Oblique inguinal hernia in combination with dropsy of the spermatic cordand edema of testicular membranes.
In areas of the open peritoneum-inguinal process, together with oblique inguinal hernias, cysts called the cysts of the spermatic cord, the funiculus, may develop (Fig. 57a). Their formation is observed throughout the path of the peritoneal inguinal process, ranging from the deep inguinal ring to the upper pole of the testicle. Also together with oblique hernias, edema of the testicular membranes may also develop (Fig. 57, b).
Fig. 57. Dropsy of the spermatic cord and oblique inguinal hernia (a), dropsy of the testicular membranes and oblique inguinal hernia (b).
On a large material revealed a significant variety of these combinations. At the same time, the hernial sac is not always determined during the inspection, since its size may be insignificant, and with a narrow neck it may not always be performed with contents.
From the anamnesis, you can get a variety of data on the time of the disease. The imperceptible development of cysts in the peritoneal inguinal process (funiculocele) is typical of most cases. With complaints of aching pain in the corresponding half of the scrotum radiating to the testicle, it is necessary to probe the spermatic cord throughout the entire length, which makes it possible to determine the initial degree of development of the cyst. When palpation of the inguinal region, there is sometimes increased pain in the inguinal canal in the absence of any protrusions. The pains are non-lasting, there are free spaces when the patient feels only a feeling of “awkwardness” in the scrotum and in the groin area. There is also an increase in pain in the corresponding half of the scrotum in the evening after a long walk and work. Observations also show that pains of a cramping nature that appear when there is a dropsy of the spermatic cord are associated with short-term infringements (usually the omentum), and the hernia itself may go unnoticed. It should be borne in mind and the possibility of the development of cysts after obliteration of the narrowest part of the hernial sac with an omentum adherent to its wall. In these cases, when feeling the spermatic cord, a dense cord coming from the upper pole of the cyst can be detected. With 82 operations for dropsy of the testicles, carried out taking into account the possible combination with oblique inguinal hernia, we found in 22 cases oblique inguinal hernia.
Of the individual types of edema of the testicle, it is necessary to note dropsy with a significant narrowing of the cavity along the length. Dropsy has the appearance of a two-cavity bag. When allocating the upper pole, it is necessary to pay attention to the adjacent connective tissue strands and narrow bags, as well as to determine the presence of slit-like (capillary) holes at the upper dome of the dropsy. When monitoring the patient, it is necessary to monitor periodic decreases in the amount of dropsy - communicating dropsy - and in this connection outline the plan of the operation.
In addition to erectile dysfunction of the testicle, developing gradually, imperceptibly, without pain, there are so-called acute dropsy of the testicular membranes. Their main symptoms are acute pain, sometimes cramping in nature, pain in the spermatic cord, pain when feeling the scrotum. This type of water can be explained by the infringement of the omentum in the narrow neck of the hernial sac testicular hernia with subsequent effusion into the cavity of the hernial sac. It is also necessary to note the accumulation of effusion in hernial sacs during acute inflammatory processes in the abdominal cavity (peritonitis) with the involvement of the peritoneal sac of the edema of the testicular membranes in the process by passing the effusion through a narrow slit with communicating dropsy.
Acutely arising cysts and dropsy of the membranes of the testicle, accompanied by pain, should be considered as strangulated hernia and apply appropriate surgical tactics.
Women also have a combination of oblique inguinal hernia with cysts located in separate areas of the non-incised peritoneal inguinal process, starting from the deep inguinal ring. These cysts are called cysts of the Nukkian diverticulum and may be located at the bottom of the hernial sac, directly adjacent to it, or separated from it by connective tissue. Developing within the inguinal canal, these cysts extend beyond the superficial inguinal ring. The cysts of the Nukkian diverticulum (peritoneum-inguinal process) are covered with the same layers as the hernia sac of the oblique inguinal hernia. During the operation, the most complete method will be the dissection of the aponeurosis of the external oblique muscle, which will make it possible to detect the accompanying hernia sac.
Prevention of complications and some details of the surgical technique during the operation of the inguinal hernia, combined with dropsy of the seed nanatin and testicle
1. In the case of an incompletely obliterated processus vaginalis peritonei, a narrow (sometimes capillary) channel may remain between the proximal peritoneal inguinal process (and if there is an outflow of the viscera, a hernial bag) and dropsy of the testicular membranes. A view of a small hernial sac may lead further to the development of an inguinal hernia.
2. With this combination, the operation is performed as in a congenital (testicular) hernia: the distal section is treated as with dropsy, according to Winckelmann, and the proximal part of the peritoneum-inguinal process (hernia sac) open to the abdominal cavity is isolated, its neck is tied up and cut off ( see figure 49).
3. When combining an inguinal hernia with a dropsy of the membranes of the testicle in middle-aged persons, it is necessary to simultaneously simultaneously operate both a hernia and dropsy. In elderly and elderly patients, large inguinal hernias are often combined with dropsy of the testicular membranes. It is advisable for 2-3 days before the operation to remove the aqueous fluid puncture and after that only operate on the hernia. Simultaneous surgery in such patients is often complicated by hematoma and edema, which aggravates the immediate and late postoperative period.
4. The cysts of the peritoneum-inguinal process (dropsy of the spermatic cord) and the Nukkiev's diverticulum are easily exfoliated with anatomic layering and hydraulic dissection according to A.V. Vishnevsky.
5. Good hemostasis in Winckelmann surgery is best achieved by imposing a continuous Reverden suture ("overlap"). If there is no confidence in reliable hemostasis, it is advisable to leave a rubber graduate in the wound for 1-2 days.
In order to prevent the recurrence of dropsy of the testicle due to the inverted sheaths slipping from it, it is useful to fix the upper edge of the parietal leaf of the actual vaginal membrane of the testicle to the connective tissue elements of the spermatic cord.
Fig. 58. Winckelmann operation.
In operations of inguinal hernia, combined with dropsy of the testicles, in order to avoid hematomas, edema is very useful after completing the operation to put on the scrotum a previously prepared sterilized suspension, corresponding in size to the contracted scrotum.
Fig. 59. Dressing after surgery for dropsy of the testicular membranes.
Oblique inguinal hernia and cryptorchidism
Oblique inguinal hernia, most often congenital, is often combined with abnormal testicular position, which is associated with incomplete (retentio) or abnormal (ectopia) process of lowering of the testicle during ontogenesis.
Anomalies of the position of the testicle in connection with the incomplete process of lowering include cases of its delay in the inguinal canal (retentio testis inguinalis) or somewhat higher (retentio testis abdominalis). There is also a free movement of the testicle in the open peritoneal inguinal process, and therefore it is located within the inguinal canal, then in the scrotum.
Fig. 60Abdominal testicular delay in a 14-year-old boy.
Usually, together with the testicle, it lingers in the groin and the tibial-inguinal process, and in more rare cases, when the lowering process is not completed successfully, the testicle, together with the distal vaginal process of the peritoneum, can be located in an unusual place — in the perineum, on the thigh, on the back of the genital member (ectopia testis perinealis, cruralis).
According to our data for 1957–1961, in 141 patients with cryptorchidism, a clinically severe inguinal (congenital) hernia was present in almost half of the cases, and the non-literized vaginal process of the peritoneum was detected in 125 patients with surgery.
Patients with congenital inguinal hernia in combination with cryptorchidism 9 suffer either from the effects of infringement when the viscera exit into a narrow long hernial sac (not grown peritoneal and inguinal process), or from painful sensations due to restraint in the inguinal canal of the testicle or torsion along with spermatic cord. An ectopic testicle usually does not give any painful symptoms and may not be seen by patients (ectopia perinealis).
Errors in the recognition of ectopia are usually associated with the fact that the doctor during inattentive examination does not notice the absence of the testicle in the scrotum or, finding this absence, does not seek to find out the abnormal situation.
The question of the surgical treatment of cryptorchidism, of more effective methods of lowering the testicle, has not yet been fully resolved, which is partly due to the underreporting of the role of the peritoneal inguinal process in ontogenesis and the cryptorchidism clinic (N.V. Voskresensky).
The failures of operations performed in a number of ways are explained by their nonphysiological, undercounting of the pathogenesis of the anomaly. This is evidenced by the term itself - "orchidopexy". After all, it is not a fixation of the testicle at the bottom of the scrotum, but in bringing it down, which is usually hampered by a short cord, surrounded by many loose connective tissue overlays, adhesions, and even scars.
It is necessary not only to separate the cord, but also to stretch it, which cannot be achieved by fixing it in one way or another for 10-12 days to the skin of the thigh or by thrusts of various systems. Traction should be long, rhythmic, dosed - it is absolutely necessary to obtain a stable result.
For the testicle, an appropriate bed should be created in the scrotum, which, with a unilateral inguinal delay, is markedly hypoplastic, and with bilateral cryptorchidism it looks like a small skin pigmented fold. Therefore, when choosing a method of operation, it is necessary to take into account the need for effective stretching of the scrotum. Simultaneous expansion of the cavity of a small scrotum with a finger or packers can not steadily eliminate congenital hypoplasia.
It is impossible to hope for rough cravings for the testicle by vigorous traction for the sutures carried through its tissues, especially when the spermatic cord is not long enough. This only creates conditions for atrophy of the organ or, even more dangerous, can lead to partial necrosis of the testicle (E.S. Shakhbazyan).
At the beginning of this century almost simultaneously in 1902-1905. There have been several reports of two-step methods of operation for inguinal delay of the testicle 10. In 1909, Torek published his method (Torek), and in 1913 N. M. Kron reported two cases of P. A. Herzen's operations.
Two-stage operations found supporters among domestic and foreign surgeons and urologists. Various modifications of these methods have been developed, in connection with which various names given to these operations by different authors have appeared: the Katzenstein-Herzen operation (B.N. Holtsov), the Beyle – Kitty operation (in all Wils-Bolz textbooks), the Katzenstein – Beil operation (K. T. Ovnatanyan), N. A. Bogoraz called it the Herzen-Torek operation, S. L. Gorelik — the Beyle — Kittley — Sokolov operation. All these operations are somewhat different in the details of the individual stages, but they all have a basic common essence: the operation is in two stages, with the aim of prolonged rhythmic and metered stretching of the spermatic cord (and scrotum) with a rather significant interval between both stages (on average from 2 to 4 months).
With some modifications, the testicle is sutured to the wide fascia of the thigh (Beyle, Torek), while others - the remnants of the Hunter strand at the lower pole of the testicle (Kitly), P. A. Herzen placed the testicle under the wide fascia of the thigh.
E. T. Krichevskaya, A. G. Kiselev, M. V. Saidov, V. N. Deev, S. L. Gorelik, Yu. D. Mirles, and others who used the two-moment operation with temporary fixation of the testicle to the thigh. We performed the first series of our operations (26 patients) according to Torek-Herzen with small variations in the details of the technique. The operation consists of the following points:
1. Layers dissect the tissue and open the inguinal canal.
2. Carefully, carefully secrete the spermatic cord from the surrounding membranes and cross the vaginal process of the peritoneum (hernial sac) high.
3. By transverse and longitudinal sections, the elements of the spermatic cord are freed from the remnants of the membranes, scars, thanks to which the cord is significantly extended. The distal part of the vaginal process of the peritoneum is dissected longitudinally and cut off so that at the lower pole of the testicle there remains a part of the membranes (Gunter strands) sufficient for flashing and subsequent fixation to the tissues of the thigh.
The spermatic cord can still be significantly lengthened by separating the adhesions at its exit from the deep inguinal ring.
4. Through the lower corner of the wound, forceps are inserted and they subcutaneously move the course (channel) into the corresponding half of the scrotum, which is expanded, revealing the branches of the forceps (or entered with the finger of a hand) (Fig. 61, a). Above the open branches of the forceps cut the scrotum in the lowest place, the forceps capture the end of a strong silk thread, which is displayed in the lower corner of the wound. This thread is stitched proteinaceous shell of the testicle (Fig. 61, c) and then relegated to the scrotum. It is also possible to directly capture the remains of a Hunter strand with a forceps and, in this way, lower the testicle (Fig. 61, b).
5. Sew up the inguinal canal, as with hernia repair.
6. On the inner surface of the thigh, according to the level of the bottom of the scrotum, a 2–3 cm long incision is made and the wide fascia is sent, to which the testicle is sutured.
Fig. 61. The scheme of operation in cryptorchidism according to Torek-Herzen.
Above the testicle, the edges of the incision on the thigh and scrotum are stitched, forming a skin cuff - the so-called femoral-scrotal anastomosis (Fig. 61, d). This ends the first stage of the operation.
The postoperative mode is the same as after the operation of the inguinal hernia repair. The patient after 10–13 days of stay in the hospital is discharged and, after a short vacation, proceeds to his usual activities 11.
Fig. 62. A patient after a Torek-Herzen operation.
For the second stage of the operation, the patient enters the hospital after 2-4 months. During this time, the spermatic cord and scrotum stretch. The testicle, isolated from its temporary bed, easily moves into the formed scrotum and is located in its lowest place at the bottom. With an insufficiently stretched scrotum, you can easily create the bottom of it, cutting along with the scrotum a strip (or flap) of the desired width from the skin of the thigh. After the second stage, the testicle lies in place and usually no retraction is observed.
We give the case histories of the two operated.
1. A patient of 16 years old was admitted to the hospital due to the absence of the scrotum and testicles. The boy is embarrassed by his comrades, avoids swimming, little sociable, depressed. The build is correct, the food is satisfactory. From the side of internal organs there are no visible deviations from the norm. On examination, there is a lack of pubic hair. Accordingly, the scrotum has a slight folding of the skin and pigmentation of it. The penis is developed normally. In the inguinal areas in both horizontal and vertical position, the testes do not contour. When the tension of the abdominals hernial protrusion is not visible. The inguinal rings barely pass the tip of the little finger, and above the pupart ligament both testicles are indistinctly palpated in the lateral part of the inguinal canal. A bilateral testicular inguinal delay was noted. The first stage of the reduction of the left testicle according to Torek-Herzen was carried out.On the 5th day after the operation, the patient is allowed to get up, on the 7th day, the sutures in the area of the inguinal canal were removed, on the 10th day - on the thigh, on the 12th day the patient was discharged in good condition. After discharge, continued to study, was fond of football. After 2 months, he entered for the second stage of the operation, which consisted in releasing the testicle from the temporary bed and moving it into the scrotum, which by this time was already quite stretched. Part of the skin of the thigh was used for the plastic of the bottom of the scrotum. After the first operation, the patient urged to perform the same operation on the right, which was performed. Currently, both testicles lie on the bottom of a well-formed scrotum. It should be noted that during the elapsed time the patient has matured noticeably, the secondary sexual characteristics are significantly pronounced, the feeling of depression has disappeared. He works as a planer in the factory.
2. Patient I., 26 years old, a doctor, came to us about phimosis and right-sided cryptorchidism. A patient of strong constitution, well developed physically, but very depressed by the presence of abnormalities on the part of the genitals, not very communicative. The right testicle is located in the inguinal canal, sedentary. The right half of the scrotum is hypoplastic. 10 days after phimosis was removed, the first stage of the Torek-Herzen operation was performed. After 3 months, the patient was admitted for the second stage of the operation. The testicle is easily placed in a well-stretched scrotum.
Currently, the patient is active in public and private life, sociable, alert. The testicle is on the same level with the left and almost the same size.
In both of these cases, the unclosed peritoneal-inguinal process was treated as with a congenital inguinal hernia — its proximal section was isolated, stitched, and tied up as a hernial sac (see Fig. 49).
In cases where the cord can be well separated and noticeably lengthened, the testicle can be fixed to the wide fascia of the thigh not through the albuginea, the remnant of the Hunter cord, around which the skin cuff is created, is similar to that of Toreka (modified by Beyle). This technique is less traumatic. The second stage of the operation in 2-3 months consists only in excision of the skin anastomosis and stitching of small wounds on the thigh and scrotum. In this operation, the principle of N. N. Sokolov was used - a thrust for the remnants of the Hunter strand and the shells, why this method can be called the Beyle operation — K and tl and — S about a lo about.
It is necessary to indicate the need for an individual approach when choosing the method of operation and performing its details in each individual case of inguinal delay of the testicle, taking into account the patient's age, height of the testicle, the presence of unilateral or bilateral anomalies.
Fig. 63. Patient after a Beyle — Kittley — Sokolov operation.
It seems to us undoubted that all the advantages have two-stage operations of the Torek-Herzen type in the Beil-China-Sokolov modification that we have developed in detail.
It is necessary to take into account the very great practical importance of the operative treatment of cryptorchidism in connection with the physical training of contingents of military age, which makes it necessary to pay great attention to obtaining perfect results of this far from simple operation.
In case of testicular ectopia, its perineal position (ectopia testis perinealis) is of practical interest, since it is easily visible and can be an unexpected finding during an operation of a free or impaired hernia. This anomaly must be remembered in unclear cases.
S.L. Gorelik described two cases of a combination of oblique inguinal hernia from the perineum with ectopia. In one of them, the perineal testicle was detected during the operation of a strangulated inguinal hernia (the testicle was ectoped in the perineum together with the vaginal process of the peritoneum), in the second, an anomaly was detected before the operation.
Patient V., 20 years old, was admitted for a right-sided inguinal hernia. When viewed from the right next to the scrotum, a wide skin fold was found, which passes from the inner thigh to the skin of the perineum, where the testicle is felt.When coughing and straining skin fold increases due to hernial protrusion, descending into the perineum. The inguinal ring is enlarged. The right half of the scrotum is much smaller than the left. Raphe scroti and skin folding are well pronounced. The left half of the scrotum, the left testicle and the inguinal canal do not represent abnormalities. Diagnosis: right-sided inguinal hernia and perineal ectopia of the right testicle. Operation. The incision typical for hernia repair is continued along the direction of the hernial protrusion. Crossed, fixed testicle in the perineum and directly passing into the distal vaginal process. Produced high ligation of the hernial bag, plastic inguinal canal according to Girard. Before the inguinal canal is sutured, the testicle is transferred to the enlarged blunt right half of the scrotum and sewn to the thigh (the spermatic cord of sufficient length) through the skin of the bottom of the scrotum. The postoperative course is smooth.
In contrast to an unstitched testicle, the perineal testicle can easily be moved to the scrotum, because the cord with an ectopic testicle is usually of sufficient length.
Details of the surgical technique and the prevention of hazards in the operation of oblique inguinal hernia, combined with cryptorchidism, as well as operations for inguinal and abdominal testicular delay.
1. When dissecting the skin and subcutaneous tissue, one should remember about the possibility of a supra-neurotic location of the testicle to avoid damage to it.
2. When dissecting the membranes of the testicle and the Hunter strand, one should be careful not to damage the vas deferens, which at the lower pole of the testicle often descends in the form of a convoluted elongated loop.
3. It is best to detect the spermatic cord and testicle by dissecting the common vaginal membrane, as recommended for congenital hernia surgery (see Fig. 49). In the proximal part, one should make a transverse section of one's own testicle and cord (raising the shell by infiltration of novocaine) and, carefully separating the central part of the testicular's own shell from the elements of the spermatic cord with a free abdominal cavity (which happens in most cases). If there is a message with the abdominal cavity, the abdominal ‑ inguinal process is highly isolated and the proximal section is tied up like a hernia sac.
4. The lengthening of the spermatic cord is relative and occurs due to the straightening of its bends by cutting the shells and cords. The deferent duct is straightened (lengthened) usually without difficulty. Damage to the blood vessels should be avoided and the sheath and the strands with a sharp scalpel (or scissors) should be carefully cut in the longitudinal and transverse directions, keeping the spermatic cord elements out of sight (see vessels under transmitted light!)
5. It is advisable when dissecting the spermatic cord to carry out a careful (finger) selection of the spermatic cord in the fascial funnel (at the deep inguinal ring), and even more carefully move the vasa epigastrica inferiores with their surrounding tissue, which can give a noticeable lengthening of the spermatic cord.
7. The formation of the skin cuff (femoral-scrotal anastomosis) is simplified if you first put two knotted sutures on the corners of the incisions. On the back of the lip impose intradermally thin catgut knotted sutures.
8. With a successful lengthening of the spermatic cord, it is possible to complete the operation according to Beyle — Kitley — Sokolov, or to apply simple orchidopexy (fix the testicle at the bottom of the scrotum).
9. When the abdominal testis is delayed, a creeping novocaine infiltrate at the mouth of the vaginal process itself, as well as careful traction for the dissected membranes and the cord, help it to better detect it.
If, with a short spermatic cord, a well-developed testicle fails to descend into the scrotum, it is possible to complete the operation by fixing it to the superficial inguinal ring, and further reduction is carried out at the second stage, after 3-4 months.In these cases, the inguinal canal should be sutured in the simplest way (stitching both cusps of the dissected aponeurosis of the external oblique muscle), which will ensure easier selection of the testicle at the third stage of the operation without any particular difficulties. The spermatic cord is usually extended to the second stage.
At the final stage of the operation, it is best to sew the inguinal canal according to A. V. Martynov, and produce Beyl-Kitley-Sokolov orchidopexy.
Choosing a way. Our experience, covering 200 operations for cryptorchidism, has demonstrated the feasibility in most cases of the Beil-Kitley-Sokolov operation. This operation is less traumatic compared with the operation on Torek-Herzen and more physiological, as the testicle moves immediately into the scrotum. The second stage of the operation is also easier when we choose the Beyle — Kitley — Sokolov method, which has been improved in the details of the operational technique, the testicle does not have to be traumatic to isolate from dense adhesions on the hip, the bridge of the skin anastomosis is excised easily, stitches are made without difficulty on the hip and scrotum.
However, in adult patients, it is often necessary to resort to a Torek — Herzen operation for the reason that the tissues are less elastic and the traction for the remnants of the Gunter rod may be insufficient.
Stitches on the scrotum must be applied in two floors, on tunica dartos and adjacent tissues with thin catgut, on the skin of the scrotum - knotted silk sutures.
If the testicle ectopic above the aponeurosis is easily reduced to the middle of the scrotum, it can be limited to simple orchidopexy (orchidopexia scrotalis).
Experience shows that with bilateral inguinal delay of the testicle in children, you should first operate on one side only, putting the operation on the other side for several months or a year. In some cases, after unilateral surgery, we observed an increase in the mobility of the testicle on the other hand and even its movement to the surface ring of the inguinal canal.
We consider the age of 12-14 years to be the most favorable period for the reduction of the testicle, since by this time the process of late descent of the testicle is completed. The rapid movement of the testicle into the scrotum and thereby the creation of normal physiological conditions occur during the onset of spermatogenesis and intensive development of the organ.
The operation is not indicated for bilateral abdominal testicular delay with common endocrine insufficiency (dystrophia adiposo ‑ genitalis).
With the simultaneous presence of an inguinal hernia with a tendency to pinch or pain in the area of the delayed testicle, the operation is indicated at any age.
“Not often, but far and not very rarely, there is a hernia form, which represents special anatomical conditions on the side of the hernia sac, difficult for inexperienced surgeons and requiring a different treatment than ordinary hernia, this is the so-called hernia par glissement, a sliding hernia. One has to be familiar with this form and it is necessary to have a clear idea of its anatomy in order to cope with the difficulties that their treatment represents. ”12
In case of sliding hernias, one of the walls of the hernial sac is formed by an organ located retroperitoneally adjacent to the sac. These organs are most often the cecum, the ascending and descending sections (colon iliacum) of the large intestine, and more rarely the bladder. Ureters, kidneys, uterus and its appendages can also descend, slide and exit through weak areas of the anterior abdominal wall, mainly in the inguinal region, less often - under the inguinal ligament through the femoral canal.
Fig. 64. Cecal hernia (A. Fischer, E. Gohrbandt, F. Sauerbruch).
Hernia terminology is varied: "hernia from sliding", "hernia from slipping", "slipping hernia". Most authors use the term "sliding hernia". A. P. Krymov identifies sliding hernias depending on the organ descending and adjacent to the hernial bag - femoral hernia of the cecum, inguinal hernia of the cecum.
The term "hernia" should be understood to emerge from the abdominal cavity into the peritoneal (hernial) sac of organs that can be inserted back into the abdominal cavity. Slipping of the same retroperitoneal organs can occur without a hernial sac, and the protruding intestines, not covered with the peritoneum, are only conventionally referred to as a hernia, in fact there is a prolapse, slippage, and the hernial sac may appear later, as the protrusion increases. A. P. Krymov points out that these protrusions clinically have all the signs of ordinary hernias, and the absence of a hernial sac is often found only during the operation, and therefore the name “hernia” for these protrusions is “consecrated with time and clinic”.
Sliding hernias occupy a small place among other abdominal wall hernias. However, difficulties in recognition, operative technique, and frequent dangerous complications during surgical treatment have attracted the attention of many prominent surgeons to these hernias. 13
According to A. V. Gizhitsky, sliding hernias make up 3.5% of all hernias, according to M. I. Lototsky (1958), - 3.06%. According to other summary statistics, the frequency of hernias varies between 0.5 and 7% (A. G. Sosnovsky, V. U. Tabolova, A. V. Ilyashenko).
According to S. Ya. Doletsky, T. F. Ganzhulevich, Riyan (Ryan), sliding hernias are also observed in childhood (from 2.9 to 4.5%).
Pathogenesis and types of sliding hernias. Part of the sliding hernias can be attributed to congenital, which may be due to defects in the development of the anterior abdominal wall and intestine, in particular the cecum - the organ most often descending through a weak area of the inguinal region. In the pathogenesis of sliding hernias, the anatomical features of the retroperitoneal space, the location of individual sections of the intestine in close proximity to the internal inguinal ring, which, with its expansion and weakness of the muscular wall in this area contributes to the slippage of retroperitoneal viscera, matter. The development of sliding hernias is also favored by the long existence of the hernial protrusion, especially in the elderly, its considerable size, as well as the constant overflow of the large intestines with gases and the lowering of the cecum with the age of the parietal peritoneum to visceral (IL Zimhes, 1926).
An increase in the hernial sac leads to its movement - further sections of the peritoneum bulge out through the hernial ring, organs that are only partially covered and connected to it (attached to it), the cecum, the ascending and descending parts of the large intestine, the bladder can follow the peritoneum. . In the case of a right-sided hernia, the cecum usually slips, while on the left-sided, the lowermost part of the descending colon and the initial part of the sigmoid, which also partly lie extraperitoneally, as a result of which they can form a sliding hernia. On the left side of the large area of the colon is the adductor and the withdrawal knee, which helps in recognizing the type of hernia.
The mechanism of the formation of sliding hernias shows that their presence can be assumed only with more or less large inguinal hernias, therefore, more often in men. According to A. V. Ilyashenko, out of 70 patients operated on by him were 67 men.
Most often, the sliding hernias are oblique right-sided, less often - straight and to the left, the femoral sliding hernias are rarely found. According to M. I. Lototsky, there were 41 cases of 50 cases of sliding hernia of oblique inguinal, 7 straight lines (including right-sided 33, left-sided 15), femoral hernias met only 2 times. Approximately the same ratios are given by A. G. Sosnovsky.
Due to the developmental mechanism and established anatomical relations, sliding hernias are divided into three types: 1) incisional hernias with a full hernial bag (this can also include colon hernia) 14, 2) paraperitoneal hernias with an incomplete hernial bag (hernias from slipping) are true sliding hernia, 3) extraperitoneal hernia, when the hernial sac is absent (prolapse of the bladder, kidneys, ureters, which can descend into the hernial ring and without going out of the peritoneal sac). The most frequent type of extraperitoneal hernia is a prolapse of the bladder with a direct or supracellular hernia (hernia supravesicalis).In rare cases, an ascending large intestine can form an extraperitoneal sliding hernia with a mobile blind, as shown in fig. 65 (Schaukelbruch - hernia in the form of a rocking chair). This type of hernia refers to the so-called hernia without a hernia sac.
In the practice of the surgeon, paraperitoneal hernias are the most common, and among them the first place is occupied by the sliding hernia of the cecum, less often the sigmoid.
Clinic and recognition. Recognition of sliding hernias presents significant difficulties. The clinical picture at first glance is not much different in its course and symptoms from ordinary inguinal hernia. However, with a more careful taking of the history and examination of these patients, in some cases it is possible to make a diagnosis correctly before the operation or at least to suggest a sliding hernia. And such an assumption will force us to turn to an X-ray examination of the colon and bladder, to draw up a specific plan of operation, and also help to avoid damage to the intestine, the bladder during surgery. According to P. S. Kakhidze (1956), at 94 operations of sliding hernias, the wound of the cecum was observed 14 times. An unrecognized bladder injury during surgery gives mortality in 27% of cases (A. M. Gasparyan).
Attention should be paid to the age of the patient, the duration of the disease, a large amount and the peculiar consistency of the hernial protrusion, rumbling when trying to reduce, wide hernial ring, as well as dyspeptic syndrome. When the bowel is sliding, dysuric phenomena may indicate the possibility of direct adherence to the sliding organs of the bladder. Sliding hernias are usually infringed more often, the clinical course of infringements is much harder. With unreducible sliding hernias, more common, recognition is difficult.
It is important to pay attention to the not quite common symptoms and the main thing to remember about the possibility of a sliding hernia.
The preoperative diagnosis of a hernia of the uterus is very difficult. In the sliding hernia of the cecum, inflammation of the appendix can develop, which significantly complicates the clinical picture and makes it difficult to diagnose. The causes leading to the displacement of the appendix into the hernia sacs of inguinal and femoral hernias are congenital anomalies of the caecum, weakening of the ligamentous apparatus of the intestine, followed by lowering of the cecum with the appendix as a sliding hernia, significant length of the appendix. The vermiform process is more often found in the right-sided inguinal hernias, and in the reverse arrangement of the viscera - and in the left-sided. The process may be located in the hernial sac completely or only by its distal part, or the middle part of the process may enter the hernial sac, and its distal part will be located in the abdominal cavity (N. I. Krakowsky). Very rarely, the vermiform process is found in hernias of the white line.
Fig. 65. Sliding hernia (hernia without hernia infringement may be a bag)
Pathological phenomena in the appendix, displaced in the hernial sac, are diverse, starting with catarrhal phenomena and ending with destructive processes up to perforation (hernial appendicitis).
Appendicitis in the hernial sac can be observed both in unresponsive and incarcerated hernia.
The clinical picture of appendicitis that develops in the hernial sac begins with pain, which is concentrated in the hernial protrusion itself.
In acute appendicitis, developed in the hernia sac of the inguinal hernia, there is a significant hyperesthesia of the scrotum skin, swelling it. Phenomena of intestinal obstruction develop later than when a hernia is pinched.
In connection with the destructive processes in the appendix there is a purulent exudate in the hernial sac, as well as in the abdominal cavity (reported peritonitis).Manual rectal examination will provide data on the inflammatory process in the abdominal cavity. With the usual strangulated hernia, the pain is not so sharply expressed as with the strangulation of the hernia with simultaneous inflammation of the appendix.
With destructive changes in the process, phlegmon may develop with the formation of fecal fistula in non-operated cases (A.M. Nechaev). After removal of the appendix, the surgeon’s tactics comply with the generally accepted method for complicated incarcerated hernias. The closure of the inguinal canal is done in the simplest way. In case of accidental detection of an unchanged appendix in the hernial bag, it must be removed. In the case of removal of the appendix, both in case of inadequate and strangulated hernia, it is necessary to indicate in the certificate issued to the patient about appendectomy.
Surgery for sliding hernias of the colon. Due to the peculiarity of surgical anatomy, these operations can present considerable difficulties, especially with poorly disposable hernias of large size.
Operational methods for sliding hernias can be divided into the following groups:
1. Reduction of hernial contents en masse (reposition).
2. Peritonization of slipped areas of the colon, followed by their reduction to the abdominal cavity.
3. Fixing the slipped part of the intestine to the abdominal wall in front of it.
4. Mesenteric plastics and fixation of the slipped area to the anterior surface of the posterior wall of the abdomen. The scheme according to M. I. Pototsky well presents the main methods of surgical treatment of the most common sliding hernias of the colon.
Methods of surgical treatment of sliding hernias
1. Savario method: open the inguinal canal, release the hernial protrusion from adhesions to the transverse fascia, open the hernial sac and after releasing the sliding intestine and stitching the opened bag, the latter together with the intestine are reduced into the abdominal cavity (Fig. 66 a, b) .
2. Method B and Vienna (Beven): after setting up the hernial contents and resection of the hernial bag, a purse-string suture is placed on the remnants of the hernial bag and intestinal wall (Fig. 66, f, d).
3. Barker’s method, Hartmann’s method and Erkes: after resection of the hernial sac, the stump of the latter is sutured, and the long ends of the filaments are held behind the Puparte ligament, possibly higher, through the anterior abdominal wall (back to front) ) (Fig. 66, d, e).
4. Lardanau's method - About to and n ch and ts a (Lardenois): after a herniolaparotomy and separation of a back wall of a gut from retroperitoneal cellulose hernial contents reduce and make a hernial sac resection. The directed intestine is fixed to the abdominal wall with several sutures (Fig. 66, g, h).
5. The method of Moresten (Morestin) is recommended for sliding hernias of the sigmoid colon. During a laparotomy (or herniolaparotomy), the intestine, which is part of the hernia, is drawn in from the side of the abdominal cavity, and two folds form in the hernial sac, the more the closer together, the more the intestine retracts into the abdominal cavity. Both of these folds sew together, forming a new "mesentery" of the intestine. The newly formed "mesentery" is stitched to the parietal peritoneum (Fig. 66, and, k, l, m).
6. The method of A. G. Sosnovsky (1950) is based on the peritonealization of the cecum with two flaps cut from a hernial sac, the author called this method a “hammock”.
Fig. 66. Surgery for sliding hernias (after MI Lototsky).
1 - small intestine, 2 - parietal peritoneum, 3 - aponeurosis, 4 - horn sac, 5 - cecum with ascending, 6 — synopteous.
JV Fedorov (1903) with sliding hernias tightened the blind and ascending intestines into the abdominal cavity and fixed them to the anterior surface of the posterior abdominal wall, the same was recommended by A. P. Krymov (1950).
Due to the peculiarities of anatomical and topographic conditions for sliding hernias, significant pathological changes, as well as the duration of the disease and the age of the patients (most people of old age turn to the surgeon), these operations are technically rather difficult even for experienced surgeons, and relapses are often observed.
P.S.Kakhidze gives long-term results of 94 operations for sliding hernias of the bladder, relapses occurred in 43.6% of cases, with 80.5% of relapses occurring during the first 6 months after surgery 15.
Prevention of dangerous complications in the operation of sliding hernias and the choice of method of operation
1. With a large unreducible (or incompletely reducible) inguinal hernia in an elderly man, accompanied by severe pain, dyspeptic symptoms, a tendency to partial injuries, you must always remember about sliding hernia.
2. Under the assumption of a sliding hernia, the history should be clarified in detail, a thorough examination should be carried out, including irrigoscopy, and if indicated, cystoscopy and cystography. According to the study, it is necessary to draw up a preliminary plan of the operation, to choose the most appropriate way to eliminate the hernia. At the same time, it is necessary to carefully consider the indication of the surgical intervention, the age and the general condition of the patient.
3. Carefully, in layers, carefully dissecting the tissue, one must remember the peculiar atypical anatomical ratios for sliding hernias, the danger of damage to the intestine, bladder.
4. If the hernial bag has an unusual appearance, the wall is thick, “fleshy”, of an unusual color, bleeds easily, should be ejected without opening the bag, take it in a fold and feel it between the thumb and index finger, while taking it can be clearly to feel the unusual pastyness of the "bag" wall, and sometimes the pulsation of the vessels (which is never the case when the bag is feeling the usual hernia). In such a situation, it is necessary to carefully open the bag along its medial surface in the thinnest area.
5. You should not strive to handle the hernial bag in the usual way (isolation and high neck ligation). This is not possible with sliding hernias, since the prolapsed intestine cannot be separated from the hernial bag, such preparation can lead to damage to the vessels that feed the wall of the large intestine. These vessels are located at the lateral surface of the "hernial sac" and can be overlooked. Scanned vascular damage may result in colon necrosis, with all the ensuing consequences, even death.
6. If the surgeon recognizes a sliding hernia only after significant organ damage or impairment of vascularization of the intestinal wall, he should quickly make a decision to expand access (gerniolaparotomy) and eliminate the dangerous complication (careful suture of the damaged organ, if indicated, bowel resection).
7. A significant danger during a sliding hernia operation is an unrecognized damage to the bladder, which can be seen if a thinned bladder diverticulum bulges into the hernial sac. In these cases, only preoperative cystoscopy (cystography) can help prevent a dangerous complication.
When a significant part of the bladder wall and all its layers fall out, recognition is facilitated (wall thickness of the "bag", developed venous network, accumulation of fatty tissue). The bladder wound should be sutured with a two-stitched suture (the lower one with catgut, without capturing the bladder mucosa) and a permanent catheter inserted for 2–3 days.
8. The complexity of the surgical procedure and the choice of the method of operation depend on the type of the sliding hernia, its size, the nature of the hernial sac and its contents, the degree of development of adhesions, sagging.
With small hernias, it can be limited to restoring the integrity of the dissected peritoneal sheet (hernial sac), reducing the hernial protrusion and reliable closing of the inguinal canal (strengthening its back wall).
In case of large, difficult-to-treat hernias, it is advisable to expand access (herniolaparotomy)release the slipped bowel from adhesions and terminate the operation with one of the above mentioned methods of restoring normal anatomical relationships (joining of peritoneum sheets, ventro fixation). These methods are anatomically justified, but they are complex in their implementation and require good orientation and sufficient experience of the surgeon.
Plasticity of the inguinal canal is made taking into account the condition of the tissues and the height of the inguinal gap.
Interstitial inguinal hernia
Superficial inguinal hernia (subcutaneous) (hernia inguinalis superficialis subcutanea). The hernial sac escapes through the superficial opening of the inguinal canal, going further not into the scrotum, but into the subcutaneous tissue, located above the aponeurosis of the external oblique abdominal muscles and superficial fascia. The hernial sac may be further directed to the anterior superior iliac spine or to the navel. The hernial sac may also go under the skin of the thigh to the upper median part of the femoral triangle (trigonum femorale - PNA) and to the perineum, posterior to the scrotum (Fig. 67a).
Inguinal preperitoneal hernia (hernia inguinalis properitonealis). In this type, the hernial sac is more often double-cavity (two-chamber). Both cavities communicate with each other. One of them goes along the usual path of oblique inguinal hernia, but usually does not descend into the scrotum, while the other cavity of the bag is located in the preperitoneal tissue between the transverse fascia and the parietal peritoneum. The preperitoneal area of the hernial sac may be directed to the bladder, to the iliac fossa and, rarely, to the obturator opening (hernia in ‑ guinalis properitonealis, iliaca, obturatoria). The anatomical relationships are significantly changed, adhesions of the preperitoneal hernial sac with the parietal peritoneum are noted, which must be taken into account when allocating the hernial sac (Fig. 67, b).
Fig. 67.Interstitial hernia.
a - hernia inguinalis subcutanea, b - hernia inguinalis properitonealis, c - hernia inguinalis interstitialis, d - hernia inguinalis interstitialis bilocularis congenita.
Inguinal intermediate intraparietal hernia (hernia inguinalis interstitialis). The subcutaneous opening of the inguinal canal can be significantly narrowed or completely closed. The inguinal canal with an inguinal intermediate hernia is enlarged and shorter than usual in length. The hernial sac at its exit from the internal opening of the inguinal canal is located under the aponeurosis of the external oblique muscle of the abdomen, between the internal oblique and transverse muscles, between the transverse muscle and the transverse fascia (Fig. 67, c). Hernia sac inguinal intermediate hernias can pass through the cracks in the aponeurosis of the external oblique muscle. The inguinal canal with the inguinal intermediate hernias is enlarged, the muscles over a greater distance away from the inguinal ligament, are atrophic. The abdominal opening of the inguinal canal is shifted somewhat upwards. With anatomical weakness, the inguinal intermediate hernia can occupy the entire inguinal triangle. The testicle is located more often at the subcutaneous opening of the inguinal canal or in the inguinal canal and as an exception descends into the scrotum. In most cases, the testicle is in a state of atrophy.
Inguinal intermediate two-chamber hernia (hernia inguinalis interstitialis bilocularis congenita). The inguinal hernia in this species has a forked hernial sac (two-chamber). The main part of the bag is located under the aponeurosis of the external oblique muscle, the other - passes through the inguinal canal and descends into the scrotum. The neck of the hernial sac at the level of the deep inguinal ring may be narrow, and the cavity of the sac will not always be filled with contents. When examining patients with these two-chamber hernias, a bulging over the aponeurosis of the external oblique muscle is determined, the superficial inguinal ring is usually narrow, the testicle in the scrotum is not always palpable. Bulging under the aponeurosis decreases in the position of the patient lying down, with slight pressure, the characteristic rumbling is determined. The aponeurosis of the external oblique muscle is not always stretched (Fig. 67, d).
With an unclear clinical picture, roentgenoscopy may help recognize the nature of the hernial protrusion.
I.S. Rosenzweig (1936) describes the observation of an intermuscular hernia, the diagnosis of which was established radiographically. When examining the patient in different positions in the area of the protrusion shadow, poorly visible portions of air were visible.It was suggested that intestinal loops emerge through the abdominal wall, and with repeated fluoroscopy after barium suspension, contrasted loops of small intestines were found in the shade of a hernial protrusion.
Intermediate hernia in women mainly correspond in their location to the inguinal intermediate hernia of men. The diverticula of the hernial sac in women descends into the big lip.
A saccural (racemoid or Cooper) hernia (hernia inguinalis encystica, hernia cystica s. Cooperi)
The encased hernia is described in 1833 by Cooper. Separate observations were published by S. P. Protopopov (1928, 1957), A. V. Kaplan (1939), A. P. Krylov (1950), N. V. Voskresensky (1951).
A sacral hernia is characterized by the presence of a bag protruding into the underlying peritoneal sac (actually a closed cavity). The location of the hernia sac of sacculated hernia is fully consistent with the direction of the oblique inguinal hernia, since its development is associated with non-incision of the peritoneal inguinal process. The inner bag communicating with the abdominal cavity is covered with the peritoneum both from the inner side and from the surface protruding into the outer bag (closed), and usually has no connection with the abdominal cavity. The contents of the hernial saccule hernia sac are located in the inner sac.
Summed hernias have a wide variety of combinations in which the usual for oblique inguinal hernias anatomical correlations are sharply violated, which complicates the diagnosis and complicates the operation.
There are two main forms of encased hernia. One of them develops according to the type of testicular hernia, the other - according to the type of kanatikovoy.
The accumulation of a small amount of serous fluid in the outer bag, which has a denser wall than the inner bag (actually the hernial bag), is noted.
A.V. Kaplan describes the operation of hernia repair in a 62-year-old patient with an encysted inguinal hernia.
The formation hanging in the hernial sac was taken as Meckel’s diverticulum. Only through close examination it turned out that this formation was a serous bag, inside which the intestinal loop was felt.
When an unrecognized hernia is unrecognized during surgery, there may be serious complications. Meri and Petit (Meri, Petit) observed a double bag hernia. The internal hernial sac of encased hernia was taken as a loop of the intestine and set with a broken loop of the small intestine.
S.P. Protopopov (1928) drew attention to the atypical nature of the anatomical structure of the inguinal region in some forms of inguinal hernia resembling confined hernias in structure: when there is a pronounced aponeurosis of the external oblique abdominal muscle, a sharply thickened cord appears, the outlines of the subcutaneous inguinal ring are not pronounced, so as the fibers of aponeurosis, in the form of a fully formed aponeurotic film, together with a thickened superficial fascia, pass to the cord, forming a container for hernial protrusion, which odvesheno at external inguinal canal, "as the udder." Only after a wide dissection of this sheath can a true hernial sac be distinguished. This atypical aponeurotic capsule makes it possible during surgery to assume the presence of an additional hernial sac.
JV Protopopov suggests calling such a hernia “hernia obstincta s. incapsularis ", leaving for the hernia of Cooper the term" hernia encystica "(in translation -" hernia in the bag ").
Hip hernia (hernia parainguinalis)
Hip hernia is a rare type of oblique inguinal hernia. After exiting the deep opening of the inguinal canal, the hernial sac is not directed to the surface inguinal ring, but to the gap between the fibers of the aponeurosis of the external oblique muscle. These gaps can be congenital or are formed with a weak aponeurosis or with blunt injuries of the inguinal region. There are also cracks in the legs of the superficial inguinal ring. The clinic of near-inguinal hernias is similar to the clinic of inguinal hernias.During the examination, a common technique for inguinal hernia is used. Indications for surgery are the same as for all other types of inguinal hernias. During the operation, an aponeurosis of the external oblique muscle is absolutely necessary throughout the incision with a dissection of the superficial inguinal ring in order to be able to orient in the atypical location of the hernial sac, the absence of the diverticula of the sac and to carry out a complete plastic of the inguinal canal.
Oblique inguinal hernia with rectified canal
There are observations on the rare form of oblique inguinal hernia, which, with a wide neck, significantly expands the hernia gate, which takes a straight direction. B. E. Linberg calls this form oblique inguinal hernia with a straightened canal, Oidtmann (Oidtmann, 1930) - hernia inguinalis externa directa. In this form, the posterior wall of the inguinal canal is deformed, the lower epigastric artery is pushed aside medially. NI Kukudzhanov (1949) cites 4 cases of oblique inguinal hernias with a straightened canal identified by him in a section. The size of the inguinal gap reached 7.5 cm along the inguinal ligament with a gap height of up to 5 cm. A thinning of the transverse fascia is also noted.
Surgery for oblique inguinal hernias with a straight canal is much more complicated than for direct hernias. High inguinal gap can not be closed by conventional means, so the plan of operation should include the use of autoplastic and alloplastic methods.
With a well-pronounced aponeurosis of the external oblique abdominal muscle, you can use the plastic version of the "triple aponeurotic shutter" (N. V. Voskresensky and S. L. Gorelik). When sewing the aponeurosis, it is imperative to fix to the compacted part of the transverse fascia — tractus iliopubicus and to the tuberculum pubicum.
Combined forms of inguinal hernia
The following one-sided combinations of various types of inguinal hernias are observed: direct inguinal and external supracellular inguinal hernias, direct and oblique inguinal hernias, direct, oblique and external supracellular hernias.
R.S. Manukyan (1933) for 1500 inguinal hernias observed 3 patients with two inguinal hernias on one side. N. I. Kukudzhanov (1945) in 1075 patients with oblique and 109 with direct inguinal hernias in 17 found combined hernias.
Combined oblique and direct hernias are divided by the inferior epigastric artery. The transverse fascia forms one common fascial sac, so without dissection of the fascia, it is difficult to establish the presence of a combined hernia. As a symptom of combined hernias, R. S. Manukyan notes the duality of the lower contour of the hernial protrusion with an unclear recess between the lateral and medial parts of the hernial sac. When coughing and straining, the location of the protrusion changes, which seems to depend on the contents of one of the bags.
A landmark herniation is considered a sign of a combined hernia, when the protrusion is reset not immediately, but in two steps. This symptom can be observed with multi-chamber hernias. Observations V. Ya. Vasilkovan (1939) show that in some cases of combined hernias during surgery, the second bag may not be noticed, and in the postoperative period, a hernial protrusion is detected, which is taken as a relapse (the so-called false relapse). It is very important during the operation to force the patient to strain, which makes it possible to timely detect the combined form of the inguinal hernia.
A direct inguinal hernia exits through the internal inguinal fossa, which is a permanent anatomical formation. Direct hernias make up 5-10% of all types of inguinal hernias. In women, direct inguinal hernia occurs in 1-2% of cases. In children, they are extremely rare. A direct inguinal hernia is an acquired etiology. Insufficient development of the inguinal region, weakness of the abdominal wall predispose to the development of direct hernias, therefore the term "acquired" should be understood in a purely clinical sense.In the initial stage of its development, the hernial protrusion has an oval, semicircular shape and usually does not extend beyond the surface of the inguinal ring. When the abdominal wall laxity, significant deposition of fatty tissue and enlarged inguinal ring, the hernial protrusion can go beyond the ring and descend into the scrotum (hernia inguinalis scrotalis). This type of hernia is rare. Straight hernias do not tend to infringe.
Clinic and recognition. Direct hernias are more often bilateral and are mainly observed in old age. With long-term existence, bilateral hernia may be in contact with each other. Patients with direct inguinal hernias usually complain of feeling uneasy when walking, physical exertion.
Pain is less pronounced than with oblique inguinal hernias, which is explained by a rather wide hernial ring and wide neck of the bag. With significant hernial protrusion can be expressed dyspeptic phenomena. Complaints of the patient on the urination disorder, frequent urge, periodic urinary retention due to the immediate proximity of the bladder or its diverticulum. When examining the superficial inguinal ring in direct hernias, a pulsation can be felt a. epigastrica inferior outwards from the hernial protrusion, which is possible with a wide superficial inguinal ring and in non-obese patients. You can also probe the pubic bone and its back surface. On examination and palpation of the hernial protrusion in the case of a direct hernia, the lateral protrusion is well defined, which is not observed in oblique inguinal hernias.
With a differential diagnosis between a straight and oblique inguinal hernias in the position of a patient lying down, pressure can be applied to the area of the deep inguinal ring - when straining, a hernial protrusion of a direct hernia appears. With oblique inguinal hernias, a protrusion is detected after the cessation of pressure on the area of the deep inguinal ring while simultaneously pressing on the area of the superficial inguinal ring.
A rare type of direct inguinal hernia is a supra vesicular hernia that leaves the fossa (fovea) supravesicalis through the vesical fossa. The place of the hernia is located between plica umbilicalis media and plica umbilicalis lateralis. This type of inguinal hernia is also called hernia vesico-pubica, as well as hernia praevesicalis pararectalis, which indicates the anatomical sites of the hernial protrusion. The hernial protrusion of the supravesical hernia further passes into the medial part of the inguinal gap.
The supracellular hernias can go out into the crevices of the twisted (collective) ligament and lie laterally from the edge of the rectus muscle. The hernial sacs of the suprambugular hernia are also directed towards the femoral canal, forming the femoral hernia of the supravesical fossa (hernia femoralis supravesicalis). As with direct hernias, the hernial protrusion of a supraboracular hernia is covered with preperitoneal fat and transverse fascia. The clinic of supravesical hernia corresponds to that of direct hernias. The adherence of the bladder to the wall may cause dysuric phenomena and discomfort when the bladder is full.
During surgery, the surgeon must consider the presence of pre-cellular fiber and the proximity of the bladder.
Surgery for direct inguinal hernia
The main objective of such operations is to strengthen the posterior wall of the inguinal canal. With a high inguinal gap and a strongly stretched transverse fascia, strengthening only the anterior wall of the inguinal canal is not a reliable way of restoring it and closing the hernial ring.
The most well-known operation for direct inguinal hernias is the Bassini method (1890), which turned out to be most common both in Russia and in other countries (reports at the VII, IX Pirogovsky congresses, at the I and III congresses of Russian surgeons and at the XII International Congress in Moscow ).
E.Bassini (1844-1919) Professor at the University of Padua (Italy).
At the XVIII Congress of Russian Surgeons (1926), B.E. Linberg presented the data of combined statistics covering 19,768 operations. According to these data, the Bassini method was most popular as the most effective for direct and oblique inguinal hernias with a straightened canal.
In the manual for private surgery of Goldhan and Jörns (R. Goldhahn and G. Jorns, 1962), Bassini’s operation for inguinal hernias is described as the main, most common, and currently.
Bassini way. The skin incision is performed parallel to the inguinal ligament, the aponeurosis of the external oblique abdominal muscle is dissected so that the inguinal ligament is visible throughout the incision. The edges of the dissected aponeurosis are retracted. The inner leaf of the aponeurosis should be well separated from the internal oblique and transverse muscles. The spermatic cord is isolated and under it
Fig. 68. Bassini operation.
a - muscles are sutured to the inguinal ligament, b - muscles are stitched to the inguinal ligament under the spermatic cord, e - iad the spermatic cord is sutured at the aponeurosis of the external oblique muscle.
gauze strip, with which the cord is retracted to the side (Fig. 68, a). After isolating the hernial sac, stitching the cervix and cutting off the sac, the internal and transverse muscles, as well as the transverse fascia, are hemmed to the inguinal ligament under the spermatic cord (Fig. 68 b). The last suture in the medial angle of the wound is hemmed by the edge of the aponeurosis of the rectus muscle to the pubic tubercle and inguinal ligament. The spermatic cord is placed on the newly formed muscle wall, and the dissected aponeurosis is stitched, leaving an opening for the passage of the spermatic cord (Fig. 68, e). Stitched on the skin. With the Bassini method, the posterior wall of the inguinal canal and the medial part of the inguinal gap adjacent to the aponeurosis of the rectus abdominis are strengthened, therefore the principle of Bassini’s operation is quite applicable to direct inguinal hernias. However, stitching heterogeneous tissues (muscles and inguinal ligament) often led to the discharge of the attached muscles, especially with a high inguinal gap, and therefore many surgeons have negatively reacted to this method of plastics. For more reliable strengthening of the posterior wall of the inguinal canal in the medial part of it, it is possible to hem it together with the muscle to the inguinal ligament and the upper leaf of the aponeurosis, which eliminates the method mentioned above. The suture through all layers of the abdominal wall to the inguinal ligament with the movement of the spermatic cord was first proposed by Postempsky (Postempski, 1887). This option is used by many surgeons (A. P. Krymov, B. E. Linberg, N. I. Krakovsky, S. L. Gorelik, and others). The Bassini version of plastics should be called the Bassini – Postempsky method. Along with the Bassini method, it is of practical interest to strengthen the posterior wall of the inguinal canal with the displacement of the spermatic cord along Hackenbruch (Hackenbruch, 1909) (Fig. 69, a, b), based on the principle of aponeurotic plasty with displacement of the spermatic cord and aimed at strengthening the posterior inguinal wall channel. The operation is performed according to the principle of muscular-aponeurotic plastics and is close to the operation of Bassini-Postempsky.
Of the newer proposals for plastics of the inguinal canal with direct hernia, the method of N. I. Kukudzhanova (1949) is of interest. The operation is based on the features of the surgical anatomy of the inguinal canal with direct hernias. After dissection of the aponeurosis of the external oblique muscle, the spermatic cord is pushed downwards and anteriorly, the hernial sac is isolated, highly bandaged and cut off. With a wide neck of the bag impose a continuous seam. Transverse fascia sewn separately.
Figure 69. Surgery for an inguinal hernia according to Gackenbruch.
and - the deep seam is imposed. The medial leaf of the aponeurosis of the external oblique muscle with internal oblique muscle is located under the spermatic cord and is hemmed to the inguinal ligament,
b - the second row of stitches.The outer leaf of the aponeurosis of the external oblique muscle is hemmed to the medial leaf of the aponeurosis above the spermatic cord. The spermatic cord is located between the leaves of double aponeurosis (E.Rehn).
Fig. 70. Operation for direct inguinal hernia (after N.I. Kukudzhanov).
a - stitched pas transverse fascia. The deep muscle of the rectus sheath is sutured to the upper pubic ligament, and the sutures, which are applied to the deep leaf of the vagina by the straight chishts and the upper pubic ligament, are tied. The lower edge of the internal oblique muscle is completely down.
The tendon layer of the transverse muscle is stitched to the iliac tract and the upper pubic ligament 16. Stitching these layers creates a strong bottom of the inguinal canal. In the medial part of the inguinal gap, the vaginal wall of the rectus muscle is stitched to the superior pubic ligament, which moves the lower part of the internal oblique muscle downwards, simultaneously reducing the size of the inguinal gap and strengthening the posterior wall of the inguinal canal. The spermatic cord is located above the stitches. When hemming the medial flap of the aponeurosis of the external oblique muscle to the inguinal ligament, the internal oblique muscle is not captured in the first medial sutures, so as not to squeeze the spermatic cord. The muscle is hemmed in the outer part of the inguinal gap to the inguinal ligament to reduce the length of the slit-oval inguinal gap. The aponeurosis of the external oblique muscle is sewn by duplicatory.
Surgical anatomy and surgerydirect inguinal hernia at certain stages of its implementation
"If relatively oblique hernia there are contradictions in the views on the way they operate, then there is even less constancy and certainty in relation to the hernia straight."
Surgical anatomy of a direct inguinal hernia. With direct inguinal hernias, which are most often observed in persons of middle and old age, the layer of subcutaneous fat is significantly pronounced. The aponeurosis of the external oblique muscle is usually stretched and stretched. The subcutaneous inguinal ring is oval-shaped and freely passes 2 fingers or more. Arcuate fibers (fibrae intercrurales), located obliquely transversely to the fibers of the aponeurosis of the external oblique muscle, are stretched.
The edges of the subcutaneous orifice are malleable and when inserting a finger, they easily lift the anterior wall of the inguinal canal. The edges of the internal and transverse muscles are located high above the inguinal ligament and the height of the inguinal gap with direct inguinal hernias can reach 4-5.5 cm. Thus, with a direct inguinal hernia in the medial inguinal canal there is a weakness of three anatomical structures that, as it were, are superimposed one on the other in the sagittal plane: a wide external opening of the inguinal canal, a high inguinal gap and a stretched transverse fascia. A.V. Martynov drew attention to these relations, which must be taken into account during the operation of direct inguinal hernia, at the XVIII Congress of Surgeons.
The inguinal ligament with direct inguinal hernias appears to be somewhat stretched, which must be borne in mind when hemming the internal oblique and transverse muscles to it and the aponeurosis of the external oblique muscle, since excessive tension of the inguinal ligament can weaken the femoral canal and predispose to subsequent formation of the femoral hernia.
Hernial protrusion, covered with transverse fascia, directly adjacent to the front wall of the inguinal canal and subcutaneous tissue, located at the extended external inguinal ring. Thus, after dissection of the aponeurosis of the external oblique abdominal muscle, a protrusion of the transverse fascia is found, forming a fascial sac, repeating basically the shape of the hernial peritoneal protrusion. After dissection of the transverse fascia, preperitoneal fatty tissue is visible, usually well pronounced and covering the hernial sac in the form of a separate membrane, moving downwards and inwards from the hernial sac into the pre-vesicular cellular tissue, which can be distinguished by a slightly different color and developed venous network near the bladder wall. The inferior epigastric arteries and vein are located outwards from the hernial sac.
The peculiar surgical anatomy of a direct inguinal hernia also reflects its pathogenesis as a hernia of acquired, “hernia of weakness”.The difference between the surgical anatomy of a direct inguinal hernia and an obliquus determines other surgical tactics, as well as the choice of the method of operation and the performance of certain technical details of it.
The operation of a direct inguinal hernia at individual stages of its implementation. During a direct inguinal hernia operation, the surgeon encounters the following anatomical layers: skin with subcutaneous tissue, superficial fascia, aponeurosis of the external oblique muscle and fascia cremasterica, transverse fascia, preperitoneal fatty tissue, peritoneum (the hernial sac itself). The first stage of the operation - layer-by-section dissection of tissues with the opening of the inguinal canal - is carried out in the same way as with oblique inguinal hernia.
For anatomical and non-traumatic separation of the hernial sac, it is necessary first of all to dissect the transverse fascia covering the hernial sac (posterior wall of the inguinal canal). It is advisable to take the edges of the transverse fascia on the clamps, after which you can proceed to the selection of the hernia sac. The spermatic cord lying outward from the hernial bag, it is better to take a gauze or rubber strip and take outwards.
Fig. 71. Surgery for direct inguinal hernia. Isolation of the hernial sac.
a - lateral facies cut. The hernial sac with its surrounding fat pad is highlighted, b - dissection of the fat pad, in the section, the wall of the hernial sac is visible.
When isolating a hernial bag, it is useful to inject novocaine solution (0.25%) at its base for hydraulic preparation. Such preparation largely guarantees against accidental damage to the bladder, rather close to the medial wall of the hernial sac.
Fig. 72. Surgery for direct inguinal hernia. Move the stump of the hernial bag.
and - the hernial bag is tied up. One of the threads with the help of a needle is moved under the transverse fascia and muscles up and laterally, b - a detail of the operation - additional stitching of the hernia sac stump, moved to the stump of the hernia sac. Stitches are tied.
Fig. 73. An operation for an inguinal hernia with a Barker — Krasintsev stump of a hernia sac moving (original drawing from the monograph by V. A. Krasintsev).
I — aponeurosis of external oblique muscle, II — hernial sac stump, III — spermatic cord, IV — hernial sac stump. The number IV shows the projection on the skin of the stump of the hernial sac, summed up under the aponeurosis of the external oblique muscle and stitched to it.
Fig. 71. Surgery for direct inguinal hernia. Stitches on transverse fascia.
With a free discharge of the hernial bag (in the absence of adhesions), it is stitched at the base with a catgut thread and tied in both directions. It is advisable for a more reliable dressing to finally tighten the thread with the bag already cut, while holding the stump on the clamp. In the presence of planar adhesions in the vicinity of the vesicular cellulose tissue (wearing of a bandage, strangulation, inflammation), it is better to stitch the hernial sac with a suede string from the inside (V.I. Razumovsky). Next, they start moving the stump of the hernial bag outwards and upwards according to V. A. Krasintsev — Barker (Fig. 72, a, b).
The stump of the hernial bag is stitched with a catgut thread, both ends of which are held with a low-bent needle under the control of a finger or spatula, brought under the edges of the transverse muscles and internal oblique, above which both ends are tied (fig. 72, e) of the thread, thus the stump of the hernial bag moves upwards , and in the groin gap there will be an unchanged and not stretched peritoneum.
When strengthening the posterior wall of the inguinal canal, it is necessary to pay special attention to the medial part of the inguinal gap, the reinforcement of which is especially important because the pathogenesis of a direct hernia has a weakening of the posterior wall of the inguinal canal.
First of all, it is necessary to sew the transverse fascia dissected earlier when the hernial sac is isolated. In case of a strongly stretched transverse fascia, it can be strengthened either by doubling or imposing a purse string suture with immersion of excess stretched fascia in this kit.
The aponeurosis of the external oblique muscle and the edges of the internal oblique and transverse muscles are hemmed to the inguinal ligament under the spermatic cord.
With flabby tissues, the posterior wall of the inguinal canal can be strengthened by duplicating the aponeurosis. The spermatic cord is placed on the newly created strong posterior wall of the inguinal canal, and outward from the new place of its exit, 2-3 silk sutures are placed on the inner leaf of the aponeurosis of the external oblique muscle and inguinal ligament (Fig. 75, c). To prevent compression of the spermatic cord, it is possible to cut the inner leaf of the aponeurosis at the site of exit of the spermatic cord slightly transversely in the transverse direction. Catgut sutures on the fiber and superficial fascia reliably cover the spermatic cord (with direct inguinal hernias, the superficial fascia is usually well defined). To strengthen the posterior wall of the inguinal canal, the most successful and effective are the operations of moving the spermatic cord with maximum reinforcement of the posterior wall of the inguinal canal.
Fig. 75. Surgery for direct inguinal hernia. Strengthening the posterior wall of the inguinal canal along Bassini – Postempsky.
a - the medial piece of the aponeurosis of the external oblique abdominal muscle is lined to the inguinal ligament under the spermatic cord, b - the sutures are imposed laterally from the spermatic cord, and in duplicate the aponeurosis of the external oblique muscle under the spermatic cord.
Fig. 76. Surgery for direct inguinal hernia. Suturing of superficial fascia.
The best option for such an operation is a muscular-aponeurotic closure of the inguinal gap (posterior wall of the inguinal canal) —Bassini-Postampsky 17 operation, in which all layers of the abdominal wall are most effectively used. It should be noted that Bassini and Cattarina attached great importance to the transverse fascia for firm closure of the inguinal gap.
Unlike oblique inguinal hernia, in which the hernia sac's stump slips under the muscles when it is highly bandaged and the peritoneal funnel is eliminated, with a direct hernia, it is highly advisable to move the hernia sac stump along the Krasintsev-Barker route.
Details of operational equipment and the prevention of complications during the operation of oblique direct hernias
1. The patient on the operating table is placed with a raised pelvis and a slight inclination of the table in the direction of the assistant for a better view of the surgical field.
2. For small hernias and in obese patients, it is advisable to perform an operation with two assistants for better access and atraumatic surgery.
3. The incision of the skin and subcutaneous tissue should not reach the pubic tubercle (tuberculum pubicum), which prevents the violation of the integrity of a. and v. pudenda externa.
4. When dissecting the aponeurosis of the external oblique muscle (anterior wall of the inguinal canal), it is necessary to take into account the proposed option of plasty of the inguinal canal due to the state of the aponeurosis (weakly expressed, stretched).
5. The hernial sac of a direct inguinal hernia is well and atraumatic only released after dissection and detachment of the transverse fascia.
6. It is better to excrete the hernial sac after dissecting it at the bottom, exfoliating fat overlays, especially from the medial side, with careful movements to prevent possible injury to the bladder.
7. A hernial sac with direct hernias is usually thin and easily tears with a coarse discharge. Violation of the integrity of the hernial sac at its neck may make it difficult to suture.
8. If the wall of the bladder is damaged, it is necessary to carefully overlay the wound with gauze napkins and carefully sew up the wall with a two-stitched seam, without taking the mucous membrane into the seam. The subsequent introduction of a permanent catheter is advisable.
9. When a purse-string suture is placed on the neck of the bag from the inside, it is necessary to use a well-bent, thin needle and sew the folds of the peritoneum, pulling them carefully into the lumen of the hernial bag. Thus, when the suture is tightened, the abdominal funnel is eliminated.
10. When moving the stump of the hernial bag under the front wall of the abdomen, it is better to hold the needle under the protection of a finger, spatula or Kocher probe, but always under the transverse fascia, otherwise it will be difficult to provide a layer-by-layer connection of tissues. To prevent possible ligature slipping superimposed on the neck of the bag, it is better to impose an additional ligature, for which the bag stump should be tightened.
11. The stretched transverse fascia can either be duplicated, or seized in one suture together with the muscles when hemming them to the inguinal ligament.
12.The inguinal ligament should be taken wide along the plane, without using a needle that is too thick or thick silk, so as not to loosen the ligament, which is important for preventing recurrences.
13. Muscles should be hemmed to the inguinal ligament with moderate tension, with strong tension, the muscle becomes loose, and with a weak tension it atrophies.
14. With a well-pronounced aponeurotic extension of the internal oblique muscle, it is advisable to capture not only the edge of the muscle, but also the aponeurotic part of it in the suture, which will ensure the best healing of homogeneous tissues.
15. When hemming to the inguinal ligament of the internal leaf of the aponeurosis of the external oblique muscle, attention should be paid to the wide inguinal gap and to strengthen the medial part of it, stitches to the aponeurosis of the internal oblique muscle, and to the edge of the rectus sheath.
16. When strengthening the posterior wall of the inguinal canal with the displacement of the spermatic cord, it is necessary to apply 1-2 seams on the aponeurosis of the external oblique muscle and inguinal ligament lateral to the exit point of the displaced cord.
17. With a high inguinal gap, in order to reduce the tension of the sutured tissue, it is advisable in some cases to perform a weakening incision of the anterior wall of the vagina of the rectus abdominis muscle. This relaxing incision is made from the symphysis 5-6 cm upwards and outwards over the middle of the rectus muscle 18.
18. With bilateral direct inguinal hernias, especially in the elderly, a single-step operation is not indicated on both sides.
Causes of the disease can be congenital and acquired. Often a hernia occurs under the influence of both factors.
- underdevelopment of the muscles of the abdominal wall,
- incomplete adhesion of tissues after lowering the testicles into the scrotum from the posterior wall of the abdominal cavity.
- excessive exercise
- regular weight lifting
- excess weight,
- chronic cough,
- problems with the gastrointestinal tract (constipation),
- previous abdominal or groin injuries,
- repeated or difficult childbirth.
What is an inguinal hernia?
The essence of all abdominal hernias is the same: parts of the internal organs (omentum or intestines) penetrate beyond the abdominal cavity through the weak points in the muscle corset. According to statistics, up to 75% of all abdominal hernias are inguinal.
They occur when a part of the intestine comes out through the inguinal canal. In this intermuscular space in men there is a sperm duct, and in women there is a round ligament of the uterus (as well as blood and lymphatic vessels).
In men, the inguinal canal is less reinforced by muscles and tendon layers, shorter and wider than in women. That is why inguinal hernia is more common among the representatives of the stronger sex.
The direct cause of hernia formation is a persistent increase in intra-abdominal pressure. And most often it occurs as a result of regular physical exertion, obesity, lasting for months of chronic cough, prolonged indigestion (constipation, flatulence) or pregnancy ...
Under the action of increased intra-abdominal pressure, areas of internal organs begin to penetrate into the defects present in the muscular layer of the inguinal canal (hernial ring). Such defects may be congenital or may appear as a result of loss of tissue elasticity with age, due to injuries.
Gradually, the hernial ring opens more and more, and the intestinal section passes through the inguinal canal beyond it. Externally, the hernia is manifested at first in the form of swelling, the size of which increases when coughing, straining, exercise. If the hernia is not treated, its size only grows with time.
The mechanism of oblique and direct inguinal hernia formation is slightly different. In the first case, the hernial sac passes through the entire inguinal canal inside the spermatic cord (and may eventually descend into the scrotum in men or the labia majora in women).In the second case, the hernial sac stretches the posterior wall of the inguinal canal and exits through the surface ring outside the spermatic cord.
Sometimes patients have two or more separate hernia sacs that do not communicate with each other in the inguinal region (combined hernia).
Complications of inguinal hernia
The main danger of the disease is possible complications. Hernia infestation is the most frequent (observed in 10% of cases), and at the same time the most dangerous of them. An intestinal loop extending beyond the abdominal cavity can be clamped in the hernial ring. In this case, the blood supply to the contents of the hernial sac is disrupted, and necrosis develops in it. To save the life of the patient in this case, an emergency operation is required.
Another possible complication of a hernia is the development of adhesive processes in the hernial sac. Ultimately, this can cause intestinal obstruction, coprostasis. Again, this is an indication for emergency surgery.
Treatment of inguinal hernia
Regardless of the size and location of the hernia, its treatment is only operational. Special bandages can only reduce the risk of infringement, but they can neither guarantee the absence of complications and stop the growth of the hernia.
The root cause of the disease is a defect in the posterior wall of the inguinal canal, and treatment should be aimed at strengthening it. For a century, the main method of treating a hernia was the so-called “tension plastic.” Surgeons tried to close the defects of the abdominal wall by tightening their own tissues in the hernia area.
Over the years, literally hundreds of methods have been created for such operations. The essence of all is approximately the same: a cut was made, the contents of the hernial sac were reset (or cut off), and the hernial gate was stitched together with sutures so as to close the lumen. And all these methods had the same set of significant shortcomings: a strong pain syndrome, a long rehabilitation period, and a high risk of hernia recurrence.
That is why in our time surgeons prefer the so-called non-tensioning methods using mesh implants - hernioplasty to “classics”.
Signs and symptoms
In the initial stages, the only symptom of a hernia may be a characteristic protrusion in the form of a soft tubercle, which disappears when a person lies on his back. External bulging in principle is the main sign of the presence of an inguinal hernia.
With the progression of the disease to the outer tubercle is added:
- acute or aching pain
- burning sensation that increases after walking or physical exertion,
- feeling of heaviness and pressure
- changing stools (constipation),
- difficulty and pain when urinating (when a bladder falls into the inguinal canal)
- temperature increase (if an infection has entered the hernial sac),
- nausea or vomiting
- blood in feces (the last two symptoms appear when a hernia is strangled).
Initially, the swelling outside will not be very large and periodic, so patients often ignore the initial stage of the disease and allow it to develop. With the progression of the protruding organ under pressure, the hernial ring expands, which allows the hernia to increase significantly in size. In this case, the discomfort and painful symptoms also increase.
Compounding a hernia increases the risk of pinching it. This occurs during a sharp expansion of the hernial ring under the influence of high intra-abdominal pressure (for example, during intense physical activities). A large portion of the internal organ enters the hernial sac, however, when the pressure drops, the gate narrows again and the organ cannot return to its place. Hernia becomes unregulated and a pinch occurs.
In this case, the pain is significantly increased, vomiting, blood in the feces. There is a general deterioration in the patient’s condition, as the blood flow is disturbed during pinching.Pinching a certain part of the intestine leads to dysfunction of the entire organ, so any additional symptoms associated with the gastrointestinal tract may appear.
Diagnosing an inguinal hernia usually takes place in several stages:
1 Initial examination by a surgeon. The doctor conducts a visual examination, asks the patient questions that help make a diagnosis (lifestyle, nature of work, etc.). Then he proceeds with the manipulation to determine the types of hernia (straight, oblique or sliding). The surgeon examines the bulging in the vertical position of the patient, as well as in the horizontal, asks him to cough. This palpation allows you to more accurately determine the location of the hernia and its type. At the initial stage of the disease, a small tubercle can even be confused with a hydrocele, varicocele, inflammation of the lymph nodes or femoral hernia. If you suspect a sliding hernia or blur symptoms, an additional examination is appointed.
Photos of inguinal hernia
2 ultrasound. Examine the scrotum, inguinal canals, bladder. Ultrasound is effective only when the hernia is out. Otherwise, the pathology will not be visible.
3 irrigoscopy (method of research of the intestine under x-rays). This technique allows you to conduct a full examination of the intestines, identify all inaccuracies and pathologies, diagnose a sliding inguinal hernia. During the procedure, contrast is introduced into the intestine (most often barium sulphate) directly through the large intestine. Then the patient lies on his back, and an x-ray takes several pictures. The advantages of irrigoscopy include accuracy and the almost complete absence of side effects. By cons - not very pleasant sensations and careful preparation (following a special diet for 3 days, cleaning the intestines and completely refusing food about 12 hours before the procedure, only clean water is allowed).
4 Herniography. With the help of a long Veress needle, a special contrast is introduced into the abdominal cavity below the navel. Then the patient lies on his stomach and strains as much as possible. At this time, the X-ray machine takes pictures of the groin area. The study allows you to accurately determine the presence of small, sliding or atypically located hernias.
It is very important to consult a doctor at the earliest stages if you detect even the slightest signs. Using the above techniques, the doctor will be able to make an accurate diagnosis and prescribe the necessary treatment. In this case, they often do without an operation, only by conservative methods. Recovery is faster, and the risk of complications is much less.
Based on the results of the examination, the doctor makes a decision on the course of treatment. In most cases, surgery is used, which has its pros and cons. In the case of the initial stage and low risk of pinching, other types of therapy may be prescribed.
During the operation, the surgeon removes the inguinal sac and strengthens the damaged areas of the inguinal canal and hernial ring with plastics using the patient’s own tissue. Hernia repair is considered an operation of average complexity and takes no more than 3 hours. Preparation for it is quite simple, the patient undergoes laboratory tests of blood and urine, the day before he carries out thorough personal hygiene and makes a cleansing enema. May be carried out under local or general anesthesia.
In recent years, laparoscopic surgery to remove an inguinal hernia has gained popularity. It is not so traumatic, it requires a short period of rehabilitation and does not leave a big scar. However, the danger of damage to internal organs and blood vessels, as well as adhesive disease.
The postoperative period in the hospital lasts 1-2 days. At this time, the patient put bed rest and rest. An antibiotic course is prescribed to prevent infection.Also shown is a diet, only light food, which is quickly absorbed and does not provoke gas formation. The nurse regularly makes dressings with sterile materials, then such procedures are performed at home. During this time, the doctor monitors the patient's condition and, in the absence of complaints or complications, releases him home. The stitches are removed after about 7-14 days, it all depends on their type. After inpatient treatment, the patient is awaiting the rehabilitation process.
Full recovery after surgery comes in a month. During this period it is necessary to exclude intense physical exertion and weight lifting. Mild walking is recommended. If the profession of a patient is related to physical exertion, it is transferred to light work for up to six months by the decision of the medical commission.
During the rehabilitation period, you must follow a diet, use only natural products and fiber to avoid constipation (this is very important!). During the first month after the operation it is forbidden to live sexually. Appointed regular wearing a special bandage for inguinal hernias.
After this period, the patient gradually returns to the usual life. It is necessary to include therapeutic gymnastics, which can later be replaced by any sport. It is also necessary to adhere to proper nutrition, monitor weight and try to avoid factors that can trigger a relapse.
Pain after surgery
Any surgery is associated with a certain pain syndrome. After hernia repair, the patient will feel unpleasant, but tolerable pain. Pain disappears as it heals, and then completely disappears. Depending on the individual pain threshold of the patient, medium-acting painkillers may be prescribed. About a week later, the pain from acute becomes painful, periodical, which may increase with walking.
Effects of the operation
Complications may be due to an error during surgery or occur during the healing period:
- damage to one of the organs of the genitourinary system,
- nerve damage
- bleeding (may occur during or after surgery),
- suppuration due to suture infection,
- blood clots
- difficulty urinating,
- inflammation of the abdominal cavity (peritonitis),
- the possibility of relapse (from 3% to 35%).
Liechtenstein grafting is an effective and very popular method for the removal of inguinal hernias. The operation is universal, suitable for all types of the disease. According to the Liechtenstein method, not the patient's own tissue is used, but special polymers (polypropylene), which are sewn onto the affected areas. Thus, the own tissues are not stretched, and the place of the hernia is strengthened by a reliable material. At present, a polymer mesh is used, which is self-absorbed with time, after all the tissues are completely regenerated in its place.
The operation has many advantages:
- small percentage of relapses (in comparison with classical surgery),
- shorter rehabilitation,
- less pain when recovering
- less chance of side effects and complications.
Cases of inguinal hernias are very diverse and completely individual. Often, surgery is prescribed as the only way to solve a problem, but non-surgical treatment is also used. With accurate adherence to all recommendations, it gives positive results.
- Therapeutic gymnastics (exercise therapy).
- Wearing a bandage.
Exercises for inguinal hernia are aimed at strengthening the abdominals:
1 Lie on the floor, legs and arms straight, the loin pressed to the floor.You will need a weight of 1 kg, suitable sports weighting, a bag of sand or other bulk filler, which must be put on the stomach and take a breath. On the exhale maximally inflate the stomach, inhale to inhale. Make 10 breaths and exhalations.
2 Lie on the floor, bend your legs at the knees, put straight arms along the body, take a breath. On the exhale, raise the pelvis, while relying on the foot, straight arms and shoulder blades. Inhale to return to its original position. Run 10 reps.
3 Sit on the chair, back is flat, the abdominal muscles are tense. Inhale, raise your right hand and bend to the right, as you exhale, return to the starting position. Perform the exercise in the other direction. Repeat 10 times left and right.
4 Sit on a chair with your back even, arms around the seat behind you. Alternately lift and pull to the chest bent at the knee. Run 10 times on each leg.
5 Exercise "mill". Become straight, feet shoulder-width apart, straight arms apart. Bend forward, trying to reach with his left hand to the toes of the right leg and vice versa. Run 10 times in each direction.
6 Exercise "bike". Lie on your back, press your lower back to the floor, extend your arms along the body, palms can be put under the buttocks. Feet lift above the floor and perform movement, replicating cycling.
7 Exercise "scissors". Lie on your back, press your lower back to the floor, extend your arms along the body, palms can be put under the buttocks. Feet lift above the floor and perform a movement that mimics scissors.
Physiotherapy.When treating with this method, laser, UHF, current and magnetic field therapy, paraffin heating, therapeutic mud are used. Physiotherapy alone is not able to completely cure a hernia, especially in adults, however, it is a good adjunct that eliminates inflammation or infection.
Belt for inguinal hernia. Regular or permanent wearing of a bandage is prescribed by doctors almost always. It exerts pressure from the outside, which allows the hernia to not fall out and be in this position for a long time. Bandage is also required for physical training and in the postoperative period. Pharmacies sell special male and female bandages for inguinal hernia.
How to choose a bandage for inguinal hernia, read here.
Massage. Self-massage also can not cope with the inguinal hernia, it is used in complex therapy. However, one should not underestimate the benefits of professional therapeutic massage, as a result of which the hernia is relieved, muscles strengthen. Massage is also useful after recovery as a prophylaxis.
Traditional medicine is not able to cure an inguinal hernia alone. Home-made recipes do not affect protrusion, they are aimed at relieving inflammation and reducing pain, so they can be used as an aid in parallel with conservative therapy. When inguinal hernia is most often used medicinal compresses, they are simple to prepare and quite effective:
1 decoction of nettle. 250 ml of water bring to a boil, then add a tablespoon with a hill of dry nettle. Boil over low heat under the lid for 15-20 minutes, then let it brew until it cools and strain the broth. To moisten in it natural fabric and to put to a hernia. Compress must be wrapped with cling film and a warming belt.
2 Fresh Gryzhnik (yellow-green herb) boil for 10 minutes (use a double boiler, a slow cooker or put a colander above a pan of boiling water). Then cool the grass, attach to the place of the hernia and wrap with a film.
3 Aloe and honey. Chopped coarse aloe leaf mixed with a tablespoon of liquid honey. Wrap the mixture in gauze and apply to the sore spot. You can only use aloe.To do this, cut the leaf of the plant along, with the side of the pulp, attach it to the hernia and fix it with adhesive plaster.
4 camphor oil effectively relieves pain and inflammation. Apply the oil in a clean form to cleansed and disinfected skin and leave until completely absorbed.
5 Apple Cider Vinegar. The place of hernia localization should be regularly cleaned with apple cider vinegar.
6 Oak bark. Chopped crust pour alcohol in a ratio of 1: 3. Medicine to insist in a dark and dry place for two weeks. Then the tincture can be drained and used for compresses.
To folk remedies, despite the fact that they are completely natural, it is necessary to approach thoughtfully. Do not forget to take into account the individual intolerance (allergy) of any of the components. It is worth agreeing to a home treatment with a doctor, since some medicines are not compatible with traditional medicine.
How to independently correct inguinal hernia?
Provided that the hernia is not accompanied by complications and is not in a disadvantaged condition, it is quite simple to correct it yourself. To do this, lie down on a not too soft surface and completely relax. Then grope hernia tubercle with your fingers and slowly push it inwards. Hernia is reset easily, so you can not make sudden movements and press too hard. To maintain the effect you can wear a bandage. It should be understood that the reduction of the hernia is temporary, it eliminates the discomfort, but without treatment, the hernia will reappear.
There is a theory according to which all diseases appear under the influence of one's own thoughts, fears, negative mood, and also influence from the outside. Psychosomatics connects human ailments with a definitely directed negative energy, in which the patient himself and his family live. This theory is studied and developed by many world-famous psychologists, including Louise Hay, Vladimir Zhikarentsev, Valeria Sinelnikova, Liz Burbo, as well as guru Ar Santarem and others.
Given the numerous studies on the impact of thoughts on a person and his condition, psychosomatics has the right to life. This does not mean that you can not go to the doctor. It is necessary to obtain qualified medical assistance. Putting thoughts in order is useful not only for hernia, but also for general mental health.
Interpretations of hernia:
- long relationship break
- heavy loads, burden
- the inability to express in creativity,
- the feeling that you have been driven into a corner, and there is no escape,
- fear of the future and fear of material problems
- pride, excessive hoarding and boasting wealth.
To improve health, it is important to abandon negative thoughts and feelings. It is necessary to tune in to the positive, to believe that everything will be fine, problems will be solved, and everything in life will work out for you. According to the last point, you need to take all others as equals, do not put yourself above the rest and keep your well-being with you. It is important not to be afraid of defeats and difficulties, to decide on something new, not to limit yourself because of fears.
Compliance with a special diet for inguinal hernia is mandatory, it is aimed at solving the main problems:
- constipation (the main "enemy" of the inguinal hernia),
- fermentation process in the stomach and intestines (only natural products are allowed),
- gas formation
- weight loss (if necessary).
- white bread and pastry,
- prunes, dried apricots, figs,
- apples, pears, peaches, cherries (fresh),
- carbonated drinks,
- semi-finished products, fast food, store sausage or sausages,
- chewing gum,
- fatty, fried, smoked.
- lean meat and fish
- cottage cheese and other natural fermented milk products without additives,
- whole wheat bread,
- buckwheat, oatmeal,
- vegetables rich in fiber (especially carrots), leaf lettuce,
- baked apples,
- natural fruit jelly,
- decoction of wild rose.
"Do they take to the army with an inguinal hernia?"
Even with the presence and diagnosis of an inguinal hernia, a medical examination is required. According to the results of the examination, the surgeon will write out his decision and submit it to a special commission.
An inguinal hernia does not guarantee a “white ticket” at all, but provides for restrictions on service, depending on the severity of the disease (the commission cannot be classified as a fully fit soldier). Usually hernia recruits belong to several groups:
- "B" - is fit with certain restrictions,
- "B" - limited shelf life, transfer to the stock,
- “G” is temporarily unfit, a repeated medical commission is appointed after a certain time (a delay is given for the operation and recovery).
"Sex with an inguinal hernia"
In this context, intimate relationships can be attributed to physical stress, so the rules will be almost the same:
- sex is allowed a month after surgery,
- in the absence of complications and infringements fully resolved,
- It is necessary to observe a certain moderation, and choose the position with the least pressure on the abdominal pressure.
Preventive measures are quite simple, they do not require special preparation and time consuming:
- strengthening the abdominal muscles,
- proper nutrition
- normal body weight
- avoidance of excessive loads and weights, especially with low physical fitness,
- solving problems with regular constipation,
- treatment of chronic cough
- general physical activity (regular exercise, walking, going to the gym, any kind of sports, active games, etc.).
It is impossible to consider an inguinal hernia as a trifle, even if it does not cause pain and discomfort. Remember the need for a full medical examination, follow the treatment prescribed by the doctor. Responsible for your health and do not forget about the simple prevention of the disease.
Brattseva Ekaterina Valerievna
Doctor of the highest category. Assistant professor. Candidate of Medical Sciences.
Medical practice experience: 13 years.