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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. Infringement is the most common and dangerous complication 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 NK, but in the later stages, the infringement of the hernia can become elastic if intestinal loops or another organ are suddenly introduced through a narrow internal opening into the hernial sac; 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 moment of a sharp increase in intra-abdominal pressure, with physical activity, cough, strain and 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.

Incarceration of the intestine by the type of Richter's hernia is dangerous because at first there is no NK with it, and therefore 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.

The clinical picture has its own characteristics with 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 signs.

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 a general state 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 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 of the abdominal wall. With this complication, there is pain in the area of ​​the hernia, skin above the hernia are 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 of a large amount of 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 an inflammatory process in it. 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, make the correct diagnosis acute diseases of the abdominal organs and exclude the infringement of the hernia helps the anamnesis of these diseases and a carefully conducted objective examination of the patient. 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.

Acute appendicitis is characterized by the appearance of pain in the epigastric region or around the navel, followed by pain moving 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 at the slightest suspicion of an acute disease of the 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 a diagnostic error, the prognosis will be unfavorable.

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, one should not postpone the surgical treatment of patients with a hernia for a long time. 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.

Elements of strangulated hernia

Strangulated hernia - Incarceration (strangulated) hernia

Rice. Types of infringement

Fecal incarceration - Fecal incarceration 1 - irreducible hernia; 2- hernial orifice is not expanded; retention of intestinal contents in the intestinal area, fixed

Richter's hernia - Parietal (Richter's) hernia

Richter's hernia = parietal infringement

Retrograde (W-shaped) strangulation = Maydl's hernia (hernia Maydl)

Features of Meidl's hernia:

We list the options for "imaginary reduction":

Rice. Varieties of "imaginary reduction".

Imaginary reduction with strangulated hernia

Bowel necrosis

What does history give?

Strangulated hernia is characterized by 4 local signs + symptoms of strangulation intestinal obstruction:

Rice. Irreducible hernia. Features: no pinching ring, no soreness, no symptom of a cough shock, there is an fusion of the hernial

Infringement of the Meckel diverticulum in the hernial sac (Littre-Littre hernia)

Stages of operation for a strangulated hernia:

General rules for operations with strangulated hernias

Dissection of the restraining ring

Unconditional signs of non-viability of the intestine

The main criteria for the viability of the small intestine

The non-viable bowel must be resected within healthy tissue.

Plastic part of surgery for strangulated hernia (national guidelines)

Features of the clinic of phlegmon of the hernial sac

Phlegmon of the hernial sac. Treatment tactics.

Strangulated hernia

Incarceration is the most severe complication of hernias, observed in 3-15% of patients with hernias. AT last years there is some increase in connection with the lengthening of life expectancy - over 60% of patients - older than 60 years (Petrovsky). Infringement is a sudden compression of the hernial contents in the hernial orifice, or a cicatricially changed neck of the hernial sac, followed by malnutrition of the strangulated organ. Distinguish between elastic infringement - due to a sudden contraction of the abdominal muscles and fecal infringement - with an abundant intake of intestinal contents into the loop lying in the hernial sac. In addition, parietal infringement (Richter's) is distinguished - infringement of the part of the intestinal wall opposite the mesentery, in a small hernia orifice (often with femoral hernias or in the inner ring with oblique inguinal) and retrograde infringement - infringement of the intermediate loop lying in the abdominal cavity, and not visible in the hernial sac - may be accompanied by necrosis of the loop in the abdominal cavity (in this case, 2 or more loops of the intestine are determined in the hernial sac). Most often, the intestinal loop is infringed, then the omentum, while the degree of oncoming changes in the incarcerated organ depends on the period of infringement and the degree of compression.

Clinical picture

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

Impairment that came on suddenly.

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

The disappearance of the symptom of "cough push".

Symptoms of intestinal obstruction - vomiting, turning into feces, non-excretion of gases and feces, bloating (absent with Richter's infringement, as well as with infringement of the omentum).

Common symptoms are pallor, cyanosis, cold extremities, dry tongue, and a small, rapid pulse.

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

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

The anamnesis must be of decisive importance. Inspection of all possible hernial gates in acute diseases of the abdominal cavity is mandatory. “In case of obstruction of the intestines, one should first of all examine the hernial orifice and look for a strangulated hernia” (Mondor).

Always prompt, as soon as possible after the infringement. In 3 days after infringement, lethality increases 10 times. Even with a timely operation, deaths are currently observed at 2.5% or more. Operation - elimination of infringement, in case of necrosis - resection of the altered intestine, followed by hernia repair and plasty.

Operation features:

The restraining ring is not dissected until the opening of the hernial sac, examination and fixation of the restrained organs. The infringing ring with femoral hernias is dissected inwards.

Caution when cutting the ring to avoid damage to the restrained organs and vessels of the abdominal wall.

Remember about the possible infection of the "hernial water" - wrapping with napkins, suction, sowing.

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

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

If there are several loops in the bag, be aware of the possibility of retrograde infringement.

Resection of the intestine is performed within healthy tissues, with the removal of at least 40 cm of the unchanged adductor and 15-20 cm of the efferent intestine, better, "end to end", novice surgeons can also "side to side". In an extremely serious condition of patients, intestinal fistulas are superimposed, in especially severe patients, the necrotic loop is brought out without resection. Plastic methods are used the simplest, least traumatic.

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

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

Conservative treatment - (as an exception !!!) Permissible only in the first 2 hours after infringement and only in especially seriously ill patients in a state of cardiac decompensation, with myocardial infarction, severe lung diseases, inoperable malignant tumors and others, as well as in debilitated premature infants.

It includes:

Emptying the bladder and bowels

Warm bath, heating pad

Raised position of the pelvis

atropine injections,

Cleansing enemas with warm water

Spraying chloroethyl,

A few deep breaths

Very careful manual setting.

After reduction, finger control of the hernial canal with the definition of a "cough push" is mandatory. With spontaneous reduction - observation in the hospital, followed by planned hernia repair. At the slightest deterioration in the condition - an urgent operation.

Prevention - dispensary method of active detection of hernia carriers, timely elective surgery, sanitary and educational work among general practitioners and the population about the need surgical treatment hernia

Coprostasis

Coprostasis - fecal stasis in the hernial sac, observed in persons with intestinal atony, more often with large irreducible hernias, in old age.

Clinical features: in contrast to infringements, the increase in pain and increase in protrusion is gradual, soreness and tension of the protrusion are insignificant, the phenomenon of a cough impulse is preserved. A picture of partial intestinal obstruction. The general condition suffers little.

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

Inflammation

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

Clinic features. The onset is acute, pain, fever, local hyperemia, edema, up to phlegmon. Treatment is surgical (often based on infringement, more often parietal).

Irreducible hernias

An irreducible hernia is a chronically occurring complication - the result of the formation of adhesions of the hernial contents with the hernial sac, especially in the cervical region, with a constant injury at the time of the exit of the viscera, when using a bandage.

Clinic features. In contrast to infringement, irreducibility occurs in the absence or slight pain, the absence of tension in the hernial protrusion, and the effects of intestinal obstruction. May be complicated by coprostasis partial obstruction intestines. Irreducible hernias are often accompanied by dyspeptic phenomena, more often they are infringed. Treatment. Hernia repair is performed in a planned manner, if an infringement is suspected, an urgent operation is performed.

Complications of external hernias of the abdomen: infringement, coprostasis, non-reducibility,

inflammation.

Incarcerated hernia is the most common and dangerous complication of a hernia, requiring

immediate surgical treatment.

The organs that have entered the hernial sac are subjected to compression more often at the level of the cervix.

hernial sac in the hernial orifice. Infringement of organs in the hernial sac itself

possibly in one of the chambers of the hernial sac, in the presence of scar bands,

compressing organs during fusion of organs with each other and with a hernial sac

(with irreducible hernias).

Incarcerated hernia occurs more frequently in middle-aged and older people.

Femoral hernias are incarcerated 5 times more often than inguinal and umbilical ones. Small hernias

with a narrow and scar-changed neck of the hernial sac are infringed more often than

reducible large hernias. Infringement is not the lot of only a hernia, for a long time

existing. A hernia, when it occurs, can immediately manifest itself as an infringement.

The frequency of certain types of hernias in adult patients with strangulated hernias: inguinal

hernias - 43.5%, postoperative hernias - 19.2%, umbilical hernias - 16.9%, femoral

hernias - 16%, hernias of the white line of the abdomen - 4.4%. Any organ can be affected, more often

the small intestine and the greater omentum are infringed.

According to the mechanism of occurrence, elastic, fecal and mixed, or

combined, infringement.

Elastic infringement occurs at the time of a sudden increase in intra-abdominal

pressure during physical exertion, coughing, straining, etc. At the same time,

overstretching of the hernial orifice, resulting in more

than usual internal organs. Return of the hernia gate to its previous state

leads to infringement of the contents of the hernia. With elastic restraint, compression

released. in the hernial sac organs occurs outside.

Fecal infringement occurs when intestinal motility is weakened, more often

observed in older people. Following accumulations of a large number

intestinal contents in the intestine, located in the hernial sac, occurs

compression of the outgoing loop of this intestine, then the pressure of the hernial gate increases

elastic is attached to the contents of the hernia and to the fecal infringement, such

Thus, a mixed form of infringement arises.

Pathological anatomy: the main reason for the development of pathological

changes in the restrained organ is a violation of blood and lymph circulation. At

strangulation of the intestine due to venous stasis, transudation into the wall occurs

intestines, into its lumen and into the cavity of the hernial sac. Fluid in the hernial sac

called "hernial water". With rapid simultaneous compression by the infringing

ring of veins and arteries of the mesentery of the intestine, located in the hernial sac, "hernial

water" is not formed, "dry gangrene" of the strangulated intestine develops.

At the beginning of infringement, the intestine acquires a cyanotic color, "hernial water"

transparent. Necrotic changes in the intestinal wall begin with the mucosa

shells. The greatest damage occurs primarily in the area

strangulation groove at the site of compression of the intestine by a restraining ring.

Over time, pathomorphological changes progress.

Infringed

the intestine is blue-black, its serous membrane is dull, multiple

subserous hemorrhage. The intestine is flabby, does not peristaltize, the vessels of the mesentery do not

pulsate. "Hernial water" is turbid, hemorrhagic in nature, has fecal

smell. Necrotic changes are accompanied by gangrene of the intestinal wall,

perforation, the development of the so-called fecal phlegmon and peritonitis.

When the intestine is infringed, the blood and lymph circulation is significantly disturbed, not only in

strangulated intestine, but also in the adductor intestine. Due to intestinal

obstruction, intra-intestinal pressure increases, intestinal walls stretch,

intramural veins are compressed, lymph circulation is disturbed. Cluster

transudate in the wall and in the cavity of the intestine, its overflow with intestinal contents

more exacerbate circulatory disorders due to compression of the intramural

arteries. First of all, the mucous membrane is damaged on a significant

stretch. From the border of the altered intestinal wall, visible from the outside, proximally

damage to the mucous membrane extends for another 20-30 cm. This is necessary

take into account when determining the level of resection of the afferent loop. Due to

damage to the mucous membrane, the intestinal wall becomes permeable to

microbes, which leads to the development of peritonitis. Perforation may occur

adductor loop in the region of the strangulation furrow.

In the outlet loop of the strangulated intestine, blood and lymph circulation disorders occur on

over 10-15 cm.

Types of infringements of hernias and their recognition

Clinical manifestations of hernia strangulation depend on the form of strangulation, strangulated

organ, time elapsed since the infringement The main symptoms of infringement

hernias are pain in the area of ​​the hernia and irreducibility of the hernia, previously free

reduced.

The intensity of pain varies. Sharp pain can cause fainting, shock

condition Local signs of hernia incarceration, hernial protrusion sharply

painful on palpation, dense, tense. Identify cough symptom

fails. On percussion, dullness is determined if the hernial sac contains

omentum bladder, "hernial water". Percussion sound is tympanic,

if there is an intestine containing gas in the hernial sac.

Elastic restraint. The onset of the complication is associated with an increase in intra-abdominal

pressure (physical work, cough, defecation, etc.)

severe constant pain in the area of ​​the hernial protrusion, previously unreducible

reducible hernia, increase, sharp tension and soreness of the hernial

protrusions It should be borne in mind that infringement may be the first manifestation

the resulting hernia.

Incarceration of the intestine is one of the forms of strangulation intestinal obstruction.

In these cases, there are signs of intestinal obstruction against the background of

constant acute pain in the abdomen due to compression of blood vessels and nerves

mesentery of the strangulated intestine, there is a cramping pain associated with increased

peristalsis, stool and gas retention, vomiting is possible. On auscultation of the abdomen

continuous bowel sounds are heard. Plain abdominal x-ray

stretched bowel loops with horizontal fluid levels and

gas above them ("Cloiber bowls"). Later, peritonitis develops.

In case of intestinal entrapment clinical course complications can be divided into three periods.

The first period is pain, or shock, the second period is imaginary well-being,

the third period - diffuse peritonitis. The first period is characterized by the most acute

pain that causes shock phenomena. Pulse is weak, blood pressure

reduced, breathing becomes frequent and superficial. This period is expressed

with an elastic form of infringement. During the period of imaginary prosperity,

reduction of pain, which was previously very intense. This may enter into

delusion of the doctor and the patient, accepting the reduction or disappearance of pain for

improvement in the course of the disease. Pain reduction can be explained by necrosis

strangulated bowel loop.

However, local manifestations of hernia incarceration remain. If the patient is not operated on,

his condition is rapidly deteriorating, the third period of diffuse peritonitis sets in.

Body temperature rises, pulse quickens. Increased bloating

fecal vomit appears. Swelling in the area of ​​hernial protrusion

increases, skin hyperemia appears, phlegmon develops.

Diagnosis: in typical cases it is not difficult. Main signs: acute

the resulting pain and irreducibility of a previously reducible hernia. Usually infringement

occurs in the external opening of the inguinal canal. When examining a patient

find in the inguinal region a painful, tense, irreducible hernial

protrusion. If the intestinal

loop, symptoms of intestinal strangulation obstruction join.

Possible infringement in the internal opening of the inguinal canal (parietal

infringement) That is why, in the absence of a hernial protrusion, it is necessary to carry out

digital examination of the inguinal canal and not limited to examination only

external inguinal ring A finger inserted into the inguinal canal can be felt

a small painful seal at the level of the internal opening of the inguinal canal

Retrograde infringement. Retrograde strangulated more often the small intestine is possible

retrograde infringement of the large intestine of the greater omentum, etc. Retrograde

infringement occurs when several intestinal loops are located in the hernial sac

(two or more), and the intermediate loops connecting them are in the abdominal cavity

Binding intestinal loops are affected to a greater extent Necrosis

begins earlier in these intestinal loops located above the restraining ring.

At this time, intestinal loops located in the hernial sac may still be

viable.

It is impossible to establish a diagnosis before the operation. During the operation, the surgeon, having found in

hernial sac two intestinal loops, should after dissection of the restraining ring

remove the binding intestinal loop from the abdominal cavity and determine the nature

changes in the entire strangulated intestinal loop.

If a retrograde strangulation is not recognized during the operation, since the surgeon does not

examined the connecting intestinal loop located in the abdominal cavity of the patient

peritonitis develops. The source of peritonitis will be necrotic binder

bowel loop.

Parietal infringement occurs in a narrow infringing ring when it is infringed

only part of the intestinal wall opposite the line of attachment of the mesentery.

Parietal infringement of the small intestine is observed more often in the femoral and inguinal

hernias less often in umbilical. Disorder of blood and lymph circulation in the strangulated

part of the intestine leads to the development of destructive changes to necrosis and perforation

The diagnosis presents great difficulties. By clinical manifestations parietal

infringement of the intestine is different oi incarceration of the intestine with its mesentery. There are no shock effects.

Symptoms of intestinal obstruction may be absent because the passage

content flows freely in the distal direction Sometimes there is

diarrhea. There is constant pain at the site of infringement of the intestinal wall in the hernia where

you can feel a small painful dense formation. Pain is not pronounced

since the mesentery, respectively, the restrained section of the intestine is free. Especially

it is difficult to recognize parietal infringement when it is the first clinical

manifestation of a hernia. In obese women, it is especially difficult to feel a small

swelling under the inguinal ligament.

The general condition of the patient at first can remain satisfactory then

progressively worsens due to the development of tissue phlegmon peritonitis

surrounding hernial sac

In patients with an advanced form of parietal strangulation in the femoral hernia, the development

inflammation in the tissues surrounding the hernial sac can simulate inguinal and acute

lymphadenitis or adenophlegmon.

Examination of the skin of the lower half of the abdominal wall, legs, buttocks and

perineum i.e. areas for which inguinal lymph nodes are

regional will reveal the entrance gate of infection (boils, scratching wounds,

cracks between the toes) If the diagnosis is not clear from the last diagnostic

method is an operation During the incision of tissues under the inguinal ligament

find either a strangulated hernia or enlarged, inflamed lymph nodes

nodes. Thus, during the operation, it is possible to diagnose

dangerous complication parietal infringement and eliminate it.

Simulate the infringement of the femoral hernia can thrombosis of the node of the great saphenous vein

at the place where it flows into the deep vein of the thigh In case of thrombosis of the venous node in a patient

pain occurs and a painful induration under the inguinal ligament is determined.

with this often there is varicose veins of the leg

operation both in case of infringement of a hernia and thrombosis of a venous node. At

strangulated hernia eliminate the infringement of the organ and produce plastic in the area

hernial ring. In case of thrombosis of the venous node, the great saphenous vein is ligated

and cross at the place where it flows into the deep vein of the thigh to prevent

thromboembolism and the spread of thrombosis to the deep vein of the thigh. Thrombosed

the vein is excised.

Sudden infringement of previously unrevealed hernias. On the abdominal wall in typical

for the formation of hernia areas may remain after the birth of the protrusion

peritoneum (pre-existing hernial sacs). More often such pre-prepared hernial

a bag in the inguinal region is an unclosed peritoneal inguinal process

The reason for the sudden appearance of a hernia and its infringement is a sharp increase

intra-abdominal pressure (significant physical stress, severe cough,

straining). In the anamnesis, patients do not have indications of signs of earlier

existing hernias: protrusions, painful sensations in places typical of

hernia localization.

The main symptom of sudden strangulated hernias is the appearance of acute pain in

typical places of exit of hernias. With the sudden onset of acute pain in

inguinal region, in the region of the femoral canal, in the navel, it is necessary when

examination of the patient to determine the most painful areas during palpation,

corresponding to the hernial ring. The hernial protrusion is small,

which corresponds to the small size of the preexisting hernial sac.

Hernial protrusion is dense, painful.

Coprostasis (stagnation of feces) and fecal infringement. Coprostasis is a complication

hernia, when the contents of the hernial sac is the large intestine. Develops in

as a result of "a disorder of the motor function of the intestine associated with a sharp

decrease in the tone of the intestinal wall.

Contribute to coprostasis irreducible hernia, sedentary lifestyle,

plentiful food. Coprostasis is observed more often in obese patients of senile age,

in men with inguinal hernias, in women with umbilical hernias.

Symptoms: supporting constipation, abdominal pain, nausea, rarely vomiting. hernial

the protrusion slowly increases as the colon fills with stool

masses, it is almost

Table 6: Differential diagnostic signs of coprostasis and elastic

forms of hernia incarceration.

CoprostasisElastic strangulation of the hernia

Occurs slowly, gradually

Hernial protrusion is not painful, testy consistency,

slightly tense

The cough impulse is determined

Intestinal closure is incomplete

Vomiting is rare

General condition of moderate severity Occurs suddenly, quickly

Hernial protrusion is very painful, very tense

Cough impulse is not defined

Complete intestinal obstruction

Frequent vomiting

General condition is severe, collapse

painless, slightly tense, pasty consistency, cough symptom

push is determined. Distinctive features of coprostasis from elastic

infringements are given in table 6.

Treatment: the release of the colon from the contents. With reducible hernias, it is necessary

try to keep the hernia in the reduced state, then it is easier to achieve

restoration of intestinal motility. Apply small enemas with

hypertonic sodium chloride solution, with glycerol or repeated siphon

enemas with a deeply inserted probe sigmoid colon. Contraindicated

the use of laxatives, since the overflow of the afferent loop

contents can cause the transition of coprostasis to the fecal form of hernia incarceration.

Coprostasis can, due to compression in the hernial orifice of the efferent loop, go

in the fecal form of hernia incarceration. Growing signs of obstructive intestinal

obstruction. Abdominal pain intensifies, acquires a cramping character,

vomiting increases. In the future, due to overflow with fecal masses of the intestine,

located in the hernial sac, the entire loop is compressed by the hernial orifice

intestines and its mesentery. There is a mixed form of infringement of the intestine. From now on

there are signs of strangulation intestinal obstruction.

Infringement of the greater omentum causes constant pain in the area of ​​the hernial

protrusions. The greater omentum is usually infringed in the umbilical and large

epigastric hernias.

Infringement of the bladder occurs with sliding inguinal and femoral hernias,

accompanied by frequent painful urination, sometimes delayed

urination, a decrease in diuresis due to a reflex decrease in the function

False infringement of a hernia. In acute diseases of the abdominal organs (acute

appendicitis, acute cholecystitis, ulcer perforation duodenum or

stomach, intestinal obstruction) exudate, getting into the hernial sac

incarcerated hernia, causes the development of inflammation in it. hernial protrusion

increases in size, becomes painful and tense. These signs

correspond to signs of infringement of a hernia.

Diagnosis: make the correct diagnosis of acute diseases of the abdominal organs

and a carefully collected anamnesis of these

diseases and purposefully carried out objective examination of the patient.

First of all, it is necessary to find out the time of occurrence of pain in the abdomen and in the area

hernia, onset of pain (sudden, gradual). Primary localization of pain in

abdomen, and then the later addition of pain in the area of ​​a reducible hernia is characteristic

more for acute diseases of the abdominal cavity than for strangulated

Sudden onset of acute pain in the epigastric region with the development

peritonitis in a patient with peptic ulcer

to perforate an ulcer. Primary localization of pain in the right hypochondrium with

irradiation under the right shoulder blade, in the right shoulder girdle, the greatest pain and

muscle tension in the right hypochondrium, positive symptoms Grekov--Ortner,

Murphy are characteristic of acute cholecystitis.

The onset of pain is primarily in the epigastric region or around the navel, followed by

movement of pain to the right iliac region, the greatest pain and

muscle tension in this area is characteristic of acute appendicitis

Consistent appearance of signs of intestinal obstruction at first, then

peritonitis and later changes in the area of ​​the hernia make it possible to interpret pain in

areas of hernia, an increase in the size and tension of the hernia as manifestations of a false

infringement.

If a false strangulation is not recognized and a hernia operation is undertaken,

it is important at this diagnostic stage to correctly assess the contents of the hernial sac

(the state of intestinal loops, the nature of the effusion). At the slightest suspicion of acute

disease of the abdominal organs (in the hernial sac, a little changed loop

intestines, purulent or hemorrhagic exudate) should produce a median

laparotomy to identify the source of peritonitis.

Treatment: strangulated hernia is an indication for emergency surgery. Necessary

eliminate the infringement and find out the viability of the incarcerated organs. Operation

carried out in several stages

The first stage is a layer-by-layer dissection of tissues up to the aponeurosis and exposure of the hernial

The second stage - the opening of the hernial sac is performed carefully so as not to

damage swollen intestinal loops that are tightly adjacent to the wall of the hernial sac.

With sliding inguinal and femoral hernias, there is a risk of damage to the wall

colon or bladder. Opening the hernial sac, remove the "hernial

water". To prevent slipping into the abdominal cavity of strangulated organs

the surgeon's assistant holds them with a gauze pad. Unacceptable

dissection of the restraining ring before opening the hernial sac, as

unexamined strangulated organs will move into the abdominal cavity along with

infected "hernial water".

The third stage - the dissection of the infringing ring is carried out under the control of vision,

so as not to damage the organs soldered to it from the inside. For femoral hernias, the incision

carried out medially from the neck of the hernial sac to avoid damage to the femoral

vein located on the lateral side of the sac. With umbilical hernias, infringing

the ring is cut in the transverse direction in both directions.

The fourth stage - the determination of the viability of the restrained organs is

the most critical stage of the operation After dissection of the restraining ring and

introduction of a solution of novocaine into the mesentery of the intestine from the abdominal cavity remove those parts

restrained organs that were above the restraining ring

tighten the intestine, as a rupture (separation) of it in the area may occur

strangulation furrow.

If there are no obvious signs of necrosis, the strangulated intestine is irrigated with warm isotonic

sodium chloride solution. It is important to remember that intestinal necrosis begins with

mucous membrane, and changes in the intestinal wall, visible from the side of its peritoneal

cover, appear later. The main criteria for the viability of the small intestine:

restoration of the normal pink color of the intestine, the absence of strangulation

furrows and subserous hematomas, preservation of pulsation of small vessels of the mesentery and

peristaltic contractions of the intestine. Indisputable signs of non-viability

intestines: dark coloration of the intestine, dull serous membrane, flabby intestinal wall,

lack of pulsation of the vessels of the mesentery, the absence of peristalsis of the intestine.

The fifth stage - the unviable intestine must be removed. From visible from the side

serous cover of the border of necrosis must be resected at least 30--40 cm

leading segment of the intestine and 15--20 cm of the outlet segment.

Resection of the intestine should be performed when found in the intestinal wall

strangulation sulcus, subserous hematomas, large edema, infiltration and

hematoma of the mesentery of the intestine.

In case of infringement of sliding hernias, it becomes necessary to assess the viability

the part of the organ that is not covered by the peritoneum. When necrosis is detected, the blind

intestines produce a median laparotomy and perform resection of the right half

colon with ileotransverse anastomosis. The operation is being completed

hernial ring plasty. Necrosis of the bladder wall requires resection

bladder with epicystostomy. In severe cases, perivesical

fiber is tamponed and an epicystostomy is applied.

The sixth stage - the restrained omentum is resected in separate sections without formation

large common stump. Sliding is possible from the massive stump of the omentum

ligatures and the resulting bleeding from the omentum's vessels.

abdominal cavity.

The seventh stage - when choosing a method of hernia repair, you should give

preference for the simplest. For example, with small inguinal oblique hernias in

young people should use the method of Girard - Spasokukotsky - Kimbarovsky, with

direct inguinal and complex inguinal hernias - methods of Bassini and Postempsky.

With a strangulated hernia complicated by phlegmon of the hernial sac, surgery is necessary

start with a midline laparotomy (first stage) to reduce the risk

infection of the abdominal cavity with the contents of the hernial sac. During laparotomy

produce resection of the intestine within viable tissues. ends

the resected section of the intestine is sutured. Between the incoming and outgoing loops

end-to-end or side-to-side anastomosis is performed. At this stage of the operation,

be carried out isolation of the peritoneal cavity from the cavity of the hernial sac. With this

the purpose around the mouth of the hernial sac is to dissect the parietal peritoneum and

prepare it to the sides by 1.5-2 cm.

of the resected intestine near the hernial ring is stitched with two rows of mechanical

sutures (or bandaged with two ligatures). Then between the seams (ligatures)

cross the loops of the resected intestine and remove them along with part of their mesentery

Over the blind ends of the strangulated intestine, located in the hernial sac, are sutured

parietal peritoneum. The edges of the prepared parietal peritoneum are sutured. So

way the peritoneal cavity is isolated from the cavity of the hernial sac. Abdominal wound

the walls are sutured tightly in layers.

The second stage is the surgical treatment of a purulent focus (hernial phlegmon).

Radical surgical treatment of a purulent focus consists in excision

non-viable, necrotic, infiltrated tissues. cyanosis, severe

hyperemia of the skin - harbingers of its subsequent necrosis. A sure sign

tissue viability is profuse capillary bleeding. Incision

should be performed taking into account the anatomical and topographic characteristics of localization

hernial phlegmon. Above the hernia, tissue is dissected in layers. hernial sac

open, remove purulent exudate. The hernial ring is carefully incised

enough to remove the strangulated intestine and its blind ends of the adductor and

outlet segments. After removal of the strangulated intestine, the mouth and neck are separated

hernial sac from the hernial orifice. Hernial ring plasty is not performed. On the

the edges of the hernial orifice impose several sutures in order to prevent

altered tissues (with umbilical, epigastric hernias, this can be done

single block).

Surgical treatment of the purulent focus is completed by draining the wound.

Perforated drainage is placed on the bottom of the wound, the ends of the drainage are removed from the wound

through healthy tissues. The leading end of the drain is connected to the system from

blood transfusion with antibacterial drugs, the outlet end is connected to

a tube lowered into a jar with an antiseptic. Through the drainage, a long

constant "flow" washing of the wound with antibacterial drugs.

The main task of the "flow" drainage method is to ensure sufficient

outflow of discharge from the wound Use of powerful modern antiseptics

(dioxidin, potassium furagin) allows you to achieve complete destruction of the wound

microflora Washing of wounds with solutions of furacilin, boric

acid, sodium bicarbonate. Advantages of this drainage method:

technical simplicity and availability.

The method of active surgical treatment of acute purulent diseases includes

early closure of the wound surface is possible with the help of primary, primary

delayed, early secondary sutures.

The main condition for suturing a purulent wound is to carry out

full surgical treatment of a purulent wound or cleansing it

chemotherapeutic agents. The usual knotted seam, stitched through all

layers of the wound, ensures good adaptation of the edges and walls of the wound.

Required component complex treatment patients should be holding

antibiotic therapy (general and local). The choice of antibiotic should be

taking into account the sensitivity of the pathogen to it.

postoperative mortality. The danger of infringement of a hernia for the patient's life

increases with the lengthening of the time elapsed from the moment of infringement to

operations. Mortality after operations performed after the onset of infringement in

the first 6 hours, is 1.1%, in the period from 6 to 24 hours - 2.1%, after 24 hours - 8.2%. After

operations during which the bowel was resected, the mortality rate is

16%. With phlegmon of the hernial sac, when the intestine was resected by

lapa-rotomy, mortality reaches 24%.

Complications after independently reduced, forcibly reduced and

operated strangulated hernias. A patient with a strangulated hernia, spontaneously

reduced, must be urgently hospitalized in the surgical department.

The danger of spontaneous reduction of the previously strangulated intestine is that

as a result of circulatory disorders that have arisen in it, it can become a source of

infection of the peritoneum and intra-intestinal bleeding If during examination

the patient at the time of admission to the surgical hospital is diagnosed

peritonitis or intra-intestinal bleeding, the patient must be operated on urgently.

The operation consists of mid-median laparotomy, resection of the altered

part of the intestine to the level of preserved sufficient blood circulation in the leading and

efferent intestinal loops

A patient who, upon admission to admission department no signs found

peritonitis, intra-intestinal bleeding, should be hospitalized in

surgical hospital for dynamic observation. Let the patient go home

dangerous. Dynamic observation of the patient should be directed to early

detection of signs of peritonitis and intra-intestinal bleeding.

Methods of dynamic study of a patient with spontaneously reduced

strangulated hernia the following:

Complaints: abdominal pain, dryness of the mucous membranes of the oral cavity.

Inspection: skin (pallor); oral cavity (dry mucous membranes).

Hemodynamic parameters: pulse, blood pressure, shock index = pulse / systolic blood pressure.

Axillary and rectal temperature.

Examination of the abdomen palpation (muscle tension and local pain),

percussion local tenderness, auscultation weakening of intestinal sounds

Examination through the rectum soreness with pressure on the walls of the intestine,

admixture of blood in the contents.

Survey roentgenoscopy of intestinal pneumatosis, free gas in the abdominal cavity.

Inspection of secretions vomit (an admixture of bile), stool (with a mixture of blood in the feces

diuresis measurement.

Laboratory studies blood test (leukocytosis, hemoglobin, hematocrit).

Early signs of peritonitis - the appearance of constant pain in the abdomen, aggravated by

cough, feeling of dryness in the mouth, increased heart rate, local soreness

on palpation and percussion of the abdomen, appearance of a lung local muscle tension

abdominal wall, leukocytosis.

Early signs of intra-intestinal bleeding weakness, dizziness, pallor

skin, increased heart rate, decreased blood pressure, decrease

hemoglobin, hematocrit, blood in the feces.

The appearance of signs of peritonitis, bleeding into the intestine is an indication for

emergency surgery The operation consists of a mid-median laparotomy, resection

altered part of the intestine to the level of preserved sufficient blood supply in

adductor and efferent intestinal loops.

A patient who, during dynamic observation, did not reveal signs

peritonitis, intra-intestinal bleeding, shown in a planned manner

hernia repair with plastic surgery of the abdominal wall in the area of ​​the hernia gate.

Forced reduction of a strangulated hernia, performed by the patient himself,

rarely observed. AT medical institutions forced reduction of a hernia

prohibited When forcibly reducing a strangulated hernia,

damage to the hernial sac and the contents of the hernia up to the rupture of the intestine and its

mesentery with the development of peritonitis and intra-abdominal bleeding. Peritonitis,

intra-abdominal bleeding are indications for emergency surgery

operations - revision of the abdominal organs, stop bleeding, removal

source of peritonitis, drainage of the abdominal cavity (see "Peritonitis").

With forced reduction, the hernial sac can be displaced into the preperitoneal

space along with the contents, restrained in the neck of the hernial sac.

When the parietal peritoneum is torn off in the neck of the hernial sac,

immersion of the restrained bowel loop together with the restraining ring into the abdominal cavity

or in the preperitoneal space.

It is important to recognize the imaginary hernia in a timely manner, since the patient may

quickly develop the phenomenon of intestinal obstruction and peritonitis. Typical sign

there is no incarceration of the hernia, there is no intense hernial protrusion However

anamnestic data (forcible reduction of a hernia), abdominal pain, sharp

pain on palpation of soft tissues in the area of ​​the hernial orifice, subcutaneous

hemorrhages suggest imaginary reduction of the hernia and urgent

operate on the patient.

Late complications observed after spontaneous reduction of strangulated

hernias and developed after operations for strangulated hernias, are characterized by

signs of chronic intestinal obstruction (abdominal pain, flatulence, rumbling

splashing sound) They result from the formation of adhesions of intestinal loops

among themselves, with other organs, with the parietal peritoneum and cicatricial strictures,

narrowing the intestinal lumen, the formation of cicatricial strictures of the intestine occurs on

place from torsion of the necrotic mucosa with subsequent development

connective tissue and its scarring.

Irreducibility is due to the presence of adhesions of internal organs in the hernial sac

among themselves, as well as with a hernial sac. The development of irreducibility is due

traumatization of organs located in the hernial sac. As a result, aseptic

inflammation, dense adhesions of organs to each other and to the wall occur

hernial sac. Irreducibility may be partial when part of the content

hernia can be reduced into the abdominal cavity, while the other part remains

irreducible. With complete irreducibility, the contents of the hernia are not reduced into the abdominal

cavity. Prolonged wearing of the bandage contributes to the development of irreducibility.

Irreducible are more often umbilical, femoral and postoperative hernias. Enough

often irreducible hernias are multi-chamber (umbilical, postoperative).

Due to the development of multiple adhesions and chambers in the hernial sac, irreducible

hernia is more often complicated by infringement of organs in one of the chambers of the hernial sac or

development of adhesive intestinal obstruction in the hernial sac.

Inflammation of a hernia occurs due to infection of the hernial sac. It can

happen from within acute inflammation appendix or diverticulum

Meckel, located in the hernial sac, as a result of perforation of typhoid

or tuberculous ulcers of the intestine into the cavity of the hernial sac, with tuberculosis

With inflammation of the hernia caused by infection from the abdominal organs

cavity, the general condition of patients worsens, body temperature is high, chills,

vomiting, gas and stool retention. The hernia increases in size as a result of edema

and infiltration of tissues, hyperemia of the skin appears.

Treatment: emergency surgery. At acute appendicitis in a hernia produce

appendectomy, in other cases, the source of infection of the hernial sac is removed.

Chronic inflammation of the hernia in peritoneal tuberculosis is recognized during

operations. Treatment consists of hernia repair, a specific anti-tuberculosis

The source of hernia infection can be inflammatory processes on the skin