Traditional medicine

Hernia types of complications. Complicated abdominal hernia

(lat. hernia) - protrusion of organs from the cavity, through a pathologically formed or naturally existing hole. At the same time, the shells retain their integrity. The formation can extend into the intermuscular space, under the skin, or into internal cavities and pockets. Eventration (prolapse of internal organs through a defect in its wall) and prolapse (exit of an organ through a natural opening during prolapse) are not hernias.

Types/classification of the disease

Highlight uncomplicated And complicated(inflammation, rupture and phlegmon of the hernial sac, strangulation) of the hernia.

The disease happens along the way:

primary;
recurrent(re-formation of a hernia in the same place);
postoperative(ventral).

By origin of hernia there may be acquired, developing as a result of illness or injury or congenital(for example, central Schmorl's hernia), which are developmental defects and have their own characteristics.

According to reducibility they are distinguished:

Reducible- a protruding hernial sac is reduced independently or can be easily reduced through the hernial orifice;
Irreversible– usually due to the formation of adhesions, strangulation or adhesions, a hernia that was previously reduced cannot be returned to its place.

Anatomically, hernias can be external(internal organs fall out under the skin, and the hernia looks like an oval or rounded protrusion), they make up 75%, these are the femoral, epigastric, inguinal, umbilical, sciatic, white line of the abdomen, xiphoid process.

Internal a hernia occurs in 25% of all such pathologies, has no clear external symptoms, organs protrude into crevices, pockets or anatomical cavities or defects. They are divided into intra-abdominal and diaphragmatic.

Symptoms and signs

A protrusion is observed at the site of the hernia formation; when palpated, a hernial orifice is felt. Sac-like swelling can be of varying sizes.

Intervertebral hernia

Dystrophic changes in the lumbosacral spine most often appear in adults between 20 and 50 years old. Pathology often becomes the basis for temporary loss of ability to work and even disability. Osteochondrosis in almost all cases provokes the development of a back hernia. In this case, a pain syndrome appears, which can be accompanied by sensory disturbances, paralysis and paresis of the leg muscles, and dysfunction of the pelvic organs. 18% of patients with intervertebral hernias require surgical intervention.

The pathology develops as a result of a disc rupture, the hernia goes back, puts pressure on the nerve root, causing swelling and inflammation. The clinical picture begins to appear one day after the onset of the disease. In almost all patients, the main complaint is pain. Most often it appears in adolescence after a long stay in an uncomfortable position, physical activity or in bed. The disease develops when turning to the side occurs parallel to bending, sometimes the person also lifts weights.

Lumbar and sacral hernia(sequestrated) begins with a dystrophic process, then changes occur in the spinal motion segments, the strength of the fibrous ring decreases, the microcirculation of this area is disrupted, an adhesive process develops, and swelling of local tissues develops. The symptoms are caused by myofixation as a result of tension in the back muscles, which provokes compensatory curvature of other parts of the spinal column. The long course of the disease leads to dysfunction of the joint-ligamentous apparatus, accompanied by severe pain.

If the intervertebral disc falls into the lumen of the spinal canal, it develops dorsal hernia, which, like other types of pathologies of the lumbosacral region, can manifest itself as autonomic disorders, such as redness, dryness and swelling of the skin, and impaired sweating.

Often, patients take a forced position, with its help the pressure on the spine is reduced, that is, scoliosis is smoothed out, flexion and extension of the body is facilitated, and tension in the long back muscles is eliminated. Occasionally, patients cannot straighten their leg due to pain. Due to atrophy, the muscles “deflate”. Motor disorders (paresis, paralysis) occur only in severe cases.

When coughing and moving, the pain intensifies and often becomes very severe; the patient needs bed rest.

Cervical and thoracic hernia are very rare and have similar symptoms:

Headache;
acute pain radiating to the arms, shoulder blades, shoulders;
unsteadiness of gait;
numbness of fingers;
restriction of movement;
hypertension or hypotension;
dizziness;
weakness in the limbs, decreased reflexes;
sleep disturbance;
chronic fatigue;
memory impairment.

Inguinal hernia- protrusion of the peritoneum into the cavity of the inguinal canal. It is 10 times more likely to form in men than in women. The main signs of the disorder are a feeling of discomfort and pain in the groin area, intensifying while walking, dysfunction of urination and digestion. A lump forms in the groin and grows when coughing and straining. In men with inguinal hernias of significant size, the affected side of the scrotum enlarges, because of this the penis moves to the opposite side, and with large volumes of formation, the penis can be completely hidden under the skin.

Brief interesting data
- It was Claudius Galen (born around 130 AD) who first introduced the term “hernia.”
- There is a term “giant hernia”, it is used to refer to hernias larger than 40 cm.
- Most often, namely in 80-90%, inguinal hernias occur.
- Statistics indicate that multiple hernias are much more common than single ones.

The linea alba is formed by tendon fibers. When a hernia forms, the patient experiences pain, as with a stomach ulcer and other gastrointestinal ailments. On the line itself there is a protrusion, which occurs mainly when straining in the epigastric region. The pain intensifies after eating, with physical activity and sudden movements. Dyspeptic disorders are often observed: belching, nausea, constipation and heartburn.

Strangulated hernia of the white line cannot be reduced and is manifested by unbearable pain, blood in the stool, nausea and vomiting, retention of gases and bowel movements.

Hiatal hernia usually has no external manifestations. With this pathology, the stomach contents backflow into the esophagus, which causes hiccups, indigestion, heartburn, belching and chest pain.

Umbilical hernia- The abdominal organs extend into the navel area. Most often found in infants. This is due to the fact that the abdominal wall has a defect in which the umbilical ring, which usually closes before birth, remains uncovered. Pathology sometimes appears in children even after they begin to walk early. A hernia of less than a centimeter in a child may disappear on its own by the age of two. If a hernia was diagnosed in a newborn in time, then it can be cured simply with the help of gymnastics, massage and proper placement on the tummy. If necessary, surgery is performed no earlier than 5 years of age.

The acquired form of the disease proceeds a little more favorably. The child most often does not have any symptoms; the pathology manifests itself as a cosmetic defect. The dimensions of the bulge, as a rule, do not exceed 5 cm in diameter. Very rarely, adults experience aching or nagging pain, especially during physical activity, and constipation.

Not only in children, but also in dogs, namely puppies, an umbilical hernia often forms. The animal may refuse food and be depressed.

Complications

Intervertebral hernias cause some discomfort, but when complications arise, rather unpleasant symptoms develop: acute pain, migraine, numbness of the limbs, even paralysis. With disorders in the spinal region, the following develop: lumbodynia, lumbago, lumboischialgia or cauda equina syndrome. If the cervical vertebrae are affected, cervicalgia and cervicobrachialgia may appear, and the thoracic vertebrae - thoracalgia, intercostal neuralgia.

Abdominal hernias are often complicated by strangulation; this is an acute condition that requires urgent help. This disrupts blood circulation, the functioning of the pinched organ, and even tissue necrosis is possible. Severe pain develops, and when the intestinal loops are compressed, digestion is disrupted, up to intestinal obstruction. Internal organs and the hernial sac can become inflamed, which leads to the formation of an abscess, phlegmon, and peritonitis.

Causes of the disease

Abdominal hernias develop as a result of defects in muscle and tendon fibers. An elastic human corset helps maintain the desired position of organs in various body positions and counteract intra-abdominal pressure.

Causes of hernia formation:

Loss of elasticity in muscle tissue due to exhaustion or aging;
increased intra-abdominal pressure in combination with other negative factors;
congenital hole in the abdominal wall;
degenerative disorders at the site of injury or wound;
congenital abnormalities of connective tissue development;
various suppurations affecting the anterior abdominal wall.

Predisposing factors include: family history, individual differences in body structure, heavy physical labor, malnutrition, pregnancy, sharp fluctuations in intra-abdominal pressure (ascites, constant screaming, crying, difficulty urinating, cough, prostate adenoma and constipation), intestinal dyskinesia.

A spinal hernia is usually the consequence of carrying heavy objects, sedentary work, prolonged vibration or incorrect posture. It develops as a result of pinched nerve trunks and narrowing of the spinal canal.

Diagnostics

First of all, the doctor will conduct an examination, since many hernias are visible to the naked eye. To confirm the diagnosis and early prediction of complications, instrumental diagnostics are performed. For different localizations, the information content of the examination differs. Often, during the study of a disease, such as osteochondrosis, a herniated disc is accidentally discovered.

Diagnostic methods that are most often used:

Ultrasound (ultrasound examination);
MRI;
X-rays are sometimes used when a contrast agent is injected;
CT (computed tomography).

Differential diagnosis is carried out with:

Hematoma, endometriosis, cyst;
dysplasia, osteochondrosis, arthrosis;
varicocele, hydrocele, lymphadenitis;
general diseases of organs and systems (pancreatitis, gastric ulcer);
neurofibroma and lipoma.

Treatment

The main treatment for hernias and their complications is surgery. During surgery, a special mesh is applied to prevent the hernia from coming out, or the damaged area is sutured. Currently, operations are performed endoscopically or using autoplasty (recovery is carried out using one’s own tissues). In order for the patient to return to normal life, a recovery period and intensive rehabilitation are necessary.

Removal of a spinal hernia is performed as a last resort; if there are no complications, traction is recommended. After the end of the acute period or during the recovery period, it is recommended to carry out massage, perform physiotherapeutic procedures (electrophoresis, diadynamic currents, hirudotherapy, acupuncture), exercises to strengthen the muscular-ligamentous frame of the back, and therapeutic exercises also contribute to this. For pain syndrome, NSAIDs (Voltaren, Ketorol, Diclofenac), glucocorticoid ointments (Lorindene, Deperzolon) are prescribed. For almost all types of hernias, to prevent complications, it is recommended to wear an orthopedic bandage.

Treatment of a hernia can be carried out in a sanatorium, where specialists will help carry out a set of measures for treatment and rehabilitation after surgery.

Prevention

To prevent this disease it is recommended:

Do not sleep on soft mattresses;
do not overeat and control weight;
stop smoking and take care of your liver;
avoid excessive loads and sudden movements;
keep your back and head straight when walking;
increase immunity and eliminate stress;
move more, play sports (swimming, yoga);
Treat constipation, urological diseases, cough in a timely manner.

Traditional methods of treatment

Any home remedy can only be used with the permission of a doctor. If you are scheduled for surgery, then traditional treatment is unlikely to be effective.

Umbilical hernia treatment is carried out using a cake made of red clay, which is placed on top of the bandage for 24 hours. You can secure it using dressing material and cling film. The cake must be changed every day for 14 days. You can replace it with a copper coin, which must be applied for 3 days. Fix with a sticky bandage and repeat several times. You can also put cut garlic cloves on the hernia for up to 12 hours, but this procedure can cause a burn.

For vertebral hernia, red clay is also used or horse fat is used in the form of a compress of horse fat, which is applied to polyethylene in a thick layer for a day. It is good if the lower back is constantly wrapped in a belt made of dog hair.

With the long-term existence of a hernia, narrow hernial orifices, and frequent exit of internal organs into the hernial sac, conditions are created for trauma and aseptic inflammation of the exiting organs.

As a result, fusion of the inner surface of the hernial sac with the intestinal loops and omentum occurs, as well as fusion of the hernial contents with each other.

Among irreducible hernias, femoral hernias come first, followed by umbilical and inguinal hernias. Clinical manifestations; the hernia is not reduced either spontaneously or with the help of hands; Constipation associated with impaired motor function of intestinal loops located in the hernial sac is not uncommon. A number of patients experience urinary dysfunction. There is constant traumatization of the irreducible hernia, which leads to further adhesions. Irreversibility can also lead to coprostasis. Treatment is only surgical. The difficulties of the operation are associated with the separation of fused organs.

Coprostasis

Clinically manifested by pain in the abdomen, in the area of the hernia, bloating of intestinal loops, retention of gases and, above all, feces. Patients may experience nausea and vomiting.

Coprosgas is promoted by the narrowness of the hernial sac, which prevents the free passage of intestinal contents from the loops located in the hernial sac. The intestines become overfilled with feces, which become compacted and interfere with the free movement of intestinal contents. Coprostasis can develop into fecal strangulation.

Hernia inflammation

Occurs due to infection entering the hernial sac

inflammatory process in organs located in the abdominal cavity (quenellitis, peritiphlitis, etc.);

inflammatory process in the hernial sac itself (rare); inflammatory process developing in the neighborhood (orchitis, lymphadenitis, skin diseases).
The inflammatory process involves the hernial sac or its contents (or all together). In the clinic of inflammation, one can note an increase in the hernia, pain, redness of the skin, dysfunction of the intestines (bloating, gas and stool retention, nausea, vomiting). If inflammation increases (no effect from general and local anti-inflammatory therapy), emergency surgery is indicated - opening the abscess.

As the inflammation subsides, adhesions form, which can subsequently lead to the irreparability of the hernia.

Most often it occurs with inguinal, femoral and umbilical hernias. Contusions of the hernial protrusion occur, as a rule, without violating the integrity of the skin. —

A great danger in the event of a bruise is a violation of the integrity of the organs included in the hernial sac. In this case, peritonitis develops, and bleeding into the abdominal cavity is possible. After injuries to the contents of the hernial sac, hemorrhages may appear under the serosa of the intestinal loops and omentum, followed by the development of aseptic inflammation. Laparoscopy is used to diagnose damage to the contents of the hernial sac (especially intestinal loops). Once the diagnosis is confirmed, treatment is only surgical.

4.Strangulated hernia

This is the most dangerous complication, always requiring emergency surgery. Inguinal hernia is especially often strangulated (50-58% of all strangulations). Among the patients, men predominate (85%). In women, femoral and umbilical hernias are more often strangulated.

According to the mechanism of infringement, elastic and fecal ones are distinguished. With elastic strangulation, a sudden tension of the abdominal wall occurs with stretching of the hernial orifice, and at the same time intra-abdominal pressure increases with the release of the contents of the abdominal cavity into the hernial sac. Subsequent contraction of the hernial orifice leads to strangulation. In case of fecal strangulation due to overflow of the afferent loop, the efferent loop is “pressed” to the hernial orifice. Elastic infringement occurs more acutely; in this case, compression of the intestinal mesentery occurs.

Pathological changes in the strangulated organ:

the presence of an intestinal strangulation groove; changes in the injured organ; changes in the adductor colon; presence of “hernial water”; i
ischemic necrosis of strangulated organs due to compression of the mesentery.

There are parietal (Richterian) strangulation, when the intestinal wall is strangulated without disturbing the passage of intestinal contents, and retrograde (or double). In the latter case, there are at least 2 loops of intestine in the hernial sac, and the loop connecting them is located in the abdominal cavity, and the greatest ischemic disorders occur there.

The clinical picture of a strangulated hernia is based on subjective and objective data. Patients report sudden pain at the site of the hernia, which is associated with ischemia of the strangulated organ. Subsequently, cramping pain in the abdomen (intestinal obstruction) appears. At the same time, the hernial protrusion ceases to be reduced and may increase in volume. Dyspeptic disorders are common - nausea and vomiting, and in later cases, vomiting of fecal contents. Patients experience gas and stool retention. Among the local signs of strangulation, one can note the presence of pain in the hernia upon palpation, an increase in its volume, and tension in the hernia protrusion. In the later stages, hyperemia develops caused by the development of fecal phlegmon. If there is a strangulation, you cannot insert a finger into the corresponding hernial orifice.

It is much more difficult to recognize strangulation with a pre-existing irreducible hernia. However, a significant increase in pain and an increase in protrusion, the appearance of tightness and tension, as well as dyspeptic disorders allow us to suspect infringement. In doubtful cases, emergency surgery is indicated.

In some patients with acute diseases of the abdominal organs, exudate flows into the hernial sac, which is commonly called false strangulation (Broca's hernia).

Treatment of strangulated hernias is always surgical. During the operation, the hernial sac is first isolated and opened, then the strangulated organ is held and only after that the strangulated ring is cut.

The second stage is determining the viability of the strangulated intestine. Signs of intestinal viability: pink color, serous shine, peristalsis, pulsation of mesenteric arteries and venous patency. If the intestine is not viable, it is resected, and the afferent section is resected by 30-40 cm, and the abductor section by 10 cm from the necrotic loop. In the afferent loop, with strangulation intestinal obstruction, sharp trophic disturbances occur: thinning of the walls, malnutrition due to stretching and compression of the submucosal veins.

After intestinal resection and anastomosis, intestinal intubation is indicated in various ways (to prevent anastomotic leakage). In the presence of peritonitis, resection of the necrotic intestine with its ends exposed to the skin is indicated.

In case of spontaneous reduction of a strangulated hernia, hospitalization in the surgical department is indicated. Laparoscopy is advisable. If peritoneal symptoms increase, laparotomy is indicated.

When forcibly reducing a strangulated hernia, the so-called imaginary, or false, reduction is possible, when the hernial protrusion is reduced beyond the strangulated ring and is not externally determined, but the strangulation remains in the scarred neck of the hernial sac.

Surgical diseases Tatyana Dmitrievna Selezneva

Complications of hernias

Complications of hernias include strangulation, coprostasis, and inflammation.

Strangulated hernia. A strangulated hernia is understood as a sudden compression of the contents of the hernia in the hernial orifice. Any organ located in the hernial sac can be injured. It usually occurs with significant tension in the abdominal muscles (after lifting heavy objects, with strong straining, coughing, etc.).

When any organ is strangulated in a hernia, its blood circulation and function are always disrupted; depending on the importance of the strangulated organ, general phenomena also arise.

There are the following types of infringement: elastic, fecal, and both at the same time.

With elastic strangulation, intra-abdominal pressure increases. Under the influence of this and the sudden contraction of the abdominal muscles, the viscera quickly pass through the hernial orifice into the sac and are pinched in the hernial ring after intra-abdominal pressure normalizes.

With fecal strangulation, the contents of the overcrowded intestine consist of liquid masses mixed with gases, less often - of solids. In the latter case, the infringement can join with coprostasis.

Pathological changes in the strangulated organ depend on the period elapsed from the onset of strangulation and the degree of compression by the strangulation ring.

When the intestine is strangulated, a strangulation groove is formed at the site of the strangulation ring with a sharp thinning of the intestinal wall at the site of compression. Due to stagnation of intestinal contents, the afferent segment of the intestine is significantly stretched, the nutrition of its wall is disrupted and conditions are created for venous stasis (stagnation), resulting in plasma leakage into both the thickness of the intestinal wall and the intestinal lumen. This further stretches the adductor section of the intestine and impedes blood circulation.

Changes at the site of the strangulated intestinal loop are more pronounced than in the adductor region. When more pliable veins are compressed, venous stasis is formed, and the intestine takes on a bluish color. Plasma sweats into the lumen of the pinched loop and its wall, increasing the volume of the loop. As a result of increasing edema, compression of the mesenteric vessels increases, completely disrupting the nutrition of the intestinal wall, which becomes necrotic. The vessels of the mesentery at this time can be thrombosed over a significant extent.

Most often, strangulation occurs in patients who have suffered from hernias; in exceptional cases, it can occur in people who have not previously noticed their hernias. When a hernia is strangulated, severe pain occurs, in some cases it causes shock. The pain is localized in the area of the hernial protrusion and in the abdominal cavity, often accompanied by reflex vomiting.

An objective examination of the anatomical location of the strangulated hernia reveals an irreducible hernial protrusion, painful on palpation, tense, hot to the touch, dulling upon percussion, since there is hernial water in the hernial sac.

It is most difficult to diagnose parietal strangulation, since they may not interfere with the movement of contents through the intestine, and besides, parietal strangulation sometimes does not produce a large hernial protrusion.

Forcible reduction of a strangulated hernia is unacceptable, since it can become imaginary. The following options are possible:

1) moving the pinched viscera from one part of the bag to another;

2) transition of the entire strangulated area together with the hernial sac into the preperitoneal space;

3) reduction of the hernial sac along with the strangulated viscera into the abdominal cavity;

4) rupture of intestinal loops in the hernial sac.

In all these variants, hernial protrusion is not observed, and all symptoms of intestinal strangulation remain.

It is also necessary to keep in mind retrograde strangulation, in which there are two strangulated intestinal loops in the hernial sac, and the intestinal loop connecting them is in the abdominal cavity and turns out to be the most altered.

Patients with strangulated external abdominal hernias should undergo urgent surgery.

When performing surgery for strangulated external abdominal hernias, the following conditions must be met:

1) regardless of the location of the hernia, the strangulating ring cannot be cut before opening the hernial sac, since the strangulated viscera without revision can easily slip into the abdominal cavity;

2) if the possibility of necrosis of strangulated areas of the intestine is suspected, it is necessary to inspect these areas by removing them back from the abdominal cavity;

3) if it is impossible to remove the intestines from the abdominal cavity, laparotomy is indicated, in which the presence of retrograde strangulation is simultaneously determined;

4) special attention must be paid to dissecting the pinching ring and accurately understanding the location of the adjacent blood vessels passing through the abdominal wall.

If during the audit it is determined that the strangulated intestine is not viable, then it is removed, then the hernial orifice is repaired and sutures are placed on the skin. The minimum boundaries of the resected non-viable small intestine: 40 cm for the afferent loop and 20 cm for the efferent loop.

After the operation, the patient is taken to the ward on a gurney; the issue of management of the postoperative period and the possibility of getting up is decided by the attending physician. This takes into account the patient’s age, the state of the cardiovascular system and the nature of the surgical intervention.

Coprostasis. With irreducible hernias, coprostasis (fecal stagnation) is observed in the intestinal loop located in the hernial sac.

Hernia inflammation occurs acutely, accompanied by sharp pain, vomiting, fever, tension and severe pain in the area of the hernial sac. Treatment is urgent surgery.

In case of phlegmon of the hernial sac, it is necessary to perform a laparotomy away from the phlegmonous area with the imposition of an intestinal anastomosis between the adducting and efferent ends of the intestine, going to the strangulating ring. The disconnected loops of intestines to be removed are tied at the ends with gauze napkins and fairly strong ligatures. Having completed the operation in the abdominal cavity, the inflamed hernial sac is opened and the dead loops of strangulated intestines are removed through the incision, and the phlegmon is drained.

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author Tatyana Dmitrievna Selezneva

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Complications of hernias include strangulation, coprostasis, and inflammation.

Strangulated hernia(herniae incarceratae).

By strangulation of a hernia (incarceratio) we mean sudden compression of the contents of the hernia in the hernial orifice. Any organ located in the hernial sac can be injured. It usually occurs with significant tension in the abdominal muscles (after lifting heavy objects, with strong straining, coughing, etc.). When any organ is strangulated in a hernia, its blood circulation and function are always disrupted; depending on the importance of the strangulated organ, general phenomena also arise.

There are the following types of infringement: elastic, fecal, and both at the same time.

At elastic infringement Intra-abdominal pressure increases. Under the influence of this and the sudden contraction of the abdominal muscles, the viscera quickly pass through the hernial orifice into the sac and are pinched in the hernial ring after intra-abdominal pressure normalizes.

At fecal impaction the contents of an overcrowded intestine consist of liquid masses mixed with gases, less often - of solids. In the latter case, the infringement can join with coprostasis.

Most often the small intestine is strangulated. Pathological changes in the strangulated organ depend on the period elapsed from the onset of strangulation and the degree of compression by the strangulation ring.

When the intestine is strangulated, a strangulation groove is formed at the site of the strangulation ring with a sharp thinning of the intestinal wall at the site of compression. Due to stagnation of intestinal contents, the afferent segment of the intestine is significantly stretched, the nutrition of its wall is disrupted and conditions are created for venous stasis (stagnation), as a result of which plasma leaks into the thickness of the intestinal wall and into the intestinal lumen. This further stretches the adductor section of the intestine and impedes blood circulation.

Changes at the site of the strangulated intestinal loop are more pronounced than in the adductor region. When more pliable veins are compressed, venous stasis is formed and the intestine takes on a bluish color. Plasma sweats into the lumen of the pinched loop and its wall, increasing the volume of the loop. As a result of increasing swelling, the compression of the mesenteric vessels intensifies, completely disrupting the nutrition of the intestinal wall, which becomes necrotic. The vessels of the mesentery at this time can be thrombosed over a significant extent.

The plasma sweats not only into the intestine, but also into the hernial sac, where fluid, the so-called hernial water, accumulates. With a narrow hernial ring, not only the veins, but also the arteries are immediately compressed, so intestinal necrosis occurs very quickly.

At the beginning of strangulation, the hernial water is transparent and sterile, then, as a result of the influx of red blood cells, it turns pink, and as microorganisms penetrate into it, it becomes cloudy, with a fecal odor. In the efferent segment of the strangulated intestine, in most cases the changes are weakly expressed.

Most difficult to diagnose parietal infringements, since they may not interfere with the movement of contents through the intestines, and besides, parietal strangulation sometimes does not produce a large hernial protrusion.

Forcible realignment strangulated hernia is unacceptable, since it can become imaginary. The following options are possible:

1) moving the pinched viscera from one part of the bag to another;

2) transition of the entire strangulated area together with the hernial sac into the preperitoneal space;

3) reduction of the hernial sac along with the strangulated viscera into the abdominal cavity; 4) rupture of intestinal loops in the hernial sac. In all these variants, hernial protrusion is not observed, and all symptoms of intestinal strangulation remain.

If the strangulated hernia has been reduced upon admission of the patient to the emergency department or hospital, then the patient must be under the supervision of a surgeon. In the absence of indications for urgent surgical intervention, such patients should be operated on after a few days, in the so-called “cold period”.

It is necessary to keep in mind retrograde infringement in which there are two strangulated intestinal loops in the hernial sac, and the intestinal loop connecting them is located in the abdominal cavity and turns out to be the most altered.

Patients with strangulated external abdominal hernias should undergo urgent surgery. Before the operation, it is necessary to empty the bladder and aspirate the gastric contents with a thick probe. In a serious condition, the patient is given cardiac medications, intravenous drips of blood, polglucin, 5% glucose solution.

During surgery for strangulated external abdominal hernias, the following conditions must be met::

2) if the possibility of necrosis of strangulated areas of the intestine is suspected, it is necessary to inspect these areas by removing them back from the abdominal cavity;

3) if it is impossible to remove the intestines from the abdominal cavity, laparotomy is indicated, in which the presence of retrograde strangulation is simultaneously determined;

4) special attention must be paid to dissecting the pinching ring and accurately understanding the location of the adjacent blood vessels passing through the abdominal wall.

If during the audit it is determined that the strangulated intestine is not viable, then it is removed, then the hernial orifice is repaired and sutures are placed on the skin. Minimum

boundaries of the resected non-viable small intestine: 40 cm for the afferent loop and 20 cm for the efferent loop.

A strangulated hernia must be differentiated from an irreducible one. The latter is painless and does not have strangulation intestinal obstruction.

Coprostasis(coprostasio).

With irreducible hernias, coprostasis (fecal stagnation) is observed in the intestinal loop located in the hernial sac.

Ekle (Exier) proposed a scheme that makes it possible to carry out a differential diagnosis between coprostasis and intestinal strangulation:

	Coprostasis	Intestinal strangulation
	Occurs: gradually, slowly Tumor: irreducible, increases gradually, sensitivity is not particularly increased	immediately, suddenly irreducible, increases gradually, very painful and sensitive
	Slightly tense, cough impulse is detectable Bowel closure: incomplete	sharply tense, no cough impulse,
	Vomiting: mild, insignificant	very severe, repeated, painful, often with intestinal contents
	General condition: slightly damaged	severe, often collapsed

Treatment of coprostasis must begin with the use of high enemas. If conservative measures are ineffective, hernia repair should be performed.

Hernia inflammation(inflammation).

Inflammation of the hernia can occur from the skin, the hernial sac, or the viscera located in the hernial sac. It can be serous, serous-fibrinous, purulent, putrefactive and occurs in acute, sometimes chronic form. Hernias can become infected through various skin lesions, ulcerations, and all kinds of irritations. Rarely, the hernial sac is primarily affected as a result of trauma. Often the inflammatory process begins from the hernial contents. When there is inflammation of the internal organs located in the hernial sac (for example, the appendix, uterine appendages, etc.), the inflammatory process spreads to the hernial sac, and then to the entire hernia wall. In the hernial sac, perforation of the organs located in it, for example the appendix, may occur, which can also cause inflammation of the hernia.

When a hernia is inflamed, the cause of which is the internal organs located in the hernial sac, the process occurs acutely, accompanied by sharp pain, vomiting, fever, tension and severe pain in the area of the hernial sac.

It is difficult to diagnose hernia inflammation. It should be differentiated from a strangulated hernia. Treatment is urgent surgery.

More rare complications of hernias include damage to the hernia, neoplasm and foreign bodies in the hernia.

Strangulated hernias

Strangulation is the most severe complication of hernias, observed in 3-15% of patients with hernias. In recent years, there has been a slight increase due to the lengthening of life expectancy - over 60% of patients are over 60 years of age (Petrovsky). Strangulation is a sudden compression of the hernial contents in the hernial orifice, or the scarred neck of the hernial sac, followed by disruption of the nutrition of the strangulated organ. A distinction is made between elastic strangulation - due to a sudden contraction of the abdominal muscles and fecal strangulation - with an abundant flow of intestinal contents into the loop lying in the hernial sac. In addition, there are parietal strangulation (Richter's) - strangulation of the part of the intestinal wall opposite the mesentery, in a small hernial orifice (often with femoral hernias or in the internal ring with oblique inguinal hernias) and retrograde strangulation - strangulation of the intermediate loop lying in the abdominal cavity, and not visible in the hernial sac - may be accompanied by necrosis of the loop in the abdominal cavity (in this case, 2 or more intestinal loops are identified in the hernial sac). Most often, the intestinal loop is strangulated, then the omentum, and the degree of changes in the strangulated organ depends on the duration of the strangulation and the degree of compression.

Clinical picture

Severe pain in the area of the hernial protrusion, up to shock; rarely the pain is minor.

Irreversibility that came on suddenly.

An increase in the size of the hernial protrusion and its sharp tension due to the presence of hernial water (absent in Richter's strangulation).

Disappearance of the “cough impulse” symptom.

Symptoms of intestinal obstruction are vomiting that turns into feces, failure to pass gas and feces, bloating (absent with Richter’s strangulation, as well as with strangulation of the omentum).

General symptoms are pallor, cyanosis, cold extremities, dry tongue, small rapid pulse.

Locally - in advanced cases, inflammation in the area of the hernial sac is hernial phlegmon.

Differential diagnosis is carried out with an irreducible hernia, inflammation of the hernia, coprostasis, hernial appendicitis, inguinal lymphadenitis, acute orchiepididymitis, intestinal obstruction of another origin, peritonitis, pancreatic necrosis. Diagnostic errors are observed from 3.5 to 18% of cases; when localization is established - femoral or inguinal - up to 30%.

Decisive importance must be attached to the anamnesis. Inspection of all possible hernial orifices in acute diseases of the abdominal cavity is mandatory. “In case of intestinal obstruction, you should first examine the hernial orifice and look for a strangulated hernia” (Mondor).

Always prompt, as early as possible after the injury. 3 days after strangulation, mortality increases 10 times. Even with timely surgery, deaths are currently observed in 2.5% or more. The operation is to eliminate the strangulation; in case of necrosis, resection of the altered intestine followed by herniotomy and plastic surgery.

Features of the operation:

The strangulating ring is not cut until the hernial sac is opened, the strangulated organs are examined and fixed. The strangulating ring for femoral hernias is dissected medially.

Be careful when cutting the ring to avoid damage to the strangulated organs and vessels of the abdominal wall.

Remember about possible infection of “hernial water” - covering with napkins, suction, culture.

Caution when reducing intestinal loops (performed after the introduction of novocaine into the mesentery).

If there are visible changes in the intestine, cover with napkins moistened with warm saline solution for 5-10 minutes. Signs of intestinal viability: a/ restoration of normal color and tone. B/ shine and smoothness of the oerosis, c/ presence of peristalsis, d/ presence of pulsation of mesenteric vessels.

If there are several loops in the bag, remember the possibility of retrograde entrapment.

Resection of the intestine is carried out within healthy tissues, with the removal of at least 40 cm of the unchanged adductor and 15-20 cm of the efferent intestine, better, “end to end”; novice surgeons can do it “side to side”. In extremely severe patients, intestinal fistulas are applied; in particularly severe patients, the necrotic loop is removed without resection. The simplest, least traumatic methods of plastic surgery are used.

In case of hernial phlegmon, a median laparotomy is performed with resection of the intestine from the abdominal cavity, then they return to the hernia and excise the strangulated part of the intestine in one block. With mandatory drainage of the abdominal cavity. Plastic surgery of the defect is not performed in these cases.

Mortality: during surgery on the first day - 2.9%, on the second - 7%, after two - 31.3% (Sklifosovsky Institute). Complications - peritonitis, pulmonary complications, embolism and thrombosis, late bleeding.

Conservative treatment - (as an exception!!!) Permissible only in the first 2 hours after strangulation and only in particularly seriously ill patients in a state of cardiac decompensation, myocardial infarction, severe pulmonary diseases, inoperable malignant tumors, etc., as well as in weakened premature infants children.

It includes:

Emptying the bladder and bowels

Warm bath, heating pad,

Raised pelvic position

Atropine injections,

Cleansing enemas with warm water,

Spraying chloroethyl,

A few deep breaths

Very careful manual reduction.

After reduction, digital control of the hernial canal is required to determine the “cough impulse”. In case of spontaneous reduction, observation in a hospital followed by planned hernia repair. At the slightest deterioration of the condition, urgent surgery is required.

Prevention - a dispensary method of active identification of hernia carriers, timely planned surgery, sanitary and educational work among general practitioners and the population about the need for surgical treatment of hernias.

Coprostasis

Coprostasis is fecal stagnation in the hernial sac, observed in people with intestinal atony, more often with large irreducible hernias, in old age.

Features of the clinic: in contrast to strangulation, the increase in pain and increase in protrusion is gradual, the pain and tension of the protrusion are insignificant, the cough impulse phenomenon is preserved. Picture of partial intestinal obstruction. The general condition suffers little.

Treatment: reduction (for reducible hernias), high enemas, ice pack. Giving laxatives is contraindicated!!! The operation is desirable after the elimination of coprostasis in a few days, but if conservative measures are unsuccessful, an urgent operation is required.

Inflammation

Inflammation - most often begins secondary, from the hernial contents - hernial appendicitis, inflammation of the uterine appendages, etc., less often - from the hernial sac or skin (with eczema, when using a bandage. Inflammation is often serous, serous-fibrinous, sometimes purulent or putrefactive, with tuberculosis - chronic.

Features of the clinic. The onset is acute, pain, fever, local hyperemia, swelling, even phlegmon. Treatment is surgical (often the basis is infringement, often parietal).

Irreversible hernias

An irreducible hernia is a chronic complication - the result of the formation of adhesions of the hernial contents with the hernial sac, especially in the cervical area, with constant trauma at the time of the release of the viscera, when using a bandage.

Features of the clinic. Unlike strangulation, irreducibility occurs in the absence or slight pain, absence of tension in the hernial protrusion, or intestinal obstruction. May be complicated by coprostasis, partial intestinal obstruction. Irreversible hernias are often accompanied by dyspeptic symptoms and are often strangulated. Treatment. Herniotomy is performed as planned; if strangulation is suspected, an urgent operation is performed.