightly tense, of a dough-like consistency, and the symptom of a cough impulse is positive. Dense lumps of feces are detected in the intestinal loops.

Coprostasis can occur as a result of compression in the hernial orifice of the outlet and develop into fecal strangulation. When fecal impaction occurs, signs of obstructive NK increase. The pain intensifies and becomes cramping in nature, and vomiting becomes more frequent. Subsequently, due to the overflow of the intestine located in the hernial sac with feces, compression of the entire intestinal loop and its mesentery occurs by the hernial orifice.

In contrast to elastic strangulation in coprostasis, strangulation occurs slowly and gradually increases, the hernial protrusion is slightly painful, has a pasty consistency, slightly tense, a cough impulse is detected, the closure of the intestinal lumen is incomplete, vomiting is rare; The general condition of the patient initially suffers slightly. In advanced cases, abdominal pain, general malaise, intoxication, nausea, vomiting may occur, i.e. a clinic of obstructive NK appears.

False strangulation of a hernia. In acute diseases of one of the abdominal organs (acute appendicitis, acute cholecystitis, perforated gastroduodenal ulcer, NK), the resulting exudate, entering the hernial sac of a non-strangulated hernia, causes an inflammatory process in it. The hernial protrusion increases in size, becomes painful, tense and difficult to correct.

These signs correspond to signs of a strangulated hernia.

In the case of false strangulations, a history of these diseases and a thorough objective examination of the patient helps to make a correct diagnosis of acute diseases of the abdominal organs and exclude strangulation of the hernia. In this case, it is necessary to find out the time of occurrence of pain in the abdomen and in the area of ​​the hernia, the onset of pain and its nature, to clarify the primary localization of abdominal pain (late onset of pain in the area of ​​a reducible hernia is more typical for acute diseases of the abdominal organs than for a strangulated hernia).

In a patient with peptic ulcer disease (PU), perforation of the ulcer is characterized by the sudden onset of acute pain in the epigastric region with the development of peritonitis.

AC is characterized by the sudden onset of acute pain in the right hypochondrium with irradiation under the right shoulder blade, into the right shoulder girdle, the greatest pain and muscle tension are observed in the right hypochondrium, Ortner and Murphy symptoms are positive.

Acute appendicitis is characterized by the appearance of pain in the epigastric region or around the navel, followed by pain moving to the right iliac region; the greatest pain and muscle tension are determined in this area.

The sequential appearance of signs of NK at first, then peritonitis and later changes in the hernia area makes it possible to interpret pain in the hernia area, an increase in the size and tension of the hernia as a manifestation of false incarceration.

If a diagnosis of false strangulation is not made and the operation is started as for a hernia, then during the operation it is necessary to correctly assess the nature of the contents of the hernial sac. Even at the slightest suspicion of acute disease of the abdominal organs, a median laparotomy should be performed in order to identify the true cause of the disease. If we limit ourselves to only hernia repair and do not eliminate the cause of peritonitis in time, then due to a diagnostic error the prognosis will be unfavorable.

Prevention and treatment of external abdominal hernias. The main method of treating uncomplicated, and even more complicated, hernias is surgery. A timely operation is the only reliable means of preventing strangulation; therefore, contraindications to it must be seriously justified. The prolonged existence of a hernia leads to the destruction of surrounding tissues (especially the posterior wall of the hernial canal) and stretching of the hernial orifice. In this regard, surgical treatment of patients with a hernia should not be delayed for a long time. The most effective measure to prevent strangulation and recurrence of a hernia is early planned surgery.

Conservative treatment (bandage) can be recommended only for those patients in whom surgery cannot be performed even after long preoperative preparation. In other cases, the use of a bandage is not permissible, since long-term use of it leads to injury and atrophy of the tissues surrounding the hernia, and also contributes to the transformation of the hernia into an irreparable one.

To prevent hernia, it is necessary, as far as possible, to eliminate all causes that contribute to a systematic increase in intra-abdominal pressure. Systematic sports exercises help strengthen the abdominal wall. It is necessary to avoid obesity and sudden weight loss.

Surgical treatment of uncomplicated hernias. The principle of surgery for uncomplicated hernias is to isolate the hernial sac, open it, inspect and reposition the organs contained in the hernial sac into the abdominal cavity. The neck of the hernial sac is sutured and bandaged. The distal part of the sac is excised. Hernial orifice plastic surgery is performed in various ways - from simple interrupted sutures to complex plastic methods. For plastic surgery of large hernial orifices, strips of the fascia lata of the thigh, deepithelialized strips of skin, and alloplastic materials are used.

Treatment of strangulated hernias. The only treatment for strangulated hernias is emergency surgery to eliminate the strangulation. The main stages of surgery for strangulated hernias are the same as for elective surgery. The difference is as follows: at the first stage, the tissues are cut layer by layer, the hernial sac is exposed, and it is opened. To prevent the strangulated organs from slipping into the abdominal cavity, they are held in place with a gauze pad. Then the pinching ring is cut, taking into account the anatomical relationships. Viable organs are inserted into the abdominal cavity. Dissection of the strangulating ring before opening the hernial sac is considered unacceptable.

If you cut the strangulating ring before opening the hernial sac, the strangulated organ may slip into the abdominal cavity. The dissection of the hernial sac is carried out carefully so as not to damage the swollen intestinal loops that fit tightly to the wall of the hernial sac.

For femoral hernias, the incision is made medially from the neck of the hernial sac to avoid damage to the femoral vein, located on the lateral side of the sac. For umbilical hernias, the strangulating ring is cut transversely in both directions.

The most critical stage of the operation after opening the hernial sac is to determine the viability of the strangulated organs. When the hernial sac is opened, serous or serous-hemorrhagic fluid (hernial water) may spill out of its cavity. Usually it is transparent and odorless; in advanced cases, with intestinal gangrene, it has the character of an ichorous exudate.

After dissecting the strangulating ring and introducing a solution of novocaine into the mesentery of the intestine, those parts of the strangulated organs that are located above the strangulating ring are carefully removed from the abdominal cavity, without strong pulling. If there are no obvious signs of necrosis, the strangulated intestine is irrigated with a warm isotonic sodium chloride solution.

The main criteria for the viability of the small intestine: restoration of the normal pink color of the intestine, absence of strangulation grooves and subserous hematomas, preservation of the pulsation of small vessels of the mesentery and peristaltic contractions of the intestine. Signs of intestinal non-viability and absolute indications for its resection are: dark color of the intestine, dullness of the serous membrane, flabbiness of the intestinal wall, absence of pulsation of the mesenteric vessels, absence of intestinal peristalsis and the presence of the “wet paper” symptom.

The presence of deep changes along the strangulation groove also serves as an indication for intestinal resection. Suturing such grooves is considered a risky undertaking. In the case of parietal intestinal strangulation, if there is the slightest doubt about the viability of the strangulated area, it is recommended to perform intestinal resection. Conservative measures, such as immersion of the changed area into the intestinal lumen, should not be carried out, since when immersing a small area, if the sutures are drawn close to its edges, they can easily separate, and when immersing a larger area of ​​the intestine, its patency becomes doubtful.

If necessary, resection of non-viable intestine is performed. Regardless of the extent of the changed area, resection should be carried out within the limits of healthy tissue. At least 30-40 cm of the adductor and 15-20 cm of the efferent section of the intestine are removed. The anastomosis is performed side to side or end to end, depending on the diameter of the proximal and distal portion of the intestine. Bowel resection is usually performed through laparotomy access.

In case of phlegmon of the hernial sac, the operation begins with laparotomy. The necrotic loop of intestine is cut off, an interintestinal anastomosis is applied, the abdominal cavity is sutured, then the strangulated intestine and hernial sac are removed, and the wound is drained.

In case of strangulation of sliding hernias, it is recommended to evaluate the viability of that part of the organ that is not covered by the peritoneum. There is a risk of damage to the bladder or bladder. If SC necrosis is detected, a median laparotomy is performed and the right half of the SC is resected with ileotransverse anastomosis. In case of necrosis of the bladder wall, it is resected and an epicystostomy is applied.

The strangulated omentum is resected in separate sections without forming a large common stump. The ligature may slip off the massive omental stump, leading to dangerous bleeding into the abdominal cavity. After this, the hernial sac is isolated and removed with suturing of its stump in any way. It is not recommended for elderly and senile people to isolate and remove the hernial sac at any cost. It is enough to isolate it only in the area of ​​the neck and slightly above it, cut transversely along its entire circumference, bandage it at the neck, and leave the distal part of the sac in place, turning it inside out.

The next important stage of the operation is the choice of method for hernial orifice repair. In this case, preference is given to the simplest plastic methods. For small inguinal oblique hernias in young people, the Girard-Spasokukotsky-Kimbarovsky method is used. For direct and complex inguinal hernias, the Bassini and Postempsky methods are used.

In case of a strangulated hernia, complicated by phlegmon of the hernial sac, the operation begins with a median laparotomy, which is aimed at reducing the risk of infection of the abdominal cavity with the contents of the hernial sac. During laparotomy, intestinal resection is performed within the limits of viable tissue. The ends of the resected area are sutured, creating an end-to-end or side-to-side anastomosis between the afferent and efferent loops. In this case, the peritoneal cavity is isolated from the cavity of the hernial sac. To do this, the parietal peritoneum is dissected around the mouth of the hernial sac and dissected to the sides by 1.5-2 cm.

After suturing the afferent and efferent loops of the resected intestine near the hernial orifice, between sutures or ligatures, the loops of the resected intestine are crossed and removed along with part of their mesentery. Then the visceral peritoneum is sutured over the blind ends of the strangulated intestine located in the hernial sac and the edges of the prepared parietal peritoneum, thereby isolating the peritoneal cavity from the cavity of the hernial sac. The abdominal wall wound is sutured tightly in layers.

After this, surgical treatment of the purulent focus is performed, i.e. hernial phlegmon. In this case, the incision is made taking into account the anatomical and topographic characteristics of the localization of the hernial phlegmon.

After opening and removing the purulent exudate from the hernial sac, the hernial orifice is carefully incised enough to remove the strangulated intestine and its blind ends of the adductor and efferent segments. After removing the strangulated intestine, separating the mouth and neck of the hernial sac from the hernial orifice, it is removed along with the altered tissues. Several sutures are placed on the edges of the hernial orifice (plasty is not performed) in order to prevent eventration in the postoperative period. To complete surgical treatment of a purulent focus, the wound is drained with a perforated drainage, the ends of which are removed from the wound through healthy tissue.

Through a drainage tube, long-term constant washing of the brine with antibacterial drugs is carried out, ensuring sufficient outflow of discharge from the wound. Only this approach to the treatment of a purulent focus with hernial phlegmon makes it possible to reduce mortality and perform early closure of the wound using primary delayed or early secondary sutures. In the postoperative period, antibiotic therapy is carried out taking into account the nature of the microflora and its sensitivity to antibiotics.

The outcome of surgical intervention for strangulated hernias mainly depends on the timing of the strangulation and on the changes that have occurred in the strangulated internal organs. The less time has passed from the moment of infringement to the operation, the better the result of the surgical intervention, and vice versa. The mortality rate for strangulated but timely (2-3 hours from strangulation) operated hernias does not exceed 2.5%, and after operations during which intestinal resection was performed, it is 16%. The outcome is especially serious with phlegmon of the hernial sac and laparotomy. The mortality rate is 24% (M.I. Kuzin, 1987).

Conservative treatment, i.e. forced manual reduction of a hernia is prohibited, it is dangerous and very harmful. It should be remembered that when a strangulated hernia is forcibly reduced, damage to the hernial sac and hernia contents can occur, including rupture of the intestine and its mesentery. In this case, the hernial sac can shift into the preperitoneal space along with the contents strangulated in the area of ​​the neck of the hernial sac; There may be a separation of the parietal peritoneum in the area of ​​the neck of the hernial sac and immersion of the strangulated, non-viable loop of intestine together with the strangulating ring into the abdominal cavity or into the preperitoneal space (Figure 4).

After forced reduction, other serious complications are observed: hemorrhages in soft tissues, in the intestinal wall and its mesentery, thrombosis of mesenteric vessels, separation of the mesentery from the intestine, the so-called imaginary, or false, reduction.

It is very important to promptly recognize an imaginary hernia reduction. Anamnestic data: abdominal pain, sharp pain on palpation of soft tissues in the area of ​​the hernia orifice, subcutaneous hemorrhages (a sign of forced reduction of the hernia) allow us to think about an imaginary reduction of the hernia and perform an emergency operation.

Figure 4. Imaginary reduction of a strangulated abdominal hernia (diagram):
a - separation of the parietal peritoneum in the area of ​​the neck of the hernial sac, immersion of the strangulated loop of intestine together with the strangulating ring into the abdominal cavity: b - displacement of the hernial sac along with the strangulated contents into the preperitoneal space

Conservative treatment, i.e. forced reduction of a hernia without surgery is considered acceptable only in exceptional cases when there are absolute contraindications to surgery (acute myocardial infarction, severe cerebrovascular accident, acute respiratory failure, etc.) and if a minimum amount of time has passed since the infringement. Among the acceptable measures for such cases, one can point out placing the patient in bed in a position with an elevated pelvis, subcutaneous administration of promedol, pantopon, atropine, local application of cold to the area of ​​the hernial protrusion, as well as novocaine infiltration of tissue in the area of ​​the pinching ring.

The lack of effect from the listed measures within 1 hour is an indication for surgical intervention in these patients, but its volume should be minimal, corresponding to the patient’s condition. Manual reduction is contraindicated for long periods of strangulation (over 12 hours), suspected intestinal gangrene, parietal strangulation, and phlegmon of the hernial sac. If a patient experiences spontaneous reduction of a strangulated hernia, he should be immediately hospitalized in the surgical department.

With spontaneous reduction of a strangulated hernia, the affected intestine can become a source of infection of the abdominal cavity, bleeding, etc. If peritonitis or internal bleeding is suspected, emergency surgery must be performed. For the remaining patients with a spontaneously reduced hernia, long-term, relentless monitoring is established in order to early identify signs of peritonitis and internal bleeding.

In case of strangulation, the organs that have entered the hernial sac are subject to compression, most often in the area of ​​the neck of the hernial sac (strangulation groove). Incarceration can also be observed in the hernial sac itself in the presence of scar cords (constrictions), between the organs that have entered the hernial sac and the wall of the hernial sac, and between organs. Infringements are also observed in so-called multi-chamber hernias, most often umbilical hernias. When incarcerated, blood and lymph circulation disorders develop with the threat of necrosis of the strangulated organs. The phenomena of venous stagnation are indicated by swelling of the intestinal wall, subserous hemorrhages, and a purple color of the loop. From the overcrowded venous and lymphatic vessels, blood plasma and lymph leak into the cavity of the hernial sac. This effusion (“hernial water”) is transparent in the initial period of strangulation, but later, when the onset of necrotic changes in the strangulated areas of the intestine lead due to translocation of intestinal microflora to infection of the effusion, the latter becomes cloudy and acquires a specific fecal odor. Pathoanatomical changes during strangulation develop not only in the loops of the intestine located in the hernial sac, but also in the adductor section of the intestine, which is sharply overfilled with contents, gases and effusion, the function of the intestine is significantly impaired, paresis of the intestinal wall develops, followed by paralytic phenomena that continue after the operation. At the same time, changes occur in the vessels. mesentery, intestinal loops (venous hyperemia, hemorrhage, thrombosis). Necrotic changes are accompanied by gangrene of the intestinal wall, perforation with the development of inflammatory changes in the circumference, followed by the so-called fecal phlegmon, which is the result of prolonged, “neglected” strangulation. Simultaneously developing peritonitis leads to death. There are two types of strangulation - elastic and fecal (Fig. 8 a, b). With elastic strangulation, compression of the organs that have entered the hernial sac occurs from the outside. With fecal strangulation, intestinal contents, accumulating in larger quantities, significantly increase the filling of the hernial sac and thereby increase the pressure of the hernial ring, as a result of which intestinal obstruction develops. The main role in strangulation is played by the strangulation ring itself, the inflexibility of which, to a greater or lesser extent, favors both the elastic, and fecal impaction. Diagnosis of strangulated hernia. A strangulated hernia is characterized by sharp pain in the hernia area, which usually appears after lifting something heavy, coughing, or straining. The hernia increases in size and becomes irreducible. When intestinal loops are strangulated, the clinical picture of intestinal obstruction (vomiting, stool and gas retention) quickly develops, which is confirmed by x-rays (Kloiber cups). When the omentum is strangulated, there is naturally no picture of intestinal obstruction. Over time, the omentum becomes necrotic and hernia phlegmon develops. One of the forms of strangulated hernias, which presents significant difficulties for timely diagnosis, is the so-called Richter hernia (parietal strangulation). With this type, only the part of the intestinal wall opposite the line of attachment of the mesentery is infringed in the hernial sac (Fig. 9, a). Symptoms of intestinal obstruction may be absent, since the contents of the intestine move freely to the distal part due to the infringement of only a small section of the wall. The general condition of the patient may remain satisfactory, since the mesentery corresponding to the strangulated area of ​​the intestine is free, and the pain syndrome is not so pronounced. Destructive changes in the wall of the strangulated intestine often develop by the end of the first day. Swelling and tissue infiltration are observed in the circumference of the infringement. Before dissecting the strangulating ring, it is necessary to fix the strangulated section of the intestine, and after cutting the ring, remove the intestinal loop at a sufficient length with a mandatory examination of the condition of the mesentery (thrombosis, hemorrhages). Removing the intestinal loop can be difficult in case of femoral hernias, when dissection of the inguinal ligament becomes necessary, and, if indicated, laparotomy. Resection of the defective section of the intestine should be carried out over a distance of at least 10-15 cm both in the distal and proximal directions from the strangulated section of the intestine. Wedge-shaped resection of a necrotic section of the intestine, as well as immersion with a purse-string suture, should be left as inferior and dangerous methods.

Retrograde entrapment is one of the types of infringement. With normal strangulation of intestinal loops, their necrosis develops within the hernial sac, and intestinal loops located in the abdominal cavity above the strangulation ring are usually not affected by severe circulatory disturbances. With retrograde strangulation, necrosis of the intestinal loops begins above the strangulation ring (Fig. 10). Intestinal loops, which are the contents of the hernial sac, may be viable or necrotic later than intestinal loops located in the abdominal cavity. Necrosis of intestinal loops develops within 2-14 hours. Retrograde strangulation most often affects the small intestine, but cases of retrograde strangulation of the large intestine, omentum, appendix, and fallopian tube have been described. Diagnosis of retrograde infringement before surgery presents significant difficulties. Unrecognized during surgery, retrograde strangulation ends in peritonitis, so the surgeon must pay attention to the nature of the effusion in the hernial sac, and after dissecting the strangulation ring, to the effusion released from the abdominal cavity. A cloudy effusion in the abdominal cavity and a transparent effusion in the hernial sac will indicate necrosis of the intestinal loop located in the abdominal cavity. The possibility of retrograde strangulation is signaled by the presence of two intestinal loops in the hernial sac, and the surgeon should think about the presence of a third, “connecting” loop (see Fig. 10), remove it and ensure its viability. The incision in doubtful cases should be wide enough to be able to provide inspection of the overlying section of the intestine.

12.Anatomy - physiological information about the cecum and appendix. The influence of variants of the location of the appendix on the clinical picture of the disease.

The cecum is that part of the large intestine that lies below the junction of the terminal portion of the small intestine. Usually the cecum is covered on all sides by peritoneum (intraperitoneal), so it is mobile. Sometimes there is a common mesentery for the cecum, the final section of the ileum, and the initial section of the ascending colon. In these cases, they speak of excessive mobility of the cecum, which can affect the clinical manifestations of acute appendicitis, and also lead to cecal volvulus. In rare cases, the cecum may occupy a mesoperitoneal position, and the appendix as a result is located retroperitoneally. The length of the cecum is 5 - 7 cm, the transverse diameter is 6 - 8 cm. On the surface of the cecum, ribbons (taenie) are visible, at the point of convergence of which the vermiform appendix begins. The vermiform appendix in its development is formed from the wall of the cecum. Its formation begins in the third month of embryonic development and is genetically the narrowed end of the cecum and occurs as a result of retardation in the growth of its lower section. In its structure, the wall of the process corresponds to the wall of the cecum. It consists of serous, muscular, submucosal and mucous layers. The process is usually covered on all sides by peritoneum and has a mesentery. Thanks to it, the appendix is ​​mobile and can occupy different positions in the abdominal cavity. Most authors usually distinguish six positions of the process: anterior; medial; lateral; descending (pelvic); retrocecal; retroperitoneal. So, with an anterior position of the appendix, there will be classic symptoms of acute appendicitis and, conversely, with retrocecal - blurred, with a pelvic location, the appendix can be fused with the rectum and simulate the clinical picture of acute dysentery, fused with the uterine appendages - symptoms of adnexitis, and with the bladder - clinical manifestations characteristic of cystitis. In a retrocecal position, the appendage may be close to the ureter and, when inflamed, involve the latter in the process, which can simulate the clinical picture of urolithiasis, pyelonephritis, etc. The length of the appendix ranges from 1 to 20 cm, on average 5–8 cm, thickness from 5 to 7 mm. A specific feature of the histological structure of the appendix is ​​the abundance of lymphoid follicles. the appendix undergoes changes with age. Sclerotic processes develop in its wall, and its lumen can be partially or completely obliterated, the mesentery shrinks. From a practical point of view (when performing an appendectomy), the distance from the appendix to the lower lip of the baugin valve is of great importance. On average, this distance is 2–4 cm. When the mouth of the appendix is ​​located near the lower lip of the Baugin valve, there is a danger of deformation of the valve when immersing its stump, performing an appendectomy, which can lead to disruption of intestinal patency. BLOOD SUPPLY The vermiform appendix is ​​carried out by the vermiform appendix artery, which is a branch of the ileocolic artery. Blood flows through the veins of the same name, then into the superior mesenteric vein and further into the portal vein, which creates the preconditions for the spread of infection through the portal vein system. LYMPHATIC SYSTEM The outflow of lymph occurs into the lymph nodes of the ileocecal region. The iliac lymph nodes anastomose with the lymph nodes of other areas, which creates the preconditions for the spread of infection from the appendix to other areas and, conversely, with inflammation of the internal organs (adnexitis, endometritis), the appendix may be involved in the inflammatory process (secondary appendicitis). INERVATION The vermiform appendix is ​​carried out by the branches of the superior mesenteric plexus, which has a close connection with the solar plexus. This explains the different localization of pain in acute appendicitis. Important practical implications takes into account the peculiarities of the position of the cecum. With a mobile cecum, the appendage may end up in the left iliac region or in other parts of the abdominal cavity. In children, the cecum is located higher than in adults. During pregnancy, it is displaced upward by the enlarged uterus. To find a worm-like of the appendix, the cecum should first be identified. It differs from thin one in color and the presence of longitudinal ribbons. There are no or weakly expressed fat pads on it, unlike the transverse colon, sigmoid colon, which differ from the cecum in that they have a mesentery. The most correct technique for finding the appendix is ​​to look for the ileocecal angle. The second method is to find the place of convergence of the three longitudinal bands of the cecum, but it is sufficient to determine one anterior (free) band of the cecum, the direct continuation of which is the vermiform appendix. Great difficulties can arise with the retrocecal and especially retroperitoneal position of the process. In such cases, it will be necessary to dissect the peritoneum to the outside of the cecum and, having mobilized it, locate the vermiform appendix along its posterior surface. Due to the variability of the position of the appendix during its inflammation, the clinic may be atypical and simulate diseases of other abdominal organs and retroperitoneal space. During embryogenesis, the intestinal tube makes several turns: First period– From about the 5th week of intrauterine life, the intestinal tube grows faster than the coelomal (embryo) cavity, and therefore part of the midgut is located outside the abdominal cavity and a temporary “physiological umbilical hernia” occurs. In this case, the intestine is located in the sagittal plane. Then the midgut loop from the sagittal plane goes into the horizontal plane, making a counterclockwise turn of 90 degrees. Second period - After the 10th week, the intestinal loops continue to turn counterclockwise, and thus the ileum, cecum and part of the colon from the left The halves of the abdomen move to the right and by the end of the 2nd period the intestine rotates 270 degrees, and the cecum reaches the subhepatic space. The entire intestine is already in the abdominal cavity. Third period - The cecum gradually descends into the right iliac region. Disruption of the normal rotation of the intestine can cause a number of anomalies in the position of the iliocecal angle and the appendix.