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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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Fig.55: Inguinal and femoral hernias. Source [55].
g
Management:
Surgical approaches:
Open surgical approaches Laparoscopic surgical approaches
1. Femoral (low, Lockwood’s).
2. Inguinal (Liechtenstein’s).
3. Preperitoneal (hi
h, McEvedy’s)
1. TAPP.
2. TEP.
Ruji repair:
1. The incision is made parallel and above the inguinal ligament.
2. The inguinal canal is opened, the spermatic cord is removed, the transverse fascia is dissected
and penetrated into the preperitoneal tissue, where the neck of the hernial sac is found.
3. A herniated sac is removed from under the inguinal ligament into the inguinal canal.
4. After the treatment of the hernial sac, the inguinal ligament is sewn to the scallop.
5. After that, the integrity of the inguinal canal is restored in one of the known ways.
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Fig.56,57,58: Ruji repair. Source [56,57,58].
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2) Umbilical hernia: Incidence 6%-14% among external abdominal hernias.
It is a ventral abdominal hernia located at the umbilicus or 3 cm above or below the umbilicus.
Historical background:
In the era of Pharaoh’s Ptah-hotep sixth dynasty, inscriptions were inscribed on the walls of the
temples showing workers in the field with umbilical hernias. Later on, in 1500 BC in ancient
Egypt, Ebers recorded the first reference about hernia in a papyrus, before Hippocraticum which
record hernia in 300 BC who also mentioned that it is related to a certain occupation.
Fig59,60,61: Inscriptions of umbilical hernia on the walls of the templet of Pharaoh’s Ptah-hotep
in Luxor, Egypt. Source [59,60,61].
Risk factors for the development of umbilical hernia (5F):
1. Female.
2. Fatty.
3. Fertile.
4. Fluid (ascites).
5. Failure of obliteration of the umbilical ring after birth.
Contents:
The normal contents of umbilical hernia are omentum, small intestinal loops, fatty tissue or
combination of them, while the incidence of transverse colon herniation into a type of hernia is
very rare.
Differential diagnosis:
The congenital hernia of the umbilical cord (incidence1: 5000 newborn), which is caused by patent
omphalomesenteric duct (OMD). Such kind of hernia may be misdiagnosed as a small
omphalocele and if is misdiagnosed, it could cause iatrogenic atresia of the ileum by clamping the
umbilical cord after birth. The contents are usually small intestinal loops, liver or other organs.
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Fig.62: Omphalocele and gastroschisis. Source [62].
The differences between exomphalos major and minor (table 13):
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Types of umbilical hernia:
1. Congenital.
2. Infantile.
3. Adult.
Fig.63: umbilical hernia. Source [63].
Management:
Mayo in 1901 was the first to describe a simple method of umbilical hernia repair (Mayo repair)
through simple closure of the fascial defect (Richter’s fascia) or by overlapping the fascia (vest
over pants) where the superior and inferior fascia are overlapped and sewn together.
Fig.64: Mayo’s repair. Source [64].
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Sapezhko repair:
Produce two longitudinal curved incisions with excision of loose skin and umbilical button. Scared
edges excised. Peritoneum from the posterior surface of one muscle detach at 2-4 cm. Stitch on
the peritoneum. Then it created is duplicate in the longitudinal direction of 2-4 cm in width (edge
aponeurosis on the one hand sutured to the posteromedial part of the vaginal rectus muscle, which
was the preparated peritoneum. The second layer stitched by duplicating). Method Sapezhko is
more physiological (reduced width of the white line, straightened the course of rectus muscle
fibers).
Fig.65: Sapezhko repair. Source [65].
Due to unsatisfactory results of plasty umbilical hernia, developed and implemented in the practice
of plasty using knitted polypropene mesh, which is fixed to the aponeurosis by polypropylene
mono-filament sutures. The use of mesh augmentation of a repair, whether inlay, sublay or onlay
is recommended. The recurrence rate (2.7%- 10%).
Fig. 66: Various mesh lays. Source [66].
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3)Paraumbilical hernia: Represents 2% of external abdominal hernias.
Paraumbilical hernia has Female predominance (63.49%) and age 50 (57.14%)
The recurrence rate with the use of prosthetic materials is (15.0_ 20.0%).
Arroyo et al in their retrospective study showed that using meshes for paraumbilical hernia repair,
could reduce the recurrence rate reduced to (0.95%).
The differences between umbilical & paraumbilical hernias (table14):
4)Epigastric hernia:
Is a midline hernia between the umbilicus and the sternum.
It is almost always presented with pain and due its narrow gate, there is a high incidence of
strangulation of the contents (peritoneal fat or omentum) which necessitates urgent surgical
management.
Usually small in size. Usually acquired but it sometimes may be congenital.
Fig.67: Epigastric hernia. Source [67].
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5)Spigelian hernia (lateral hernia (semilunar hernia): Represents about (0.12%-2%) of
external abdominal hernias.
Herniation of the abdominal contents or the peritoneum through a defect in the spigelian fascia
which is compressed of the internal and transversus abdominis muscles, deep to the external
oblique muscle.
Historical background:
Adriaan V. D. Spiegel in 1627 was the first to describe this rare hernia which was named after
him. In 1645, 2 years following the death of Spiegel, the acknowledge of the history of the
spigelian hernia had been done. In 1764, J. Klinkosch acknowledged and described a hernia located
in the Spigelian fascia and therefore applied the term Spigelian hernia in 1764.
Aetiology:
Is unclear; but due to a certain risk factor which are highly related to female sex such as: obesity,
multiple pregnancies and chronic obstructive pulmonary disease (COPD) plus the recent studies
which suggested that Spigelian hernia could be caused by a previous trocar insertion caused by the
increasing incidence of laparoscopic procedures by gynecologists.
Contents:
Is frequently the omentum, but small or large bowel, ovary, appendix, fallopian tube or can be
presented. Moreover, Richter’s hernia and bowel obstruction caused by incarcerated small
intestine may occur.
Mangment:
IPOM procedure with a lightweight titanium-coated mesh fixation is the gold standard for
Spigelian hernia repair.
The rate of recurrence is (1-5%).
Fig.68: Spigelian hernia. Source [68].
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6) Incisional (post-operative) hernia:
Postoperative hernias of the abdominal wall exit the abdominal cavity in the area of the
postoperative scar and are located under the skin.
Postoperative hernias are classified by size, location of the hernial defect and clinical feature.
It is necessary to clarify the clinical sign: correctable, unrecoverable, partially correctable, pinched,
repeatedly recurrent, perforated, with phenomena of partial or acute intestinal obstruction.
The incidence of development of post-operative incisional hernia is as follows:
1. Laparotomy; midline incisions: 8.1%.
2. Laparotomy; Horizntal incisions: 5.1%.
3. Laparoscopy (trocar’s hernia): 0.3%.
Diagnosis:
1.Palpation
2.Ultrasound diagnostics
3.X-ray examination
4.In the absence of complications, patients constantly complain of chronic constipation and other
dyspeptic disorders: belching, nausea, flatulence
Management:
The basic plan of the operation is as follows:
1) Prompt access to the hernia gate.
2) Opening of the hernial sac and separation of abdominal organs from its walls.
3) Partial or complete excision of the hernial sac.
4) Mobilization and economical excision of the edges of the hernial gate.
5) Plastic surgery of the anterior abdominal wall.
6) Suturing of the postoperative wound.
Developments in incisional hernia repair then were directed towards the mesh placing techniques
which are:
1.The first involves placing the mesh inside the peritoneal cavity in contact with the viscera
(intraperitoneal inlay or intraperitoneal onlay).
2.Chevrel had introduced the second technique, which is the premuscular onlay technique, in
which the mesh is placed over the abdominal wall closure in the subcutaneous perifascial space.
3.Rives and Stoppa introduced the third technique; which is the retromuscular sublay technique,
in which the mesh is placed over the closed posterior rectus sheath and peritoneum. In fact, Stoppa
described retrofascial placement and Rives described retromuscular placement. The combined
Rives-Stoppa technique has subsequently been adopted as the gold standard for open incisional
hernia repair.
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Fig.69: Rives-Stoppa technique. Source [69].
4.Oscar Ramirez in 1990 developed his ‘component separation of the abdominal wall’ technique
to address this group of complex incisional hernias. The advantage of the component separation
technique is that the abdominal wall can be recreated in a one-stage procedure without the need of
an additional musculofascial transfer (distant flaps) or the use of a bridging material. This
technique was ideal for large incisional hernias with loss of abdominal domain from lateral
retraction of the abdominal muscle present a difficult problem because of lack of healthy tissue for
mesh placement or primary closure.
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