Hernia (lat. Hernia) - the exit of organs in whole or in part from their anatomical cavity through a natural or pathologically formed opening in the tissues. The protrusion of the organ occurs in the space between the muscles or the adjacent anatomical pockets and cavities.
The term was introduced in antiquity by K. Galen. Hernias can be pulmonary, diaphragmatic, cerebral, inguinal, muscle, ventral (hernia of the abdomen).
The most common are ventral and inguinal. Their only method of treatment is hernioplasty, i.e., a surgical method.
Causes of ventral hernia
Its main reason is the failure of the abdominal muscles, which cannot withstand the increase in intra-abdominal pressure. Most often this occurs with obesity, exhaustion, pregnancy, weight lifting, frequent crying and crying in infants, chronic pulmonary pathologies, constipation, etc.
By origin
Hernias are congenital (malformation) and acquired, correctable and irreducible. They become irreparable after infringements and adhesions.
By the presence of complications - complicated and uncomplicated.
With the course - primary, postoperative and recurrent.
Methods and types of operations
Surgery for abdominal hernias includes 2 stages: herniotomy (herniotomy) and hernioplasty (suturing of hernial gates).
At the first stage, a hernial sac is searched for and detected, its dissection is made, the contents are revised and, if possible, the viable parts are reduced into the abdominal cavity. In the presence of necrotic tissue - they are cut off.
Gernioplasty is the second and most important stage of the operation. It can be carried out in many ways. They are combined into 3 large groups:
- suturing by tensioning one's own tissues;
- strengthening hernial glands with flaps from other tissues;
- closing the hernial opening with a polymer mesh with its further implantation.
The main drawback of all previously performed umbilical hernia hernioplasty methods until the 1960s was the tension of the tissues when the hernia was sutured. Such a procedure gave up to 70% of complications and relapses, since such a seam turned out to be insolvent. Therefore, today a similar method has been replaced by more effective methods - without tension.
Varieties of hernia surgery
Today, tension hernioplasty of umbilical hernia is used less and less because:
- gives a strong postoperative pain syndrome;
- long recovery period;
- disability is lost for at least 3 months;
- at the slightest voltage the seam diverges;
- in a third of cases relapses occur.
Patient reviews about this method are extremely negative.
Most practicing surgeons today for non-tensioning methods, for example, often use the installation of a mesh implant. He fully assumes all the pressure. Its cellular structure is created so that fibrous cells quickly grow in it, and in the future the wall of the abdomen only strengthens. The mesh is made of polymer inert materials and perfectly fits.
Hernioplasty with umbilical hernia mesh reduces the likelihood of relapse less than 3%. In addition to these 2 methods, a mixed version is also used when the tissue tension is combined with the implant.
Depending on the access, hernioplasty can also be:
Laparoscopy is preferred because of its minimal morbidity and complications. Anesthesia is prescribed endotracheal with muscle relaxation.
Stages of the operation as a whole
There are many methods, but the steps are the same:
- First, soft tissue is cut and a hernia is found.
- Its audit is carried out and the viability of the tissues is assessed.
- If possible, it is adjusted or excised.
- Then comes the plastic stage.
Indications and contraindications for hernioplasty
When planning hernia repair, the doctor assesses the benefits and risks of the operation. Especially when it comes to elderly patients.
Absolute indications:
- Injury of a hernia is an emergency operation.
- Relapse after surgery.
- The likelihood of rupture of a hernia with thinning of the skin above it.
- The appearance of adhesions after surgery in combination with intestinal obstruction.
- Obstructive bowel obstruction.
Contraindications:
- age after 70 years;
- acute infections;
- terminal states;
- shock conditions and sepsis;
- obesity;
- cirrhosis of the liver with ascites;
- varicose veins of the esophagus;
- diabetes;
- bleeding disorder;
- hernia after cancer.
Modern possibilities of anesthesia and laparoscopic treatment method make ventral hernia hernioplasty possible even with contraindications, but the degree of risk is always evaluated individually.
Preoperative preparation
The patient undergoes all standard tests and makes an ultrasound of the abdomen. Anticoagulants are canceled per week. On the eve of a light dinner, in the morning you can not drink and eat.
Liechtenstein Method
Hernioplasty of umbilical hernia according to Liechtenstein is the most popular version of plastic surgery, because long preparation of the patient is not required, the technique of the method is quite simple.
The only drawback is the implantation of a polymer mesh, which is expensive at a price. This type of operation is applicable for many hernias - umbilical, inguinal, femoral. The mesh is set under muscle aponeurosis, without muscle incisions and fascia. Therefore, this operation is less traumatic, and this is its most important plus.
The largest number of positive reviews about hernia repair of umbilical hernia is accounted for precisely by the method of Liechtenstein. She has virtually no relapse (99% success).
Bassini Tension Hernioplasty
Gernioplasty of an inguinal hernia according to this method is a classic operation with tension in an inguinal hernia. Local or spinal anesthesia. A cut up to 8 cm in length is made without dissecting the peritoneum.
The surgeon searches for and opens the spermatic cord, the contents of the hernial sac returns to the abdominal cavity, and part of the non-viable membranes is cut off. Then the inguinal ligament is sutured to the rectus abdominis muscle, the spermatic cord is moved up, then the aponeurosis of the external oblique muscle of the abdomen is sutured. All this was called the plasty of the posterior wall of the inguinal canal by Bassini.
Mayo Way
Mayo hernioplasty of umbilical hernia is a tension method. The section of the abdominal wall is longitudinal, with left-sided bypass of the navel. The skin and fiber are then separated from the wall of the hernial sac and the umbilical ring is dissected. After the hernia has been repaired, the surgeon provides a strong and multilayered abdominal wall with a complex sequence of suturing, so that there are no discrepancies.
Other methods
Gernioplasty of an inguinal hernia according to the Postemsky method is a tension method. During the operation, the inguinal canal is completely excised, from the remaining muscles the surgeon models a new canal through which the testis passes, the muscles are sutured. Local anesthesia is sufficient for this method.
Umbilical hernia repair according to the Sapezhko method. Anesthesia is common. During the operation, both the skin and the navel are completely removed. Hernia gates open longitudinally. After filling the hernial contents of the sac into the peritoneum, the incision is stitched.
Lexer method of hernia repair - open hernia repair of umbilical hernia. It is used for soldering the navel with the bottom of the hernial sac. After opening, the technique of revision and reduction is the same as in a normal operation. The skin flap cut at first returns to its place and is hemmed with a nodal suture.
Hernia repair according to the method of Krasnobaev. Any kind of anesthesia. This method is used in pediatric surgery for children after six months. Removal of the hernial sac occurs without incision of the child’s aponeurosis, closing of the hernial canal is performed with silk thread.
Marcy's method - the extended deep inguinal ring narrows . The operation is also called simply closing the ring. In this case, it is damaged minimally. The method is designed for oblique inguinal hernias in individuals of any gender.
Inguinal hernia repair
Laparoscopic surgery completely eliminates the causes of hernia. The protrusion site is stitched, an implant is applied - a polymer mesh. That is, the non-tensioning method. A feature of inguinal hernias is the fact that an inguinal hernia of the opposite side is often found during surgery.
Laparoscopy is typical: 3 small incisions are made slightly above the inguinal region - for the introduction of a laparoscope and 2 for performing manipulations. The stages of removal are the same: detection of a hernia, revision of the hernial sac, establishing the cause of the hernia. The loop of the small intestine that has fallen into the bag returns to its place (it happens to be a provocateur of protrusion) and a patch is applied. Its fixation occurs on the peritoneal muscles with titanium clips.
The duration of the operation is about an hour. The pain is small after surgery, pass after 2-3 days. Full recovery within a month. Usually, this method does not give relapses and complications.
Laparoscopic umbilical hernia surgery
The advantages of laparoscopic umbilical hernia repair are:
- minimize damage to the abdominal wall;
- good aesthetic effect;
- the absence of complications in the form of suppuration and bleeding;
- minimization of pain and quick recovery;
- the possibility of surgery in severe patients.
The disadvantages include the need for general anesthesia and the use of muscle relaxants, the duration of the operation.
With endoscopic hernia repair of the abdominal hernia, the surgeon makes the same 3 small incisions that were mentioned. Gas is pumped into the abdominal cavity, which improves visibility, in the future the technique is similar to any hernia repair.
Among the shortcomings, one can note the existing possibility of damage by the manipulators themselves of subcutaneous poorly distinguishable vessels. The bleeding that occurs with this can be stopped not very quickly. Therefore, endoscopic surgery is always best done by experienced, qualified surgeons.
Postoperative period and complications
The rehabilitation period proceeds most often within 2 weeks. There are no complications. Sutures with such a favorable course are removed after a week. According to the testimony, the doctor can recommend wearing a bandage that keeps the seam from the load and pressure of the internal organs.
After endoscopy, a bandage is usually not required. Pain after surgery lends itself perfectly to the action of conventional analgesics.
For anti-inflammatory purposes and to relieve swelling around the wound, NSAIDs are prescribed for a short time. No physical exertion and lifting, even small weights should not be.
After an individual period, you can begin to perform therapeutic exercises. Training should take place without records, very gradually. Pain should not be. Normalization of weight is necessary.
Complications are rare, but they are still possible:
- Inflammation and suppuration of the suture.
- Relapse.
- Possible damage to the neurovascular bundle or adjacent organs during surgery.
- The eruption of suture threads with all the ensuing consequences, a sharp tension of the tissues.
- Displacement of the mesh implant from its place.
- Adhesive disease.
- Implant rejection.
- Complications of general anesthesia.
Properties of polymer networks for implantation
The benefits include:
- increased strength;
- do not enter into chemical and biological reactions;
- hypoallergenic;
- non toxic
- do not allow infections and inflammation to develop;
- flexible and resilient;
- have anti-cancer properties.
Gernioplasty is the “gold standard” for the treatment of hernias. Operations are carried out individually. An early recovery is possible if you follow the doctor’s instructions and lead a healthy lifestyle.