38. Operations for hernias of the white line of the abdomen.
Operations for hernias of the white line are often performed under local anesthesia according to A.V. Vishnevsky. A skin incision is made over the hernial protrusion in the longitudinal or transverse direction. The hernial sac is isolated and processed in the usual way. Around the hernial orifice for 2 cm, the aponeurosis is freed from fatty tissue, after which the hernial ring is cut along the white line.
Hernioplasty is produced according to the method Sapezhko-Dyakonova, i.e. create a duplication of flaps of the aponeurosis of the white line of the abdomen in the vertical direction by first applying 2-4 U-shaped sutures, similar to how it is done with the method mayo, followed by suturing the edge of the free flap of the aponeurosis with interrupted sutures to the anterior wall of the sheath of the rectus abdominis muscle.
If the operation is performed on a preperitoneal lipoma, then the latter is separated from the surrounding subcutaneous tissue and from the edges of the aponeurosis, and then dissected to make sure that there is no hernial sac in it. In the absence of a hernial sac, the lipoma is bandaged at the base of the leg and cut off. The stump is immersed under the aponeurosis, the edges of which are sutured with a purse-string suture or interrupted sutures.
39. Operations for umbilical hernias (according to Lexer, Mayo, Sapezhko).
Umbilical hernias of childhood and adult hernias can be operated on both extraperitoneally and intraperitoneally. The extraperitoneal method is rarely used, mainly for small hernias, when the reduction of the hernial contents is not difficult. In other cases, the hernial sac is opened.
Intraperitoneal methods of surgical treatment of umbilical hernias include methods Lexera, K. M. Sapezhko, mayo etc. Method Lexera used for small umbilical hernias. For medium and large umbilical hernias, it is more expedient to K. M. Sapezhko or mayo.
Lexer method. The skin incision is carried out semi-lunar, bordering the hernial tumor from below, less often - circular. During the operation, the navel can be removed or left. If the hernia is small, then the navel is usually left. The skin with subcutaneous tissue is peeled upward and a hernial sac is isolated.
It is often very difficult to isolate the bottom of the hernial sac, which is intimately soldered to the navel. In such cases, the neck of the hernial sac is isolated, it is opened, and the hernial contents are set into the abdominal cavity. The neck of the bag is stitched with silk thread, tied up and the bag is cut off. The stump of the bag is immersed behind the umbilical ring, and its bottom is cut off from the navel. Having finished processing the hernial sac, proceed to the closure of the hernial ring. To do this, under the control of the index finger inserted into the umbilical ring, a silk purse-string suture is applied to the aponeurosis around the ring, which is then tightened and tied. Over the purse-string suture, another 3-4 interrupted silk sutures are applied to the anterior walls of the sheaths of the rectus abdominis muscles. The skin flap is placed in place and sutured with a number of interrupted sutures.
The method of K. M. Sapezhko. The skin incision is made over the hernial protrusion in the vertical direction. The hernial sac is isolated from the subcutaneous fatty tissue, which is exfoliated from the aponeurosis to the sides by 10-15 cm. The hernial ring is cut up and down along the white line of the abdomen. The hernial sac is processed according to generally accepted methodology. After that, the edge of the dissected aponeurosis of one side is sutured with a number of interrupted silk sutures to the posterior wall of the sheath of the rectus abdominis muscle of the opposite side. The remaining free edge of the aponeurosis is placed on the anterior wall of the sheath of the rectus abdominis muscle of the opposite side and is also fixed with a number of interrupted silk sutures. As a result of this, the sheaths of the rectus abdominis muscles are layered on top of each other along the white line, like the floors of a coat. The operation is completed by suturing the skin. If necessary, several sutures connect the subcutaneous fatty tissue.
Mayo method. Two semilunar skin incisions are made in the transverse direction around the hernial protrusion. The skin flap is grasped with Kocher clamps and peeled off from the aponeurosis around the hernial orifice for 5-7 cm. The hernial ring is cut in the transverse direction along the Kocher probe. Having selected the neck of the hernial sac, it is opened, the contents are examined and set into the abdominal cavity. In the presence of adhesions of the hernial contents with the hernial sac, the adhesions are dissected. The hernial sac is excised along the edge of the hernial ring and removed along with the skin flap. The peritoneum is closed with a continuous catgut suture. If the peritoneum is fused with the edge of the hernial ring, then it is sutured together with the aponeurosis. Then, several U-shaped silk sutures are applied to the aponeurotic flaps so that when they are tied, one flap of the aponeurosis overlaps the other. The free edge of the upper flap is sutured next to the interrupted sutures to the lower one.
The skin incision is closed with several interrupted silk sutures.
Indications: umbilical hernias.
Tooling:
Model of umbilical hernia;
Scalpel, scissors, grooved Kocher probe, blunt and sharp hooks, anatomical tweezers, surgical tweezers, hemostatic forceps, Hegar needle holder, round curved needle, silk No. 4-6, catgut No. 1-2, silk No. 1-2 (2/0 ).
With small umbilical hernias in children, plastic can be used by Lexer:
Technics:
I. Online access:
An arcuate incision is made along the lower semicircle of the hernial swelling (Fig. 13.1)
II. Operational reception.
The neck of the hernial sac is isolated from fiber, without disturbing the fusion of the bottom of the hernial sac with the skin (Fig. 12a);
Open the neck of the hernial sac
Set (resect, remove) hernial contents;
The neck of the hernial sac is sutured with catgut and bandaged (Fig. 12b);
Cross the neck of the hernial sac distal to the ligature (Fig. 12c);
After crossing the neck of the hernial sac, together with the ligature, is immersed into the abdominal cavity.
The rest of the hernial sac is excised, except for the bottom, fused with the skin.
2. Hernioplasty:
A silk purse-string suture is applied to the edges of the umbilical ring and tightened;
Over the purse-string suture, 3-4 interrupted silk sutures are applied to the white line (Fig. 12d);
The rest of the bottom of the hernial sac is sutured with silk thread to the white line.
Catgut sutures are applied to the subcutaneous fatty tissue and silk sutures to the skin.
Rice. 12. Umbilical hernia repair according to Lexer:
a - isolation of the neck and body of the hernial sac;
b - suturing the neck of the hernial sac;
c - cutting off the body and the bottom of the hernial sac from the neck;
d - the imposition of interrupted sutures on the white line of the abdomen.
Plastic according to Sapezhko.
Technics:
I. Online access.
Separate skin flaps from the aponeurosis to the right and to the left until the hernial ring appears.
II. Operational reception.
1. Treatment of the hernial sac:
The hernial sac is isolated from the subcutaneous fatty tissue, which is exfoliated from the aponeurosis to the sides by 10-15 cm;
A grooved Kocher probe is inserted between the neck of the hernial sac and the umbilical ring, and the ring is cut up and down along the white line of the abdomen along it.
The hernial sac is opened, the hernial contents are inspected, its contents are set (or removed if necrosis is present), the neck of the hernial sac is sutured, and its distal end is cut off.
2. Hernioplasty:
Placement of the first row of sutures. On Kocher's clamps, the left edge of the aponeurosis is pulled back and bent so as to turn its inner surface as much as possible. The right edge of the aponeurosis is pulled up to it and sutured with separate interrupted or U-shaped silk sutures, trying to bring it as far as possible (Fig. 13).
Placement of the second row of sutures. The free left edge of the aponeurosis is placed over the right one and sutured with silk interrupted sutures. This achieves a muscular-aponeurotic doubling of the abdominal wall (Fig. 13).
III. Suturing the surgical wound:
Rice. 13. Plastic according to Sapezhko.
a - front view: 1 - the first row of seams; 2 - the second row of seams.
b - horizontal section of the abdominal wall:
: 1 - the first row of seams; 2 - the second row of seams.
Plastic according to Napalkov.
Technics:
I. Online access.
II. Operational reception.
Treatment of the hernial sac.
Hernioplasty.
For plasty of the hernia gate, 3 rows of interrupted sutures are applied:
1 row - seams on the white line of the abdomen (Fig. 14);
Before applying the 2nd and 3rd rows of sutures, the anterior walls of the sheaths of the rectus abdominis muscles are dissected in two parallel incisions near their medial edge;
Stitches are placed first on the inner (2nd row), and then on the outer (3rd row) edges of these incisions.
III. Suturing the surgical wound:
Rice. 14. Plastic according to Napalkov:
1 - seams on the white line of the abdomen;
2 - seams on the inner edges of the anterior wall of the sheaths of the rectus abdominis muscles;
3 - seams on the outer edges of the anterior wall of the sheaths of the rectus abdominis muscles.
Mayo plastic.
Technics:
I. Online access.
An oval incision is made in the skin and subcutaneous fat. The skin with the umbilicus is excised. The anterior walls of the sheaths of the rectus abdominis muscles are freed from the pancreas at a distance of 5-6 cm from the hernial orifice. The hernial gate is expanded in the transverse direction along the grooved probe to the inner edges of the rectus muscles.
II. Operational reception:
Treatment of the hernial sac.
2. Hernioplasty:
The parietal sheet of the peritoneum is sutured with a continuous catgut suture;
The upper leaf of the aponeurosis is separated from the underlying muscles;
U-shaped silk seams hem the lower flap under the upper one;
The upper leaf of the aponeurosis is sutured with interrupted silk sutures to the lower one with the formation of a duplication (Fig. 15).
Rice. 15. Mayo plastic surgery:
1 - continuous suture on the parietal sheet of the peritoneum;
2 - U-shaped seams;
3 - interrupted sutures.
Plastic according to Menge.
Technics:
I. Online access:
Cross section at the base of the hernial sac. The hernial orifice is dissected to the edges of the rectus muscles.
II. Operational reception:
Treatment of the hernial sac.
2. Hernioplasty:
The imposition of the first (transverse) row of sutures on the back wall of the vagina of the rectus abdominis muscle, the transverse fascia and the peritoneum;
The second (longitudinal) row of sutures - on the medial edges of the rectus muscles;
Third (transverse row) - on the front wall of the vagina of the rectus abdominis muscle.
III. Suturing the surgical wound.
The structure of the inguinal canal
Located within the groin area inguinal triangle, limited:
Below - inguinal ligament Pupartova ligament);
Medially - the outer edge of the rectus abdominis muscle;
From above - a perpendicular lowered from a point between the outer and middle third of the inguinal ligament to the rectus abdominis muscle.
Within the inguinal triangle is located inguinal canal having two holes and four walls.
outer hole- superficial inguinal ring (Fig. 16) - limited:
Laterally and medially - lateral and medial legs formed by divergent fibers of the aponeurosis of the external oblique muscle of the abdomen;
Above - interpeduncular fibers;
Below - a bent ligament.
The dimensions of the surface ring in men are 1.0-4.5 x 0.6-3.0 cm, in women - 0.5-1.8 x 0.5-1.8 cm.
inner hole- deep inguinal ring is located 1 - 1.5 cm above the middle of the inguinal ligament and is an opening in the transverse fascia through which the spermatic cord (round ligament of the uterus) passes. It corresponds to the lateral inguinal fossa, limited (Fig. 16):
Outside - the inguinal ligament, enveloping the edge of the deep inguinal ring and representing a bundle of fibrous fibers in the thickness of the intra-abdominal fascia;
From the inside - the outer umbilical fold, which is formed when the lower epigastric vessels pass under the peritoneum.
Rice. 16. Inguinal region.
1 - pyramidal muscle; 2 - rectus muscle; 3- bladder, 4 - middle umbilical fold; 5 - lower epigastric artery and vein; 6.8 - vas deferens; 7 - external iliac artery and vein; 9 - testicular artery and vein; 10 - parietal sheet of the peritoneum; 11 - preperitoneal fatty tissue; 12 - transverse fascia; 13 - ilioinguinal nerve; 14.19 - spermatic cord; 15 - femoral artery and vein; 16 - muscle that raises the testicle; 17.20 - inguinal ligament; 18 - interpeduncular fibers; 21 - medial leg; 22 - lateral leg.
The walls of the inguinal canal:
Anterior - aponeurosis of the external oblique muscle of the abdomen;
Posterior - transverse fascia;
Inferior - inguinal ligament;
Upper - overhanging edges of the internal oblique and transverse abdominal muscles.
In the inguinal canal pass:
In men, the spermatic cord, in women, the round ligament;
The ilioinguinal nerve, passing along the anterior-inner surface of the spermatic cord or round ligament of the uterus;
The genital branch of the genitofemoral nerve pierces the transverse fascia medially to the deep inguinal ring and lies on the posterior surface of the spermatic cord or round ligament of the uterus.
The space between the lower and upper walls of the inguinal canal is called inguinal interval(spatium inguinale), whose height varies from 1 to 5 cm.
When diagnosing a hernia, the question of the need for hernia repair and hernioplasty arises as a priority. The patient and his relatives want to know what these terms hide in themselves, how interventions are carried out, what they will face in the postoperative period. Let's analyze these questions in more detail.
Treatment of hernias is not carried out by therapeutic methods. The use of various bandages, physiotherapy and gymnastic exercises aimed at strengthening the muscular belt are only preventive measures and cannot eliminate the existing pathology.
Surgical techniques
In the case of a planned operation, when it is not required to immerse the loops of the intestine into the abdominal cavity, it is used hernioplasty(hernioplasty in literal translation). If there is a pathological protrusion, then the surgical intervention takes place in two stages: hernia repair(reduction of the organ with removal of altered surrounding tissues) and strengthening of the muscle wall.
In practice, different techniques are used in accordance with the localization of the hernia and the purpose of the intervention.
Hernioplasty for umbilical hernias
Among open ways surgical intervention for umbilical hernia resort to plastic surgery according to Sapezhko or according to Mayo. The basis for strengthening the umbilical ring and the anterior abdominal wall is the creation of an aponeurotic duplication. After preoperative preparation, anesthesia, the intervention is started.
The operation begins with a layer-by-layer separation of the skin with a scalpel, subcutaneous fat to the aponeurosis (tendon formation between the muscles). With the help of special instruments, an incision is made, giving access to the hernial sac containing intestinal loops.
After the release of the intestine, its condition is assessed and immersed in the abdominal cavity. Then excised areas of excess tissue and proceed directly to the plastic.
Aponeurotic tissues are sutured with a U-shaped suture so that a double fold is obtained. The difference between Mayo plastic surgery and Sapezhko surgery lies in the direction of the incision, and, accordingly, the stitching of tissues. In the first case, the cutting line runs horizontally. The aponeuroses are sutured in the following order: first, the upper flap from the outside to the inside, then the lower one in the same way, after which the thread passes in the opposite direction. When plastic according to Sapezhko, the right and left aponeurotic parts are compared by the same technique.
With small sizes of the umbilical ring in children, it is possible to use the method developed by Lexler. In this case, a purse-string (circular) suture is applied to the hernial ring, the edges are pulled together, and then all tissues are compared with ordinary knotted stitches.
Hernioplasty for inguinal hernias
The technique of hernia repair is chosen in accordance with the type of hernia (oblique and direct) and the purpose of strengthening a certain wall of the inguinal canal.
Method according to Martynov used to reinforce the front wall. The operation is carried out with the definition of access. The incision is made approximately 1.5 cm above the inguinal ligament, the layers are alternately separated until the contents of the hernial sac are released and repositioned into the abdominal cavity. After that, the upper part of the aponeurosis is sutured to the inguinal ligament, and then the lower part of the connective tissue structure is applied over this and stitched. Carry out further layer-by-layer closure of the wound.
To strengthen the back wall resort to Bassini technique. After hernia repair, deep sutures are applied behind the spermatic cord between the muscles that make up the upper wall of the canal (internal oblique and transverse), the transverse fascia and the pupart ligament. Thus, there is a complete closure of the posterior wall by the muscular-fascial layer. Next, compare all the tissues with each other.
A technique has been developed for creating a "new" inguinal canal to replace the old one. Hernioplasty according to Postempsky carries out suturing of canalis inquinalis and transfer of the spermatic cord to the area of another localization. At the same time, after excision of the hernial sac, the upper-lateral part of the funiculus is deviated outward and slightly higher, if necessary, slightly excising the internal oblique and transverse muscles with immersion in the resulting space f.spermaicus and fixing between the muscle fibers. From below, the muscle tendons are sutured to the pubic tubercle and the Cooper ligament (between the frontal tubercles). The remaining tissues are connected to the inguinal ligament with U-shaped sutures. Then compare the lower and upper parts of the aponeurosis of the external oblique. As a result, the spermatic cord is placed in fatty tissue.
Among the classical techniques, the use of mesh materials occupies a worthy place. Plastic according to Liechtenstein involves the use of a synthetic graft to strengthen the hernial ring. After all standard surgical manipulations, a mesh flap is sutured in the area of least strength, which subsequently fuses firmly with the surrounding tissues and prevents the occurrence of a hernia.
Video
3D simulation of such an operation as a teaching material.
Alternative operations
Along with hernia repair by open access, endoscopic operations are successfully used. The latter types of interventions are less traumatic. Operations using endoscopic technique are carried out by means of punctures at 3 points. Through one of them, an optical technique is carried out, which allows you to display the image on the monitor and see everything that happens in the surgical field. Other punctures are used to introduce special instruments used for direct hernia repair and mesh implant placement.
Such an intervention has its advantages in the easier course of the postoperative period, and the remaining scars at the site of several punctures are hardly noticeable and do not cause aesthetic discomfort. However, despite all the advantages, endoscopic techniques cannot completely replace traditional operations, both for some technological reasons (not all institutions have specialized equipment), and due to the objective need on the part of a number of patients to operate through open access.
Do not start the disease and seek medical help in a timely manner. There are frequent cases of infringement of the intestine in the hernial orifice, requiring emergency surgical intervention.
The actions of doctors after a preliminary examination and examination:
- conducting anesthesia;
- preparation of the operating field;
- layer-by-layer dissection of tissues up to the hernial sac;
- opening the hernial sac and assessing the condition of the strangulated intestine;
- in the presence of peristalsis, pulsation of blood vessels and looking good the organ after "resuscitation" actions (warming and irrigation with saline solution) is reduced;
- in the absence of viability, resection (removal) of a section of the intestine is carried out within 40-50 cm to and 15-20 cm from the site of infringement. If there is damage to the mucosa in the remaining areas, a resection is performed within healthy tissues. The ends of the inlet and outlet sections are compared with subsequent stitching and immersion in the abdominal cavity.
- layer-by-layer suturing of tissues.
What is tension and non-tension plastic?
Initially, hernioplasty methods were carried out by connecting only one's own tissues. In this case, the tension of the structures naturally occurs. Tension plastic has a number of disadvantages, which manifest themselves in:
- failure of the seams;
- thread cutting and inflammation;
- large tissue edema;
- recurrences of hernias, etc.
Video
To reduce complications, it was proposed to use a synthetic mesh. E. Lisin, Candidate of Medical Sciences, Head of the Surgical Department, talks about such implemented methods. The interview is accompanied by a visual video about the treatment of hernias.
Is anesthesia provided?
The fear of pain during surgery is understandable and understandable. The operation can be performed both under local infiltrative anesthesia, with the use of epidural analgesics, and under general anesthesia. The type of anesthetic benefit is determined in accordance with the general condition of the patient, the urgency of the intervention and other additional circumstances. In severe cases, combined anesthesia is used, accompanied by respiratory support.
Restrictions in the postoperative period
V early period after the intervention, the patient is first under the supervision of medical professionals who control bed rest and diet.
The main questions arise after discharge from the hospital. The healing of the wound surface is relatively successful by the end of the second week. Therefore, at first it is important to observe physical and sexual rest. You can't lift weights. It is necessary to establish a fractional diet with the elimination of spicy, fatty foods, legumes, carbonated drinks, and other foods that contribute to constipation and flatulence (factors that provoke a relapse of the disease). Cough is also accompanied by an increase in intra-abdominal pressure, therefore, if necessary, it is worth discussing with the doctor the possible connection of antitussive drugs and quit smoking. After 14 days, you need to start physical education.
Gradually, you can master easy exercises:
- "scissors" (crossing the legs in the prone position);
- "bicycle" (alternate movements of the legs in a position on the back);
- plank;
- squats.
It must be remembered that classes are carried out in a dosed manner, at first in small quantities and as own forces. You can't overexert your body.
Up to 3-4 months, the operated person should be on light labor. Lifting weights over 10 kg is strictly prohibited (in individual cases, the permitted weight is several times less).
Note!
Sex life is allowed no earlier than 2 weeks. Meanwhile, during intimate connection you need to carefully monitor the absence of pressure on the wound area and limit activity.
Hernia repair followed by hernioplasty is the "gold standard" for the treatment of hernias of various localization. Operations are carried out with an individual approach, adhering to the developed standards. In the postoperative period, the patient is not left alone with his pain, but is under close medical supervision. The further state mostly depends on the implementation of the recommendations and the lifestyle of the operated.
(Total 2 303, today 1)
Mayo umbilical hernia repair remains a reliable method of treating the disease in cases of small hernial formations and the impossibility of using other methods of plastic surgery.
Symptoms of the disease
The appearance of a convex formation in the navel is a sign of a hernia. The initial stages do not have painful manifestations, the hernia is reduced without difficulty.
With an increase in protrusion, adhesions develop at the points of contact of the hernial sac with the anterior abdominal wall.
The adhesive process makes the hernia irreducible. There are pains in the abdomen, nausea, chronic constipation. Strong cough, physical activity provoke symptoms of the disease. Symptoms depend on the size of the defect, the development of the adhesive process, and complications.
Indications for the operation
Indications for hernia repair are usually divided into relative and absolute. The presence of a reducible umbilical hernia of small size with a minimal risk of infringement is considered a relative indication for surgical intervention.
The development of relapses, hernia irreducibility, the presence of adhesive disease, infringement are absolute indications for hernia repair.
Mayo plastic surgery for umbilical hernia is feasible subject to the following conditions:
- the parameters of the hernia gate should be no more than 3-5 cm;
- the presence of signs of irreducible hernia;
- intolerance to general anesthesia;
- the absence of a high degree of obesity in the patient.
The doctor assesses the degree of risk of surgery. For this, a complete examination is carried out.
The essence of the approach
Mayo repair performed after herniotomy is justified for small hernias. The ability to perform surgery under local anesthesia is considered the advantage of choosing this technique. Herniotomy with the use of epidural anesthesia is also used for this disease.
General anesthesia gives more side effects and complications. Local and epidural anesthesia provide sufficient analgesic effect. The operation is possible in full and without complications.
The essence of plastics according to the Mayo method is to create a double protection of the anterior abdominal wall in the umbilical region, the application of U-shaped sutures that provide reliable closure of the umbilical defect.
Disadvantages and advantages of the method
Each operational technique has its own advantages and disadvantages. The doctor, conducting an examination, chooses the option that suits the patient. Not only the characteristics of the hernial protrusion are taken into account, but also the state of the body, the presence of concomitant diseases.
The advantages of this method include:
- surgery using local anesthesia;
- technically uncomplicated surgical intervention;
- no complications dangerous for the patient;
- a fairly small percentage of relapses with the right choice.
The advantages of this technique have not lost their relevance.
The method of tension hernioplasty has a number of disadvantages:
- pain persists after surgery;
- the rehabilitation period is lengthened;
- the occurrence of relapses in plastic surgery of large areas.
The patient is warned about possible shortcomings. A small defect and a planned operation provide a minimal risk of recurrence.
Preparation for surgery
Preoperative preparation is carried out according to general rules. After examining the patient, the surgeon draws up a conclusion that contains:
- substantiation of the diagnosis;
- indications for surgical treatment;
- operation plan, anesthesia method;
- preoperative activities.
Before the Mayo umbilical hernia repair, the patient must undergo a series of examinations and tests. Mandatory for surgical treatment are:
- clinical, biochemical blood test;
- Analysis of urine;
- electrocardiogram;
- ultrasonography;
- chest x-ray.
Before the start of the operation, blood clotting, group affiliation are determined. Find out the presence of drug allergies. The day before surgery, anticoagulants and antiaggregants are canceled. The operation is carried out 2 weeks after the transferred infectious diseases.
In the presence of chronic diseases, a conclusion of specialists about the absence of exacerbations, permission for surgical intervention is necessary.
During the last 3 days, you must follow a sparing diet. Exclude from the diet bakery products, vegetables. An enema is given the day before. The last meal and liquid should take place 8 hours before the start of surgery.
Operation progress
The first step is a herniotomy. A transverse incision is made, bypassing the hernial formation on both sides. They hold the skin flap, separate the subcutaneous tissue and aponeurosis. A transverse dissection of the aponeurosis is made up to the rectus abdominis muscles, making it possible to immerse the contents of the hernia into the abdominal cavity and close the defect.
Carefully cut the receptacle, grabbing its edges with clamps. Existing adhesive formations must be dissected carefully so as not to damage the intestinal wall. The contents are inspected, filled into place. The receptacle of the hernia is excised along the hernial ring and removed.
Hernioplasty is the last stage of the operation and consists in closing the defect.
Mayo's proposed technique is to create a double protection weak point and the imposition of U-shaped seams. The lower part of the aponeurosis is placed under the upper one, fixed with sutures. Interrupted sutures fix the remaining free upper edge of the aponeurosis.
This type of transverse fixation will provide minimal tension as a result of muscle contraction. With existing changes in the skin of the paraumbilical zone, adhesive formations of the walls of the hernial sac with the umbilical ring, the navel is removed. Such actions are carried out in order to prevent the development of complications in the form of fluid accumulation, inflammation of the wound and necrosis in the umbilical region.
Restrictions in the postoperative period
Tension hernioplasty methods require a longer recovery time.
The positive dynamics of the early postoperative period allows the sutures to be removed at the end of the first week.
In this period, it is necessary to prescribe analgesics to relieve pain.
A properly organized recovery period will ensure complete recovery and the absence of complications.
After the operation, the following rules are required:
- give up physical activity;
- use a special bandage;
- avoid movements associated with tension in the abdominal muscles;
- stick to a healthy diet.
The return to a full life should occur gradually. Remedial gymnastics, physiotherapy procedures are prescribed. Physical exercise limited to up to a year. Fats are excluded from the diet, spicy dishes, carbonated drinks. Bowel function must be adequate. Properly organized postoperative period will ensure recovery and the absence of complications.
Umbilical hernia in adults: causes, symptoms, infringement, diagnosis, consequences
Umbilical hernia, wen, severe weakness/trembling of hands, nutrition after GIST removal / Dr. Myasnikov
Disease prevention
The development of an umbilical hernia can be prevented by observing simple preventive measures:
- Follow the correct diet, ensuring the normal functioning of the digestive tract.
- Do regular exercise strengthening abdominal muscles.
- Control body weight.
- Use a bandage and special exercises during pregnancy.
With the existing genetic predisposition to the development of the disease, it is necessary to abandon hard physical labor, regularly strengthen the muscular system. You should avoid the development of obesity, monitor the functioning of the intestines.
Accurate implementation of doctor's prescriptions after surgical treatment for umbilical hernia increases the chances of a full recovery.
A hernia of the abdominal wall in surgery is the protrusion of the abdominal viscera through previous openings, fissures, channels of the abdominal wall or through defects in the muscular-aponeurotic layers of the abdominal wall that have arisen after trauma or surgical interventions. All Methods surgical treatment hernias can be divided into two types. During operations of the first type, tissue connection occurs with their tension (such operations are called “traditional”), in the second type of operations, tissue tension is absent, and implants are used. Surgical treatment of inguinal hernias by traditional methods involves plastic surgery aimed at strengthening the anterior or posterior wall of the inguinal canal. The following methods are currently used for surgical treatment of inguinal hernias: traditional methods. 1) Plastic according to Bassini and its varieties (plastic according to N. I. Kukudzhanov, etc.) Plastic according to Marcy, Bobrov-Girard Method, S.I. Spasokukotsky, McVay plastic, M.A. Kimbarovsky 2) Plastic according to E. E. Shouldice. Modern methods 3) Operation I.L. Lichtenstein. 4) Plastic using PHS (prolen hernia system) 5) “Plug and patch” technique (plug and patch) 6) Endoscopic hernioplasty (J.D.Corbitt (1992)).
Hernioplasty according to Bassini. Plastic stage of the operation.
1 . After processing the hernial sac, proceed to the plastic stage of the operation. With the first 1~3 sutures, the edge of the rectus abdominis muscle is sutured together with its tendon sheath and the underlying sheet of the transverse fascia to the Cooper ligament. 2 . To reduce tension in the suture area with a high inguinal gap, a relieving incision is made in the anterior wall of the vagina of the rectus abdominis muscle, 4-6 cm long. Usually, a relieving incision is made after suturing and tying the sutures that form the back wall of the inguinal canal. 3 . Then, with 5-6 non-absorbable sutures placed at a distance of 1-1.5 cm from each other, a triple layer (internal oblique, transverse abdominal muscles, transverse fascia) is fixed to the inguinal ligament.
4 . The posterior wall is repaired with separate sutures or a continuous suture. The tying of the sutures is started from the medial angle of the wound. In cases where the deep inguinal ring remains uncovered by the internal oblique muscle of the abdomen, an additional suture is applied lateral to the spermatic cord. 5 . The spermatic cord is placed on the newly formed posterior wall of the inguinal canal, over its edge to edge, the aponeurosis of the external oblique abdominal muscle, subcutaneous tissue and skin are sutured with separate or continuous sutures Plastic according to E E.Shouldice characterized by the imposition of a continuous seam in 2 or 3 layers. Such operations give 5-10% relapses. Operation I.L. Lichtenstein implies traditional access and plasty of the posterior wall of the inguinal canal with a 2-dimensional polypropylene or Teflon mesh implant. Relapses are about 1%. Plastic using PHS. The method involves the use of a complex 3-dimensional prosthesis in non-tight hernioplasty, consisting of a suprafascial flap, a connector, a subfascial flap. Traditional access to the inguinal canal is carried out. The internal flap of the prosthesis is folded, inserted through the internal inguinal ring and straightened in the preperitoneal space under the transverse fascia. The outer flap is formed, ensuring the passage of the spermatic cord, is fixed similarly to Liechtenstein plastic. Plug and Patch Method or "plug and patch" could be considered a variant of Liechtenstein's operation. With this operation, a typical access to the inguinal canal is performed. As a rule, during this operation, the hernial sac is not opened, but is immersed in an obturator (“plug”) made of a polypropylene mesh in the form of a shuttlecock. The obturator with its tip is directed towards the hernial sac, and in the base area it is fixed with several sutures to the surrounding tissues. The posterior wall of the inguinal canal is strengthened with a “patch” mesh, as is done with Liechtenstein plasty. Endoscopic hernioplasty forms the posterior wall of the inguinal canal according to the type of operation I.L. Lichtenstein, but are carried out using a special hardware and instrumental complex through laparoscopic access.
92. Topographic anatomy of the umbilical region. Borders, layers, main anatomical elements of the umbilical ring. Fistulas of the navel. The concept of umbilical hernia. The main methods of hernioplasty. Terms of surgical treatment. Navel, umbilicus, is a retracted scar of the skin approximately in the middle of the white line at the site of the umbilical ring. umbilical ring, anulus umbilicalis, - a hole in the white line with sharp and even edges formed by the tendon fibers of the aponeuroses of all the broad abdominal muscles. In the intrauterine period, the umbilical cord passes through the umbilical ring, connecting the fetus to the mother's body. In this hole, along the lower semicircle, there are two umbilical arteries and the urinary duct (urachus), on the upper semicircle - the umbilical vein. In adults, these formations are neglected. Near the umbilicus are paraumbilical veins, w. paraumbilical, connecting the superficial veins of the abdominal wall with the portal vein system. In composition of the navel includes the following layers: skin, scar tissue, transverse fascia and parietal peritoneum, tightly fused together. There is no subcutaneous or preperitoneal tissue. Due to the lack of muscular coverage, the navel is another “weak spot” in the abdominal wall where umbilical hernias often occur. FISTULAS OF THE NAUL Most often a congenital pathology. Develop as a result of non-closure of the yolk-intestinal or urinary duct. When the yolk-intestinal duct is not closed in the umbilical region, an entero-umbilical fistula with intestinal or mucous discharge is formed. Sometimes the intestinal mucosa falls out through the fistulous passage, less often the omentum. When the urinary duct (urachus) is not closed, a vesico-umbilical fistula is formed, and then the discharge, as a rule, is urine. An umbilical hernia is an exit under the skin through a hole formed in the navel (hernial orifice) of the internal organs of the abdominal cavity along with the serous membrane lining the inside of the abdominal cavity - the peritoneum.
Methods of surgical treatment of umbilical hernia. 1) Plastic surgery with local tissues. 2) Plastic with synthetic prostheses. 3) Laparoscopic hernioplasty.
Types of operations (hernioplasty): 1. Traditional plastic local fabrics are produced according to the methods of Sapezhko and Mayo. Technique: the edges of the aponeurosis of the umbilical ring are sutured in two layers, either vertically or transversely. In most cases, during these operations, it is necessary to remove the navel, and in patients with obesity, it is possible to remove the excess fatty apron. The main disadvantages of the operation: (a long period of rehabilitation (limitation of physical activity up to 1 year); a high risk of hernia recurrence (reappearance of a hernia in the same place)). 2. Plastic with the use of mesh implants. There are two ways to set up grids. a) The mesh is placed over the aponeurosis (above the umbilical ring), directly under the skin. Such an operation is performed in cases where it is impossible to suture the hernial orifice due to their large size. b) The mesh is placed under the aponeurosis (under the umbilical ring). This is the most optimal way to treat an umbilical hernia. There are no disadvantages of this method of surgical treatment. Advantages: a short rehabilitation period (no more than 1 month even for athletes); a low percentage of recurrence (less than 1%); the operation is performed under any type of anesthesia.
93. Femoral canal: formation mechanism, walls, openings. The concept of femoral hernia. Methods of surgical treatment of femoral hernias, differential diagnosis, errors, dangers. Femoral canal, canalis femoralis The angle between the inguinal ligament attached to the pubic tubercle and the crest of the pubic bone is filled with lacunar ligament, lig. lacunar. Between the femoral vein and the lacunar ligament in the vascular lacuna there remains a gap filled with loose tissue through which femoral hernias exit. It contains the Pirogov-Rosenmuller lymph node. In the presence of a femoral hernia, a femoral canal is formed in this area (Fig. 36). Its deep ring, annulus femoralis profundus, faces the pelvic cavity and is bounded in front by the inguinal ligament, behind by the pectinate ligament, lig. pectineal (lig. pubicum C o open; BNA), medial-lacunar ligament and lateral femoral vein. On the inner surface of the abdominal wall, this ring is covered by the transverse fascia, which here looks like a perforated plate, septum femorale. The subcutaneous ring of the femoral canal corresponds to the hiatus saphenus. It is made by fascia cribrosa. The length of the canal, depending on the level of attachment of the upper horn of the falciform edge to the inguinal ligament or to the deep plate of the wide fascia on the pectineus muscle, ranges from 1 to 3 cm. The femoral canal is a trihedral pyramid facing anteriorly (comu superius margo falciformis). It is limited in front by the sickle-shaped edge of the wide fascia, outside by the inner semicircle of the femoral vein; and sleep three and behind - a deep plate of the wide fascia covering the comb muscle. The deep femoral ring in case of anomalies of the obturator artery discharge (from the inferior epigastric or from the external iliac artery) may be surrounded by large vessels: along its upper and medial edges it can pass, heading towards the pelvic opening of the obturator canal, an o crimson obturator artery; outside is the femoral vein, and inside, on the inner surface of the lacunar ligament, is the pubic branch of the inferior epigastric artery. Arterial anastomoses around the deep ring in these cases were called the “crown of death” (corona mortis), since the dissection of this ring when the femoral hernia was incarcerated by the herniotomy (blindly) often led in former times to fatal bleeding from damaged arteries. A distinction is made between the femoral method of operations, when access to the hernial sac and closing of the femoral ring is performed from the side of the thigh, and the inguinal method. In the latter case, access to the hernial sac is carried out through the inguinal canal. Femoral method of operations for femoral hernia.
A skin incision 10-12 cm long is made vertically above the hernial protrusion starting 2-3 cm above the inguinal ligament. The skin and subcutaneous tissue are dissected, the lymph nodes and the great saphenous vein are shifted to the side. Bare hernial femoral hernia sac and stupidly allocate it to the neck, release the hernial orifice (femoral ring) from the side of the thigh. Outside protect the femoral vessels to avoid damage.
Opening of the hernial bag for femoral hernia, revision and immersion of its contents, ligation of the neck and removal of the bag are performed in the same way as with inguinal hernias. Hernial ring in femoral hernia closed by suturing the inguinal ligament to the pectinate. To do this, pull the inguinal ligament up, and the femoral vein outward. It is necessary to use sharply curved needles to capture the pectineal ligament deeper and connect it to the inguinal. Usually impose 2-3 such seam. The outer sickle-shaped edge, limiting the subcutaneous sac, hiatus saphenus, is sutured with several sutures to the fascia of the pectineus muscle ( Bassini method for femoral hernia).
Inguinal method of operations for femoral hernia.
An incision of the skin, subcutaneous tissue, superficial fascia and aponeurosis of the external oblique muscle of the abdomen is made in the same way as with inguinal hernias.
After opening the inguinal canal, the spermatic cord is isolated and taken upwards. Longitudinally open the back wall of the inguinal canal - the transverse fascia. The upper edge of this fascia is pulled upward. They penetrate into the preperitoneal space and look for the neck of the hernial sac in it. femoral hernia withdraw into the inguinal canal.
The inguinal and pectinate ligaments are released from fiber, the inguinal ligament is sutured to the pectinate ligament with 2-3 silk sutures behind the spermatic cord ( Ruggi's method for femoral hernia). In this case, the inguinal ligament moves down somewhat, increasing the height of the inguinal gap, which creates favorable conditions for the formation of direct inguinal hernias in the future. To avoid this, the lower edges of the internal oblique and transverse abdominal muscles in front of the spermatic cord are sutured to the pectineal ligament together with the inguinal ligament, which, simultaneously with the elimination of the femoral ring, eliminates the inguinal gap ( Parlaveccio method for femoral hernia).
