Restrained Hernia: Symptoms, Treatment, Clinical Guidelines

2024 Author: Rachel Wainwright | [email protected]. Last modified: 2024-01-15 19:51

Strangulated hernia

The content of the article:

Kinds
Symptoms
Clinical guidelines
Treatment
Video

A strangulated hernia is a dangerous complication of a typically leaking hernia and, due to the frequency of its occurrence, is considered a separate nosological disease. The disease is based on pinching of the hernial sac in the hernial orifice with squeezing of tissues and organs that are located in it. The greatest danger is the compression of the intestinal loop, since this causes the phenomenon of strangulated intestinal obstruction and necrosis of a part of the intestine.

Infringement is a complication of the course of the disease, it requires immediate medical attention

Kinds

Depending on the localization, restrained hernias are:

inguinal;
femoral;
umbilical;
white line of the abdomen;
postoperative (ventral);
atypical areas (spigelium line, internal);
post-traumatic, associated with damage to the muscular aponeurosis (median, lateral).

According to clinical variants of the course:

Infringement type	Characteristic
Elastic	It occurs due to a significant and sudden increase in pressure in the abdominal cavity. At the same time, a greater number of different structures emerge into the already formed hernial sac (pronounced expansion of the hernial orifice). At the time of the return of the hernia to its original state, an infringement occurs.
Kalovoe	Occurs in case of compression of the abducting section of the intestine. In the projection of the hernia, the overflowing adductor gut is clearly visualized, which squeezes the abducent section directly in the hernial orifice.
Parietal (Richter)	Inside the hernial sac, there is only a part of the intestinal wall, and not the entire loop (the area opposite to the mesentery). This group includes an extremely rare type of infringement - Littre's hernia (infringement of Meckel's diverticulum).
Retrograde	In the cavity of the hernial sac, there are immediately discharging and adducting loops. The part of the intestine between them is outside the hernial sac (the intestine forms the letter w). It is this area that is most affected. With its necrosis, the phenomenon of peritonitis occurs, there is no obstruction as such.

Depending on the outcome:

Uncomplicated. During the operation, only the elimination of the infringement is required without additional intervention.
Complicated. Hernia is associated with severe damage to organs and tissues in the hernial sac. During the operation, in addition to plastic surgery of the inguinal canal, other measures are required (bowel resection in order to eliminate obstruction, anastomosis with pronounced necrotic processes in the abdominal cavity).

The severity of the pathology directly depends on the duration of the infringement - the more time from the moment of compression, the more severe the patient's condition.

Symptoms

The common clinical manifestations for all types of impairment are:

Pain of varying intensity. It occurs in most cases acutely, but with Richter's infringement it can be gradual. Irradiation is observed along the hernial protrusion. As the bowel wall progresses and necrosis, the pain moves to the abdominal area.
Intense irreducible education in the place of infringement. Localization depends on the type of hernial protrusion (groin, thigh). The tissues over the protrusion can be changed (cyanosis, swelling).
There is no symptom of a cough shock. The hernial mass does not disappear in a horizontal position. This condition is due to the fact that the formation loses its connection with the abdominal cavity and becomes completely isolated (does not depend on pressure changes).
Symptoms of intestinal obstruction. The main ones include nausea / vomiting, constipation, increased intestinal pneumatization, sharp abdominal pain of different localization. X-rays show fluid levels (a classic sign).
Signs of peritonitis. Occurs in the case of perforation of the intestinal wall. The abdomen becomes hard, the pain turns into a dagger. The general condition deteriorates sharply.
Dysuric disorders occur when a hernia is localized near the bladder or urethra. Disorders are represented by frequent painful urging and hematuria.

Features of infringement with various types of hernias (all of the previously listed symptoms are present, but with each specific type of hernia there are dominant manifestations):

View	Dominant manifestations
Inguinal	Painful mass in the groin with all the characteristic hernia symptoms. Difficulties arise when the hernia is localized in the projection of the inguinal canal (oblique hernia). In this case, the difficulty lies in finding the formation itself, since it has a small size (detection is only palpation in the area of the lateral inguinal fossa). The main symptom is a painful bulge in the groin.
Femoral	Often, when assessing the clinical picture, difficulties arise in the differential diagnosis with an inguinal hernia due to the similarity of the two diseases. Often, it is possible to make the correct diagnosis only with the help of an ultrasound scan. The main symptom is a painful protrusion in the groin with a partial transition to the thigh.
Umbilical	The main symptoms: local soreness in the navel and adjacent tissues, the phenomenon of obstruction (Richter infringement more often) are not pronounced.
White line of the abdomen	One of the rarest options. More often there are false hernias associated with the infringement of adipose tissue and without elements of the classic hernial protrusion (hernial sac). However, there are also true hernias with the following signs: the phenomenon of obstruction is not pronounced (Richter infringement), painful protrusion along the midline of the abdomen.
Postoperative	The main symptoms: a pronounced clinic of strangulated intestinal obstruction (by fecal or elastic type), sharp pain in the place of infringement.
Spigelian (crescent) line	It has a characteristic localization: it occurs in the segment between the navel and the anterior superior axis of the ilium. They are located more often subcutaneously and in most cases is manifested only by local pain.
Internal	Compression of the contents of the hernial sac occurs inside the abdominal cavity without any external manifestations. Infringement is possible in the folds of the peritoneum, at the Treitz's ligament, in the lesser omentum. Initially, there are phenomena of strangulated intestinal obstruction, and with prolonged absence of treatment, peritonitis occurs. A special form is diaphragmatic hernia, in which the contents pass through the weak areas of the diaphragm into the chest. It can be congenital and acquired, true and false. The clinic is represented by the following symptoms: the phenomenon of acute intestinal obstruction, manifestations from the cardiovascular and respiratory systems (tachycardia, tachypnea, difficulty breathing, a sharp decrease or increase in blood pressure). May be fatal.

Post-traumatic injuries are separated into a separate nosological group, since infringement can be accompanied by bleeding, muscle necrosis (a special form). The degree of manifestation of certain symptoms depends on the nature of the infringement (fecal flow has a more rapid flow, elastic and Richter flow is more smoothed).

Clinical guidelines

Recommendations depend on the type of hernias, the causes and the clinical picture.

Reduction of any formation on your own is not allowed.
On palpation, the doctor palpates the hernia gently, without excessive intensity. In some cases, upon examination, a variant of an imaginary reduction arises, which refers to extremely dangerous conditions.
It is necessary to confirm the diagnosis by laboratory and instrumental studies. The goal is to identify possible signs of obstruction and perforation (leukocytosis, increased ESR, shift of the formula, fluid in the abdominal cavity, free gas under the dome of the diaphragm).
Emergency surgical treatment is shown within 2-3 hours from the moment of infringement.
In case of infringement without gangrene, it is sufficient to insert catheters (bladder, stomach, peripheral vein).
In the case of gangrene, in addition to catheters, mandatory administration of antibiotics and infusion therapy is indicated.

Treatment

Strictly surgical treatment is indicated. The table shows the main criteria for the viability of the restrained segment of the intestine (in case of non-viability, resection is performed).

Specifications	Viable gut	Unviable gut
Colour	Pink, shiny. Slight redness and cyanosis are allowed.	Dark (up to black) with occasional bruising.
Mesentery	Vascular pulsation is present and slight edema may be observed.	Mesenteric vascular thrombosis.
Save function	Visible peristalsis.	Dumb gut.
Reaction after 15-minute saline wrap	The color takes on a normal pink tint.	The color does not change.

In the preoperative period, stabilization of the patient is required (hemodynamics and saturation). General anesthesia is used more often, since local anesthesia is unacceptable when there is a risk of intestinal damage.

The main objectives of the operation:

removal of a hernia and all its components;
loosening of internal organs;
plastic closure of the defect in order to prevent relapse.

In case of infringement, necrotic tissue is removed, after which hernioplasty is performed

Some points in surgical tactics for different types of hernias are presented in the table.

A type	Features:
Inguinal	The skin and subcutaneous tissue are dissected 2 cm above and parallel to the pupar ligament. Next, the aponeurosis of the external oblique muscle is dissected with the capture of the inner inguinal ring. The hernial sac is separated from the adjacent structures, excised and sutured. The front or back wall of the inguinal canal is fixed with a mesh and plastic is done. It is extremely rare with these hernias to infringement of the intestine (according to indications, a section of the intestine or omentum is resected). This requires a dissection of the posterior wall of the inguinal canal and the intersection of muscle structures. This provides access to the intestines. If it is impossible to perform the operation through this incision, a standard midline laparotomy is performed. After removal of the affected intestine, an anastomosis is made between the intestine and the intestine or the stoma is brought out and the wound is sutured layer by layer.
Femoral	During the operation, the incision goes strictly medially. Sometimes the femoral, not inguinal, approaches to the hernial formation are used. Only the Basini method is used as plastic. Infringement of the intestine occurs extremely rarely; to eliminate it, use the method of resection according to Rudzhi - Parlavecchio. Their inguinal access is made by an incision that passes to the thigh, then the femoral canal is opened, the restrained organs are immersed in the abdominal cavity, and the hernia is removed with plastic surgery of the inguinal canal.
Umbilical	Surgical access includes two bordering incisions around the hernial protrusion. The tissue is dissected in layers, including the aponeurotic ring around the navel on both sides. Next, the hernial sac is opened somewhat from the side. Evaluate the viability of the restrained section of the intestine, if necessary, perform resection and impose anastomosis end-to-end. The wound is sutured in layers with plastic of the anterior abdominal wall. Sometimes Grekov's operation is performed (removal of a hernia in a single block with a restrained ring). In this case, the intestine is intersected in the efferent and adducting sections (the restrained part is cut off) and anastomosis is applied.
White line	The hernial sac is opened, the viability of the strangulated tissues is checked and immersed in the abdominal cavity, and the hernia is excised. Plastic surgery is rarely done; simple suturing of the anterior abdominal wall is sufficient.
Postoperative	The bordering incision is made in the area of the hernial protrusion. Then, if necessary, the restrained ring is dissected and the viable organs are immersed in the abdominal cavity. Sometimes the entire hernial sac is not removed, but the entrance gate is sutured in order to prevent recurrence. Skin plastics can be done using different methods depending on the indications.
Atypical	A classic surgical technique with the only difference in the increase in the number of accesses.
Internal	Conducting laparoscopy or midline laparotomy is indicated. The scope of further surgical intervention is determined by the specific situation. In most cases, the defects are simply sutured or closed with grafts.

In the postoperative period, the following are shown:

antibiotic therapy - for prophylactic purposes;
infusion therapy - taking into account the daily fluid loss;
substrate antioxidants and antihypoxants - to prevent ischemic processes in the intestine;
thrombolytics - to prevent blood clots;
proton pump blockers - to prevent ulcers.

The patient is on enteral nutrition for some time.