Strangulation of the intestine. Complicated abdominal hernia

• Question 1: Hernias. Definition of the concept, etiology, pathogenesis. Elements of abdominal hernias. Anatomical features of sliding hernias. Hernia prevention.
• Question 2: Classification, general symptomatology of free abdominal hernias. Diagnostics. Indications and contraindications for surgery. Treatment results. Reasons for relapses.
• Question 3: Irreducible hernia. The reasons. Clinic, diagnosis, treatment. Preparing patients for surgery. Management of the postoperative period. Prevention.
• Question 4: Postoperative hernia. Causes of occurrence. Clinic. Diagnostics. Prevention. Operation methods. Postoperative hernias are formed in the area of ​​the postoperative scar.
• Symptoms
• Treatment of postoperative hernia
• Question 5: Strangulated hernia. Clinic. Diagnostics, differential diagnostics. False infringement. Features of operational technology.
• Question 7: Tactics of the surgeon with a dubious diagnosis of incarcerated hernia, with spontaneous reduction. Complications of violent reduction.
• Question 8: Inguinal hernia. Anatomy. Direct and oblique inguinal hernia. Congenital inguinal hernia. Diagnosis and differential diagnosis. Prevention. Operation methods.
• Question 9: Femoral hernias. Anatomy of the femoral canal. Clinic. Diagnostics. Differential diagnosis. Prevention. Operation methods.
• 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 infringements (Fecal, elastic, retrograde, parietal), pathological changes in the incarcerated organ and general changes in the body with an incarcerated hernia.
• Question 12: Anatomical and physiological information about the caecum and appendix. Influence of variants of the location of the appendix on the clinical picture of the disease.
• Question 13: Acute appendicitis. Etiology. Pathogenesis. Classification.
• Question 14: Acute appendicitis. Clinic, differential diagnosis, features of the course of acute appendicitis in children, pregnant women, elderly and senile people. Treatment.
• Question 15: complications of acute appendicitis (infiltrates, abscesses, pylephlebitis, peritonitis). Clinic. Diagnosis, treatment. Prevention.
• Question 16: Acute appendicitis. Preparing patients for surgery. The choice of operative access and anesthesia in acute appendicitis and its complications.
• 17 Management of patients after appendectomy:
• 18Chronic appendicitis:
• 20 Ulcerative pyloric stenosis-
• 21 Perforated ulcer of the stomach and 12 intestines -
• 22 Bleeding ulcer of the stomach and 12 intestines
• 23 Indications for surgical treatment of yabzh
• 24 Complications of peptic ulcer:
• 25 Preoperative preparation in patients with PU
• 26 Preoperative preparation in patients with stomach diseases:
• 27 Zhkb. Chronic cholecystitis
• 28 Acute cholecystitis
• 29 Complications of acute cholecystitis:
• 30 Choledocholithiasis
• 33 Methods for the study of extrahepatic biliary tract:
• 41. Anatomical and physiological information about the spleen. Trauma, infarction of the spleen. Thrombosis of the splenic vein. Clinic, diagnostics, differential diagnostics, treatment.
• The reasons
• Symptoms
• Course of the disease
• 42. Intestinal obstruction. Classification. Methods of examination of patients.
• 43. Intestinal obstruction. Clinic. Diagnostics. Differential diagnosis.
• 44. Mechanical intestinal obstruction. Classification. Clinic. Diagnostics. Treatment.
• 45. Mechanical intestinal obstruction. Features of violation of water - electrolyte balance and acid-base status, depending on the level and type of intestinal obstruction.
• 50. Strangulation intestinal obstruction (volvulus, nodulation, infringement). Features of pathogenesis. Clinic. Diagnostics. Differential diagnosis. Treatment. Indications for bowel resection.
• Types by localization
• Extraintestinal manifestations[edit | edit source]
• Extraintestinal manifestations
• Diagnostic studies
• Surgical complications
• 24.1. Research methods
• 69. Acute paraproctitis. Causes of occurrence. Classification. Clinic. D-ka. Treatment.
• 70. Precancerous diseases of the rectum. Etiology. Pathogenesis. Clinic. Differential diagnosis. Survey methods. Treatment.
• 72. Cancer of the rectum. Etiology. Clinic. D-ka. Methods of treatment (palliative and radical operations) Radiation therapy, chemotherapy.
• 73. Cancer of the rectum. Classifications. Ways of metastasis. Clinic, diagnostics, differential diagnostics. Treatment.
• 74. Anatomical and physiological information about the thyroid gland. Classification of diseases. Methods for the study of the thyroid gland. Prevention.
• 75. Thyroiditis and strumitis. Goiter Hashimoto. Goiter Riedel. Concept definition. Etiology, pathogenesis. Clinic. Dif. D-ka. Treatment.
• 76. Endemic and sporadic goiter. Concept definition. Classification. Etiology and pathogenesis. Clinic, Diagnostics. Prevention and treatment.
• Sporadic goiter (simple non-toxic goiter)
• 77. Thyrotoxicosis. Classification, etiology, pathogenesis. Clinic. Diagnostics and diff. D-ka.
• 78. Thyrotoxicosis. Indications for surgery and preoperative preparation. Operation methods. Complications during and after surgery.
• 79. Benign and malignant tumors of the thyroid gland. Classification. Clinic. Diagnostics. Diff. Diagnosis. Flow.
• Benign tumors (follicular adenomas)
• Malignant tumors.

• Under the infringement of a hernia is understood a sudden or gradual compression of any organ of the abdominal cavity in the hernial orifice, leading to a violation of its blood supply and, ultimately, to necrosis. Both external (in various cracks and defects of the walls of the abdomen and pelvic floor) and internal (in the pockets of the abdominal cavity and apertures of the diaphragm) hernias can be infringed.

  Elastic restraint occurs at the time of a sudden increase in intra-abdominal pressure during physical exertion, coughing, straining. At the same time, overstretching of the hernial orifice occurs, as a result of which more than usual enters the hernial sac. internal organs. The return of the hernial orifice to its previous state leads to infringement of the contents of the hernia. With elastic infringement, the compression of the organs that have entered the hernial sac occurs from the outside.

  Fecal infringement more commonly seen 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, the discharge loop of this intestine is compressed, the pressure of the hernial gate on the contents of the hernia increases and the elastic is attached to the fecal infringement. So there is a mixed form of infringement.

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

  parietal infringement occurs in a narrow infringing ring, when only a part of the intestinal wall is infringed, opposite to the line of attachment of the mesentery; observed more often in femoral and inguinal hernias, less often in umbilical. The 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 is disturbed, due to venous stasis, fluid is transuded into the intestinal wall, its lumen and the cavity of the hernial sac (hernial water). The intestine acquires a cyanotic color, the hernial water remains clear. Necrotic changes in the intestinal wall begin with the mucous membrane. The greatest damage occurs in the region of the strangulation furrow at the site of compression of the intestine by a restraining ring.

  Over time, pathomorphological changes progress, gangrene of the strangulated intestine occurs. The intestine acquires a blue-black color, multiple subserous hemorrhages appear. The intestine is flabby, does not peristaltize, the vessels of the mesentery 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. Incarceration of the intestine in the hernial sac is a typical example of strangulation ileus.

  The infringement of the intestine is accompanied by significant changes in its adductor loop, in which a lot of intestinal contents accumulate. It stretches the intestine, compresses the intramural vessels, disrupting blood and lymph circulation, which causes damage to the mucous membrane. At the same time, a violation of blood and lymph circulation occurs in the outlet part of the strangulated intestine. The toxins accumulated as a result of decomposition are absorbed into the blood, causing intoxication of the body. The reflex vomiting that occurs during infringement contributes to the rapid development of water and microelement deficiency. The progression of necrosis of the intestine, phlegmon and hernial sac leads to purulent peritonitis.

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Strangulated hernia. This is the hernia in which any organ is infringed in the hernial sac. Incarceration of a hernia is usually the result of a sudden compression of the hernial contents, either at the hilum of the hernial sac, or among adhesions in the hernial sac, or at the entrance to a natural, as well as an acquired pocket in the abdominal cavity. The intestinal loops, omentum, walls of the hernial sac, hernial membranes are infringed, sometimes only the free edge of the intestinal loop in the form of a "parietal" or "Richter" infringement.

Approximately the same is the infringement of the sedentary departments of the OK, in particular the blind, with a normal and with a "sliding" hernia. Sometimes only the mesentery is infringed. Then circulatory disorders develop over a large area 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 infringement of the intestinal loop, a picture of strangulation NK develops.

With Richter's (parietal) infringement of the intestinal loop, there are only local symptoms - soreness or irreducibility of the hernia; there are no signs of NC, but in late dates the incarceration of the hernia can become elastic if loops of the intestine 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 infringement, there is a compression of the organ by a contracted hole, which, with a sudden initial expansion, missed a section of the viscera that did not correspond to its size. With fecal infringement, the adducting section of the intestinal loop is stretched and, increasing in size, can squeeze the discharge end of the intestine in the hernial orifice. When new portions of the contents enter the adducting knee of the intestine, it stretches even more and begins to compress not only the discharge end of the intestine, but also the feeding vessels. Thus, infringement can occur even in wide hernial orifices.

There are also direct infringement of the intestinal loop in the hernial sac; retrograde infringement, when two loops are in the hernial sac, and the third (middle loop) located in the abdominal cavity is infringed. There is also a combined infringement. A significant danger is the parietal infringement of the intestinal loop - Richter's hernia(picture 1).

When infringing, the organs that have entered 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 cicatricial bands compressing the organs, with fusion of organs with each other and with the hernial sac.

Figure 1. Parietal infringement (Richter's hernia)

Femoral hernias are incarcerated 5 times more often than inguinal and umbilical ones. Small hernias with a narrow and cicatricial-altered neck of the hernial sac are infringed more often. With reducible hernias, this occurs relatively rarely. Infringement does not occur when a hernia occurs. Infringement occurs with inguinal hernias (43.5%), postoperative hernias (19,2%), umbilical hernia(16.9%), femoral hernias (1b%), hernias of the white line of the abdomen (4.4%) (M.I. Kuzin, 19871. The TC cup and the greater omentum are infringed, but any organ (bladder, ovary , PR, Meckel's diverticulum).

Elastic restraint occurs suddenly, at the time of a sharp increase in intra-abdominal pressure, during physical exertion, coughing, straining in other situations. At the same time, more than usual intra-abdominal organs enter the hernial sac. This occurs as a result of overstretching of the hernial ring. The return of the hernial orifice to its previous position leads to infringement of the contents of the hernia (Figure 2). With elastic infringement, the compression of the organs that have entered the hernial sac occurs from the outside.

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

The main violations occur in CO. This is due to the fact that the vessels that feed the intestinal wall pass through the submucosal layer. In the serous pathological changes appear 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 abductor knee, at a distance of about 15 cm. This circumstance must be taken into account when determining the level of resection of the afferent loop. Strangulated hernia is essentially one of the varieties of acute strangulation NK.

With a strong and prolonged infringement and complete cessation of blood circulation in the arteries and veins, irreversible pathomorphological changes occur in the strangulated organ. When the intestine is infringed, 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 the infringing ring, dry gangrene can develop without the accumulation of hernial water.

At the beginning of infringement, the intestine is cyanotic, hernial water is clear. Pathological changes in the intestinal wall gradually progress over time. The strangulated intestine acquires a blue-black color, the serous membrane becomes dull, and multiple hemorrhages occur. The intestine becomes flabby, there is no peristalsis, the vessels of the mesentery do not pulsate. Hernial water becomes cloudy, with a hemorrhagic tinge, there is a fecal odor. The resulting necrotic changes in the intestinal wall can be complicated by perforation with the development of fecal phlegmon and peritonitis.

As a result of NC, intra-intestinal pressure increases, the intestinal walls stretch, the intestinal lumen overflows with intestinal contents, which further aggravates the already disturbed blood circulation. As a result of damage to CO, the intestinal wall becomes permeable to microbes. The penetration of microbes into the free abdominal cavity leads to the development of peritonitis.

Infringement of the intestine by the type of Richter's hernia is dangerous because at first there is no NK with it, 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.
A certain danger is also a retrograde strangulation of the hernia (Figure 3).

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

Figure 3. Retrograde strangulation

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

Clinical picture has its own characteristics in case of infringement Bladder, ovary, omentum and other organs.

When examining a patient, a sharply painful hernial protrusion of a densely elastic consistency is found, which does not retract into the abdominal cavity.

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

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

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

With elastic infringement, a sudden strong and constant pain in the area of ​​​​the hernial protrusion is due to compression of the vessels and nerves of the mesentery of the strangulated intestine.

Infringement is manifested by signs of NK: cramping pain associated with increased intestinal motility, retention of stools and gases, vomiting. Abdominal auscultation reveals increased bowel sounds. Panoramic fluoroscopy of the abdomen reveals distended bowel loops with horizontal levels of fluid and gas above them (“Kloiber’s cups”). Somewhat later, signs of peritonitis appear.

There are three periods of the clinical course of 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, 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 alleged improvement in the course of the disease. Meanwhile, the decrease in pain is due not to an improvement in the patient's condition, but to the necrosis of the strangulated loop of the intestine.

If no assistance is provided to the patient, his condition deteriorates sharply, diffuse peritonitis develops, i.e. the third period begins. At the same time, the body temperature rises, the pulse quickens. Appears bloating, vomiting with a fecal odor. Edema develops in the area of ​​the hernial protrusion, skin hyperemia appears, and phlegmon occurs.

Diagnostics in typical cases is not difficult and is carried out on the basis of characteristic features: acute, sudden onset pain and irreducibility of a previously reducible hernia. When examining a patient in the inguinal region, a painful, tense, irreducible hernial protrusion is revealed (at the external opening of the inguinal canal). When the bowel loop is infringed, the phenomena of strangulation NK join the indicated symptoms.

You should also think about the possibility of infringement in the internal opening of the inguinal canal (parietal infringement). In this regard, in the absence of a hernial protrusion, it is necessary to conduct a digital examination of the inguinal canal, and not be limited only to the study of the external inguinal ring. With a finger inserted into the inguinal canal, it is possible to feel a small painful seal at the level of the internal opening of the inguinal canal. Mistakes are often made in the diagnosis of strangulated hernias. Sometimes diseases of the urogenital area (orchitis, epididymitis), inflammatory processes in the inguinal and femoral lymph nodes or tumor metastases to these nodes, swell abscesses in the groin area, etc. are sometimes taken as infringement.

Retrograde infringement(See Figure 3). TC is more often exposed to retrograde infringement. Possible retrograde infringement of the colon, greater omentum, etc.

Retrograde infringement occurs when several intestinal loops are located in the hernial sac, and the intermediate loops connecting them are 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 binding intestinal loops located in the abdominal cavity are subjected to infringement to a greater extent. Necrotic changes develop to a greater extent and earlier in these intestinal loops located above the strangulated ring.

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

Diagnosis cannot be established prior to surgery. During the operation, the surgeon, having found two intestinal loops in the hernial sac, must, after dissecting the restraining 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 the retrograde infringement during the operation remains unrecognized, then the patient will develop peritonitis, the source of which will be the necrotic binding loop of the intestine.

parietal infringement(see figure 1). Such infringements occur in a narrow infringing ring. In this case, only a part of the intestinal wall, opposite to the line of attachment of the mesentery, is infringed.

Parietal infringement of the small intestine is more often observed with femoral and inguinal hernias, less often with umbilical ones. As a result of the upcoming 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 infringement of the intestine is clinically different from the incarceration of the intestine with its mesentery. With parietal infringement, shock does not develop. Symptoms of NK may be absent, since the patency through the intestines 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 expressed sharply, since the mesentery of the strangulated section of the intestine is not compressed.

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

If the general condition of the patient initially remains satisfactory, then 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 infringement can simulate an acute inguinal lymphadenitis or adenophlegmon.

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

Sudden appearance and infringement 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. More commonly, such a hernial sac in the inguinal region is an unclosed vaginal process of the peritoneum.

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

In patients in the anamnesis, there are no indications of pre-existing hernias, protrusions, pain in the characteristic places of hernia localization. The main symptom of sudden strangulated hernias is acute pain in typical places exit of hernias. 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, dense, painful.

Differential Diagnosis . Infringement of a hernia is differentiated from inflammation of the lymph nodes, tumors of the ovary and spermatic cord, volvulus, cases of "false" infringement, when inflammatory exudate accumulates in the hernial sac during peritonitis; tumor metastases. The 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. It develops with severe infringement of the hernia. It is observed mainly in elderly and senile patients with late visits to the doctor. Phlegmon of the hernial sac can be serous, putrefactive or anaerobic in nature.

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

In the area of ​​hernial protrusion, hyperemia of the skin is determined, on palpation - a tumor of a densely elastic consistency, tissue swelling, enlarged regional lymph nodes.

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

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

Elastic infringement also joins the fecal infringement. Thus, there is a combined form of infringement.

Coprostasis contributes to the irreducibility of the hernia, sedentary lifestyle, plentiful food. Coprostasis is observed in men with inguinal hernias, in women with umbilical hernias. With this form of infringement, as the OK is filled stool hernial protrusion is almost painless, slightly tense, dough-like consistency, positive cough symptom. In the intestinal loops, dense lumps of feces are determined.

Coprostasis can occur as a result of compression in the hernial orifice of the efferent bed and go into fecal incarceration. When a fecal infringement occurs, signs of obstructive NK increase. At the same time, the pain intensifies and acquires a cramping character, vomiting becomes more frequent. In the future, due to the overflow of fecal masses of the intestine located in the hernial sac, compression of the entire loop of the intestine and its mesentery by the hernial ring occurs.

Unlike elastic infringement during coprostasis, the infringement occurs slowly and gradually increases, the hernial protrusion is slightly painful, doughy in consistency, slightly tense, the cough impulse is determined, the closure of the intestinal lumen is incomplete, vomiting is rare; the general condition of the patient at first suffers slightly. In advanced cases, abdominal pain, general malaise, intoxication, nausea, vomiting, i.e. there is a clinic of obstructive NK.

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

These signs correspond to signs of infringement of a hernia.

With false infringements, the anamnesis of these diseases and a carefully conducted objective examination of the patient help to make the correct diagnosis of acute diseases of the abdominal organs and exclude the infringement of the hernia. At the same time, 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 pain in the abdomen (later accession of pain in the area of ​​a reducible hernia is more typical for acute diseases of the abdominal organs than for strangulated hernia).

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

OH is characterized by a sudden onset of acute pain in the right hypochondrium with irradiation under the right shoulder blade, to the right shoulder girdle, the greatest soreness and muscle tension are observed in the right hypochondrium, Ortner's and Murphy's symptoms are positive.

For acute appendicitis the appearance of pain in the epigastric region or around the navel is characteristic, followed by the movement of pain to the right iliac region, in this area the greatest soreness and muscle tension are determined.

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

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

Prevention and treatment of external abdominal hernias. The main method of treatment of uncomplicated, and even more complicated hernias is operational. A timely operation is the only reliable means of preventing infringement, 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, it should not be postponed for a long time surgical treatment patients with hernia. The most effective measure to prevent strangulation and recurrence of a hernia is an early elective operation.

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

To prevent a hernia, it is necessary to eliminate, as far as possible, all the causes that contribute to a systematic increase in intra-abdominal pressure. Strengthening the abdominal wall is facilitated by systematically carried out sports exercises. Obesity and sudden weight loss should be avoided.

Surgical treatment of uncomplicated hernias. The principle of the operation for uncomplicated hernias is to isolate the hernial sac, open it, revise and reduce 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 bag is excised. Hernial orifice plasty is performed in various ways - from simple interrupted sutures to complex plasty methods. For plasty of large hernia gates, strips of the broad fascia of the thigh, deepithelized skin strips, and alloplastic materials are used.

Treatment of strangulated hernias. The only treatment for strangulated hernias is an emergency operation - the elimination of the strangulation. The main stages of the operation for strangulated hernias are the same as for the planned operation. The difference is as follows: at the first stage, the tissues are dissected in layers, the hernial sac is exposed, and it is opened. To prevent slipping of the restrained organs into the abdominal cavity, they are held with a gauze napkin. Then the restraining ring is dissected, taking into account the anatomical relationships. Viable organs are put into the abdominal cavity. Dissection of the restraining ring before opening the hernial sac is considered unacceptable.

If the restraining ring is cut before opening the hernial sac, then the restrained organ may slip into the abdominal cavity. Dissection of the hernial sac is carried out carefully so as not to damage the swollen intestinal loops that are tightly adjacent to the wall of the hernial sac.

With femoral hernias, the incision is made medially from the neck of the hernial sac in order to avoid damage to the femoral vein located at the lateral side of the sac. With umbilical hernias, the restraining ring is cut in the transverse direction 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 gangrene of the intestine, it has the character of ichorous exudate.

After dissection of the pinching ring and introducing novocaine solution into the mesentery of the intestine, those parts of the pinched organs that are above the pinching 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 warm isotonic sodium chloride solution.

The main criteria for the viability of the small intestine: the restoration of the normal pink color of the intestine, the absence of a strangulation groove and subserous hematomas, the preservation of the pulsation of the small vessels of the mesentery and peristaltic contractions of the intestine. Signs of non-viability of the intestine and unconditional 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 a “wet paper” symptom.

The presence of deep changes along the strangulation furrow also serves as an indication for bowel resection. Suturing such furrows is considered a risky undertaking. In the case of parietal infringement of the intestine, with the slightest doubt about the viability of the area that was in the infringement, it is recommended to resect the intestine. Conservative measures, such as immersion of the altered area into the intestinal lumen, should not be performed, since when a small area is immersed, if the sutures are drawn close to its edges, they can easily disperse, and when a larger area of ​​the intestine is immersed, its patency becomes doubtful.

If necessary, resection of the non-viable intestine is performed. Regardless of the length of the altered area, resection should be carried out within the limits of, of course, healthy tissues. Remove at least 30-40 cm of the leading and 15-20 cm of the outlet section of the intestine. The anastomosis is applied side to side or end to end, depending on the diameter of the proximal and distal portion of the intestine. Resection of the intestine, as a rule, is performed from the laparotomy access.

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

In case of infringement of sliding hernias, it is recommended to assess the viability of that part of the organ that is not covered by the peritoneum. In this case, there is a risk of damage to the OK or the bladder. If SC necrosis is detected, a median laparotomy is performed and the right half of the OK is resected with the imposition of an ileotransverse anastomosis. In case of necrosis of the bladder wall, its resection is performed with the imposition of an epicystostomy.

The restrained omentum is resected in separate sections without the formation of a large common stump. The ligature can slip off the massive stump of the omentum, which will lead to dangerous bleeding into the abdominal cavity. After that, the hernial sac is isolated and removed with suturing of its stump in any way. Streets of elderly and senile age are not recommended to isolate and remove the hernial sac at all costs. It is enough to select it only in the neck area and slightly above it, cut it transversely along its entire circumference, tie it up at the neck, and leave the distal part of the bag in place, turning it inside out.

The next important stage of the operation is the choice of the method of hernia repair. At the same time, preference is given to the simplest methods of plastic surgery. With 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.

With 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, the intestine is resected within viable tissues. The ends of the resected area are sutured by applying end-to-end or side-to-side anastomosis between the afferent and efferent loops. At the same time, the peritoneal cavity is isolated from the cavity of the hernial sac. To do this, around the mouth of the hernial sac, the parietal peritoneum is dissected and it is dissected to the sides by 1.5-2 cm.

After stitching the afferent and efferent loops of the resected colon near the hernial orifice, between the sutures or ligatures, the loops of the resected colon are crossed and removed along with a 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 wound of the abdominal wall is sutured tightly in layers.

After that, 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 so as to remove the strangulated intestine and its blind ends of the adducting and retracting segments. After removal of the strangulated intestine, separation of the mouth and neck of the hernial sac from the hernial orifice, it is removed along with the altered tissues. Several sutures are applied to the edges of the hernial orifice (plasty is not performed) in order to prevent eventration in postoperative period. To complete surgical treatment purulent focus, the wound is drained with perforated drainage, the ends of which are removed from the wound through healthy tissues.

Through drainage tube carry out a long-term constant washing of the brine antibacterial drugs, while ensuring sufficient outflow of discharge from the wound. Only such an approach to the treatment of a purulent focus with hernial phlegmon makes it possible to reduce mortality and perform early wound closure 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 infringement and on the changes that have occurred in the strangulated internal organs. The less time passed from the moment of infringement to the operation, the better the result of the surgical intervention, and vice versa. Mortality in case of incarcerated, but in a timely manner (2-3 hours from incarceration) operated hernias does not exceed 2.5%, and after operations during which bowel resection was performed, it is 16%. The outcome is especially serious with phlegmon of the hernial sac and laparotomy. Mortality in this case 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 with the forcible reduction of a strangulated hernia, damage to the hernial sac and the contents of the hernia can occur, up to the rupture of the intestine and its mesentery. In this case, the hernial sac can shift into the preperitoneal space along with the contents, restrained in the region of the neck of the hernial sac; there may be a separation of the parietal peritoneum in the neck of the hernial sac and immersion of the restrained, non-viable loop of the intestine, together with the restraining ring, into the abdominal cavity or into the preperitoneal space (Figure 4).

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

It is very important to recognize the imaginary reduction of a hernia in a timely manner. Anamnestic data: pain in the abdomen, 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 you to think about the imaginary reduction of the hernia and perform an emergency operation.

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

The lack of effect from the above 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 infringement (over 12 hours), suspected intestinal gangrene, parietal infringement, with phlegmon of the hernial sac. If the patient had a spontaneous reduction of the 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, and so on. If peritonitis or internal bleeding is suspected, emergency surgery should be performed. For the rest of the patients with spontaneously reduced hernia, a long-term unremitting observation is established in order to early detection signs of peritonitis and internal bleeding.

Pinched abdominal hernia is a clamping of the organ in the hernial sac, against which the blood circulation is disturbed, the functioning gradually changes, the organ begins to die. Abdominal hernias are more common in people whose activities are associated with high physical activity, in pregnant women, with traumatic damage to the abdominal organs. The pinched hernia is localized in the region of the protrusion gate. The most prone to such a complication are hernias of the white line of the abdomen and inguinal ones.

The stomach, part of the intestine, the esophagus can suffer from pinching in the white line hernia bag, and when inguinal hernia- bladder, intestines, omentum, ovaries in women.

This complication occurs with inadequate treatment of the disease, ignoring preventive measures and increasing the load.

Allocate primary and secondary pinching of organs. The primary form manifests itself acutely, has not been previously observed, and the first manifestations are associated with pinching. A secondary pathological process develops with an already existing protrusion, the patient knows about the pathology, but neglects preventive measures.

The reasons

Main clinical manifestations infringement of the protrusion of the white line of the abdomen depends on the affected organ, the cause, the degree of the disease and general condition patient. There are elastic and fecal pinching, the symptoms of which also differ. The elastic process occurs with a sharp change in intra-abdominal pressure during coughing, stomach overflow, increased physical activity. An overstrain of the protrusion gate leads to the penetration of more intestinal contents into it, and at the moment of relaxation, a direct pinching of a part of the intestine occurs. With fecal infringement, there is an accumulation of a large amount of feces in the affected part of the intestine. A fecal lesion can be combined with an elastic one, and a combined infringement occurs.

The provoking factors of pinched hernia of the white line of the abdomen are:

• a sharp increase in intrauterine pressure;
• constipation, inflammatory disease stomach;
• weight lifting, physical and emotional overstrain;
• decreased immune defense, exacerbation of chronic diseases.

The organ, localized in the hernial sac, gradually changes, the processes of blood circulation and lymph distribution are disturbed.

The secretory function of the stomach is disturbed, venous stasis provokes the penetration of fluid into the walls of the intestine and the cavity of the protrusion sac. A hernia of the white line of the abdomen is accompanied by an accumulation of exudate, which, when perforated, leads to intoxication and acute peritonitis. The progression of the pathology leads to necrosis of the intestine, it changes in color, the hernia of the abdomen becomes painful and is a thunderstorm for the life of the patient. the only the right treatment belly protrudes surgical intervention Therefore, it is important to identify the symptoms of complications in a timely manner and consult a doctor.

Clinical manifestations

Morphological and physiological changes in the abdominal organs occur, the disease progresses and manifests itself with specific symptoms:

• gangrenous lesion of the strangulated abdominal organ;
• discoloration of the intestines to black;
• change in the consistency of the intestine, loss of elasticity, lack of pulsation;
• the color of the aqueous fluid in the hernial sac gradually changes, a fecal odor appears;
• neglected infringement of the protrusion of the abdomen ends with perforation, peritonitis, internal bleeding.

Any organ located in the abdominal part can fall under the infringement of a hernia of the white line, but more often it is an intestinal loop, colon or gland.

Early symptoms of a pinched hernia of the white line of the abdomen:

• increased intestinal peristalsis, flatulence, gas retention;
• pains are acute, paroxysmal;
• dyspeptic disorders: nausea, vomiting (in case of complications, it can be with blood).

When clamped in the hernial orifice of the omentum, the symptomatic complex is less pronounced, the pain is moderate, vomiting with blood is rare. With local palpation, a pronounced pain syndrome is manifested, the affected area is dense, does not increase with straining.

Late symptoms of a pinched hernia of the esophagus are observed in people with weakened immune systems, while the main complaint of patients is nausea and moderate pain at the site of the hernia:

• an attack of pinching passes for the patient without a trace, does not manifest itself outwardly;
• after a few days on the diagnosis, you can see a phlegmonous lesion;
• hyperemia skin, accumulation of exudate in the hernial sac;
• localized increase in temperature at the site of the protrusion;
• deterioration in general well-being occurs within three days, manifested by fever.

Clinical manifestations of strangulated internal hernia of the esophagus:

• mild pain when feeling the pathological area;
• weak breathing;
• percussion sound is dulled;
• the heart moves to a healthy area;
• Peristaltic noise is heard in the region of the lower part of the chest.

Diagnosis of infringement of the protrusion of the esophagus is complicated by a reduced reactivity of the organism, such patients are often hospitalized with signs of pneumothorax.

How is the disease diagnosed?

A hernia of the esophagus begins to manifest itself pronouncedly in the event of complications. When bleeding, symptoms of vomiting with blood appear, severe pain, change in the consistency and color of feces. Gastric bleeding can be chronic, when the cause is an ulcerative or erosive lesion of the esophagus. In this case, bleeding has one manifestation - anemic syndrome. Difficulty swallowing is a mandatory accompanying symptom of any form of the disease.

Long-term experience of specialists has shown the effectiveness of diagnosing a pinched hernia of the esophagus using radiography and endoscopy. The upper sections of the digestive organs are amenable to research.

To confirm the diagnosis, additional measures are used: ultrasound, CT scan or magnetic resonance imaging:

• radiographic diagnosis of a hernia of the esophagus shows a violation of the anatomical position of the stomach or intestines, its partial localization above the diaphragm;
• ultrasound shows concomitant diseases of the protrusion: the localization of an ulcer or erosion of the esophagus, the presence of bleeding or perforation;
• gastroscopy of the esophagus is indicated for a thorough visual assessment of the mucous membrane of the digestive organs. On the study, you can see almost any type of lesion of the esophagus, stomach and duodenum;
• histological examination of tissues is carried out to exclude a malignant disease, acid concentration is also evaluated gastric juice, daily pH of the esophagus;
• a general blood test shows deviations in the total protein, glucose and amylase, allows you to see the inflammatory process, symptoms of intoxication of the body.

After a detailed assessment of the lesion and localization of the pathological process, the doctor prescribes a conservative, physiotherapeutic or surgery followed by prevention of complications and recurrence of hernia.

Complex treatment

Infringement requires immediate surgical treatment.

Surgical treatment is carried out in several stages:

• dissection of tissues in layers to the location of the aponeurosis and visual determination of the hernia sac;
• the hernial sac is opened, the fluid is removed;
• the hernial ring is dissected;
• visual assessment of pinched organs, determination of the level of damage;
• removal of a necrotic loop, strangulated in the hernia sac;
• hernia gate plasty (white line, umbilical ring or inguinal canal).

Strangulated hernia. Concept definition. Types of infringement. Pathological and anatomical and pathophysiological changes in various parts (departments) of the strangulated organ. Clinic of infringement. Differential Diagnosis

Hernia incarceration is understood as a sudden compression of the hernial contents in the hernial orifice, followed by ischemic necrosis of the organs and tissues in the hernial sac. Infringement is the most frequent and dangerous complication hernia. It occurs in 10-15% of patients with hernias. In the structure of acute surgical diseases of the abdominal organs, strangulated hernias occupy 34th place and account for about 4.5%. Among patients with strangulated hernias, elderly and senile people predominate.

From the point of view of the mechanism of occurrence of a strangulated hernia, there are two fundamentally various types infringements: elastic and fecal. It is also possible to have a combination of both

Elastic infringement occurs with a sharp increase in intra-abdominal pressure and a sudden release of a larger than usual number of internal organs through the hernial orifice. Due to the narrowness of the hernial orifice and the resulting spasm of the surrounding muscles, the released organs cannot be reduced into the abdominal cavity. Their compression (strangulation) occurs, leading to ischemia of the strangulated organs and impaired venous outflow. The resulting edema of the hernial contents contributes to an even greater increase in strangulation.

Fecal infringement develops as a result of overflow with fecal masses of the intestinal loop located in the hernial sac. Its leading section is stretched and, increasing in size, begins to compress the outlet section of this intestine together with the adjacent mesentery in the hernial ring. Ultimately, a pattern of strangulation develops, similar to that observed with elastic infringement. For the occurrence of fecal infringement, it is not physical effort that is of primary importance, but a violation of intestinal motility, a slowdown in peristalsis, which is more common in the elderly and senile age. In addition, wide hernial orifices, kinks and adhesions of the intestine with the wall of the hernial sac contribute to fecal infringement. In some cases, the overflow of the leading section of the intestinal loop, located in the hernial sac, is combined with elastic pressure from the hernial orifice, resulting in the development of a mixed (combined) infringement.

In case of infringement in the hernial orifice of the intestinal loop, 3 sections should be distinguished in it: adductor knee; the central section, located in the hernial sac; abducting knee. The greatest pathoanatomical changes occur in the central part of the strangulated intestinal loop and the strangulation furrow, which is formed at the site of compression of the intestine by the strangulating ring.

As a result of violations of blood and lymph circulation in the strangulated organ, prolonged venous stasis, plasma leaks into the wall and lumen of the intestine. The subsequent transudation of fluid from the strangulated intestine into the closed cavity of the hernial sac leads to the appearance of the so-called "hernial water", which at first is transparent, and then, due to sweating of erythrocytes and infection, becomes turbid hemorrhagic. Gradually, purulent inflammation develops in the hernial sac, which comes out (in the absence of timely treatment) outside the hernial sac. A similar purulent inflammation of the hernial sac and surrounding tissues, which develops in the late stages of infringement, is called the phlegmon of the hernial sac.

With rapid and simultaneous compression of both the veins and arteries of the mesentery of the intestine by the restraining ring, "hernial water" is not formed. The so-called "dry gangrene" of the strangulated intestine develops.

In case of infringement, not only the part of the intestine located in the hernial sac suffers, but also the department that leads to it, located in the abdominal cavity. It undergoes all those changes that are characteristic of acute intestinal obstruction: overflow with contents and overstretching of the intestinal wall, the development of putrefactive processes in its lumen, fluid extravasation, sweating of toxins and microorganisms into the free abdominal cavity, the development of peritonitis.

When any hernia is infringed, the following 4 are most characteristic clinical signs: 1) sharp pain in the area of ​​the hernial ring; 2) irreducible hernia; 3) tension and soreness of the hernial protrusion; 4) lack of transmission of the cough impulse.

Pain is the main symptom of infringement. It is so strong that the sick cannot help moaning and screaming. Quite often the phenomena of the real painful shock are observed. Pain occurs at the moment of physical exertion and does not subside for several hours: until the moment when necrosis of the strangulated organ occurs with the death of intramural nerve elements.

The second sign of irreducible hernia is of great diagnostic value when a free hernia is infringed. In this case, patients note that the previously reduced hernial protrusion has ceased to be reduced into the abdominal cavity since the onset of pain.

The tension of the hernial protrusion and a slight increase in its size accompany the infringement of both reducible and irreducible hernia. Therefore, this sign is much more important for recognizing the infringement than the irreducibility of the hernia itself. Diagnostic value is not only the tension of the hernial protrusion, but also its sharp pain when palpated.

The negative symptom of a cough shock is due to the fact that at the moment of infringement, the hernial sac is disconnected from the free abdominal cavity and becomes an isolated formation. In this regard, an increase in intra-abdominal pressure at the time of coughing is not transmitted to the cavity of the hernial sac.

In addition to these four signs, when a hernia is infringed, symptoms can be observed due to the development of intestinal obstruction: vomiting, bloating, flatulence, etc. When the bladder is infringed, there are pains above the pubis, dysuric disorders, microhematuria.

differential diagnosis. It is necessary to differentiate the infringement of a hernia: 1) with pathological conditions the hernial protrusion itself (irreducibility, coprostasis, inflammation of the hernia, "false infringement"); 2) with diseases that are not directly related to the hernia (inguinal lymphadenitis, swell abscess, tumors of the testicle and spermatic cord, volvulus).

Internal infringement can occur in the presence of Meckel's diverticulum, adhesions, in the openings of the mesentery, omentum, broad ligament of the uterus.

Internal infringement in Meckel's diverticulum

Among the various malformations that can cause internal infringement and obstruction, it occupies the first place.

Internal infringement is more common with a fixed diverticulum and less often with a free diverticulum. With a free diverticulum, the infringement of the diverticulum itself or the infringement of it together with the loop of the small intestine can occur in all internal openings and pockets of the peritoneum.

Internal infringement most often develops when the diverticulum is fixed to the loops of the small intestine, its mesentery and to the caecum. In such patients, a ring is formed into which loops of the small intestine, omentum, large intestine or other organs slip.

In this ring, necrosis of the retrograde located loop can sometimes develop.

Internal entrapment of the small intestine with Meckel's diverticulum may occur at the mesenteric orifice, appendix, inguinal or femoral canal.

Diagnosis of obstruction with internal infringement presents significant difficulties: the diverticulum is an appendage that is unstable, and its presence is not always assumed. There are no pathognomonic symptoms. However, sometimes it is possible to determine more intense pain in the right iliac region compared to other areas, more intense muscle tension, a symptom of Shchetkin-Blumberg. This is explained more frequent localization diverticulum in this area and the concomitant development of inflammatory changes in it.

With a diverticulum fixed to the navel or to the parietal peritoneum, drawing pains in the navel, right iliac region are often noted. They are very difficult to distinguish from those in acute, therefore, when performing an appendectomy and not finding changes on the part of the process that are adequate to the severity of the patient's condition, one should always remember the possibility of the presence of Meckel's diverticulum. Then it is necessary to expand the surgical wound and inspect the terminal part of the ileum for at least 1 m.

In addition, obstruction caused by the presence of Meckel's diverticulum can be combined with.

The variability of the diverticulum contributes to the development of a wide variety of clinical forms obstruction: obstructive, strangulation, combined and dynamic.

Strangulation develops mainly according to the type of internal infringement. The clinical picture is no different from other types of strangulation obstruction.

Adhesive obstruction occurs only with a fixed diverticulum. Cord-like cords most often consist of remnants of an obliterated vitelline duct or are formed by fusion of the apex of the diverticulum with the greater omentum, appendix, and fallopian tube. A diverticulum can be a strangulated or strangulated organ. Planar adhesions between the diverticulum and the intestine are formed after the former diverticulitis, transferred and peritonitis of any origin. The mechanism of such obstruction is no different from ordinary adhesive obstruction without Meckel's diverticulum.

When a loop of the small intestine with a closed diverticulum is inverted, its perforation and the development of peritonitis may occur.

When removing an obstruction, Meckel's diverticulum should always be removed at the same time.

Entrapment of the intestines in the openings of the mesentery, omentum and broad ligament of the uterus

Such internal infringements are a rare cause acute obstruction intestines. Such infringement accounts for 92% of all forms of this disease.

The origin of the mesenteric openings has not been precisely established. Most likely, the formation of defects in the mesentery should be explained by the peculiarities of phylogenetic development, which is based on the process of intrauterine regression of its tissue.

Sometimes holes in the mesentery and omentum are of traumatic origin, as a result of a closed or open injury abdomen, they can also be left by the surgeon after surgery.

In addition to the presence of a gap, additional factors are needed that contribute to infringement: sudden onset fluctuations in intra-abdominal pressure and negative pressure in the subdiaphragmatic space, sucking the intestine and contributing to its infringement, as well as spasmodic contraction of individual loops, leading to a decrease in the caliber of the intestine and its easy slipping into this gap .

Preoperative diagnosis of this type of obstruction presents significant difficulties. There is not a single sign by which one can distinguish internal infringement of the intestine in the mesenteric openings from other types of strangulation obstruction.

In the mesenteric openings, any parts of the intestine, omentum, Meckel's diverticulum, appendix can be infringed. More often loops of small intestines penetrate independently or together with sections of the large intestine.

In addition to internal infringement, nodulation, volvulus, adhesive obstruction, or a combination of these types of obstruction may develop.

Sometimes the initial infringement in the mesenteric opening can be spontaneously eliminated by expanding or rupturing this opening with further advancement of the insides into it. With such a rupture, the mesenteric vessels can be damaged. In such cases, the leading symptoms instead of symptoms of obstruction may be symptoms of internal bleeding, which is the rarest pathology.

Internal infringement of the intestine can occur in the opening of any localization: the mesentery of the small intestine, the opening of the mesentery of the appendix, the mesentery of the transverse colon, sigmoid colon. Holes in the mesentery of the transverse colon are sometimes left by surgeons in the stomach. Prevention of infringements in such holes consists in careful suturing of cracks in the mesentery during operations.

Internal infringement in the openings of the broad ligament of the uterus is rare. Clinical course it was no different from the infringements in the holes of other localization.

Treatment of obstruction arising from the introduction of the intestines into the mesenteric openings can only be operative: to eliminate the infringement, it is necessary to expand the opening in the mesentery or release the incarcerated loop after emptying it from the contents by puncture, resect the necrotically altered area and close the opening in the mesentery by suturing its edges . It is not recommended to sew an omentum, mesentery or intestinal loop to the hole.