A strangulated hernia is a dangerous complication of a typically leaking hernia and, due to its frequency, is classified as a separate nosological disease.. The basis of the disease is the pinching of the hernial sac in the hernial orifice with compression of the tissues and organs that are located in it. The greatest danger is the compression of the intestinal loop, since this causes the phenomena of strangulation intestinal obstruction and necrosis of part of the intestine..

Infringement is a complication of the course of the disease, it requires immediate medical attention. Types Depending on the localization, strangulated hernias are:.

inguinal;

femoral;

umbilical;

white line of the abdomen;

postoperative (ventral);

atypical areas (spigelian line, internal);

post-traumatic, associated with damage to the muscle aponeurosis (median, lateral).

According to the clinical course:.

Type of infringement.

Characteristic.

elastic.

Occurs due to a significant and sudden increase in pressure in the abdominal cavity. At the same time, a larger number of different structures enter the already formed hernial sac (pronounced expansion of the hernial orifice). At the moment the hernia returns to its original state, infringement occurs.

Fecal.

Occurs in case of compression of the discharge section of the intestine. In the projection of the hernia, the overflowing adductor intestine is clearly visualized, which compresses the discharge department directly in the hernial orifice.

Wall (Richter).

Inside the hernial sac is only part of the intestinal wall, and not the entire loop (the area opposite the mesentery).

This group includes an extremely rare type of infringement - Littre's hernia (infringement of Meckel's diverticulum).

retrograde.

Abductor and adductor loops are located in the cavity of the hernial sac. The part of the intestine between them is outside the hernial sac (the intestine forms the letter w). This area is most affected. With its necrosis, the phenomenon of peritonitis occurs, there is no obstruction as such.

Depending on outcome:.

Uncomplicated. During the operation, only the elimination of infringement is required without additional interventions..

Complicated. Hernia is associated with severe damage to organs and tissues in the hernial sac.. During the operation, in addition to plastic surgery of the inguinal canal, other measures are required (resection of the intestine in order to eliminate obstruction, the imposition of anastomosis in case of severe necrotic processes in the abdominal cavity).

The severity of the course of the pathology directly depends on the duration of the infringement - the more time from the moment of compression, the more difficult the patient's condition.

Symptoms Common clinical manifestations for all types of infringements are:.

Pain of varying intensity. Occurs in most cases acutely, but with Richter infringement it can be gradual. Irradiation is observed along the hernial protrusion. As the bowel wall progresses and necrosis, the pain moves to the abdominal area.

Tense irreducible formation at the site of infringement. Localization depends on the type of hernial protrusion (inguinal zone, thigh). Tissues over the protrusion may be changed (cyanosis, swelling).

No cough symptom. Hernial formation does not disappear in a horizontal position. This condition is due to the fact that the formation loses its connection with the abdominal cavity and becomes completely isolated (does not depend on pressure changes).

Symptoms of intestinal obstruction. The main ones include nausea/vomiting, constipation, increased intestinal pneumatization, severe abdominal pain of different localization.. Fluid levels show up on x-rays (classic).

Signs of peritonitis. Occurs when the intestinal wall is perforated. The stomach becomes hard, the pain turns into a dagger. General condition worsens.

Dysuric disorders occur when a hernia is localized near the bladder or urethra. Disorders are represented by frequent painful urges and hematuria.

Prolonged infringement leads to the attachment of a secondary infection and the appearance of phlegmon of the hernial sac with characteristic signs of inflammation.

Features of infringement in various types of hernias (all the symptoms listed above are present, but for each specific type of hernia there are dominant manifestations):.

View.

Dominant manifestations.

inguinal.

Painful mass in the groin, with all the characteristic symptoms of a hernia.. Difficulties arise when the hernia is localized in the projection of the inguinal canal (oblique hernia). In this case, the difficulty lies in finding the formation itself, since it is small in size (detection is only palpatory in the region of the lateral inguinal fossa). The main symptom is a painful protrusion in the groin area..

femoral.

Often, when assessing the clinical picture, there are difficulties in differential diagnosis with inguinal hernia due to the similarity of the two diseases.. Often a correct diagnosis can only be made with the help of ultrasound.. The main symptom is a painful protrusion in the groin with a partial transition to the thigh.

umbilical.

The main symptoms: local pain in the navel and adjacent tissues, obstruction phenomena (Richter's infringement more often) are not pronounced.

White line of the abdomen.

One of the rarest. More often there are false hernias associated with the infringement of fatty tissue and without elements of the classic hernial protrusion (hernial sac). However, there are also true hernias with the following signs: obstruction phenomena are not pronounced (Richter's infringement), painful protrusion along the midline of the abdomen.

Postoperative.

The main symptoms: a pronounced clinic of strangulation intestinal obstruction (by fecal or elastic type), a sharp pain at the site of infringement.

Spigelian (lunate) line.

Has a characteristic localization: occurs in the segment between the navel and the anterior superior axis of the ilium. They are located more often subcutaneously and in most cases are manifested only by local soreness..

Internal.

Compression of the contents of the hernial sac occurs inside the abdominal cavity without any external manifestations. Infringement is possible in the folds of the peritoneum, at the ligament of Treitz, in the lesser omentum. Initially, there are phenomena of strangulation intestinal obstruction, and with prolonged absence of treatment, peritonitis occurs.

A special form is diaphragmatic hernia, in which the contents pass through weak areas of the diaphragm into the chest. Can be congenital and acquired, true and false. The clinic is represented by the following symptoms: acute intestinal obstruction, manifestations of the cardiovascular and respiratory systems (tachycardia, tachypnea, shortness of breath, a sharp decrease or increase in blood pressure).

May be fatal.

Post-traumatic injuries are singled out in a separate nosological group, since infringement may be accompanied by bleeding, necrosis of muscle tissue (special form). The degree of manifestation of certain symptoms depends on the nature of the infringement (fecal has a more rapid course, elastic and Richter - more smoothed).

Clinical guidelinesRecommendations depend on the type of hernial formations, the causes of occurrence and the clinical picture.

It is not allowed to reposition any formation on its own.

On palpation, the doctor feels the hernia gently, without excessive intensity.. In some cases, during examination, there is a variant of imaginary reduction, which are extremely dangerous conditions..

It is necessary to confirm the diagnosis with laboratory and instrumental studies.. The goal is to identify possible signs of obstruction and perforation (leukocytosis, elevated ESR, formula shift, fluid in the abdominal cavity, free gas under the dome of the diaphragm).

Shown emergency surgical treatment within 2-3 hours from the moment of infringement.

In case of strangulation without gangrene, catheters are sufficient (bladder, stomach, peripheral vein).

In the case of gangrene, in addition to catheters, mandatory administration of antibiotics and infusion therapy is indicated..

TreatmentStrictly surgical treatment is indicated. The table shows the main criteria for the viability of the strangulated segment of the intestine (in case of non-viability, resection is performed).

Characteristics.

viable gut.

Non-viable gut.

Color.

Pink, shiny. Slight redness and bluishness allowed.

Dark (up to black) with occasional bruising.

Mesentery.

Vascular pulsation is present and slight edema may be observed.

Thrombosis of the vessels of the mesentery.

Saving a function.

Visible peristalsis.

dumb gut.

Reaction after exposure to a 15-minute saline wrap.

Color returns to normal pink..

Color does not change.

In the case of Littre's hernia, the removal of Meckel's diverticulum is indicated, regardless of its viability, since it belongs to rudimentary organs.. To remove it, use the ligature-purse-string method of stitching (like appendectomy).

In the preoperative period, stabilization of the patient is required (hemodynamics and saturation). General anesthesia is used more often, since if there is a risk of intestinal damage, local anesthesia is unacceptable.

The main objectives of the operation:.

removal of a hernia and all its components;

destruction of internal organs;

plastic closure of the defect to prevent recurrence.

In case of infringement, necrotic tissues are removed, after which hernioplasty is performed. Some points in operational tactics for different types of hernias are presented in the table.

Type.

Peculiarities.

inguinal.

Cut the skin and subcutaneous tissue 2 cm above and parallel to the pupart ligament. Next, the aponeurosis of the external oblique muscle is dissected with the capture of the internal inguinal ring. The hernial sac is separated from adjacent structures, excised and sutured. The anterior or posterior wall of the inguinal canal is fixed with a mesh and plastic surgery is performed.

It is extremely rare for these hernias to infringe on the intestine (according to indications, a section of the intestine or omentum is resected). This requires a dissection of the posterior wall of the inguinal canal and the intersection of muscle structures. It provides access to the intestines. If it is impossible to perform the operation through this incision, a standard median laparotomy is performed.. After removal of the site of the affected intestine, an anastomosis of the intestine to the intestine is applied or the stoma is taken out and the wound is sutured in layers.

femoral.

During the operation, the incision goes strictly to the medial side..

Sometimes femoral rather than inguinal access to hernial formation is used. Only the Basini method is used as a plasty.

The incarceration of the intestine occurs extremely rarely; for its elimination, the method of resection according to Rugi - Parlavecchio is used. Their inguinal access is made with an incision passing to the thigh, then the femoral canal is opened, the strangulated organs are immersed in the abdominal cavity, and the hernia is removed with plastic surgery of the inguinal canal.

umbilical.

Operative access includes two fringing incisions around the hernial protrusion. Dissect in layers of tissue, including the aponeurotic ring around the navel on both sides. Next, the hernial sac is opened somewhat from the side. The viability of the strangulated intestine is assessed, if necessary, a resection is performed and an end-to-end anastomosis is performed. The wound is sutured in layers with plastic surgery of the anterior abdominal wall.

Sometimes a Grekov operation is performed (removal of a hernia in a single block with a strangulated ring). In this case, the intestine intersects in the outlet and adductor sections (the strangulated part is cut off) and anastomosis is applied.

white line.

The hernial sac is opened, the viability of the strangulated tissues is checked and immersed in the abdominal cavity, and the hernia is excised. Plastic surgery is rarely done, a simple suturing of the anterior abdominal wall is enough.

Postoperative.

A fringing incision is made in the area of \u200b\u200bthe hernial protrusion. Then, if necessary, the strangulated ring is dissected and viable organs are immersed in the abdominal cavity.. Sometimes the entire hernial sac is not removed, but the entrance gate is sutured to prevent recurrence.. Skin plastic surgery can be done by different methods depending on the indications..

Atypical.

Classical operative technique with the only difference in the increase in the number of accesses.

Internal.

Laparoscopy or median laparotomy is indicated. The volume of further surgical intervention is determined by the specific situation. In most cases, defects are simply sutured or closed with grafts..

In the postoperative period are shown:.

antibiotic therapy - with a preventive purpose;

infusion therapy - taking into account the daily loss of fluid;

substrate antioxidants and antihypoxants - to prevent ischemic processes in the intestine;

thrombolytics - to prevent blood clots;

proton pump blockers - to prevent ulcers.

The patient has been on enteral nutrition for some time..

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