Hernia

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

Depending on the location, there are: cerebral, muscular, diaphragmatic, abdominal hernias. Abdominal hernia is the most common, accounting for up to 95% of all forms of hernias. In this section, we will consider only external abdominal hernias, in which the protrusion occurs through an "opening" in the abdominal wall.

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

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

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Inguinal hernias

Depending on the exit site, there are: oblique inguinal hernias (exit through the lateral inguinal fossa), which are 10 times more common; than direct ones (exit through the medial inguinal fossa). They can be reducible and non-reducible, more often with sclerosis or adhesions in the omentum, exiting into the hernial sac (the Voskresensky symptom is noted - "a stretched string" - the appearance or increase of pain in the hernia when the patient straightens up).

The symptoms of inguinal hernia depend on the size and the organ that enters the hernial sac. Most often, pain, discomfort, especially when walking, and dyspeptic disorders are observed. The hernia is visible to the eye and increases with abdominal distension. With small sizes, the protrusion is eliminated by drawing in the abdomen, in a lying position; especially with raised and bent legs. With large sizes, the contents do not go into the abdominal cavity on their own, but with a light massage and drawing in the abdomen, the contents go away with a reducible hernia. Rumbling and tympanitis with percussion indicate the exit of intestinal loops. An elastic formation and percussion dullness are characteristic of omentum prolapse. With a hernia of the bladder, dysuric disorders are noted in the form of two-act urination. Palpation reveals an expansion of the external inguinal ring, and a symptom of a cough impulse is revealed. After the contents have been repositioned, the course of the hernial canal is determined: with an oblique inguinal hernia, it goes obliquely, along the spermatic cord; with a straight one, the finger goes in a straight direction, the canal is short. An expanded external inguinal ring is not a sign of a hernia. This can be observed with an elongated spermatic cord, varicocele, and some tumors.

Femoral hernias

Most often observed in women aged 40-60. There are 3 types of femoral hernias (according to A.P. Krymov):

1. vascular-lacunar, the most common, emerging through the vascular lacuna;
2. passing through the lacunar ligament (Laugier's hernia);
3. passing through the muscular lacuna (Hesselbach's muscular-lacunar hernia with an outlet into the vagina).

Vascular-lacunar hernia has 4 more varieties, but they are important for choosing surgical tactics, and not for 5 diagnostics. But by the degree of development, it is necessary to determine 3 types: complete, incomplete, initial. The protrusion is located below the inguinal fold in the Scarpava triangle. More often, one hernial sac is noted, less often there are multi-chamber hernias (Cooper-Astley hernia).

The contents of the hernial sac are most often the omentum, less often the intestine, and very rarely the urinary bladder. Patients complain of pain in the lower abdomen, groin and thigh, dysuric disorders, and swelling of the limb on the side of the hernia, more often in the evening or after exercise. The triad of symptoms is the same: the presence of a hernial protrusion, a canal, and a cough impulse symptom. In obese patients, differential diagnostics with inguinal hernia may be difficult. Cooper's maneuver is used for this: the hernial protrusion is taken in the hand and an attempt is made to palpate the pubic tubercle with the index finger - with inguinal hernias it can be palpated, but not with femoral hernias. It is extremely rare to have to differentiate a hernia from lymphadenitis, varicose veins, or tumors.

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Umbilical hernia

It is necessary to differentiate between hernias in children and adults, since in childhood they are treated mainly conservatively. A distinction is made between direct and oblique inguinal hernias, but the difference may not be apparent. Mostly single-chamber, but there may be multi-chamber. The protrusion occurs through the umbilical ring, which distinguishes it from a hernia of the white line of the abdomen. The hernial sac is often: fused with the skin and the umbilical ring. Free hernias are easily reduced, irreducible hernias often cause pain, but strangulation is quite rare. The contents are most often the omentum, small intestine, but may also be other organs. An umbilical hernia must be differentiated from a protrusion of the navel, which is formed when the umbilical cord is improperly tied, the child is crying: the ring is dilated, there is a protrusion, there may even be a diverticulum of the peritoneum, but there is no prolapse of internal organs and omentum, there is no symptom of a cough impulse.

Postoperative (ventral) hernia

It is formed during unnoticed partial eventration of the abdominal wall after operations or during wound healing by secondary intention. A distinctive feature is its formation in the area of the postoperative scar, with which it is most often intimately connected. The contents can be any organ.

Other hernias

Lumbar, obturator, xiphoid process, lateral abdominal hernias - are quite common and do not present any diagnostic difficulties. They are always free, easily reducible, and disappear in a horizontal position when the muscles are relaxed. But they need to be differentiated from benign tumors (lipomas, myomas, fibromas), which do not disappear in a horizontal position. With hernias of the obturator foramen, the Gauschi-Romberg symptom (pain along the inner thigh, from the hip joint to the knee, sometimes reaching the toes) and the Treves symptom (abduction and rotation of the leg) may be noted, which requires differential diagnostics with neuralgia and radicular syndrome.

In case of pain in the area of the hernia, especially irreducible, differential diagnostics with strangulation and coprostasis should be carried out.

A distinction is made between elastic strangulation, which develops with spastic contraction of the tissues surrounding the hernial sac, or with narrowness of the hernial canal with compression of the contents of the hernial sac. There may be direct strangulation of the omentum, intestinal loops, diverticulum, Meckel's (Littre hernia) with their necrosis in the hernial sac; only part of the intestine may be strangulated without disruption of the passage of feces (Littre-Richter hernia); the mesentery may be strangulated, but the passage of feces in the intestine located in the abdominal cavity is disrupted - "retrograde" strangulation (Meidl's hernia) with its rapid necrosis. The second is fecal strangulation, in which the afferent section of the intestinal loop is overflowing with feces with strangulation of a section of the intestine and mesentery located in the hernial sac.

Clinically, the hernia is enlarged, tense, painful to palpation, coughing, attempts at reduction (which should never be done!), there is no cough impulse symptom. A picture of intestinal obstruction develops: repeated vomiting is noted, the passage of stool and gases is impaired, the ampulla of the rectum expands, signs of dehydration and intoxication appear, which is a consequence of the development of peritonitis. Coprostasis in an irreducible hernia does not cause drastic changes in the patient's condition, the pain is moderate, there is no tension, an increase is noted during straining, palpation is slightly painful.