HERNIAHERNIA

HERNIAHERNIA Hernia of the abdominal wall or external Hernia of the abdominal wall or external

herniahernia is such surgical disease, which is is such surgical disease, which is characterized by outlet of the visceral organs characterized by outlet of the visceral organs from the place of their physiological placement from the place of their physiological placement through the natural channels or defects of the through the natural channels or defects of the abdominal and pelvic wall. In such case all abdominal and pelvic wall. In such case all visceral organs covered by parietal peritoneum visceral organs covered by parietal peritoneum and skin are not damaged.and skin are not damaged.

Internal herniaInternal hernia is such disease, visceral organs is such disease, visceral organs hit the peritoneum pouch. It formed in the place hit the peritoneum pouch. It formed in the place of natural peritoneum fold or recess and of natural peritoneum fold or recess and generally kept in the abdominal cavity.generally kept in the abdominal cavity.

Anatomy of a HerniaAnatomy of a Hernia

TThe Walls Of The Inguinal Canal he Walls Of The Inguinal Canal ANTERIOR WALL ANTERIOR WALL laterally - muscles fibers of the external oblique laterally - muscles fibers of the external oblique medially - aponeurosis of the external oblique medially - aponeurosis of the external oblique most medially there is not wall but instead there is a deficiency called the most medially there is not wall but instead there is a deficiency called the

superficial inguinal ring. superficial inguinal ring. SUPERIOR -- arching fibers of the internal oblique and sometimes transverse SUPERIOR -- arching fibers of the internal oblique and sometimes transverse

abdominis. These fibers start anterior and lateral, pass over the spermatic abdominis. These fibers start anterior and lateral, pass over the spermatic cord and the medially forms part of the posterior wall of the canal. cord and the medially forms part of the posterior wall of the canal.

POSTERIOR -- lateral the posterior wall is deficient at the deep inguinal ring. POSTERIOR -- lateral the posterior wall is deficient at the deep inguinal ring. Medially the posterior wall is made up of the fused aponeuroses of the Medially the posterior wall is made up of the fused aponeuroses of the internal oblique and transverse abdominis, called the conjoined tendon X. internal oblique and transverse abdominis, called the conjoined tendon X.

INFERIOR (or floor) -- inguinal ligament. Medially, some of the fibers of the INFERIOR (or floor) -- inguinal ligament. Medially, some of the fibers of the inguinal ligament curve under the spermatic cord and fasten into the inguinal ligament curve under the spermatic cord and fasten into the pectineal line of the pubis, this is the lacunar ligament which forms part of pectineal line of the pubis, this is the lacunar ligament which forms part of the floor of the inguinal canal. the floor of the inguinal canal.

ETIOLOGY AND PATHOGENESISETIOLOGY AND PATHOGENESIS Hernias are divided into two main groups: Hernias are divided into two main groups:

congenital and acquiredcongenital and acquired. . The main reason of The main reason of congenitalcongenital hernias is hernias is malformation. Thus, inguinal hernia arose malformation. Thus, inguinal hernia arose in case of noclosure of the process of in case of noclosure of the process of peritoneum, which passes by inguinal peritoneum, which passes by inguinal channel during descending the testis. On channel during descending the testis. On such hernias testis is located in the hernia such hernias testis is located in the hernia pouch. pouch. AcquiredAcquired inguinal hernia has hernia inguinal hernia has hernia pouch and testis located outside it. pouch and testis located outside it.

PATHOMORPHOLOGYPATHOMORPHOLOGY

Each abdominal hernia consists of hernia Each abdominal hernia consists of hernia gate, hernia sac and hernia contentsgate, hernia sac and hernia contents. . Hernia sac formsHernia sac forms by outpouching of by outpouching of parietal peritoneum and can contain small parietal peritoneum and can contain small intestine and omentum. Sometimes it intestine and omentum. Sometimes it containes other organs: large intestine, containes other organs: large intestine, urinary bladder, ovary, and appendix.urinary bladder, ovary, and appendix.

The main parts of the The main parts of the hernia pouchhernia pouch are are neck, body and fundusneck, body and fundus. .

CLASSIFICATIONCLASSIFICATION 1) Depends on anatomical localization: inguinal 1) Depends on anatomical localization: inguinal

(indirect and direct), midline hernia, (indirect and direct), midline hernia, omphalocele, femoral hernia, lumbar hernia, omphalocele, femoral hernia, lumbar hernia, sciatic hernia, (enterischiocele), lateral hernia, sciatic hernia, (enterischiocele), lateral hernia, ischiorectal hernia (perineocele).ischiorectal hernia (perineocele).

2) depends on etiology: congenital (2) depends on etiology: congenital (herniae herniae conqenitaeconqenitae) and acquired () and acquired (herniae acguisitaeherniae acguisitae).).

3) Depends on clinical presentations: complete 3) Depends on clinical presentations: complete and incomplete, reducible and nonreducible, and incomplete, reducible and nonreducible, traumatic and postoperative, complicated and traumatic and postoperative, complicated and noncomplicated.noncomplicated.

Clinical variants and Clinical variants and complicationscomplications

Inguinal hernias Inguinal hernias is developed in two ways: through the is developed in two ways: through the internal (middle) inguinal cavity and external (lateral). In internal (middle) inguinal cavity and external (lateral). In the first case formed direct in other - indirect inguinal the first case formed direct in other - indirect inguinal hernia. hernia.

IndirectIndirect hernias could be congenital and acquired. hernias could be congenital and acquired. DirectDirect hernias are only acquired and occur in older hernias are only acquired and occur in older patients. patients.

There are two main signs, which differentiate direct and There are two main signs, which differentiate direct and indirect hernias. Direct hernia is always located medially indirect hernias. Direct hernia is always located medially from from a. epigastrica inf.a. epigastrica inf. Indirect hernia is always located Indirect hernia is always located laterally from laterally from a. epigastrica inf. a. epigastrica inf. The other sign is: direct The other sign is: direct hernia located medially from deferent duct, indirect hernia located medially from deferent duct, indirect hernia located inside it.hernia located inside it.

DIAGNOSIS PROGRAMDIAGNOSIS PROGRAM Anamnesis and physical examination.Anamnesis and physical examination. Digital investigation of the hernia Digital investigation of the hernia

channel.channel. Sonography of the hernia pouch.Sonography of the hernia pouch. Common blood analysis.Common blood analysis. Common urine analysis.Common urine analysis.

Choice of treatment methodChoice of treatment method Bassini repair.Bassini repair. After extraction of the hernia sac, we are After extraction of the hernia sac, we are

taking spermatic duct on holders. Between the borders taking spermatic duct on holders. Between the borders of transverse muscle, internal oblique muscle, transverse of transverse muscle, internal oblique muscle, transverse fascia and inguinal ligament interrupted sutures placed. fascia and inguinal ligament interrupted sutures placed. Except that, couples sutures placed between border of Except that, couples sutures placed between border of abdominal rectus muscle sheath and pubic bone abdominal rectus muscle sheath and pubic bone periosteum. In such way, inguinal space closured and periosteum. In such way, inguinal space closured and posterior wall strengthened. Spermatic duct placed on posterior wall strengthened. Spermatic duct placed on the new-formed posterior wall of the inguinal channel. the new-formed posterior wall of the inguinal channel. Over the spermatic duct aponeurosis restored by Over the spermatic duct aponeurosis restored by interrupted sutures. interrupted sutures.

Bassini repairBassini repair

Bassini repairBassini repair

Choice of treatment methodChoice of treatment method GirardGirard in such kind of the operations in such kind of the operations

propose to attach the edges of the internal propose to attach the edges of the internal oblique muscle and transversal muscle to oblique muscle and transversal muscle to the inguinal ligament over the spermatic the inguinal ligament over the spermatic duct. The aponeurosis of the external duct. The aponeurosis of the external oblique muscle sutured by second layer of oblique muscle sutured by second layer of the suture. Excess of the aponeurosis is the suture. Excess of the aponeurosis is fixed to the muscle in the form of fixed to the muscle in the form of duplicationduplication

GirardGirard repairrepair

Choice of treatment methodChoice of treatment method Spasokukotskyy Spasokukotskyy proposed to catch the proposed to catch the

edges of the internal oblique muscle and edges of the internal oblique muscle and transversal muscle with aponeurosis of the transversal muscle with aponeurosis of the external oblique muscles by single-layer external oblique muscles by single-layer interrupted suture interrupted suture

Choice of treatment methodChoice of treatment method Martynov Martynov proposed the fixation to the proposed the fixation to the

Poupart's ligament only internal edge of Poupart's ligament only internal edge of the external oblique muscle aponeurosis the external oblique muscle aponeurosis without muscles. External edge of the without muscles. External edge of the aponeurosis sutured over internal in the aponeurosis sutured over internal in the form of duplication form of duplication

Choice of treatment methodChoice of treatment method KimbarovskyyKimbarovskyy, based on the principles of , based on the principles of

joining similar tissues, proposed special joining similar tissues, proposed special suture: Sutures placed on 1 cm from the suture: Sutures placed on 1 cm from the edge of the external oblique abdominal edge of the external oblique abdominal muscle aponeurosis, grasped the part of muscle aponeurosis, grasped the part of the internal oblique and transversal the internal oblique and transversal muscle. After that, aponeurosis is sutured muscle. After that, aponeurosis is sutured one more time from behind to the front and one more time from behind to the front and attached to the Poupart’s ligament attached to the Poupart’s ligament

Choice of treatment methodChoice of treatment method PostempskyyPostempskyy proposed the deaf closing of proposed the deaf closing of

inguinal interval with the латеральним moving inguinal interval with the латеральним moving of spermatic duct. The plastic narrowing of of spermatic duct. The plastic narrowing of internal inguinal ring of to 0,8 cm is the important internal inguinal ring of to 0,8 cm is the important moment of this modification. On occasion, when moment of this modification. On occasion, when internal and external inguinal rings are in one internal and external inguinal rings are in one plane, a spermatic duct is displaced inlateral plane, a spermatic duct is displaced inlateral direction by transversal incision of the oblique direction by transversal incision of the oblique and transversal muscles. Then edge of the and transversal muscles. Then edge of the vagina of direct muscle and aponeurosis of the vagina of direct muscle and aponeurosis of the internal and transversal muscles is fixed to the internal and transversal muscles is fixed to the Couper’s ligament Couper’s ligament

Laparoscopic treatmentLaparoscopic treatment

Laparoscopic treatmentLaparoscopic treatment

Treatment of the femoral herniaTreatment of the femoral hernia

The Bassini method is attributed to The Bassini method is attributed to “femoral”. It is performed from a cut, that “femoral”. It is performed from a cut, that passes under inguinal fold. After removal passes under inguinal fold. After removal of hernia sack a hernia gate is liquidated of hernia sack a hernia gate is liquidated by suturing of inguinal to the pectineal by suturing of inguinal to the pectineal ligament ligament

Treatment of the femoral herniaTreatment of the femoral hernia

The Rudgi-Parlavecho Method. A cut The Rudgi-Parlavecho Method. A cut passes parallel to the inguinal fold and passes parallel to the inguinal fold and higher it (the same as at inguinal hernia). higher it (the same as at inguinal hernia). A hernia sack is removed. After that the A hernia sack is removed. After that the edges of the transversal and internal edges of the transversal and internal oblique muscles and inguinal ligament oblique muscles and inguinal ligament sutured to the periosteum of pubic bone.sutured to the periosteum of pubic bone.

Treatment of umbilical hernia Treatment of umbilical hernia

The Lexer operation is most widespread. It The Lexer operation is most widespread. It performed by imposition of sutures on an performed by imposition of sutures on an umbilical ring umbilical ring

Treatment of umbilical herniaTreatment of umbilical hernia

After the Meyo After the Meyo method defect method defect of anterior of anterior abdominal wall abdominal wall in the umbilical in the umbilical ring is sutured ring is sutured by U-shaped by U-shaped stitches in stitches in transversal transversal direction direction

Treatment of umbilical herniaTreatment of umbilical hernia

Sapezhko Sapezhko proposed to proposed to form form duplicationduplication of of the abdominal the abdominal white line by white line by stitches in stitches in longitudinal longitudinal direction.direction.

INCARCERATED HERNIA INCARCERATED HERNIA

Incarcerated hernia Incarcerated hernia is sudden pressing of is sudden pressing of hernia contents in a hernia orifice. hernia contents in a hernia orifice. Incarceration is the most frequent and Incarceration is the most frequent and most dangerous complication of hernia most dangerous complication of hernia diseases.diseases.

Etiology and pathogenesisEtiology and pathogenesis At At the elastic incarceration,the elastic incarceration, after increasing after increasing

intraabdominal pressure, one or a few organs intraabdominal pressure, one or a few organs relocated from an abdominal cavity to the hernia relocated from an abdominal cavity to the hernia sack, where it is compressed with following sack, where it is compressed with following ischemia and necrosis in the area of hernia gate. ischemia and necrosis in the area of hernia gate.

At the At the fecal incarcerationfecal incarceration in the intestinal loop in the intestinal loop which is in a hernia sack, plenty of excrement which is in a hernia sack, plenty of excrement passed quickly. Proximal part of loop is passed quickly. Proximal part of loop is overfilled, and distal is compressed in a hernia overfilled, and distal is compressed in a hernia gate. gate.

Classification of the incarcerated Classification of the incarcerated herniahernia

complete complete IncompleteIncomplete partial (the Richter’s hernia) partial (the Richter’s hernia) retrograde retrograde without the destructive changes of hernia without the destructive changes of hernia

contents contents with the phlegmon of hernia sackwith the phlegmon of hernia sack

Clinical variantsClinical variants

Retrograde incarcerationRetrograde incarceration Parietal incarceration (the Richter’s Parietal incarceration (the Richter’s

hernia)hernia) The Littre’s herniaThe Littre’s hernia Incarceration at sliding herniaIncarceration at sliding hernia

Retrograde incarcerationRetrograde incarceration

Retrograde incarcerationRetrograde incarceration

Diagnosis programDiagnosis program Anamnesis examination.Anamnesis examination. Physical examination.Physical examination. Blood analysis and urine analysis.Blood analysis and urine analysis. Digital investigation of the rectum.Digital investigation of the rectum. Survey X-Ray of abdominal cavity Survey X-Ray of abdominal cavity

organs.organs.