Infringement is one of the serious complications that can occur during the development of a hernia. This is an unexpected compression of the organs in the hernial sac. Such a process can occur in the area of \u200b\u200bthe neck of the sac or in the hernial orifice. Its consequence is a disruption of the circulatory system.

Classification of restrained hernias

In medicine, the following types of strangulated hernias are distinguished:

• Primary infringements. This category is quite rare, it can arise only after a momentary effort that was made by a person. An important condition in this case is the presence of a predisposition to the appearance of protrusion. During this short but significant load, a hernia instantly forms, which at this moment is pinched in the hernial orifice. Diagnosis of such a disease is difficult;
• Secondary strangulated hernia. All other protrusions belong to this category. As a rule, it occurs against the background of an already existing hernia.

In addition, there are two forms of strangulated hernias:

• Elastic variety. It is observed at a young age, caused by exhausting physical exertion. Symptoms are sharp bouts of pain, tension in the hernial sac. The hernia itself does not correct, nausea appears, accompanied by vomiting;
• Fecal infringement of a hernia of the abdomen. It can be found in elderly people and old people who are carriers of hernias for a long time. They gradually increase in size, become irreducible.

Special types of infringement:

• Retrograde infringement. Its peculiarity is the presence of two intestinal loops that do not fall into the hernial sac. It contains the bend of the third loop, to which, as a result, the blood supply is disrupted. This kind of infringement is rare, but it is difficult;
• Parietal infringement. In this case, the intestine, located in the hernial sac, is squeezed only in several places. In this case, the development of such complications as intestinal obstruction is excluded, however, necrosis of the intestinal wall may appear. This kind of entrapment never occurs in giant hernias;
• Littre's hernia. A similar infringement occurs in the groin area. This pathology is in many ways similar to the previous type, the only difference is that necrosis develops several times faster.

Photo: fecal infringement of a hernia of the abdomen

Symptoms of pinched hernias

For a strangulated hernia, four symptoms are characteristic. They are found in any form of pinching. These include:

1. Pain of a sharp nature, manifested in the area of \u200b\u200bthe hernia;
2. The protrusion cannot be adjusted even in the supine state;
3. The hernia is painful and constantly tense;
4. The cough impulse is not transmitted.

The most important symptom is pain! It occurs during physical stress and does not disappear after it stops. In especially severe cases, it is so strong that the patient is unable to refrain from moaning. At the same time, the skin begins to turn pale, painful shock develops, pressure decreases.

If you do not consult a doctor immediately, then the development of peritonitis begins. The process of inflammation gradually spreads throughout the abdomen, capturing the digestive organs.

Diagnosis

Diagnosing a pinched hernia in simple cases is not difficult for doctors and is quickly carried out. The first stage is the study of anamnesis. With its help, it is possible to determine a hernia, which was previously reducible and was not accompanied by pain.

The next step is a physical examination. Usually, when viewed, the protrusion is clearly visible. It does not disappear when changing position, its outline does not change when moving.

The methods for diagnosing a restrained hernia include:

• Determination of skin temperature at the site of the hernia;
• Delivery of general tests: blood, urine, feces;
• Ultrasound of the abdominal cavity, radiography of the peritoneum.

Conservative treatment

A pinched hernia can only be cured surgically! The only contraindication is the patient's agonal state. Any attempt to reposition a hernia is unacceptable because of the likelihood of getting into the abdominal cavity of an organ that has undergone irreversible ischemia.

However, there are several exceptions to this rule. They apply to patients who are in serious condition due to the presence of additional diseases. In this case, no more than an hour should pass from the infringement that occurred in front of the doctor. In such cases, surgical intervention for the patient is much more risky than trying to correct the hernia without surgery.

You can also try to correct the hernia for young children, if not much time has passed after the infringement.

Preparing for surgery. Anesthesia

It is necessary to prepare for the operation to remove and reposition the pinched hernia. This requires the removal of urine using a crankcase, in some cases, emptying the stomach.

For the operation, local or epidural anesthesia can be used. The latter option is preferred.

Surgical intervention. Operation progress

The operation is quick and urgent. The main task of the surgeon is to expose and fix the restrained organ. Only this will prevent it from slipping into the abdominal cavity.

Operation progress:

Of course, if you abandon the plastic of the hernial orifice, then this will lead to the re-development of the hernia. However, the main and main task of a doctor during an emergency operation is to save the patient's life. The operation to remove the recurrent hernia can be performed later, but according to the plan, without urgent hospitalization.

A similar tactic is used in the situation of phlegmon of the hernial sac, the only exception is purulent inflammation.

In patients who are in serious condition, it is allowed to use the exteriorization of the restrained organ. In such situations, under local anesthesia, the dissection of the hernial sac is performed, the withdrawal and fixation of the affected organ beyond its limits. After that, the hernial orifice is dissected.

Photo: types of infringement: retrograde and parietal

Effects

When an experienced and professional surgeon works, there are no negative consequences after the operation. However, to possible complications can be attributed:

• Relapse;
• Refusal of work of a previously restrained body;
• Suppuration formation.

All consequences, except for relapse, are determined shortly after the surgical intervention.

Preventive measures

After the operation, a rehabilitation period begins, during which one should not forget about preventive measures... They will prevent the development of relapse:

• Wearing a bandage or a special corset for the first months after the operation;
• Visiting examinations with a doctor;
• Refusal from exhausting physical activity, weight lifting;
• Crushing food into several portions is recommended. This will facilitate the work of digestion, restore emptying.

Do not forget that pinching a hernia of the abdomen requires quick and immediate hospitalization!

Catad_tema Surgical diseases - articles

Standard of care for patients with strangulated hernia

On November 26, 2007, the Ministry of Health approved the protocols for the diagnosis and treatment of restrained hernia.

Strangulated hernia (ICD - 10 K40.3 - K 45.8) - sudden or gradual compression of the contents of the hernia in its gate.

Infringement is the most common and dangerous complication of hernial disease. The lethality of patients increases with age, varying between 3.8 and 11%. Necrosis of the strangulated organs is observed in at least 10% of cases.

The forms of infringement are different. Among them are distinguished:
1) elastic restraint;
2) fecal infringement;
3) parietal infringement;
4) retrograde infringement;
5) Litre's hernia (entrapment of Meckel's diverticulum).

According to the frequency of occurrence, the following are observed:
1) strangulated inguinal hernia
2) strangulated femoral hernia;
3) restrained umbilical hernia;
4) restrained postoperative ventral hernia;
5) restrained hernia of the white line of the abdomen;
6) strangulated hernias of rare localizations.

A restrained hernia may be accompanied by acute intestinal obstruction, which proceeds according to the mechanism of strangulated intestinal obstruction, the severity of which depends on the level of strangulation.
With all types and forms of restrained hernia, the severity of the disorder is directly dependent on the time factor, which determines the urgent nature of the therapeutic and diagnostic measures.

Protocols for the diagnosis of strangulated hernias in the emergency department (EMF)

Patients admitted to AEMF with complaints of abdominal pain, symptoms of acute intestinal obstruction should be purposefully examined for the presence of hernial protrusions in their typical places.

On the basis of complaints, clinical history and objective examination data, patients with strangulated hernias should be divided into 4 groups:
Group 1 - uncomplicated restrained hernia;
Group 2 - complicated restrained hernia

With a complicated restrained hernia, 2 subgroups are distinguished:
a) restrained hernia, complicated by acute intestinal obstruction;
b) strangulated hernia, complicated by phlegmon of the hernial sac.
Group 3 - straightened hernia, which has been reduced;

Uncomplicated restrained hernia;

Criteria for diagnosing uncomplicated restrained hernia in AEMF:

A restrained uncomplicated hernia is recognized by:
- sudden onset of pain in the area of \u200b\u200ba previously repaired hernia, the nature and intensity of which depends on the type of infringement, the affected organ and the patient's age;
- the impossibility of repositioning a previously freely repositionable hernia;
- an increase in the volume of hernial protrusion;
- tension and soreness in the area of \u200b\u200bhernial protrusion;
- lack of transmission of "cough jolt";

Symptoms and signs of acute intestinal obstruction in uncomplicated restrained hernia are absent.

Laboratory research:
- clinical blood test,
- blood group and Rh-factor,
- blood sugar,
- bilirubin,
- coagulogram,
- creatinine,
- urea,
- blood on RW,
- clinical analysis of urine.

- ECG

Therapist consultation

Protocols of preoperative preparation for uncomplicated restrained hernia in OEMP

Surgical tactics protocols for uncomplicated restrained hernia.

1. The only method of treating patients with restrained uncomplicated hernia is an emergency operation, which should be started no later than 2 hours after the patient is admitted to the EMF. There are no contraindications to surgery for a strangulated hernia.
2. The main objectives of the operation in the treatment of uncomplicated strangulated hernias are:
- elimination of infringement;
- examination of the restrained organs and appropriate interventions on them;
- plastic hernia orifice.
3. An incision of a sufficient size is made according to the location of the hernia. The hernial sac is opened and the organ restrained in it is fixed. Dissection of the restraining ring before opening the hernial sac is unacceptable.
4. In case of spontaneous reduction into the abdominal cavity of the restrained organ, it should be removed for examination and assessment of its blood supply. If it cannot be found and removed, enlargement of the wound (herniolaparotomy) or diagnostic laparoscopy is indicated.
5. After dissection of the restraining ring, the state of the restrained organ is assessed. The viable intestine quickly takes on a normal appearance, its color becomes pink, the serous membrane is shiny, the peristalsis is distinct, the vessels of the mesentery are pulsating. Before setting the intestine into the abdominal cavity, it is necessary to inject 100 ml of 0.25% novocaine solution into its mesentery.
6. In case of doubts about the viability of the intestine, 100 - 120 ml of 0.25% novocaine solution should be injected into its mesentery and the dubious area should be warmed up with warm tampons soaked in 0.9% NaCl. If doubts remain about the viability of the bowel, the bowel should be resected within the healthy tissue.
7. Signs of intestine nonviability and indisputable indications for its resection are:
- dark coloration of the intestine;
- dull serous membrane;
- flabby wall;
- lack of intestinal peristalsis;
- absence of pulsation of the vessels of her mesentery;
8. Except for the restrained section of the intestine, the entire macroscopically altered part of the adducting and efferent intestine plus 30-40 cm of the unchanged part of the adducting gut and 15-20 cm of the unchanged segment of the efferent intestine is subject to resection. The exception is resections near the ileocecal angle, where it is allowed to limit the specified requirements with favorable visual characteristics of the intestine in the area of \u200b\u200bthe proposed intersection. In this case, the control indicators are used for bleeding from the vessels of the wall at its intersection and the state of the mucous membrane. It is also possible to use transillumination or other objective methods assessment of blood supply. When resecting the intestine, when the level of the anastomosis is at the most distal part of the ileum - less than 15 - 20 cm from the caecum, one should resort to the imposition of ileoascendo - or ileotransverse anastomosis.
9. In case of doubts about the viability of the intestine, especially over its large extent, it is permissible to postpone the decision of the question of resection, using programmed laparoscopy after 12 hours.
10. In cases of parietal infringement, bowel resection should be performed. Immersion of the altered area into the intestinal lumen is dangerous and should not be performed, since this may cause divergence of the immersion sutures, and immersion of a large area within the unchanged parts of the intestine can create a mechanical obstacle with impaired intestinal patency.
11. Restoration of the continuity of the gastrointestinal tract after resection is carried out:
- with a large difference in the diameters of the lumen of the stitched sections of the intestine with a side-to-side anastomosis;
- if the diameters of the lumens of the stitched sections of the intestine coincide, it is possible to apply an end-to-end anastomosis.
12. When the omentum is infringed, indications for its resection are given if it is edematous, has fibrinous deposits or hemorrhages.
13. Surgical intervention ends with plastic hernia orifice, depending on the localization of the hernia.

Protocols of postoperative management of patients with uncomplicated restrained hernia

2. All patients are assigned intramuscular injection painkillers (analgin, ketarol) 3 times a day for 3 days after surgery; broad-spectrum antibiotics (cefazolin 1 g x 2 r / day) within 5 days after surgery.

Complicated restrained hernia

Restrained hernia, complicated by acute intestinal obstruction

Criteria for the diagnosis of a strangulated hernia complicated by intestinal obstruction in AEMF:

Symptoms of acute intestinal obstruction are added to the local symptoms of infringement:
- cramping pain in the area of \u200b\u200bhernial protrusion
- thirst, dry mouth,
- tachycardia\u003e 90 beats in 1 min.
- recurrent vomiting;
- delay in the discharge of gases;
- during the examination, abdominal distension, increased peristalsis are determined; mb "splash noise";
- on the survey radiograph, Kloyber's bowls and small bowel arches with transverse striation are determined, the presence of an "isolated loop" is possible;
- at an ultrasound examination, dilated bowel loops and "pendulum" peristalsis are determined;

Examination Protocols at OEMP

Laboratory research:
- clinical blood test,
- blood group and Rh-factor,
- blood sugar,
- bilirubin,
- coagulogram,
- creatinine,
- urea,
- blood on RW,
- clinical analysis of urine.

Instrumental research:
- ECG
- Plain chest x-ray
- Plain radiography of the abdominal cavity.
- Ultrasound of the abdominal cavity.

Therapist consultation

Protocols for preoperative preparation of a restrained hernia complicated by intestinal obstruction in the EMF

1. Before the operation, a gastric tube is placed without fail and the gastric contents are evacuated.
2. Emptying in progress bladder and hygienic preparation of the surgical site and the entire anterior abdominal wall.
3. The presence of pronounced clinical signs of general dehydration and endotoxicosis is an indication for intensive preoperative preparation with the placement of a catheter into the main vein and infusion therapy (intravenously 1.5 liters of crystalloid solutions, 400 ml Reamberin, 10 ml diluted with 400 ml of 5% glucose solution In this case, antibiotics are administered intravenously 30 minutes before the operation.

Protocols of surgical tactics for strangulated hernia complicated by intestinal obstruction.

1.Operation for a complicated restrained hernia is always performed under anesthesia by a three-doctor team with the participation of the most experienced surgeon on the team on duty or the responsible surgeon on duty no later than 2 hours after the patient is admitted to the OEMP.
2. The main objectives of the operation in the treatment of a strangulated hernia complicated by intestinal obstruction are:
- elimination of infringement;
- determination of intestinal viability and determination of indications for its resection;
- establishing the boundaries of resection of the altered intestine and its implementation;
- determination of indications and method of bowel drainage;
- sanitation and drainage of the abdominal cavity
- plastic hernia orifice.

3. The initial stages of the operation to eliminate a strangulated hernia complicated by intestinal obstruction correspond to the provisions set forth in paragraphs. 5 - 12 surgical tactics for uncomplicated restrained hernia.
4. The indication for drainage of the small intestine is the overflow of the contents of the adducting intestinal loops.
5. The preferred method for drainage of the small intestine is nasogastrointestinal intubation from a separate midline laparotomic approach.
6. Surgical intervention ends with drainage of the abdominal cavity and plastic hernial orifice, depending on the localization of the hernia.

Protocols of postoperative management of patients with strangulated hernia complicated by intestinal obstruction

1.Enteral nutrition begins with the appearance of intestinal peristalsis by introducing glucose-electrolyte mixtures into the intestinal probe.
2. Removal of the nasogastrointestinal drainage probe is carried out after the restoration of stable peristalsis and independent stool for 3-4 days. The drainage tube, inserted into the small intestine through a gastrostomy tube or retrograde according to Velch-Zhitnyuk, is removed a little later - on the 4th - 6th day.
3.In order to combat ischemic and reperfusion injuries of the small intestine, infusion therapy is carried out (intravenously 2-2.5 liters of criticalloid solutions, 400 ml Reamberin, 10.0 ml diluted with 400 ml of 0.9% sodium chloride solution, trental 5, 0 - 3 times a day, contrikal - 50,000 units / day, vitamin C 5% 10 ml / day).
4.Antibacterial therapy in postoperative period should include either II-III aminoglycosides, III generation cephalosporins and metronidazole, or II generation fluoroquinolones and metronidazole.
5.To prevent the formation of acute gastrointestinal ulcers, therapy should include antisecretory drugs.
6. Complex therapy should include heparin or low molecular weight heparins to prevent thromboembolic complications and microcirculation disorders.
Laboratory tests are performed according to indications and before discharge. Discharge for uncomplicated postoperative period is made on the 10-12th day.

Restrained hernia, complicated by phlegmon of the hernial sac

Criteria for the diagnosis of a strangulated hernia complicated by phlegmon of the hernial sac in AEMF:
- the presence of symptoms of severe endotoxicosis;
- the presence of fever;
- hernial protrusion, swollen, hot to the touch;
- hyperemia of the skin and edema of the subcutaneous tissue, extending far beyond the hernial protrusion;
- there may be crepitus in the tissues surrounding the hernial protrusion.

Examination Protocols at OEMP

Laboratory research:
- clinical blood test,
- blood group and Rh-factor,
- blood sugar,
- bilirubin,
- coagulogram,
- creatinine,
- urea,
- blood on RW,
- clinical analysis of urine.

Instrumental research:
- ECG
- Plain chest x-ray
- Plain radiography of the abdominal cavity.

Therapist consultation

Protocols for preoperative preparation of restrained hernia complicated by phlegmon of the hernial sac in OEMP

1. Before the operation, a gastric tube is placed without fail and the gastric contents are evacuated.
2. The bladder is emptied and the hygienic preparation of the surgical intervention area and the entire anterior abdominal wall is performed.
3. Shows intensive preoperative preparation with the placement of a catheter into the main vein and infusion therapy (intravenously 1.5 liters of crystalloid solutions, 400 ml Reamberin,
4. It is obligatory to administer broad-spectrum antibiotics (cephalosporins of the third generation and metronidazole) intravenously 30 minutes before the operation.

Surgical tactics protocols for strangulated hernia complicated by phlegmon of the hernial sac.

1.Operation for a complicated restrained hernia is always performed under anesthesia by a three-doctor team with the participation of the most experienced surgeon of the team on duty or the responsible surgeon on duty no later than 2 hours from the moment the patient enters the EMF.
2. Surgical intervention begins with a midline laparotomy. When the loops of the small intestine are infringed, it is resected with the imposition of an anastomosis. The question of how to complete the colon resection is decided individually. The ends of the intestine to be removed are sutured tightly. Then a purse-string suture is applied to the peritoneum around the inner ring of the hernial orifice. The intra-abdominal stage of the operation is temporarily stopped.
3. A herniotomy is performed. The restrained necrotic part of the intestine is removed through a herniotomy incision while tightening the purse-string suture inside the abdominal cavity. At the same time, special attention is paid to preventing the ingress of inflammatory purulent-putrefactive exudate of the hernial sac into the abdominal cavity.
4. Primary hernia repair is not performed. A necrectomy is performed in a herniotomy wound, followed by loose packing and drainage.
5. If indicated, drainage of the small intestine is performed.
6. The operation ends with drainage of the abdominal cavity.

Protocols of postoperative management of patients with strangulated hernia, complicated by phlegmon of the hernial sac.

1. Local treatment of a herniotomy wound is carried out in accordance with the principles of treatment of purulent wounds. Dressings are daily.
2.Detoxification therapy includes intravenous administration 2-2.5 liters of crystalloid solutions, 400 ml reamberin, 10.0 ml diluted with 400 ml 0.9% sodium chloride solution, trental 5.0 - 3 times a day, contrikal - 50,000 units / day, ascorbic acid 5 % 10 ml / day.
3. Antibacterial therapy in the postoperative period should include either aminoglycosides II-III, cephalosporins of the III generation and metronidazole, or fluoroquinolones of the II generation and metronidazole.
4.To prevent the formation of acute gastrointestinal ulcers, therapy should include antisecretory drugs.
5. Complex therapy should include heparin or low molecular weight heparins to prevent thromboembolic complications and microcirculation disorders.
Laboratory tests are performed according to indications and before discharge.

A retracted restrained hernia.

Criteria for the diagnosis of a retracted restrained hernia OEMP:

The diagnosis "restrained hernia, condition after infringement" can be made when there are clear instructions from the patient himself about the fact of infringement of a previously set hernia, the time interval of its non-direction and the fact of its independent reduction.

A strangulated hernia should also be considered a hernia, the fact of self-reduction of which occurred (and was recorded in medical documents) in the presence of medical personnel (at the prehospital stage - in the presence of an ambulance staff, after hospitalization - in the presence of a DEMP surgeon on duty).

Examination Protocols at OEMP

Laboratory research:
- clinical blood test,
- blood group and Rh-factor,
- blood sugar,
- bilirubin,
- coagulogram,
- creatinine,
- urea,
- blood on RW,
- clinical analysis of urine.

Instrumental research:
- ECG
- Plain chest x-ray
- Plain radiography of the abdominal cavity.

Therapist consultation

Protocols for preoperative preparation of a reduced restrained hernia in OEMP

1. Before the operation, a gastric tube is placed without fail and the gastric contents are evacuated.
2. The bladder is emptied and the hygienic preparation of the surgical intervention area and the entire anterior abdominal wall is performed.

Surgical tactics protocols for a strangulated hernia.

1. When the restrained hernia is reduced and the duration of the infringement is less than 2 hours, hospitalization to the surgical department is indicated, followed by dynamic observation for 24 hours.
2. If during dynamic observation there are symptoms of deterioration in the general condition of the observed, as well as peritoneal symptoms, diagnostic laparoscopy is indicated.
3. When self-restoring a restrained hernia before hospitalization, if the fact of infringement is not in doubt, and the duration of infringement is 2 or more hours, diagnostic laparoscopy is indicated.

Management protocols for patients with a restrained restrained hernia.

Postoperative management of patients after diagnostic laparoscopy is determined by diagnostic findings and the volume of surgical intervention in them.

Restrained incisional ventral hernia

Diagnostic criteria for restrained postoperative ventral hernia OEMP:
- the clinical picture depends on its size, the type of infringement and the severity of intestinal obstruction. Distinguish fecal and elastic infringement.
- with fecal infringement, a gradual onset of the disease is observed. Constantly existing pains in the area of \u200b\u200bhernial protrusion increase, acquire a cramping character, then symptoms of acute intestinal obstruction join - vomiting, gas retention, absence of stool, and bloating occur. The hernial protrusion in the supine position does not decrease, it acquires clear contours.
- Elastic infringement is typical for hernias with small hernial gates. There is a sudden onset of pain due to the introduction of a large section of the intestine into the hernial sac through a small defect in the anterior abdominal wall. Subsequently, the pain syndrome intensifies and the symptoms of intestinal obstruction join.
- the main symptoms of a restrained postoperative ventral hernia are:
- pain in the area of \u200b\u200bhernial protrusion;
- irreducibility of hernia;
- sharp pain on palpation of the hernial protrusion;
- with a long period of infringement, clinical and radiological signs of intestinal obstruction are possible.

Examination Protocols at OEMP

Laboratory research:
- clinical blood test,
- blood group and Rh-factor,
- blood sugar,
- bilirubin,
- coagulogram,
- creatinine,
- urea,
- blood on RW,
- clinical analysis of urine.

Instrumental research:
- ECG
- Plain chest x-ray
- Plain radiography of the abdominal cavity.

Therapist consultation

Protocols of preoperative preparation of a restrained postoperative ventral hernia in OEM.

1. Before the operation, a gastric tube is placed without fail and the gastric contents are evacuated.
2. The bladder is emptied and the hygienic preparation of the surgical intervention area and the entire anterior abdominal wall is performed.
3. In the presence of intestinal obstruction, intensive preoperative preparation is shown with the placement of a catheter into the main vein and infusion therapy (intravenously 1.5 liters of crystalloid solutions, 400 ml Reamberin, 10 ml diluted with 400 ml of 5% glucose solution) for 1 hour or on the operating table, or in the OXP.

Surgical tactics protocols for incarcerated incisional ventral hernia.

1. Treatment of a restrained postoperative ventral hernia consists in performing an emergency laparotomy within 2 hours from the moment of admission to the hospital.
2.Tasks surgical treatment with restrained incisional ventral hernia:
- Thorough revision of the hernial sac, taking into account its multi-chamber nature and the elimination of the adhesive process;
- assessment of the viability of the organ strangulated in the hernia;
- if there are signs of nonviability of the restrained organ - its resection.
3.In case of infringement of large multi-chamber postoperative ventral hernia of the abdominal wall, the operation ends with the dissection of all fibrous septa and suturing only the skin with subcutaneous tissue.
4. With an extensive hernial defect more than 10 cm in diameter, in order to prevent abdominal compartment syndrome, it is possible to close the hernial orifice with a mesh explant.

The protocols of postoperative management of patients with impaired postoperative ventral hernia.

1. Treatment of patients with restrained postoperative ventral hernia until hemodynamic stabilization and restoration of spontaneous breathing is carried out in the OHR.
2. Therapeutic measures in the postoperative period should be aimed at:
- suppression of infection by prescribing antibacterial agents;
- fight against intoxication and violation metabolic processes;
- treatment of complications from the respiratory and cardiovascular system;
- restoration of the gastrointestinal tract function.

Restrained hernia, complicated by peritonitis

Criteria for diagnosing a restrained hernia complicated by peritonitis in AEMF:
- the general condition is severe;
- Symptoms of severe endotoxemia: confused consciousness, dry mouth, tachycardia\u003e 100 beats. in 1 min., hypotension 100 - 80/60 - 40 mm. RT.art .;
- periodic vomiting of stagnant or intestinal contents;
- during the examination, bloating, lack of peristalsis, a positive Shetkin-Blumberg symptom are determined;
- Multiple fluid levels are determined on a plain X-ray;
- with an ultrasound study, extended intestinal loops are determined;

Examination Protocols at OEMP

Laboratory research:
- clinical blood test,
- blood group and Rh-factor,
- blood sugar,
- bilirubin,
- coagulogram,
- creatinine,
- urea,
- blood on RW,
- clinical analysis of urine.

Instrumental research:
- ECG
- Plain chest x-ray
- Plain radiography of the abdominal cavity.

Therapist consultation
Reanimatologist examination

Preoperative preparation protocols for strangulated hernia complicated by peritonitis in OEM

1. Preoperative preparation and diagnostics are carried out in conditions of OXR.
2. A gastric tube is placed and gastric contents are evacuated.
Intensive preoperative preparation is shown with the placement of a catheter into the main vein and infusion therapy (intravenously 1.5 liters of crystalloid solutions, 400 ml Reamberin, 10 ml diluted with 400 ml of 5% glucose solution) for 1 hour either on the operating table or in SECURITY.
3. Mandatory administration of broad-spectrum antibiotics (third generation cephalosporins and metronidozole) 30 minutes before surgery intravenously.
4. The bladder is emptied and the hygienic preparation of the surgical site and the entire anterior abdominal wall is performed.

The protocols of surgical tactics for strangulated hernia complicated by peritonitis.
1. Surgery for a complicated restrained hernia is always performed under anesthesia by a three-doctor team with the participation of the most experienced surgeon of the team on duty or the responsible surgeon on duty in the operation.
2. Surgery begins with median laparotomy.

Attempts to reposition a restrained hernia are contraindicated.

The diagnosis of a repaired restrained hernia can be made when there are clear indications of the patient himself about the fact of infringement of a previously repaired hernia, the time interval of its non-direction and the fact of its independent repositioning. A strangulated hernia should also be considered a hernia, the fact of self-reduction of which occurred (and was recorded in medical documents) in the presence of medical personnel (at the prehospital stage - in the presence of an ambulance staff, after hospitalization - in the presence of a DEMP surgeon on duty).

4 group - restrained postoperative ventral hernia

Infringement of postoperative ventral hernias is observed in 6-13% of cases. The clinical picture depends on its size, the type of infringement and the severity of intestinal obstruction. Distinguish fecal and elastic infringement.
With fecal infringement, a gradual onset of the disease is observed. Constantly existing pains in the area of \u200b\u200bhernial protrusion increase, acquire a cramping character, then symptoms of acute intestinal obstruction join - vomiting, gas retention, absence of stool, and bloating occur. The hernial protrusion in the supine position does not decrease, it acquires clear contours.
Elastic entrapment is typical for hernias with small hernial dents. There is a sudden onset of pain due to the introduction of a large section of the intestine into the hernial sac through a small defect in the anterior abdominal wall. Subsequently, the pain syndrome intensifies and the symptoms of intestinal obstruction join.

Examination Protocols at OEMP

Laboratory research:
- clinical blood test,
- blood group and Rh-factor,
- blood sugar,
- bilirubin,
- coagulogram,
- creatinine,
- urea,
- blood on RW,
- clinical analysis of urine.

Instrumental research:
- ECG
- Plain chest x-ray
- Plain radiography of the abdominal cavity.
- Ultrasound of the abdominal cavity and hernial protrusion - according to indications

Therapist consultation
Consultation with an anesthetist (if indicated)

When the diagnosis is established, the injured hernia of the patient is immediately sent to the operating room.

Protocols of preoperative preparation in OEMP

1. Before the operation, a gastric tube is placed without fail and the gastric contents are evacuated.
2. The bladder is emptied and the hygienic preparation of the surgical intervention area and the entire anterior abdominal wall is performed.
3. In the presence of a complicated strangulated hernia and a serious condition, the patient is sent to the surgical intensive care unit, where intensive therapy is carried out for 1-2 hours, including active aspiration of the gastric contents, infusion therapy, aimed at stabilizing hemodynamics and restoring the input-electrolyte balance, as well as antibiotic therapy. After preoperative preparation, the patient is sent to the operating room.

II. Protocols for anesthetic operation

1. In case of infringement of inguinal and femoral hernias with short periods of infringement, general satisfactory condition, absence of symptoms of acute intestinal obstruction, surgical intervention can be started under local infiltration anesthesia to visually assess the viability of the organ restrained in the hernia.
2. The method of choice is endotracheal anesthesia.

III. Differentiated Surgical Tactics Protocols

13. For strangulated hernias complicated by small bowel obstruction, small bowel drainage is performed using a nasogastrointestinal probe
14. When phlegmon hernia sac operation is performed in 2 stages. The first stage is laparotomy. In the abdominal cavity, resection of the restrained organ is performed with delimitation of the hernial sac and its contents from the abdominal cavity with a purse-string suture. The second stage is herniotomy with removal of the restrained organ outside the abdominal cavity. Plastic surgery of the hernial orifice with phlegmon of the hernial sac is not performed.
15. Surgical intervention ends with plastic closure of the hernia orifice. The nature of the plastic is determined by the location and type of hernia. Plasty of the hernia orifice is not performed for giant multichamber incisional ventral hernias.

VI. Protocols for postoperative management of patients with uncomplicated course

1. A general blood test is prescribed one day after the operation and before discharge from the hospital.
2. All patients are prescribed intramuscular administration of anesthetic drugs (analgin, ketarol) in 1 - 3 days after the operation; broad-spectrum antibiotics (cefazolin 1 g x 2 r / day) for 5 days after surgery.
3. The stitches are removed on the 8-10th day, the day before the patients are discharged for treatment at the polyclinic.
4. Treatment of developing complications is carried out in accordance with their nature

Injury of a hernia - acts as the most frequent and most dangerous complication that can develop during the formation of a hernial sac of any localization. Pathology develops independently of age category person. The main factor leading to pinching is an increase in intra-abdominal pressure or a sharp lifting of weights. However, a large number of other pathological and physiological sources can also contribute to this.

The clinical picture consists of rather specific symptoms, among which: non-controllability of hernial protrusion, pain syndrome of varying degrees of intensity and an increase in the size of the defect.

Diagnosis of the pathology is possible using the information obtained after studying the life history, objective examination data and instrumental examinations of the patient.

Treatment of a hernia of the esophagus or any pathology of any other localization is carried out only with the help of a hernia dissection operation, during which the contents of the bag can also be resected.

The international classification of diseases identifies several ciphers for such a disease. It follows that the code for ICD-10 will be K40.3-K45.8.

Etiology

Regardless of where the pinched hernia is located, the pathology development mechanism will be similar for all options. In such situations, a process of compression of the tissues of internal organs is formed, which have fallen into the cavity of the hernial sac.

All hernias include the following components:

• gates - represent a weakened hole in the ligaments or muscles;
• the bag is the cavity into which the internal organs;
• the hernial contents are part of the organs that penetrate the pathological opening that forms between the ligaments. In the vast majority of situations, an integral part of the hernial sac is intestinal loops, a large omentum, as well as part of the stomach or bladder, which cannot independently return to their normal anatomical location.

The main reason affecting the infringement of the hernia is an increase in intra-abdominal pressure, which, in turn, can be triggered by:

• strong straining during the act of defecation;
• coughing or sneezing;
• sharp lifting of weights;
• violation of the urination process;
• weakness of the abdominal muscles;
• traumatic injury to the abdomen;
• a sharp decrease in body weight;
• , and other gastroenterological diseases;
• violent crying or loud screaming are the fundamental sources of infringement of a hernia of the abdomen in the navel in children;
• severe course generic activity;
• the patient has any stage;
• wearing excessively tight belts or belts.

After the intra-abdominal pressure returns to normal, a change in the size of the hernial orifice is observed downward, against the background of which the process of pinching of the internal organs that have gone beyond the hernia occurs. It is worth noting that the likelihood of the formation of such a process does not depend on the diameter of the gates of pathological protrusion and its magnitude.

Classification

Varieties of the disease, depending on the location of the bag:

• infringement of umbilical hernia, which is most often diagnosed in children;
• infringement of inguinal hernia - this also includes the development of inguinal-scrotal hernia in males;
• infringement diaphragmatic hernia;
• infringement of a femoral hernia, which is very important to differentiate from an inguinal hernia sac. This is due to the fact that such diseases have almost the same clinical picture;
• infringement of a hernia of the white line of the abdomen;
• infringement of a postoperative ventral hernia - is diagnosed most rarely;
• infringement of a spigel or semilunar hernia - in this case, the focus is on the line that connects the navel with the anterior top part ilium;
• infringement of a lumbar hernia;
• infringement of the sciatic hernia;
• infringement of the obturator hernia.

According to the degree of overlap of the lumen, the disease is:

• complete;
• incomplete, which is also called parietal hernia infringement;
• open - this variant of the course of the disease is possible only when the appendage of the cecum or Meckel's diverticulum is infringed.

Depending on the developmental characteristics, hernia infringement is divided into:

• antegrade;
• retrograde;
• false or imaginary;
• sudden.

According to the formation mechanism, infringement of inguinal hernia in men, women and children, exactly like any other, exists in 4 forms. Thus, allocate:

• elastic infringement - is formed against the background of a sudden increase in pressure inside the abdominal cavity, which causes oxygen starvation and death of the tissues of the contents of the bag;
• fecal infringement of a hernia - is implemented in cases of overcrowding of the intestinal loop inside the protrusion with feces. In this case, there is a violation of the blood circulation process, a disorder of the intestinal motor function and the development of adhesions;
• retrograde infringement - occurs when several internal organs are involved in the pathology;
• richter infringement of a hernia - in this case, only the edge of an internal organ located in the hernial sac is infringed.

Some patients develop mixed pinching.

In addition, hernia infringement is:

• primary;
• secondary.

The spread of pathological protrusion of the disease can be:

• external - this includes inguinal, umbilical, femoral and spigel hernia;
• internal - this category includes the supraphrenic, subphrenic, intra-abdominal, epigastric and pelvic hernial sac.

Symptomatology

Clinical manifestations will differ slightly depending on which hernia has been pinched. However, in all cases, the first and main symptom, against which additional signs develop, are pain sensations, which can have varying degrees of intensity.

For the infringement of an umbilical hernia, the following manifestations are characteristic:

• an increase in the size of the abdomen;
• redness and swelling of the skin surrounding the hernial sac;
• increase in local temperature;
• fever;
• nausea and vomiting - vomit may smell like feces;
• violation of the act of defecation;
• lack of gas discharge due to intestinal obstruction;
• the presence of blood impurities in feces;
• weakness of the body;
• tingling in the hernial sac;
• tension of the bulge;
• fluctuations in blood pressure.

Signs of infringement of an inguinal hernia include:

• painful shock;
• heart rate increase;
• decrease in blood tone;
• stool and gas retention;
• bloating;
• single vomiting;
• pallor of the skin;
• anxiety;
• the spread of pain in the epigastrium, groin and thigh;

Symptoms of an infringement of a hernia of the white line of the abdomen:

• constant nausea with occasional vomiting;
• pallor of the skin;
• pulse weakening;
• fever;
• shock state;
• anxiety and restlessness;
• tension and increase in the volume of the bag.

Infringement of a diaphragmatic hernia or hiatal hernia may be indicated by:

• frequent belching;
• regular swelling of the anterior abdominal wall;
• shortness of breath and increased heart rate;
• the appearance of a characteristic rumbling;
• nausea and vomiting;
• asymmetry of the abdomen;
• profuse cold sweat;
• increase in temperature indicators;
• swelling and hyperthermia of the skin around the hernia.

The remaining varieties of pathology are relatively rare and have similar symptoms.

It is also very important to remember that a restrained hernia requires first aid, which includes such manipulations:

• calling an ambulance;
• providing the victim with a horizontal position of the body;
• ridding a person of tight clothing;
• the implementation of cold compresses on the forehead;
• providing a small amount of fluid;
• airing the room in which the patient is.

Diagnostics

Due to the presence of a typical clinical picture, any types of infringement of hernias are diagnosed completely without problems. It follows from this that the correct diagnosis can be made already at the stage of the initial examination, which includes:

• study of medical history;
• analysis of life history - this is necessary to find the cause of infringement of a hernia;
• careful examination and palpation of pathological protrusion;
• a detailed survey of the patient - to compile a complete picture of the course of the disease and determine the severity of symptoms.

Additional instrumental examinations can be:

• Ultrasound of the peritoneum;
• contrast-enhanced radiography;
• CT and MRI.

In implementation laboratory research and differential diagnosis a pinched hernia does not need.

Treatment

Regardless of the type of flow, location and pinching times shown surgical intervention for hernia. The operation for infringement of a hernia must necessarily include:

• release of internally affected organs;
• resection of the hernial sac, followed by drainage and stitching of the wound;
• hernioplasty;
• determination of the viability of the components of pathological protrusion - if necessary, excision of necrotic or atrophied sites is performed.

Surgical intervention can be performed in several ways:

• open way;
• laparoscopic - currently the most preferred technique.

Possible complications

Ignoring signs of infringement of a hernia and untimely treatment of the disease is fraught with the occurrence of:

• dysfunction of the restrained organ;
• suppurations;
• the death of parts of the internal organs located in the hernial sac;

Prevention and prognosis

Preventive measures to prevent infringement of the hernial sac include:

• timely treatment of hernia of any localization;
• preventing an increase in intra-abdominal pressure;
• strengthening the abdominal muscles;
• control over that body weight is within normal limits;
• refusal to wear tight belts;
• regular prophylactic examination in a medical institution.

A timely operation ensures a favorable outcome of the disease. Late seeking qualified help or independent attempts to get rid of the infringement lead to the formation of complications. Mortality from such a disease is approximately 10%.

Injured hernias are one of the most frequent and formidable complications of hernias of the anterior abdominal wall. They belong to acute surgical diseases of the abdominal organs and occupy the fourth place among them after acute appendicitis, acute cholecystitis and acute pancreatitis. The relative frequency of strangulated hernias among all these diseases is 4 - 5%.

The development of restrained hernias is associated with compression in the hernial orifice of the contents of the hernial sac, which are most often the internal organs of the abdomen (omentum, small intestine, etc.).

There are primary and secondary strangulated hernias. Primary restrained hernias are extremely rare and occur after an extreme simultaneous physical effort made by a person who has a predisposition to the development of hernia. During this short-term, but significant physical activity, a hernia forms at the same time, its infringement occurs in the hernial orifice, and a detailed clinical picture of a restrained hernia develops. Diagnosis of primary restrained hernias is extremely difficult, but it is much easier if the ambulance doctor remembers the existence of such a nosological form of restrained hernias and knows the features of the mechanism of their development.

All other restrained hernias are classified as secondary. Injury of a hernia occurs, as a rule, against the background of an already more or less long-existing hernia of the anterior abdominal wall.

In everyday clinical practice, typical classical infringement is most common. Clinicians distinguish 2 forms: elastic and fecal.

Elastic restraint is observed more often. It occurs in young and middle age. The provoking factor is excessive and abrupt physical effort. In this case, in the place of a pre-existing hernia appear sharp pain and painful swelling. It gradually increases, becomes irreducible and tense, and the pain is constantly growing. Patients are restless, complain of pain in the area of \u200b\u200bhernial protrusion, which is often accompanied by nausea and vomiting, stool and gas retention. In advanced cases, tachycardia, dry tongue are observed, asymmetry of the abdomen, positive symptoms of peritoneal irritation are possible. The hernial protrusion is increased, tense, painful.

Typical local signs of a restrained hernia are as follows:

pain, as a rule, in the place of a previously existing hernia with the development of its infringement,

the appearance in this area of \u200b\u200bswelling (protrusion), which becomes irreducible;

increase painan increase in hernial protrusion and its tension;

the lack of transmission of a sensation of a cough push to a hernial protrusion.

The last sign of infringement of the hernia is considered pathognomonic. It is due to the fact that the abdominal cavity is completely delimited from the hernial sac cavity by the restraining ring.

The atypical forms of infringement of a hernia by the elastic type are parietal and retrograde.

Parietal infringement most often occurs with small hernias of the anterior abdominal wall, the hernial gates of which are formed by dense and elastic tissues. Such an infringement is characteristic of beginning and small femoral, umbilical and inguinal hernias. When starting inguinal hernia parietal infringement can develop in the area of \u200b\u200bthe internal inguinal ring. Parietal infringement is very insidious. The condition of patients with this form of infringement is satisfactory. They do not have signs of intestinal obstruction and any dyspeptic disorders, since the permeability of the intestinal tube is preserved with this kind of infringement. Only marked pain in the area of \u200b\u200ba suddenly appeared non-healing hernia protrusion is noted. Delay in the operation with parietal infringement leads to necrosis of that part of the intestinal wall, which is located in the hernial sac, the formation of an opening in the intestine and the development of a clinical picture of acute diffuse peritonitis.

The clinical picture with retrograde infringement consists of the presence of all local and general signs of a restrained hernia, which are soon associated with symptoms of acute intestinal obstruction, and after some time - acute diffuse peritonitis due to necrosis of the intestinal loop located in the abdominal cavity, the nutrition of which is largely disrupted - for a sharp compression of the mesenteric vessels.

Fecal infringement occurs in the elderly and the elderly, who have been carriers of hernias for many years (even decades). These hernias, gradually increasing in size, become irreparable, which is explained by chronic trauma to the hernial sac and its contents and the development of scar adhesions between the organs located in the hernial sac and its walls. The essence of fecal infringement is that due to the inflection of the loop of the intestine located in the hernial sac, the intestinal contents overflow its inferior segment. The development of fecal infringement is also promoted by intestinal atony, which is often observed in the elderly and old people.

The clinical picture of this kind of infringement develops gradually: pain in the area of \u200b\u200bthe hernial protrusion increases, it increases in size, becomes dense, tense and painful. At the same time, symptoms of acute obstructive intestinal obstruction develop and, as a consequence of the latter, all signs of intoxication.

Patients complain of growing pain in the area of \u200b\u200ban irreducible hernia, which did not bother them before. Nausea, vomiting, stool and gas retention, tachycardia are noted. The abdomen is usually swollen. Almost over the entire surface of the anterior abdominal wall, tympanitis is noted.

At late periods of treatment of patients with a restrained hernia for medical help, a clinical picture of acute inflammation or even phlegmon of the hernial sac develops. In this case, the skin over the hernial protrusion takes on a bluish-purple color, becomes hot to the touch. On palpation, patients note a sharp pain. Above the entire surface of the hernial protrusion, fluctuation is recorded.

First step - layer-by-layer dissection of tissues to the aponeurosis and exposure of the hernial sac.

Second phase - the opening of the hernial sac is done carefully so as not to damage the inflated bowel loops that fit snugly against the wall of the hernial sac. With sliding inguinal and femoral hernias, there is a risk of damage to the wall of the colon or bladder. Opening the hernial sac, remove the "hernial water." To prevent slipping into the abdominal cavity of the restrained organs, the surgeon's assistant holds them with a gauze. It is inadmissible to dissect the restraining ring before opening the hernial sac, since unexamined restrained organs will move into the abdominal cavity together with the infected "hernial water".

Third stage - the dissection of the restraining ring is performed under visual control so as not to damage the organs soldered to it from the inside. For femoral hernias, an incision is made medially from the neck of the hernial sac to avoid damage to the femoral vein located on the lateral side of the sac. At umbilical hernia the restraining ring is dissected in the transverse direction in both directions.

Stage four - Determining the viability of impaired organs is the most critical stage of the operation. After dissecting the restraining ring and introducing a solution of novocaine into the mesentery of the intestine, those parts of the restrained organs that were above the restraining ring are removed from the abdominal cavity. It is impossible to tighten the intestine strongly, as a rupture (detachment) may occur in the area of \u200b\u200bthe strangulation groove. If there are no obvious signs of necrosis, the strangulated intestine is irrigated with warm isotonic sodium chloride solution. It is important to remember that intestinal necrosis begins with the mucous membrane, and changes in the intestinal wall, visible from the side of its peritoneal cover, appear later. The main criteria for the viability of the small intestine: restoration of the normal pink color of the intestine, absence of strangulation groove and subserous hematomas, preservation of pulsation of small vessels of the mesentery and peristaltic contractions of the intestine. Indisputable signs of non-viability of the intestine: dark color of the intestine, dull serous membrane, flabby wall of the intestine, lack of pulsation of the vessels of the mesentery, lack of intestinal motility.

Fifth stage - a non-viable colon must be removed. From the border of necrosis visible from the side of the serous cover, at least 30-40 cm of the adducting segment of the intestine and 15-20 cm of the abducting segment should be resected.

A bowel resection should be performed if a strangulation groove, subserous hematomas, large edema, infiltration and mesentery hematoma are found in the intestinal wall. In case of infringement of sliding hernias, it becomes necessary to assess the viability of that part of the organ that is not covered by the peritoneum. If necrosis of the cecum is detected, a median laparotomy is performed and a resection of the right half of the colon is performed with the application of ileotransversoanastomosis. The operation ends with plastic hernia orifice. In case of necrosis of the bladder wall, a bladder resection with the imposition of an epicystostomy is necessary. In severe cases, near-bubble tissue is plugged and an epicystostomy is applied.

Sixth stage- the restrained omentum is resected in separate areas without the formation of a large common stump. From a massive omentum stump, the ligature may slip and result in bleeding from the omentum vessels into the abdominal cavity.

Seventh stage - when choosing the method of hernia orifice plasty, the simplest one should be preferred. For example, with small inguinal oblique hernias in young people, the Zirard-Spasokukotsky-Kimbarovsky method should be used, with direct inguinal and complex inguinal hernias - the Bassini and Postempsky methods.

Choledocholithiasis, obstructive jaundice.

Choledocholithiasis occurs when a gallstone passes from the bladder into the common duct or when the stone is not noticed during cholangiography or examination of the common duct. Stones in the common bile duct can be single or multiple. They are detected during cholecystectomy in 10-20% of cases. After removal of the gallbladder, a stone may form in the common duct, especially in the presence of stasis caused by obstruction of the duct. Stones in the common bile duct are found in approximately 10-25% of cases of cholecystolithiasis. In some surgical reports of choledocholithiasis, it is mentioned that it reaches 40%. Such data, in all likelihood, are due to the relatively more frequent admission of complicated cases to surgical departments. Most calculi enter the choledoch from the gallbladder. Stones in the common bile duct, usually increase due to layers of salts, primarily calcium bilirubinate. Sometimes stones are found only in the common bile duct, although they are primarily formed in gall bladder. This is evidenced by the nature of the stones and the dilated cystic duct, which can be as thick as a finger. With choledocholithiasis, the common bile duct is usually expanded, although the presence of stones is not excluded in the bile duct of normal width. Occasionally, autochthonous formation of calculi in the common bile duct is observed, as a rule, with infection and obstruction of the outflow of bile into the duodenum due to the presence of a stone in the end segment of the common bile duct, a valve stone over the papilla of Vater, or with stenosis of the papilla. Autochthonous calculi can be single or multiple. They are structureless, have a brownish tint, consist of calcium bilirubinate and in most cases are located in the end piece of the bile duct. An accumulation of putty masses and small grains consisting of calcium bilirubinate is even more common. They can fill not only the bile duct, but often the hepatic ducts. In this case, the common bile duct and intrahepatic bile ducts are dilated. The choledoch can reach a width of more than 3 cm, and its walls are thickened due to a chronic inflammatory process. In severe inflammation of the bile duct, it may contain bile sludge, consisting of organic elements - desquamated epithelium, fibrin and bacteria, which, sticking together, can serve as the nucleus for the formation of a new stone. Sludge sedimentation is observed especially during stagnation of thickened bile, in which lithogenic substances are easily deposited. Bile slime and amorphous putty mass can mask stones trapped in the bile duct from the gallbladder. Changes in the mucous membrane of the bile duct with lithiasis may be minor. In some cases, most often with endoscopy, severe inflammatory changes are found on the operating table in the form of fibrin deposits, ulcerations remaining after gallstones, and stenosis of the bile duct. With stagnation of bile, there is a greenish tint, strongly condensed and often contains an admixture of purulent flakes.

The clinical manifestations of the disease depend on the location of the stone in the common bile duct. The stone in the supraduodenal segment of the common bile duct is dumb, since with such an arrangement there are no signs of blockage and stagnation, and the stone can remain suspended in the bile, especially if the common bile duct is dilated. So, for example, the x-ray picture of a dilated common bile duct filled with numerous stones may seem paradoxical, since clinical manifestations may be insignificant. And, on the contrary, infringement of stones in the terminal segment of the common bile duct, in most cases, has a pronounced clinical picture, since they are the cause of incomplete blockage of the bile duct and stasis with all the consequences. According to data published in the literature, approximately one third of cases of choledocholithiasis remain without clinical manifestations.

The clinical picture:

1. On colicky pains, in the right hypochondrium, with radiating pains to the right and in the back.

2. For fever, headache, chills.

3. Jaundice

5. With latent choledocholithiasis, the patient does not make complaints or only complains of dull pain under the right costal arch.

6. With a dyspeptic form of choledocholithiasis, the patient complains of an uncharacteristic oppressive pain under the right costal arch or in the epigastric region and for dyspepsia - nausea, belching, gas and fat intolerance.

7. With a cholangitic form, an increase is characteristic body temperature, often of a septic nature, accompanied by jaundice.

On examination:

1. Yellowness of the skin. With valve stones, jaundice can be temporary - with a decrease in inflammation, swelling of the common bile duct, the stone comes out and bile secretion is restored.

2. With palpation of the abdomen, pain in the right hypochondrium is determined, with a cholangitic form - an increase in the liver, moderate soreness.

3. Clinical course complicated choledocholithiasis is severe, since, in addition to liver damage, with secondary stenosis of the Vater papilla, the pancreas is simultaneously affected.

Diagnostics:

1. Anamnesis: presence of cholelithiasis, attacks of cholecystitis, etc.

2. Complaints (see above)

3. Inspection data

4. Laboratory research data:

Biochemical blood test: an increase in the content of bilirubin, alkaline phosphatase and transaminases

5. Data of instrumental research:

Ultrasound: choledoch stones

Percutaneous, transhepatic cholangiography or radioisotope study, CT - visualization of common bile duct stones.

Treatment .

Intraoperative cholangiography

Cholecystectomy

Choledochotomy (opening of the common bile duct)

Revision of the common bile duct, removal of stones, installation of temporary external drainage of the common bile duct. Antibiotics are prescribed to prevent or treat infectious complications. Removal of calculi by the endoscopic method is very effective.

Indications for autopsy and revision of the common bile duct.

Palpation of a stone in the lumen of the common bile duct

Increased diameter of the common bile duct

Episodes of jaundice, cholangitis, history of pancreatitis

Small gallstones with wide cystic duct

Cholangiographic indications: filling defects in the intra- and extrahepatic bile ducts; obstruction of the entry of contrast agent into the duodenum.

Temporary external drainage is necessary to reduce pressure in the biliary system and prevent leakage of bile into the abdominal cavity and the development of peritonitis:

Kera T-shaped drain

G - shaped drainage Vishnevsky. The inner end of the tube is directed towards the liver hilum. Additional hole (for the passage of bile to the side duodenal ulcer) is located at the bend of the tube. To prevent premature drainage, the catgut is sutured to the wall of the common bile duct.

Tubular drainage of Halstead-Pikovsky is carried out in the stump of the cystic duct.

Complications of choledocholithiasis.

1. Obstructive jaundice.

2. Acute and chronic pancreatitis.

3. Biliary cirrhosis.

4. Stenosis of the large duodenal papilla.

5. Acute cholangitis.

Date of publication of the article: 08.07.2015

Article update date: 10/23/2018

A ventral hernia is any exit of abdominal organs through natural or pathological openings of the abdominal wall under the skin. However, in medicine, this term is usually called a hernia, where the hernia gate is the postoperative scar, i.e., this protrusion is a late complication of surgical interventions on the abdominal organs.

A characteristic feature of a ventral hernia is its large size. The larger the postoperative scar, the greater the protrusion.
The disease causes not only cosmetic inconveniences: in addition to the risk of infringement, ventral hernias can disrupt the anatomical interaction of organs in the abdomen, disrupting the functioning of the stomach, intestines, diaphragm, and urinary system.
It is difficult to treat such a protrusion, but the situation is not hopeless. Modern technology allows to eliminate hernias in any places and any sizes. Hospitals of a general surgical profile are engaged in this.

Causes of pathology

Ventral hernia occurs due to a violation of the healing process of the wound after surgery. What is it and what is the point here? Non-healing wounds in humans are rare. But the longer the wound does not heal, the less dense the scar becomes.
Five reasons why a postoperative wound heals slowly:

Intestinal perforation is one of the most serious complications of ventral hernia.
Click on the photo to enlarge

Symptoms and Diagnosis

The symptoms of a postoperative ventral hernia are obvious: it is the appearance of a bulge in the area postoperative scar, which may be accompanied by pain in this area.

It is not recommended to independently correct any hernia, including the ventral one.

Surgical treatment

Any hernia can only be treated surgically. Without surgery, protrusions can take place on their own only in children, and even then not all. Postoperative ventral hernia is a direct indication for surgical treatment.

Surgical removal of this type of protrusion has certain difficulties:

• The presence of a large amount of scar tissue from an old operation, which is poorly supplied with blood and creates the basis for recurrence of a hernia.
• Usually this is a protrusion of large sizes, which creates a lot of problems during the operation.

Two types of techniques for surgery for ventral hernias:

Stretched. To close the hernial orifice, use their own abdominal wall tissue.

Lightweight. The hernial gate is closed with artificial materials.

• Open: Make a large skin incision. The old scar is usually excised (this means that the new scar will be slightly longer than the old one).
• Laparoscopic: the hernia is closed from the inside using a special instrument (laparoscope). This technique is used mainly for protrusions of small sizes.

The advantages and disadvantages of both methods are shown in the table:

(if the table is not fully visible, scroll to the right)

Today, up to 90% of ventral hernias are removed using tension-free techniques.

Treatment without surgery

A ventral hernia cannot be treated without surgery - it is impossible.

Conservative therapy consists in wearing a special bandage that prevents the abdominal organs from extending under the skin. Wearing a bandage is time consuming and inconvenient, therefore this method is used only when the operation is contraindicated:

• severe general condition of the body;
• elderly and senile age;
• pregnancy;
• cardiac, renal, hepatic failure;
• refusal of the patient from the operation.

Wearing a bandage is a conservative method of treating a ventral hernia

Preventive measures

It is easier and cheaper to prevent the formation of postoperative protrusion than to treat it. To do this, you must:

exercise to maintain proper muscle condition

fight excess weight;

eat rationally, avoid constipation.

Also, after any operations on the abdominal cavity, it is necessary:

• follow the recommendations of the attending surgeon;
• not expose oneself to excess physical activity within 6 months after the intervention;
• if necessary, wear a bandage for prevention.

Conclusion

No hernia, especially postoperative, will not pass by itself. The longer the patient postpones the operation, the larger the protrusion becomes, and the more difficult it is to treat it. If you have a hernia in the area of \u200b\u200bthe postoperative scar, contact the surgeon immediately.

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