Hernia

Hernia is the protrusion of internal organs or parts thereof through openings in anatomical intermediate spaces under the skin, into intermuscular spaces or internal pockets and cavities. The place of exit of the hernia can be normally existing openings or gaps: (slits) enlarged in pathological conditions (weight loss, loosening of the ligamentous apparatus, loads exceeding its elasticity, etc.) or arising at the site of a tissue defect, thinning of the postoperative scar, and divergence of the aponeurosis.

Depending on the location distinguish: cerebral, muscular, diaphragmatic, abdominal hernia. The abdominal hernia is the most frequent, constituting up to 95% of all forms of hernias. In this section, we will consider only the external abdominal hernia, in which protrusion occurs through the "hole" in the abdominal wall.

Abdominal hernia - exit from the abdominal cavity of the internal organs along with the parietal peritoneum covering them through the weak points of the abdominal wall (hernial gates) under the skin, other tissues, cavities, pathologically formed pockets of the peritoneum. The components should be: hernia gates; hernial sac, the contents of which can be any organ of the peritoneal cavity; an outlet through which the hernia manifests clinically. Most often they are single-chambered, but can also be multi-chambered. With sliding hernias, the peritoneal leaflet may not completely cover the bulging organ.

Depending on the anatomical location, there are: inguinal (66.8%), femoral (21.7%), umbilical (6%), epigastric, lumbar, sciatic, lateral, perineal (1% in total). Hernia is divided into congenital and acquired; traumatic, postoperative, artificial, complete and incomplete, irreparable and irreparable, complicated and uncomplicated. Inguinal hernia in 92% of cases are observed in men, femoral and umbilical in 74% of cases in women. Complications include: infringement, coprostasis, peritonitis, inflammation and damage to the hernia, neoplasms, foreign bodies.

[1], [2], [3], [4], [5], [6]

Inguinal hernia

Depending on the place of exit, they distinguish: oblique inguinal hernia (exit through the lateral inguinal cavity), which occur 10 times more often; than straight lines (they exit through the medial inguinal fossa). There may be irreparable and irreparable, more often with sclerosis or adhesive process in the omentum that opens into the hernial sac (the symptom of Voskresensky - "strung string") is the appearance or intensification of pain in the hernia during rectification of the patient.

Symptomatology of inguinal hernia depends on the size and organ that opens into the hernial sac. Pain, a feeling of inconvenience, especially when walking, dyspeptic disorders are more common. The hernia is visible to the eye, it increases with inflating of the abdomen. At small sizes, protrusion is eliminated when the abdomen is pulled in the prone position; especially with raised and bent legs. At large sizes, the contents do not go into the abdominal cavity, but with gentle massage and retraction of the abdomen, the contents go away with the correct hernia. Rumbling and tympanitis with percussion indicate the exit of the intestinal loops. Elastic formation and percussion dullness are characteristic for the proliferation of the omentum. In the hernia of the bladder, dysuric disorders are noted in the form of two-act urination. With palpation, the outer inguinal ring is enlarged, and a symptom of a cough thrust is revealed. After the content is corrected, the course of the hernial canal is determined: with oblique inguinal hernia, it goes obliquely, along the course of the spermatic cord; with a straight line - the finger goes in the forward direction, the channel is short. The enlarged outer inguinal ring is not a sign of a hernia. This can occur with lengthening of the spermatic cord, varicocele, some tumors.

Femoral hernia

Women are more often noted for 40-60 years. There are 3 types of femoral hernias (according to AP Krymov):

1. vascular lacunar, the most frequent, leaving through a vascular lacuna;
2. Passing through lacunar ligament (hernia of Loezhye);
3. Passing through a muscular lacuna (muscular-lacunar hernia of Hesselbach with an exit into the vagina).

Vascular-lacunar hernia has 4 more varieties, but they are important for the choice of operational tactics, and not for 5 diagnostics. But according to the degree of development, it is necessary to identify 3 types: complete, incomplete, initial. The protrusion is located below the paddock fold in the Scarpau triangle. More often there is one hernial sac, fewer there are multi-chambered hernias (hernia Cooper-Estley).

The contents of the hernial sac are often the omentum, rarely the intestine, rarely the bladder. Patients complain of pain in the lower abdomen, in the groin and thigh, dysuric disorders, the appearance of limb edema on the side of the hernia, often in the evening or after a load. The triad of symptoms is the same: the presence of a hernial protrusion, a canal, a symptom of a coughing thrust. In obese patients, there may be a difficulty in differential diagnosis with inguinal hernia. To do this, use Cooper's reception: the hernial protrusion is taken into the hand and the forefinger is tried to probe the pubic hillock - with inguinal hernias, it is probed, it is not possible with the femoral ones. It is extremely rare to differentiate the hernia with lymphadenitis, varicose veins, tumors.

[7], [8], [9], [10], [11], [12], [13], [14],

Umbilical hernia

It is necessary to distinguish the hernia of children and adults, since in childhood they are treated mainly conservatively. There are direct and oblique inguinal hernias, but the difference may not be evident. Predominantly there are single-chambered, but can be multi-chambered. The protrusion occurs through the umbilical ring, which distinguishes it from the hernia of the white line of the abdomen. Hernial sac often: soldered to the skin and umbilical ring. Free hernias are easily corrected, unrecoverable hernias often give pain, but infringement is rarely noted. The contents are often the epiploon, the small intestine, but there may be other organs. Umbilical hernia must be differentiated with bulging of the navel, which is formed when the umbilical cord is bandaged, the baby is crying: the ring is widened, there is protrusion, maybe even the diverticulum of the peritoneum, but there is no ablation of the internal organs and the omentum, there is no symptom of coughing.

Postoperative (ventral) hernia

It is formed with unnoticed partial ablation of the abdominal wall after operations or when the wound is healed by secondary tension. A distinctive feature is its formation in the field of postoperative scar, with which it is most intimately connected. The content can be any body.

Other hernias

Lumbar, obturator, xiphoid process, lateral hernia of the abdomen - the edge is not uncommon and does not present difficulties in diagnosis. They are always free, easily rechargeable, disappearing horizontally when the musculature is relaxed. But they need to be differentiated with benign tumors (lipomas, fibroids, fibroids) that do not disappear in the horizontal position. For hernias of the occlusal opening, a Gauchy-Romberg symptom can be noted (pains on the inner surface of the thigh, from the hip joint to the knee, sometimes reaching the toes) and the symptom of Treves (abduction and rotation of the leg), which requires differential diagnosis with neuralgia and radicular syndrome.

In case of pain in the hernia, especially irreparable, differential diagnostics with infringement and coprostasis should be carried out.

There are elastic infringement, developing with spastic reduction of tissues surrounding the hernial sac, or with narrowness of the hernial canal with compression of the contents of the hernial sac. There can be direct infringement of an epiploon, loops of an intestine, a diverticulum, Meckelja (a hernia of Littre) with their necrosis in a hernial sac; Only a part of the intestine can be infringed without violating the passage of stool (Littre-Richter's hernia); may be impaired mesentery, but the passage of stool in the intestine, located in the abdominal cavity, violated the "retrograde" infringement (hernia of Maydle) with rapid necroticization. The second is a caloric infringement, in which the calving masses overwhelm the leading part of the intestinal loop with infringement of the intestine and mesentery in the hernial sac.

Clinically, the hernia is enlarged in size, tense, painful on palpation, coughing, attempts of correction (which one can never do!), There is no symptom of coughing. The picture of intestinal obstruction develops: multiple vomiting is noted, the stool and gases disappear, the ampoule of the rectum widens, signs of dehydration and intoxication appear, which is a consequence of the development of peritonitis. Coprostasis with unrecoverable hernia does not cause sharp changes in the patient's condition, pain is moderate, there is no stress, there is an increase in straining, palpation is slightly painful.