Hernias.ppt

Hernias
Associate Professor faculty surgery,
PhD Isaev Dmitri Nicolaevichpersonal
identifier zoom 932 653 5999
code 123

In the CIS countries, in the USA, in the
UK, up to 500 thousand patients with hernias
are operated on annually.
Celsus (II century), gave the
classical definition of a hernia as
the protrusion of viscera through
congenital and acquired gate,
calling it a hernia.
Prevalence of hernias

1 hernia gate,
2 hernial sac
3 hernial content.
Hernia gate is an opening in the muscular-aponeurotic layer
through which the parietal peritoneum and the intestines of the abdomen
protrude.
The shape of the hernia gate can be oval, round, slit-shaped, triangular and
indefinite. The boundaries of the hernial gate are variable.
Hernial sac – part of the parietal peritoneum that fell through the
hernial gate. Distinguish the neck, body and top of the hernial sac. Its value
varies widely.
Herniation contents usually are moving the abdominal organs: the
omentum, loops of small bowel, sigmoid, transverse colon, cecum, etc.
The contents of the diaphragmatic hernia can be the stomach, kidneys,
spleen, liver.
The components parts of a hernia

1 hernia
gate(ring)
2 hernial sac
3 hernial content.

Hernia sac

Classification of hernias
Abdominal hernias are divided into external and internal.
External hernia (hernia abdominalis externa) is a surgical
disease in which through various holes in the muscular-aponeurotic
layer of the anterior or posterior abdominal wall and pelvic floor there
is a protrusion of the intestines together with the wall leaf of the
peritoneum with the integrity of the skin.
Internal hernia (hernia abdominalis interna) is called such
hernias of the stomach, which are formed inside the abdomen in
peritoneal pockets and folds or penetrate into the chest cavity through
a natural or acquired holes and slits of the diaphragm.

Anatomy classification of hernias
Abdominal hernias are classified according to anatomical,
etiological and clinical signs
Anatomically distinguish
1 inguinal,
2 femoral,
3 umbilical hernia
4 hernia of the white line of the abdomen.
Much rarer hernias
5 Spiegel line
6 xiphoid process,
7 lumbar,
8 ischiatic,
9 perineal
10 diaphragmatic hernias.

Etiology of all hernias are divided into
congenital (hernia congenita)
or acquired (hernia acquired).
a) postoperative
b) traumatic
c) neuropathic
A large group consists of so-called postoperative hernias that occur in
different parts of the abdominal wall after surgery. If these operations were
performed for a hernia, the newly emerging hernias in the same area are
called recurrent.
If a relapse occurs two or more times, such hernias are called
repeatedly recurrent.
Hernias of the stomach, formed after injury is called traumatic, and
in connection with certain diseases, e.g. after poliomyelitis – neuropathic.
The most important etiological moment of hernia is a violation of
the dynamic balance between intra-abdominal pressure and the ability of
the abdominal walls to counteract it.
Etiology

Clical classification of hernias
Reducing (setting) (hernia reponibilis) – a hernia in which the contents
of the hernia sac is free to move from the abdomen into the hernia sac and
back.
Irreducible or partially reducing hernia (hernia irreponibis seu acereta).
This hernia condition is due to the adhesive process in the abdominal
cavity.
Strangulated hernia (hernia incarcerata). The essence of the
infringement is that the organs released into the hernial sac are subjected
to compression in the neck. At the same time, disorders of blood and
lymph circulation develop and there is a real threat of necrosis of the
affected organs.
Infringement (strangulation) of hernia
elastic,
fecal,
retrograde (Maidl hernia)
and parietal (Richter's hernia).
Infringement of the diverticulum of Mekele called Littre hernia.
Inflammation of the hernia is a consequence of the penetration of
infection into the hernial sac. The outcome of inflammation may be the
formation of a hernial sac phlegmon.

General factors of hernia formation are divided into two groups:
predisposing and producing.
Predisposing factors include features of the human constitution, formed
on the basis of hereditary or acquired properties. This is primarily a hereditary
predisposition to the formation of hernias, as well as typical, sexual and age
differences in the structure of the body.
Constitutional factors include changes in the abdominal wall associated
with pregnancy, adverse working and living conditions, as well as various
pathological conditions, such as obesity or exhaustion.
Producing are factors that contribute to an increase in intraperitoneal
pressure or its sharp fluctuations, for example, hard physical labor, frequent crying
and screaming in infancy, difficult childbirth, cough in chronic diseases, prolonged
constipation, difficulty urinating in prostate adenoma or stricture of the urethra.
Individuals hypersthenic (brachiopod) body type there are preconditions for the
emergence of diaphragmatic, epigastric, and direct inguinal hernias.
In asthenic (dolichomorphic) physique often observed the umbilical, oblique
inguinal and femoral hernia.
Pathogenesis

Inguinal hernias are much more common than all other abdominal
hernias.
If patients with ventral hernias make up 8-18 % of the total number of
patients in surgical hospitals, 75-80% of them are patients with inguinal
hernias.
Inguinal hernias are observed mainly in men. This is due to the fact
that the inguinal canal in women is much more often slit-shaped, better
strengthened by muscles and tendon layers, somewhat longer and
narrower than in men. The ratio of men and women in inguinal hernias is
approximately 6:1.
The main anatomically due to the varieties of inguinal hernia
are the oblique (hernia inguinalis externa s. obtigua)
and direct (hernia inguinalis interna s. directa) hernia.
Inguinal hernias

1 In the middle line is the median fold — it passes obliterated urinary duct (urachus).
2 Visible lateral to the medial pair of folds, which are obliterating of the umbilical
artery.
3 Lateral folds with lower epigastric vessels (arteries and veins) are located externally
from them.
Anatomy of the groin (inguinal region)
When examining the
anterior abdominal wall from
the abdominal cavity, five
folds of the peritoneum can
be seen.

Anatomy of the groin (inguinal region)

Between the folds are lateral, supravesical, and medial inguinal
fossa.
Lateral inguinal fossa lie immediately outward from the respective folds.
Supravesical fossa is located behind a solid of the rectus abdominis
muscle and in the integrity of it cannot be the seat of hernia.
The middle inguinal fossa serves as the entry point of the direct inguinal
hernia.
The lateral inguinal fossa corresponds to the deep opening of the
inguinal canal, the entry point of the external oblique inguinal hernia.
The fossa is projected on the skin about above the middle of the
inguinal ligament, if shifted to the inside of it by 1-1. 5 cm.
No matter which hole includes hernia, they all go through a
subcutaneous hole of the inguinal canal.
Inguinal fosses

The Inguinal canal is normally a slit-like space occupied in men by
the spermatic cord, in women by the round ligament of the uterus.
The inguinal canal passes obliquely, parallel to the inguinal ligament
in men has a length of about 4-4,5 cm walls of the inguinal canal are:
1 front — aponeurosis of the external oblique muscle;
2 lower — inguinal (poupartia) ligament;
3 posterior — transverse fascia of the abdomen, the upper free edge of
internal oblique and transverse muscles.
The deep inguinal ring is the lateral part of the posterior wall of the
inguinal canal and is a funnel-shaped protrusion of the transverse fascia. The
external (superficial) opening of the inguinal canal is formed by the split legs
of the aponeurosis of the external oblique muscle, one of which is attached to
the pubic tubercle, the other to the pubic joint. Normally, its diameter in men is
1.2-2.5 cm.
Boundaries of the inguinal gap:
1 lower and lateral inner and middle part of the inguinal ligament;
2 medially — the outer edge of the rectus abdominis;
3 from top to lower edge of internal oblique and transverse muscles.
The Inguinal canal

The Inguinal canal
Exernal Inguinal ring

Oblique inguinal hernias
Oblique inguinal hernias depending on the origin of the hernial
sac are congenital and acquired.
With oblique inguinal hernias, the hernial sac makes its way
from the deep inguinal ring, through the inguinal canal under the skin at
the root of the scrotum and can, under favorable conditions for the
development of hernia, descend into the scrotum, forming an inguinal-
scrotal hernia.
Oblique inguinal hernia, repeating the course of the inguinal
canal, directed from top to bottom, back and front, from outside to inside.

Stages of inguinal hernias
In its development, it goes through a
number of successive stages:
1) beginning oblique hernia, when the
bottom of the hernia protrusion doctor reaches
a finger inserted into the outer opening of the
inguinal canal, only when straining the patient
or coughing;
2) channel hernia, in which the bottom of the
hernia sac comes to the external opening of
the inguinal canal;
3) oblique inguinal hernia the spermatic
cord where the hernia emerges from the
inguinal canal and is palpated in the form of
tumor masses of the inguinal region;
4) oblique inguinal-scrotal hernia, when the
hernial protrusion, following the spermatic
cord, descends into the scrotum.

Inguinal hernias
Congenital inguinal hernia, in which the hernial sac is
the vaginal process of the peritoneum (processus vaginalis
peritonei), is often combined with dropsy of the testicle and the
spermatic cord.
Direct inguinal hernia-which protrudes the peritoneum in
the fovea inguinalis medialis area and penetrates the inguinal
canal outside the spermatic cord, through the inguinal gap. This
hernia is always acquired.
Combined inguinal hernia - treat complicated inguinal
hernias and are characterized by the fact that the patient on one
side there are two or three separate hernia sacs, interconnected
and self-hernial holes leading into the abdominal cavity. The
practical significance of these hernias is that one of them can be
viewed during the operation.
Recurrent inguinal hernias. It is necessary to distinguish
between recurrent inguinal hernia, which occurred after any
period of time after herniation, and repeatedly recurrent, when it
reappeared after 2-3 and more operations.

Inguinal hernias
Congenital Inguinal hernia Acquired Inguinal hernia

Sliding inguinal hernias
Sliding inguinal hernia-hernia, in which the formation of the
hernial sac in addition to the parietal peritoneum takes part and visceral
peritoneum, covering a small length of the sliding organ. The most
practical value are sliding inguinal hernias of the bladder, caecum and
female genital organs (ovaries, tubes, uterus). The fact that one of the
walls of the hernial sac of the sliding hernia is formed by the nearby
organ located retroperitoneal, is the cause of frequent complications
during surgery.

Clinic & diagnostics of inguinal hernias
The clinical picture of uncomplicated inguinal hernias is quite typical.
Complaints of the patient on the presence of tumor-like protrusion in the
groin and pain of varying intensity, especially with physical stress, in most
cases immediately suggest the presence of a hernia.
During the examination, the surgeon should pay attention to the
shape and size of the hernial protrusion in different positions of the patient -
vertical and horizontal. With an oblique inguinal hernia, the protrusion has
an oblong shape, located along the inguinal canal, often falls into the
scrotum.
With a straight (direct) hernia, it is rounded or oval, located at the
medial part of the inguinal ligament, near the outer edge of the pubis.
In cases where the hernial protrusion is located above the projection of the
external opening of the inguinal canal, the presence of a perinatal or
interventional hernia should be suspected.
If there are two protrusions, a combined hernia is possible. With
large inguinal hernias in men, half of the scrotum from the hernia side is
sharply enlarged, its skin is stretched, the penis evades in the opposite
direction, and with giant hernias it hides in the folds of the skin.

Clinic & diagnostics of inguinal hernias
Normally, the outer hole passes the tip of the finger. With a hernia,
depending on its size, the diameter of the hole increases to 2-3 cm or more,
missing 2-3 fingers, and sometimes, with giant hernias, the entire brush.
Without removing the finger, the surgeon offers the patient to strain
or cough. However, he feels jerky pressure on the tip of your finger -
symptom cough shock. The definition of this symptom is especially
important in the diagnosis of initial or canal hernia.
With a sharp expansion of the inguinal canal, the finger moves
easily along the hernia.
If the hernia is oblique, the advanced course follows the direction of
the spermatic cord, and if is direct hernia, then finger goes straight,
penetrating into the inguinal gap. Sometimes you can determine the
pulsation a. epigastrica interna.
With a direct hernia, the pulsation of this artery is felt from the
outside of the finger, and with an oblique one - from the inside.

Diagnosis of sliding inguinal hernias
Diagnosis of sliding inguinal hernias before surgery is very important.
The presence of a sliding hernia should be assumed:
1) at long existing hernia or a large wide hernial gates;
2) when multiply recurrent hernias when often there is a destruction of the
posterior wall of the inguinal canal;
3) in the presence of patient complaints characteristic of the slipping of an organ;
4) partial or complete irreducible hernia;
5) when palpation of the hernia sac (after reduction content) is determined by
paste consistency; sometimes hernial protrusion consists of two parts, one of
which is more thickened;
6) when there is urination in two doses (with sliding hernias of the bladder, the
patient first empties the bladder, and then, after the hernia is set, he has an urge
to urinate).
If you suspect the presence of a sliding hernia, it is advisable to apply
additional research methods: irrigoscopy, cystography, cystoscopy, bimanual
gynecological examination. If there was a thought of involvement in the process
of the ureter or kidney, it is necessary to make infusion urography.

Femoral hernias
Femoral hernias are called, which come out through the
femoral canal. They make up 5-8 % of all abdominal hernias, are more
often pinched and have a more insidious course.
Meet predominantly have women in the second half of life. The
absolute predominance of women is due to the fact that they have a
wider pelvis, that is, more expressed muscular and vascular lacunae and
less strength of the inguinal ligament.
Hernial gate when femoral hernia is the femoral ring (anulus
femoralis), located in the center of the medial vascular lacuna and
limited
1 medial-lacunar ligament,
2 front - inguinal ligament,
3 behind - the Cooper ligament
4 lateral wall of the femoral vein.
The femoral ring is filled with fat. Here lies a large lymph node
Rosenmuller-Pirogov.

The femoral canal (canalis femoralis)
The femoral canal (canalis femoralis) is formed by the passage
of a hernia. Its inner opening is the femoral ring, the outer is the oval fossa:
an opening in the broad fascia of the thigh through which the great saphena
magna (V. saphena magna) passes.
The channel has a triangular shape. Its walls are:
1 front - inguinal ligament,
2 behind - deep leaf wide fascia,
3 outside - femoral vein.
Clinic and diagnosis of femoral hernia
The most characteristic clinical sign of a complete typical femoral
hernia is the presence of a hernial protrusion in the area of the femoral-
inguinal fold.
As a rule, it is a smooth hemispherical formation of small size,
located below the inguinal ligament inwards from the femoral vessels.
Often, the first clinical manifestation is a hernia infringement, which
occurs quite often.

The femoral canal (canalis femoralis)

Umbilical hernias in adult
Make up 3-5 % of all external abdominal hernias, occupying the
frequency of 3rd place after inguinal and postoperative hernias. Occur
mainly in women over 30 years.
The hernial gate is the umbilical ring. Usually they have a rounded
shape. The hernia sac is thin, soldered with stretched and thinned skin and
the edges of the hernia collar. With a small irreducible hernias the contents
of the bag is often a fixed adhesions of the omentum. With large hernias,
the hernial sac is often multi-chamber.
Clinic
Small umbilical hernias do not cause patients much concern, if they
are adjustable and do not have a tendency to infringement. The most
pronounced clinical picture is observed, as a rule, with hernias of
considerable magnitude. Such patients suffer from constipation, periodically
appearing pains, nausea and even vomiting often occur. Especially these
phenomena are expressed in irreducible hernia.

Umbilical hernias in adult
Strangulated Umbilical
hernia

Postoperative hernias
Postoperative abdominal wall hernias emerge from the
abdominal cavity in the area of postoperative scar and are located under
the skin.
Classification
Are distinguished:
a) small, postoperative hernia that is localized in any region of the
anterior abdominal wall, does not change the configuration of the
abdomen and is determined only by palpation;
b) the average postoperative hernia, which is a part of any region,
sticking out her;
c) extensive - when the hernia is fully occupies a certain area of the
anterior abdominal wall, deforming the stomach of the patient;
d) giant, holding 2-3 or more regions sharply deforming the stomach of
the patient, preventing him to walk.

Postoperative hernias
Etiological factor.
In some cases, the occurrence of a defect in the muscular-
aponeurotic layer is a consequence of early postoperative complications.
In others, due to flabbiness and muscle atrophy, thinning and
degeneration of aponeurosis and fascia. Finally, the etiological factors of the
third group are directly related to the quality of regenerative processes in the
sutured postoperative wound, when the scars are too malleable and fragile
to counteract intra-abdominal pressure.
Medial postoperative Lateral

Strangulation hernias
The clinical picture of hernia strangulation (infringement) is very
characteristic and, as a rule, typical.
Infringement is usually accompanied by suddenly appearing pains in the
area of hernial protrusion, and sometimes throughout the abdomen.
Sometimes, especially in the elderly and old people, the pain is
minor and relatively easy to carry, in other cases, especially in young
people, reach great strength and can be accompanied by tachycardia
and a decrease in blood pressure. Sometimes the pain subsides due to
the necrosis of the intestine.
The cardinal symptom of infringement of free setting hernia is the
inability to reposition hernial protrusion into the abdominal cavity. Hernial
protrusion increases in volume, becomes tense and painful.
When percussion is determined the dullness (if the hernial sac
contains fluid, the omentum) or bloat (bloated bowel loop). In case of an
unrecoverable hernia, the diagnosis of infringement is made on the basis
of the sudden occurrence of pain, soreness and tension of hernial
protrusion.
An important feature of strangulation is the absence of
transmission the cough impulse in region of hernial protrusion.

Strangulation hernias (cont)
Hernia infringement is often accompanied by vomiting, sometimes
repeated. Initially, vomiting is reflex, and later due to intoxication.
When the infringement of a intestine develop the phenomenon of
intestinal obstruction.
When examining the abdomen are determined:
1 bloating,
2 increased intestinal peristalsis,
3 antiperistaltic waves.
In some patients, there is an urge to defecation (tenesmus), gases
and feces can depart from the part of the intestine located distal to the place
of infringement. It is characteristic that emptying the intestine does not
improve the health of the patient.
In the future, with the progression of acute intestinal obstruction, the
patient's health and condition deteriorate rapidly due to the increase in
intoxication and the development of peritonitis.
The big danger in connection with the difficulty in diagnosis is
parietal impairment of the gut – hernial protrusion at the same small size and
difficult to define obstruction of the colon is incomplete and disadvantaged
section of the intestine, often and pretty soon undergoes necrosis.

Strangulation hernias (cont)
In connection with necrosis of the strangulated organ (usually the
intestine) symptoms of intoxication and peritonitis: the deterioration of
general condition, weakness, thirst, dry mouth, rapid pulse, vomiting, fever,
bloating, etc. old people, all these symptoms usually weaker than younger
people.

General principles of abdominal hernias treatment
The basic principle of surgical treatment of abdominal hernias is an
individual, differentiated approach to the choice of herniation. In solving this
problem, it is necessary to take into account the shape of the hernia, its
pathogenesis, the state of the abdominal wall tissues and the size of the
hernial defect.
There are five main methods of hernioplasty:
1) fascial-aponeurotic;
2) muscular-aponeurotic;
3) muscle;
4) plastic with additional biological or synthetic materials (alloplasty,
xenoplasty, explantation);
5) combined (use of auto tissues and foreign tissues).
The first three methods are combined into autoplastic, the other two
are called alloplastic.
The advantage of fascial-aponeurotic plasty is that this method most
fully implements the principle of joining homogeneous tissues, resulting in
their reliable splicing. Example Martynov.

Muscle aponeurotic plastic abdominal hernias
The main method of hernia treatment is muscle aponeurotic plastic
surgery. In this method, the strengthening of the abdominal wall defect is not
only the fascia, but the muscles.
These are the ways
1 Girard,
2 Spasokukotsky,
3 Bassini,
4 Postemsky,
5 Kirchner;
when the umbilical is the way
1 Mayo;
2 method Sapezhko and its numerous modifications.
Plastic is also widely used with the help of additional biological and
synthetic materials.

Muscle aponeurotic plastic by Bassini

Mesh plastic inguinal hernias Lichtenstein
The Lichtenstein tension-free mesh repair, which is an example
of hernioplasty and is currently one of the most popular open
inguinal hernia repair techniques, includes the following
components:
-Opening of the subcutaneous fat along the line of the incision
-Opening of the Scarpa fascia down to the external oblique aponeurosis and
visualization of the external inguinal ring and the lower border of the inguinal
ligament
-Opening of the deep fascia of the thigh and exposure of the femoral canal
to check for a femoral hernia
-Division of the external oblique aponeurosis from the external ring laterally
for up to 5 cm, safeguarding the ilioinguinal nerve
-Mobilization of the superior (safeguarding the iliohypogastric nerve) and
inferior flaps of the external oblique aponeurosis to expose the underlying
structures
-Mobilization of the spermatic cord, along with the cremaster, including the
ilioinguinal nerve, the genitofemoral nerve, and the spermatic vessels; all of
these structures may then be encircled in a Penrose drain or tape.

-Opening of the coverings of the spermatic cord and
identification and isolation of the hernia sac
-Inversion, division, resection, or ligation of the sac, as
indicated
-Placement and fixation of mesh to the edges of the defect or
weakness in the posterior wall of the inguinal canal to create a
new artificial internal ring, with care taken to allow some laxity
to compensate for increased intra-abdominal pressure when
the patient stands
-Resection of any nerves that are injured or of doubtful integrity
In males, gentle pulling of the testes back down to their normal
scrotal position
-Closure of spermatic cord layers, the external oblique
aponeurosis, subcutaneous tissue, and the skin

Surgical tactics in case of strangulated hernias
A strangulated hernia requires immediate surgical treatment. The
only contraindication to surgery is the agonal state of the patient.
Forcible reduction of the injured hernia is unacceptable, as it can
cause hemorrhages in soft tissues, intestinal wall and mesentery, thrombosis
of vessels, detachment of the mesentery, perforation of the intestine.
In addition, such an attempt can lead to an imaginary reduction of hernia.
The most important step in strangulated hernia is to allocate the
hernia sac, opening, fixing content, and then, after dissection of the restrained
ring (to dissect medially and upward), - inspection and assessment of the
viability of the organs. The affected parts of the omentum should be resected
in all cases.
The main criteria for determining the viability of the small intestine are:
1) restore normal pink color;
2) preservation of the pulsation of the vessels of the mesentery;
3) presence of peristalsis;
If all these signs are present, the intestine can be recognized as
viable and immersed in the abdominal cavity. Necrosis begins with the
intestinal mucosa, then passes to the entire wall. Therefore, at the slightest
doubt, it is necessary to make a resection of the intestine, 40 cm proximal and
20 cm distal.

Surgical tactics in case of strangulated hernias
It is particularly necessary to focus on the infringement of sliding
hernias, when there is a need to assess the viability of the affected organ in
the part that is not covered by the peritoneum.
The most often slip and pinch the cecum and bladder. In the first
case, the necrosis of the intestinal wall produce a median laparotomy and
resection of the right colon with the imposition of retransliteration. After the
end of this stage of the operation proceed to the plastic closure of the hernia
gate. Necrosis of the bladder wall requires its resection with the imposition of
epicystostomy.
At the phlegmon of hernia sac operation should start with mediana
laparotomy. This reduces the risk of infection of the abdominal cavity with the
contents of the hernial sac.
Resect the intestine, located in the hernial sac, between the abductor
and adductor loops impose anastomosis end to end or when there are large
differences in diameters ranging sew the bowel, side in side.

Operations for strangulated hernias
The median incision of the abdominal wall is sutured tightly. Then, an
incision over the hernial "tumor" dissects the skin, fiber and hernial sac.
Purulent exudate is removed. Very carefully cut hernial gates, just
enough to be able to remove and remove the pinched loop and the blind ends
of the intestine left in the abdominal cavity. Isolation of the hernial sac from
the surrounding tissues is not produced.
The neck of the sac is sutured with a purse-string seam, after which
the cavity of the hernia sac is filled with tampons.

Laparoscopic methods of treatment

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