Hernia of the white line of the abdomen
The content of the article:
- Causes and risk factors
- Forms of the disease
- Disease stages
- Symptoms
- Diagnostics
- Treatment of hernia of the white line of the abdomen
- Possible complications and consequences
- Forecast
- Prevention
A hernia of the white line of the abdomen is a disease in which there is the formation of one or more cracks in the tendon fibers along the midline of the abdomen, through which the abdominal organs protrude.
A hernia of the white line of the abdomen in adults is diagnosed more often than in children
Hernias of the white line of the abdomen make up 3-12% of the total structure of hernias of the anterior abdominal wall, most often found in males at the age of 20-30. The development of a hernia of the white line of the abdomen in a child is observed rather rarely in comparison with other types of hernias - in no more than 1% of cases.
The white line of the abdomen is a connective tissue structure, which is located along the midline of the anterior abdominal wall and is formed by adjacent fibrous fibers of the aponeuroses of the rectus abdominal muscles. The white line of the abdomen runs from the xiphoid process of the sternum to the pubic articulation, its width is 1–2.5 cm above the navel and 0.2–0.3 cm below the navel. Due to the fact that the white line of the abdomen consists of connective tissue and there are practically no blood vessels and nerve endings in it, its longitudinal dissection is one of the common surgical procedures.
Hernias of the white line of the abdomen are formed with the divergence of the aponeuroses, which form the white line of the abdomen, and protrusion into the formed slit-like defects of the abdominal organs. In this case, multiple hernias can form, which are localized one above the other. The hernial sac with a hernia of the white line of the abdomen is covered with skin, subcutaneous tissue, transverse fascia and preperitoneal tissue.
Causes and risk factors
The main reason for the development of a hernia of the white line of the abdomen is the weakness of the connective tissue fibers of the white line of the abdomen (both congenital and acquired), which causes its thinning and expansion, followed by the appearance of slit holes and the divergence of the rectus abdominis muscles relative to the white line (diastasis). The development of a hernia of the white line of the abdomen in a child sometimes occurs after he reaches the age of five due to insufficient development of the aponeurosis.
Risk factors are:
- genetic predisposition;
- overweight;
- trauma to the anterior abdominal wall;
- scars after surgical interventions in the anterior abdominal wall.
Overweight is a risk factor for developing a hernia of the white line of the abdomen
In addition, conditions in which there is a significant increase in intra-abdominal pressure can contribute to the development of the disease. Such conditions include the period of pregnancy and labor, excessive physical exertion, ascites, hacking cough with bronchopulmonary pathologies, difficulty urinating, frequent constipation, prolonged crying and crying in children.
Forms of the disease
Depending on the localization relative to the navel, the hernia of the white line of the abdomen is divided into:
- umbilical (paraumbilical) - localized near the umbilical ring, diagnosed in about 1% of cases;
- sub-umbilical (hypogastric) - located above the navel, registered in about 9% of cases;
- supra-umbilical (epigastric, epigastric) - localized above the navel, are most common.
In addition, hernias of the white line of the abdomen can be single and multiple, complicated and uncomplicated, reducible and irreducible.
Disease stages
In the clinical picture of a hernia of the white line of the abdomen, three stages are distinguished:
- Preperitoneal lipoma - preperitoneal tissue comes out into the formed slit-like defect of the white line of the abdomen.
- The initial stage - a hernial sac is formed, which includes a part of the omentum or small intestine.
- The stage of final formation - all components of the hernia are formed, the wall of the stomach, the omentum, parts of the small intestine, the tissue of the umbilical-hepatic ligament, the transverse colon can enter the hernial sac.
Stages of development of a hernia of the white line of the abdomen
Symptoms
In some cases, a hernia of the white line of the abdomen is asymptomatic or asymptomatic and is detected by chance. Usually, the disease begins with the bulging of the preperitoneal tissue and internal organs along the white line of the abdomen, which is accompanied by painful sensations that can appear even in the early stages of pathology due to entrapment of the nerves of the preperitoneal tissue. In this case, the painful sensations intensify after eating, during physical exertion, as well as in other cases when there is an increase in intra-abdominal pressure. The pain can radiate to the lower back, hypochondrium, scapula. With a decrease in intra-abdominal pressure, the protrusion disappears, and the pain subsides. Sometimes patients with a hernia of the white line of the abdomen complain of belching, heartburn, nausea, vomiting, and other dyspeptic disorders.
A hernia of the white line of the abdomen begins with a bulging of the preperitoneal tissue and internal organs along the white line of the abdomen
The divergence of tendon fibers during the formation of a hernia of the white line of the abdomen can reach 10-12 cm. With narrower hernial orifices (no more than 5-6 cm), the risk of hernia infringement increases.
Diagnostics
The diagnosis of a hernia of the white line of the abdomen can be made on the basis of data obtained during the collection of complaints, anamnesis and a thorough physical examination. During palpation of the anterior abdominal wall in patients with a hernia of the white line of the abdomen, a dense oval or round protrusion of 1–12 cm in size is found, which is localized along the white line of the abdomen. Palpation of the protrusion is painful. The contours of the hernial protrusion are better defined through the anterior abdominal wall with the patient's trunk thrown back. In the case of a reducible hernia, the hernial orifice can be detected by palpation. On auscultation, a rumbling is heard over the hernial sac.
Ultrasound of the abdominal cavity in order to diagnose hernia of the white line of the abdomen
In order to confirm or clarify the diagnosis, as well as to determine the contents of the hernial sac, contrast radiography of the stomach and duodenum, esophagogastroduodenoscopy, ultrasound examination of hernial protrusion, multispiral computed tomography of internal organs, and X-ray examination of the hernia (herniography) are prescribed.
Differential diagnosis is carried out with pancreatitis, cholecystitis, gastritis, gastric ulcer and duodenal ulcer.
Treatment of hernia of the white line of the abdomen
The main method of treating a hernia of the white line of the abdomen is its removal by surgery. Conservative methods of treatment are used in the presence of contraindications to surgery, as well as supportive therapy during preoperative preparation.
There are a number of absolute and relative contraindications to surgical treatment of hernia of the white line of the abdomen. The absolute contraindications include acute infectious diseases, myocardial infarction, stroke, malignant neoplasms of different localization in the later stages, and other severe pathologies in the stage of decompensation. Relative contraindications include the second half of pregnancy, exacerbation of chronic diseases, prostate adenoma or urethral stricture (surgery can be performed after they are eliminated).
Indications for urgent surgical treatment may be tissue suppuration and inflammation, infringement of the contents of the hernial sac, necrosis, acute peritonitis, intestinal obstruction.
A feature of the surgical treatment of a hernia of the white line of the abdomen is the need to eliminate diastasis (divergence) of the rectus abdominis muscles. Removal of a hernia of the white line of the abdomen, or hernioplasty, can be performed in two ways:
- tension - hernia repair with local tissues, i.e. the edges of the hernial ring are pulled together and sutured;
- tension - free - hernia repair using synthetic implants, that is, the hernial gap is closed with a special mesh insert.
In addition, surgery for a hernia of the white line of the abdomen can be performed using an open or laparoscopic approach.
Laparoscopic hernioplasty - a method of removing a hernia of the white line of the abdomen
Before the operation to remove a hernia of the white line of the abdomen, preoperative preparation of patients is carried out. For this purpose, improvement of the functional state of the lungs, preparation of the cardiovascular system, therapy of concomitant diseases, preparation of the skin in the area of intervention, etc. can be carried out.
When carrying out tension hernioplasty using local tissues, the hernial defect of the white line of the abdomen is sutured with continuous or purse-string catgut sutures, plastic aponeurosis is performed by stitching its leaves with the formation of a duplicate of the aponeurosis. The incidence of relapses after the operation by this method is 20-40%.
For tension-free hernioplasty, mesh implants are used. In this case, the implant can be located above the aponeurosis, under the aponeurosis, between the leaves of the aponeurosis, or installed from the inside of the abdominal cavity. The likelihood of recurrence during an operation using tension-free hernioplasty is extremely low. This method is preferred in most cases.
During surgical intervention to remove a hernia of the white line of the abdomen, laparoscopic access involves several small punctures in the anterior abdominal wall, which are necessary for the introduction of an endoscope and other instruments. The advantage of this method is minimal tissue trauma, reduced risk of blood loss, a relatively short rehabilitation period, and a low risk of disease recurrence.
In the case of a divergence of the rectus abdominis muscles accompanying a hernia of the white line of the abdomen, the operation can be performed using the Napalkov method. In this case, during the surgical intervention, the neck of the hernial sac and the edges of the aponeurosis are sutured along the white line, after which the anterior wall of the rectus sheath is dissected on one side and on the other along the entire length of the hernial orifice. After that, the inner and outer edges of the dissected aponeurotic sheaths are alternately sutured with interrupted sutures.
The course and management of the postoperative period in patients who have undergone surgery to remove a hernia of the white line of the abdomen depend on the individual characteristics of the patient, the quality of the preoperative preparation, as well as on the method by which the surgical treatment was performed. In uncomplicated forms of hernia of the white line of the abdomen, the postoperative period is usually easy. The administration of analgesic drugs and the processing of postoperative sutures are shown. The patient is recommended to bed rest for several days after the operation. Prolongation of bed rest in the absence of complications is not encouraged, since the patient's early physical activity prevents the development of thromboembolism and other complications from the cardiovascular and respiratory systems.
After surgical interventions for strangulated hernias of the white line of the abdomen, the main attention is focused on preventing intoxication and dehydration of the body, preventing the addition of an infectious process, preventing complications, normalizing the functions of the gastrointestinal tract, and preventing peritonitis.
In the rehabilitation period, the patient can be prescribed physiotherapy procedures, in addition, the patient is shown a diet, wearing a bandage and therapeutic exercises to strengthen the muscles of the anterior abdominal wall. Until the final healing of the tissues, the patient is not recommended to drive vehicles. If the performance of professional duties was associated with significant physical exertion, in addition to this, a change in professional activity is recommended.
Possible complications and consequences
A hernia of the white line of the abdomen can be complicated by the development of infringement. Infringement of the hernia consists in the sudden squeezing of the contents of the hernial sac in the hernial orifice; it is no longer possible to correct the hernia in the horizontal position of the body. In this case, the patient develops intense abdominal pain, nausea, vomiting, delayed passage of gases and / or defecation. Infringement of a hernia of the white line of the abdomen is dangerous by the development of intestinal obstruction, necrosis of organs compressed by the hernial orifice, peritonitis.
Forecast
With timely adequate treatment, the prognosis is favorable. The likelihood of recurrence varies depending on the chosen method of hernioplasty, the individual characteristics of the patient, as well as the thoroughness of the patient's compliance with the doctor's prescriptions.
Prevention
In order to prevent the development of a hernia of the white line of the abdomen, it is recommended to timely treat diseases that increase intra-abdominal pressure, strengthen the muscles of the anterior abdominal wall, eat rationally, maintain a normal body weight, avoid excessive physical exertion, and use the correct weight lifting technique. For women during pregnancy, it is recommended to wear a bandage.
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Anna Aksenova Medical journalist About the author
Education: 2004-2007 "First Kiev Medical College" specialty "Laboratory Diagnostics".
The information is generalized and provided for informational purposes only. At the first sign of illness, see your doctor. Self-medication is hazardous to health!
