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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_718_Библиотеки_им_академика_М_И_Перельмана
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4.The purulent exudate from purulent appendicitis can penetrate through the right-side channel
into the upper floor of the abdominal cavity, which sometimes leads to the formation of a subdiaphragmatic abscess.
2- The left-side channel (canalis lateralis sinister):
Borders:
Superiorly, the diaphragmatic-colonic ligament, which separates the canal from the spleen bed.
Inferiorly, it communicates with the left iliac fossa and the peritoneal cavity of the pelvis
To the right, the descending colon and sigmoid colon.
To the left, side wall of the abdomen.
Surgical importance of canalis lateralis sinister:
1.At the top, the transfer of fluid to the left subhepatic space is obstructed by the diaphragmatic-
colonic ligament.
2.In an upright position, only a large amount of pus and blood from the spleen bed can flow over
the edge of the diaphragmatic-colonic ligament into the left lateral canal.
N.B: At the top, both sinuses communicate with each other through a narrow slit bounded by the
initial jejunum and the overhanging mesentery of the transverse colon.
Sinuses of the abdominal cavity:
1-Right mesentericus sinus (Sinus mesentericus dexter).
Borders:
Superiorly; The transverse colon.
To the right: The ascending colon.
2-Left mesentericus sinus (Sinus mesentericus sinister).
Borders:
Superiorly, The transvers colon.
To the left, the descending colon.
Inferiorly; it communicates with the pelvic cavity.
Fig.130: Sinuses of the abdominal cavity. Source [130].
The surgical importance of the side channels and mesenteric sinuses is that they can develop
peritonitis and spread of hematoma, as pus or blood can pass into upper floor of the abdominal
cavity (especially on the right) and to the pelvic cavity.
120
Recesses (Pockets) of the abdominal cavity:
1-Recessus duodenojejunalis (sinister et dexter).
At the junction between jejunum and duodenum (flexura duodenojejunalis), small pits are
formed – recessus duodenalis superior et inferior.
2-Recessus ileocaecalis superior et inferior.
A. The upper ileocecal depression (recessus ileocaecalis superior) is the lowest part of the
right mesenteric sinus, where liquid pathological contents can accumulate. Between the
mesentery, ascending colon and ileocecal warehouse.
B. The lower ileocecal depression (recessus ileocaecalis inferior) between the mesentery,
caecum, and ileocecal fold.
Fig. 131: Recessus ileocaecalis superior. Source [131].
Fig.132: Recessus duodenalis inferior. Source [132].
121
3-Recessus retrocaecalis.
Behind the caecum in the fossa of the caecum is a small opening leading to the recessus
retrocaecalis.
Fig.133: Recessus retrocaecalis. Source [133].
4-Recessus intersigmoideus.
Fig.134: Recessus intersigmoideus. Source [134].
The surgical significance of recesses (Pockets):
1. Accumulation of pus.
2. Formation of an internal hernia.
3. Formation of retroperitoneal hernias; a variant of a hernia that forms inside the abdominal
cavity in the peritoneal pockets and folds and prolapses into the retroperitoneal space.
122
CHAPTER FOUR: INTERANAL ABDOMINAL HERNIAS.
A.V Protasov ,M.Sh F .Mekhaeel , S.Sameh
1.Diaphragmatic hernias.
Weak points of the diaphragm:
1. The left sternocostal triangle is located to the left of the xiphoid process between the sternal and
costal parts of the diaphragm.
2. The right sternocostal triangle is located to the right of the xiphoid process between the sternal
and costal parts of the diaphragm.
3. 2 more triangles are located at the back - lumbar-costal triangles - between the legs of the lumbar
parts of the diaphragm and its costal parts. They are called Bogdalek cracks.
Classification:
1.By time of occurrence: Congenital and acquired hernias.
Fig.135: Congenital diaphragmatic hernia (CDH). Source [135].
2.According to the structure of hernial protrusion: True and false hernias. True hernias have a
hernial sac formed by the parietal peritoneum and pleura. The false hernia sac is missing.
3.By origin and localization: Traumatic and non-traumatic hernias. Non-traumatic protrusions can
be false congenital, true weak zones, true atypical localization, sliding and paraesophageal orifices
of the diaphragm.
Symptoms:
1.A characteristic symptom is gurgling in the chest. Due to irritation of the diaphragmatic
nerves; intense chest pains radiating into the shoulder.
2.There is also tachycardia after eating, shortness of breath, difficulty swallowing liquid food,
and a feeling of "lump".
2.Congenital pathology; cyanosis of the skin, asymmetry of the chest, regurgitation, refusal to
feed, body weight deficiency, sleep disorders, constant crying.
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Diagnosis:
1.Chest X-ray; with a contrast agent in the patient's Trendelenburg position to assess the
localization and size of a diaphragmatic defect, visualize the intrathoracic organ penetration.
0
Fig.136: CXR showing bowel loops in the thorax from a diaphragmatic hernia in a neonate.
Source [136].
2.Esophagogastroscopy; shortening the distance to the lower esophageal sphincter, incomplete
closure of the gastric cardia, smoothness of the folds of the mucous membrane of the Gubarev
valve.
3.Intraesophageal pH-metry; diagnosis of GERD.
4.Ultrasound, CT, and MSCT of the abdominal cavity; thinning of the diaphragm muscle with
prolapse of retroperitoneal tissue.
5.ECG; to exclude cardiac pathology.
Indications for surgical intervention:
1. Paraesophageal
2. sliding hernias
3. strangulated hernia
Methods of surgical intervention:
1.Laparoscopic fundoplication; The formation of an esophageal sleeve from the bottom of the
stomach with fixation to the diaphragm and narrowing of the diaphragmatic;
2.Laparotomy and thoracotomy hernioplasty. Nissen fundoplication; small diaphragmatic
openings; tissue duplication. Large defects; alloplasty by nylon and Teflon prosthesis.
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Fig.137: Nissen fundoplication. Source [137].
2.Hiatal hernia (Esophageal hernia, Diaphragmatic Hernia, Paraesophageal hernia):
Definition:
The eruption of the esophageal orifice of the diaphragm is a hernial protrusion formed when
anatomical structures are displaced into the thoracic cavity, which are normally located under the
diaphragm - the abdominal segment of the esophagus, the cardiac part of the stomach, and
intestinal loops.
Clinical picture:
Chest pain, heartburn, regurgitation, dysphagia, hiccups, arrhythmia are noted.
Diagnosis:
Involves X-ray examination of the esophagus and stomach, esophagomanometry, and
esophagogastroscopy.
Classification:
A) Based on the radiological signs and the volume of displacement of the stomach into the chest
cavity, modern abdominal surgeons and gastroenterologists distinguish three degrees of hernial
protrusion:
I degree. The abdominal part of the esophagus is located above the diaphragm, the cardia is located
at the level of the diaphragm, and the stomach is directly adjacent to it.
II degree. There is a displacement of the abdominal part of the esophagus into the thoracic cavity
and the location of the stomach in the area of the esophageal orifice of the diaphragm.
III degree. All subdiaphragmatic structures are located in the thoracic cavity - the abdominal part
of the esophagus, the cardia, the bottom and the body of the stomach (sometimes the antrum of the
stomach).
125
Fig.138: Barium swallow demonstrating hiatus hernia. Source [138].
B) In accordance with the anatomical features, sliding, paraesophageal and mixed diaphragmatic
hernias are distinguished:
1.Axial (sliding): abdominal segment of the esophagus, cardia and fundus of the stomach into
the chest cavity
2.Paraesophageal(rolling); part of the stomach (fundus or antrum) with the normal location of the
distal segment of the esophagus and cardia.
3.Mixed hiatal hernia.
126
Complications:
Fig.139: Types of hiatal hernia. Source [139].
1.Respiratory: aspiration pneumonia, chronic tracheobronchitis.
2.Cardiovascular; irritation of the vagus nerve with spasm of the coronary vessels, the risk of
myocardial infarction.
3.Reflux esophagitis include:
A. peptic ulcers;
B. esophageal and gastric bleeding;
C. cicatricial stenosis of the esophagus;
D. infringement of a hernia;
E. perforation of the esophagus.
F. Metaplasia; Barrett’s esophagus.
G. malignant tumor
Conservative treatment of sliding hernias:
1. Lifestyle changes
o Decrease in weight
o Diet control with increased intake of proteins and decreased consumption of fat
and sugar.
o Decreased alcohol and tobacco consumption.
2. Oesophageal mucosa protection
o Antacids.
o H
blockers: Ranitidine.
2
o Proton pump inhibitors: Omeprazole.
3. Reflux prevention
o Oesophageal reflux: metoclopramide
o Gastric reflux: Domperidone, metoclopramide
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Indications for surgical treatment of sliding hernias:
1. Resistance of gastroesophageal reflux symptoms for conservative management.
2. Risk of its infringement.
Surgical methods:
1.Suturing of the hernial gate and strengthening of the esophageal-diaphragmatic ligament
(plastic surgery of the diaphragmatic hernia, crural surgery).
2.Fixation of the stomach (gastropexy).
3.Fundoplication.
4. Resection of the esophagus may be required in case of cicatricial stenosis.
Fig.140: Hill’s fundoplication and posterior gastropexy. Source [140].
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3.Relaxation of the diaphragm:
Definition:
Relaxation of the diaphragm is not a true hernia; it is a total or limited relaxation and high
standing of the dome of the thoracic septum with the prolapse of the abdominal organs adjacent
to it into the chest.
Fig.141: Relaxation of the diaphragm. Source [141].
Clinic:
1.Respiratory;
A. shortness of breath
B. dry unproductive painful cough after eating.
2.Cardiovascular;
A. tachycardia, heart rhythm disturbances, palpitation.
B. chest pain resembling cardialgia in angina pectoris.
3.Dyspeptic:
A. pain in the epigastric region, right or left hypochondria after eating.
B. paradoxical dysphagia.
C. heartburn, hiccups, nausea, vomiting, flatulence and periodic constipation.
Diagnosis:
1. Inspection; paradoxical movement of one of the diaphragms and positive Hoover symptom
– the rise of one of the rib arches and the displacement outward with a deep breath.
2. Percussion; The upward expansion of subdiaphragmal space is determined.
3. Auscultation; weak breath sound at the base of the lung, increased heart rate, rhythm
disturbance.
4. Spirometry; decrease in the vital capacity of the lungs.
5. ECG; extrasystole, signs of myocardial ischemia.
6. Chest radiography and CT ; high location of one of the domes (level II–V ribs).
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