Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_718_Библиотеки_им_академика_М_И_Перельмана
.pdf
8.Female adnexa: The ovary or even the uterus could be a hernial contents. (Extremely rare).
Fig44: Herniated uterus. Source [44].
F) Clinical presentation:
1.The presence of protrusion in the inguinal or umbilical region, along the midline of the abdomen
or in the area of the postoperative scar, which patients can independently detect (in the supine
position, the protrusion may completely disappear).
2.Pulling pains in the lower abdomen, in the navel area of varying intensity, especially during
physical exertion.
3.Abdominal pain, bloating, constipation associated with the presence of adhesions inside the
hernial sac in large postoperative hernias.
G) Radiological diagnosis:
1.Ultrasound; makes it possible to clarify the location of the hernia, the shape and size of the
hernial gate, assess the condition of the surrounding tissues (this allows you to choose the most
effective technique for hernia repair), determine the contents of the hernial sac cavity.
2.Radiography; for hernia allows you to obtain additional information about the presence of
adhesions, parietal hernia infringement and partial intestinal obstruction.
3.Computed tomography; for hernia is used if the ultrasound data is insufficient.
H) Complications of external abdominal hernias:
I) Pain:
Due to pressure on surrounding tissues including nerves.
1. Groin pain.
2. Back pain.
3. Inner thigh pain.
4. Testicular pain.
II) Irreducibility:
Due to the presence of adhesions between the hernial contents and sac resulting in intestinal
obstruction with is 4 cardinal signs:
1. Pain.
2. Abdominal distention.
3. Vomiting.
4. Absolute Constipation.
40
III) Incarceration & Strangulation:
Clinical picture:
The infringement is usually accompanied by sudden pain in the area of hernial protrusion, and
sometimes throughout the abdomen. A cardinal sign of infringement of a free reversible hernia is
the inability to reduce hernial protrusion into the abdominal cavity. Hernial protrusion increases
in volume, becomes tense and painful.
With percussion, bluntness is determined (if the hernial sac contains fluid, an omentum) or
tympanitis (an inflated loop of the intestine).
In case of an incurable hernia, the diagnosis of infringement is made on the basis of the sudden
occurrence of pain, soreness and tension of hernial protrusion.
An important sign of infringement is also the absence of transmission of the cough shock to the
area of hernial protrusion.
Hernia infringement is often accompanied by vomiting, sometimes repeated. Initially, vomiting is
reflex, and later due to intoxication.
When one or another part of the intestine is infringed, intestinal obstruction phenomena develop.
Incarceration Strangulation
1.Irreducibility. + +
2. Pain Painful Ischemic
3. Pain release
Disappear Persist
after reduction
4. Blood
Good Comprised
supply.
5. Systemic
NO SEVER
toxicity.
Table 10: The differences between incarceration and strangulation.
Management:
First stage; Layered dissection of tissues to aponeurosis and exposure of the hernial sac.
Second stage; Opening and removal of hernial sac (herniotomy).
Third stage; Dissection of the infringing ring under visual control, avoiding damaging the hernial
contents.
Fourth stage; Determining the viability of the affected organs.
Fifth stage; Resection of a non-viable loop of the intestine.
Sixth stage; Repair of the hernial defect surgery.
Complications of self-repaired and forcibly repaired strangulated hernias:
1) Separate the entire hernial sac from the surrounding tissues and set it together with the
pinched organ into the abdominal cavity or preperitoneal tissue.
2) Detach the neck from the rest of the hernial sac and set it together with the pinched organ into
the abdominal cavity or preperitoneal tissue;
3) Completely tear off the neck of the hernial sac, both from its body
and from the parietal peritoneum and, together with the pinched organ, set it into the abdominal
cavity;
4) Move the pinched insides in a multicameral hernial sac from one chamber to another, lying
deeper, most often in the preperitoneal tissue.
41
Fig.45: The differences between incarceration and strangulation. Source [45].
Management of external abdominal hernias:
1.The use of a bandage is a palliative measure.
The first attempts of dealing with hernia were carried by Pierre Franco and Ambroise Paré, where
they used conservative treatments with a strong bandage.
It is shown only in cases where, for one reason or another, the operation cannot be performed.
2.Surgical treatment; Either herniorrhaphy or hernioplasty.
3. Injection method.
Preoperative chemical component separation (CCS) with botulinum toxin A (BTA) in hernia repair
including complex ones; increase lateral abdominal wall muscles and abdominal cavity, decreased
defect size, facilitating closure allows construction of the linea alba without lateral release,
improving diastasis thus preventing recurrence.
Surgical management:
Principles: Individual approach, take into account the shape of the hernia, its pathogenesis, the
condition of the abdominal wall tissues and the size of the hernial defect, low injury, impeccable
technical performance.
There are five main methods of hernioplasty:
1) Fascial-aponeurotic.
2) Muscular-aponeurotic.
3) Muscular.
4) Plastic with the help of additional biological or synthetic materials:
a) Autologous (taken within the same organism).
b) Allogenic (taken in the body of the same species as the recipient's body).
c) Xenogenic (taken in the body of another species).
d) Explants (non-biological tissues).
e) Combined transplants (a combination of biological, more often autologous and non-biological
tissue).
42
Main steps of hernioplasty:
Step 1. Access implementation;
Step 2. Opening of the hernial sac, revision and assessment of the condition of the organs in the
hernial sac.
Step 3. Setting the “fallen out” organs into the abdominal cavity (reduction of contents).
Step 4. Resection and suturing of the hernial sac (hernioectomy).
Step 5. Plastic surgery of the defect of the musculoaponeurotic layer
1)Groin hernias:
Represent 75% of external abdominal hernias.
Henri Fruchaud was the first to use the term “groin hernia” in the early 1950’s of the last century.
Groin hernias include both inguinal and femoral hernias.
A) Inguinal hernia:
Represent 97% of groin hernias.
The main anatomically determined varieties of inguinal hernias are oblique (hernia inguinalis
externa, s. obliqua) and straight (hernia inguinalis interna, s. directa) hernias.
Types of indirect (oblique) inguinal hernia:
Bubonocele: within the inguinal canal.
Funicular: reaching the external inguinal ring.
Complete: Reaching the bottom of the scotum.
Fig.46: Direct and indirect inguinal hernias. Source [46].
43
r
y
1. Predisposing
factors.
2. Age. Young Elderly.
3. Sex. Male>females. Common in elderly men.
4. Site of protrusion. Internal inguinal ring. Medial inguinal fossa
5. Direction. Goes through the whole length if the
6. Relation to the
spermatic co
7. Relation to the
inferior epigastric
arter
8. Descent to the
scrotum.
9. Felt on palpation. Hits the tip of the finger. Hits the side of the finger.
10. Direction of
reduction.
11. After reduction. The bulge appears in the middle of the
12. After reduction. It is controlled; pressure on the deep ring
13. After reduction. The defect can't be palpable (it lies behind
d.
.
Indirect Inguinal Hernia Direct Inguinal Hernia
Congenital, Injury. Heavy lifting, straining, muscular,
inguinal canal
Within. Outside.
Lateral. Medial.
May occurs. Rare.
Upward then laterally and backward. Upward then straight backward.
inguinal region.
prevents descend.
the fibers of the external oblique).
weakens
Expands through the posterior wall
of the inguinal canal.
The bulge reappears exactly where it
was before.
Uncontrolled; pressure of the deep
ring doesn’t prevent descend.
The defect may be palpable above
the pubic tubercle.
Table (11): The differences between indirect (oblique) and direct inguinal hernias.
Methods of surgical mangment:
The main stages of the operation:
The first stage; is access to the groin canal.
The second stage; is isolation from the surrounding tissues and removal of the hernial sac.
The third stage; is suturing the inguinal opening to normal size when it expands or collapses.
Bassini method:
Bassini method is aimed at strengthening the posterior wall of the inguinal canal. After removal
of the hernial sac, the spermatic cord is pushed aside and the lower edge of the internal oblique
and transverse muscles, together with the transverse fascia of the abdomen, is sewn under it to the
inguinal ligament. The spermatic cord is placed on the formed muscle wall.
Fig.47: Bassini repair. Source [47].
44
McVay repair:
Similar to Bassini, expect that it uses Cooper’s ligament instead of the inguinal ligament. It is also
based on the narrowing of the deep inguinal ring and the reconstruction of the posterior wall of the
inguinal canal. The deep inguinal ring is formed by suturing the transverse fascia. Before restoring
the posterior wall of the inguinal canal, a large laxative incision 4-5 cm long is made on the vagina
of the rectus abdominis muscle for greater mobility of the muscle layers and the connected tendon,
then the transverse fascia, together with the connected tendon of the internal oblique and transverse
muscles, is sewn to the cooper ligament with frequent stitches.
Fig.48: McVay repair. Source [48].
Shouldice repair:
Shouldice invited a 2-layer repair. A continuous running sutures reapproximates the inguinal floor.
A second layer is started near the internal ring, approximating the internal oblique muscle and the
transversus abdominus to a band of external oblique aponeurosis superficial and parallel to
Poupart’s ligament. The suture line ends at the pubic crest. A fourth suture line may be added.
Fig.49: Shouldice repair. Source [49].
45
Kukudzhanov method:
Kukudzhanov method is proposed for direct and complex forms of inguinal hernias. It consists in
suturing between the outer edge of the vagina of the rectus abdominis muscle and the upper pubic
ligament (Cooper) from the pubic tubercle to the fascial cases of the iliac vessels.
Fig.50: Kukudzhanov method. Source [50].
Liechtenstein “Tension-free repair”:
The basic principle is the stitching of fabrics without tension.
After removal of the hernial sac, the spermatic cord is separated from the surrounding tissues
throughout. Next, take a synthetic polypropylene mesh measuring 8x6 cm and make a small
incision at one of its ends so that two branches about 2 cm long are formed.
Fig.51: Liechtenstein repair. Source [51].
46
Postempsky method:
This method provides for the complete elimination of the inguinal canal, the inguinal gap and the
creation of an inguinal canal with a completely new direction.
The spermatic cord is isolated, taken on a holder, the hernial sac is treated, then the internal oblique
and transverse muscles are dissected laterally from the deep opening of the inguinal canal so that
the spermatic cord is moved to the upper - lateral corner of this incision. After that, the muscles
are sewn up. From above, 4 layers are captured into the seam: the upper flap of the aponeurosis of
the external oblique abdominal muscle together with the edge of the internal oblique and transverse
abdominal muscles and the transverse fascia and sewn under the spermatic cord to the inguinal
ligament together with the lower flap of the aponeurosis of the external oblique abdominal muscle.
Fig.52: Postempsky method. Source [52].
Laparoscopic mangment:
Historical background:
Lawson Tait in 1891 had published a technique about that principle where laparoscopic
transabdominal preperitoneal (TAPP) repair is based on. After there, P. Fletcher in 1979 was the
first to employ a laparoscope to repair a groin hernia. Followed by; Ralph Ger in 1982, S.
Bogojavalensky in 1989, Leonard Schultz in 1990, and Maurice E. Arregui in 1992 and 1993
reported their respective TAPP repair techniques.
Endoscopic totally extraperitoneal repair (TEP) is based on the preperitoneal anatomy clarified by
Henri Fruchaud in 1956. Jean Louis Dulucq in 1991was the first to report mesh implantation into
the preperitoneal space; thereafter, George S. Ferzli in 1992, Jacques M. Himpens in 1992, and
John Barry McKernan in 1993 performed this procedure. Edward H. Phillips was the first to use
the term “totally extraperitoneal” in 1993.
Laparoscopic intraperitoneal on-lay mesh repair does not involve groin dissection. F. K. Toy and
R. T. Smoot in 1991 described that the procedure of laparoscopic intraperitoneal on-lay mesh
repair does not involve groin dissection, which was employed by Muhammed A. Memon et al in
the same year.
47
Fig.53: TAPP and TEP. Source [53].
In comparison between (TAPP) and (TEP), no statistically significant difference was detected
between the operative time, acute and chronic postoperative pain recurrence rates, improving the
quality of life pre- and postoperatively repair of recurrent inguinal hernia repair of recurrent
inguinal hernia. Seroma was found to be higher with (TEP) recommending the use of (TAPP) over
(TEP) secondary to complication rate. Operative cost is slightly higher with (TEP) due to the use
of a balloon dissector.
Looking to the future, we find that although TAPP and TEP have a higher cost than conventional
repair, the cost-effectiveness of TAPP repair has been documented in medically advanced
countries. The direct cost and is nearly equivalent between robotic and laparoscopic surgery,
although robotic surgery results in a higher cost for unilateral groin hernia.
Robotic surgery is employed in the field of hernia repair; the articulate robotic arms are
advantageous for approaches without any visual disturbance by the medial umbilical ligament and
bowels. Moreover, a single port robotic surgery system (da Vinci SP system) is currently available.
In comparing the net results of both laparoscopic and robotic TAPP (rTAPP), both operative time
and postoperative complications were nearly the same in (TEP) and (rTAPP). while (rTAPP)
improved pain scores and recovery in comparison to laparoscopic (TAPP) moreover, the overall
cost was less in laparoscopic (TAPP) than (rTAPP), taking into consideration the calculation of
the cost is done with counting the cost of the robotic system.
48
B) Femoral hernia: Represent 3% of groin hernias.
Common among females.
Protrusion through the femoral ring, annulus femoralis.
After exiting from the femoral canal, it becomes in the subcutaneous cellular tissue though the
superficial femoral ring (hiatus saphenus).
Contents:
Are usually omentum or may me appendix, small intestine, a knuckle of bowel (Richter’s hernia),
ectopic testis, and stomach, fallopian tube (Rare).
Clinically:
Most of patients present as an emergency with symptoms and signs of intestinal obstruction and is
presented by tender, irreducible swelling with no cough impulse and is situated below and lateral
to the pubic tubercle.
Differential diagnosis:
Inguinal hernia, lipoma, saphena varix, enlarged lymph nodes, femoral artery aneurysm, sarcoma,
obturator hernia, psoas abscess, psoas bursa, and in males, ectopic testis.
Fig.54: Differential diagnosis of femoral hernia. Source [54].
The differences between inguinal and femoral hernias (Table 12):
1. Incidence among groin
hernias.
2. Sex dominance. Males Females
3. Passes through Inguinal canal Femoral canal
4. Sac mainly contains Intestine Omentum
5. Relation to pubic tubercle. Superior and medial. Inferior and lateral.
6. Three finger test. Impulse on index or middle
7. Incidence of strangulation Low High
8. Surgical management Can be postponed or even
Inguinal Hernia Femoral Hernia
97% 3%
Impulse on ring finger.
finger.
Almost always represented with
cancelled if not urgent.
49
complications which necessities
urgent surgical management.
Соседние файлы в папке Библиотека им академика М.И. Перельмана