A symptom characteristic of infringement of a hernia. Strangulated hernia. Pathogenesis in hernial exits with infringement

A strangulated hernia is a condition in which organs that have fallen out through a pathological opening are compressed. The reason is a violation of blood circulation. Any hernia can be infringed (intervertebral, umbilical, femoral, white line of the abdomen, inguinal). This condition requires emergency surgery.

The cause of a strangulated hernia is a violation of blood circulation.

The reasons

Reasons for the formation of a hernia:

heavy physical labor;
weight lifting;
a sharp increase in pressure in the abdominal cavity (possibly with strong cough, sneezing or pushing during constipation);
a sharp decrease in body weight;
irrational nutrition;
obesity;
low physical activity.

Risk factors for strangulation include difficult labor, excessive physical effort, difficulty urinating, excessive crying, and injuries to the abdomen and back.

Symptoms

Signs of infringement of hernial contents (intestinal loops, omentum, stomach, bladder):

Intense local or diffuse pain. Does not subside at rest. In the case of intestinal obstruction, the pain becomes spastic. It lasts several hours or days. A sharp disappearance indicates the death of nerves against the background of tissue necrosis.
Inability to set the hernial sac.
Tension and soreness.
Absence of a cough impulse (determined during palpation).
The fall blood pressure.
Anxiety.
Tachycardia (fast pulse).
Coprostasis (fecal retention). Occurs against the background of intestinal obstruction. It is observed when pinched inguinal and femoral hernias.
Paleness of the skin. common cause is bleeding.
Bloating.
Dysuric disorders (frequent urination or urinary retention). Occurs when the bladder is blocked. Most often, dysuria develops in old age.
Vomit.
Swelling and redness of the skin. Indicate the development of complications in the form of phlegmon.
Fever.

When a hernial protrusion is pinched in the region of the diaphragm opening, the following symptoms occur:

sharp, cramping pain in the hypochondrium, abdomen or chest;
vomiting like coffee grounds or a fountain, often mixed with bile and feces;
furrowedness and dryness of the tongue;
dyspnea;
bloating;
cold and clammy sweat; depression of consciousness (stupor or stupor).

Diagnostics

If there is a suspicion of pinching of organs (intestinal loops, stomach) in the area of the hernial ring, a comprehensive examination is required. It is necessary to contact a gastroenterologist or surgeon. To clarify the diagnosis and exclude other pathology, you will need:

Questioning the patient and his relatives. Complaints, duration of symptoms, nature of pain and conditions of occurrence are determined.
Assessment of objective status. Includes physical examination, measurement of body temperature, pressure, heart rate and respiration. Important diagnostic sign strangulated hernia - lack of peristalsis. In the case of intestinal obstruction, Val's positive symptoms and splashing noise are determined.
X-ray of the neck, chest and lumbar spine. It is carried out with suspicion of an intervertebral hernia.
CT or MRI. most reliable and informative methods disease diagnosis.
Inspection. With abdominal hernias, asymmetry of the abdomen and signs of peritonitis (positive symptom of Shchetkin-Blumberg) are often detected.
Ultrasound of the abdominal organs. The appearance of Kloiber's cups indicates intestinal obstruction.
Endoscopic examination of the intestine.

This pathology must be differentiated from orchiepididymitis (inflammation of the seminal vesicles and testicles), hydrocele (dropsy of the testicles), acute coronary syndrome and esophagitis (for chest pain), peptic ulcer 12 duodenal ulcer and stomach, inflammation of the gallbladder and pancreas, as well as tumors and diseases of the female genital organs.

Classification

Allocate Richter's and false infringement of a hernia. In the first case, partial compression of the intestine occurs, which is fraught with tissue necrosis.

Intestinal obstruction rarely develops. This type infringement is characteristic of the umbilical and hernia of the white line of the abdomen.

False pinching is different in that there is no tissue necrosis, but there is a clinical picture characteristic of organ pinching. The reason is the ingress of exudate into the hernial sac, which leads to inflammation.

Primary and secondary infringement

Primary infringement occurs at the moment of strong tension. In this case, a hernia is formed, which is immediately pinched. Secondary strangulation occurs in people with a previously diagnosed hernia.

Anatomical location

Allocate external (femoral, epigastric, ischial, hernia xiphoid process and white line of the abdomen, inguinal, umbilical) and internal (intra-abdominal, intervertebral and diaphragmatic) strangulated hernias. The first are characterized by prolapse of organs under the skin. They are determined visually in the form of rounded or oval formations.

According to the organ strangulated in the hernial orifice

Allocate hernia with damage to the intestinal loop, uterus, Cooper's ligament, genital appendages, bladder, omentum and stomach. These are often protruding organs. Rarely, Meckel's diverticulum and the appendix of the cecum (appendix) are infringed.

The nature of the infringement

Depending on the characteristics of development, infringement is divided into the following types:

antegrade (damage to 1 intestinal loop or other organ);
retrograde (2 intestinal loops are compressed at once, while the connective tissue loop remains in the abdominal cavity);
parietal (characterized by infringement of 1 intestinal wall located opposite the mesentery).

The degree of compression of the prolapsed organ

Strangulated femoral hernia

When the femoral hernia is infringed, the organs that go out through the femoral canal become inflamed. These are the appendages of the uterus, appendix and intestines. The hernial sac increases and does not retract. Palpation reveals an increase in organ density and severe pain. Prolonged pinching is fraught with intestinal obstruction, manifested by fecal vomiting, hiccups, retention of stools and gases, bloating and cramping pain.

Pinched herniated spine

Infringement of a hernia of the spine is most often observed in people suffering from osteochondrosis. Signs of pathology:

severe pain along the spine;
torticollis (with damage to the cervical region);
chest pain of the type of angina pectoris (with a hernia of the thoracic region);
muscle spasm;
difficulty swallowing;
restriction of mobility;
dysfunction of the pelvic organs.

Possible pinching sciatic nerve, syndrome vertebral artery, radicular syndrome, impaired sensitivity, movement disorders, impaired sensory perception and extinction of reflexes.

Treatment

If a strangulated hernia is found, emergency surgical treatment is indicated. Self-healing of the body a rare event. Urgent care includes calling an ambulance, giving painkillers and providing the patient with complete physical rest. Conservative therapy and the use of folk remedies for fecal infringement are ineffective. Compresses are made to relieve pain.

Treatment involves:

surgery to restore the normal arrangement of organs;
gymnastic exercises after surgery to strengthen muscular frame and in order to prevent relapses;
complete nutrition;
limitation of physical activity;
wearing an elastic bandage for fixing organs.

Absolutely forbidden

With a restrained hernia, it is prohibited:

independently, before the arrival of the ambulance, administer antispasmodics or NSAIDs to the patient;
set the hernial sac;
take laxatives;
self-medicate;
tighten the abdominal muscles.

Surgery

The purpose of the operation is the release of the organs restrained in the hernial sac. Treatment goals:

elimination of symptoms;
restoration of the normal arrangement of organs;
strengthening muscles and natural openings with own tissues or synthetic materials;
prevention of complications and relapses.

With a strangulated hernia, the following interventions are effective:

Tension hernioplasty. It involves the strengthening of organs with a flap of tissue. Disadvantages of this plastic method - big risk relapse and a long period of recovery of the body. Tissue access requires median laparotomy. During the operation, the doctor dissects the skin, removes the bag with the fallen organs, opens it, removes the liquid, carefully examines (in case of necrosis, removes dead tissue), sets the organs back and performs plastic surgery. It also requires suturing (suturing the wound).
Hernia repair using a mesh (non-stretch plastic surgery). This method of treatment is more effective. The recurrence rate is much lower.
Imposition of intestinal fistulas. It is required when it is impossible to remove part of the intestine in case of its necrosis.
Laparoscopy (endoscopic intervention using a probe equipped with a camera). Similar treatment less traumatic.

Forecast

With timely surgery, a hernia is not dangerous. The prognosis worsens if complications develop. Among the elderly, mortality reaches 10%. The development of phlegmon of the hernial sac exacerbates the prognosis for health.

After the operation, recovery does not occur immediately. Rehabilitation is delayed for a month or more. During tension hernioplasty, a hernia can form and be incarcerated again.

Prevention

Most effective measures prevention of the occurrence and pinching of a hernia:

There is no specific prophylaxis for hernia.

This condition is the most severe complication of a hernia and represents great danger for the patient. Infringement of a hernia of the abdomen mainly occurs with the so-called external hernias of the anterior abdominal wall (inguinal, femoral, umbilical, postoperative). Infringement occurs in the area of the hernial ring, therefore, large hernias emerging from relatively small defects in the anterior abdominal wall are much more likely to be infringed.

Symptoms of the development of infringement of a hernia of the abdomen

Elastic infringement occurs at the moment of a sudden increase intra-abdominal pressure at physical activity, coughing, straining. At the same time, overstretching of the hernial orifice occurs, as a result of which more than usual enters the hernial sac. internal organs. The return of the hernial orifice to its previous state leads to infringement of the contents of the hernia. With symptoms of elastic infringement of a hernia of the abdomen, the compression of the organs that have entered the hernial sac occurs from the outside.

Fecal infringement of a hernia is more often observed in older people. Due to the accumulation a large number intestinal contents in the leading loop of the intestine, located in the hernial sac, the discharge loop of this intestine is compressed, the pressure of the hernial gate on the contents of the hernia increases and the elastic is attached to the fecal infringement. So there is a mixed form of infringement.

In the strangulated organ, blood and lymph circulation is disturbed, due to venous stasis, fluid is transuded into the intestinal wall, its lumen and the cavity of the hernial sac (hernial water). The intestine acquires a cyanotic color, the hernial water remains clear. Necrotic changes in the intestinal wall begin with the mucous membrane. The greatest damage occurs in the region of the strangulation furrow at the site of compression of the intestine by a restraining ring.

Over time, pathomorphological symptoms of infringement progress:

Gangrene sets in strangulated intestine.

The intestine acquires a blue-black color, multiple subserous hemorrhages appear.

The intestine is flabby, does not peristaltize, the vessels of the mesentery do not pulsate.

Hernial water becomes cloudy, hemorrhagic with a fecal odor.

The intestinal wall may undergo perforation with the development of fecal phlegmon and peritonitis.

Incarceration of the intestine in the hernial sac is a typical example of strangulation intestinal obstruction (see "Intestinal Obstruction").

Almost any organ of the abdominal cavity can be strangulated in the hernial sac, but most often it is a loop of the small intestine or its wall, less often the omentum or the large intestine. Often a symptom of infringement occurs after a forced lifting of gravity, due to an increase in intra-abdominal pressure. There are primary strangulated hernias (the hernia occurs for the first time against the background of physical activity) and secondary (the infringement occurs against the background of an already existing hernia).

Early symptoms of a strangulated external abdominal hernia

External infringement is characterized sudden appearance in her sharp pains and her loss of ability to be set into the abdominal cavity. The nature of the clinical manifestations in a strangulated hernia mainly depends on which abdominal organ has been compressed. When the intestinal loop is infringed, a picture of strangulation, usually small bowel obstruction appears with quite pronounced manifestations:

sharp cramping pains

gas retention,

increased periodic intestinal peristalsis.

Infringement in the hernial sac of the omentum is characterized by less pronounced pain, intermittent single vomiting, which has a reflex character.

Local infringement is a dense, sharply painful formation, located in the area of the hernial ring under the skin of the anterior abdominal wall. Due to isolation from the abdominal cavity, unlike a free hernia, it does not increase with straining. For the same reason, another characteristic sign of pathology arises - the loss of the ability to transmit a cough shock by a hernial protrusion.

Percussion is determined by dullness (if the hernial sac contains an omentum) or tympanitis (when there is a gut containing gas in the hernial sac). In most cases, the diagnosis of a strangulated hernia is not difficult, especially since patients usually know that they have a hernia and themselves declare that, after the onset of sharp pains, they are not able to set the hernia, which used to be easily reduced into the abdominal cavity; with a hernia of the anterior abdominal wall, infringement is very rarely its first clinical manifestation.

Late signs of strangulated hernia

Often with a significant delay, strangulated hernias are recognized in elderly people with reduced reactivity, when pain in the area of strangulated hernia is not pronounced and the main complaint is abdominal pain and vomiting (consequences of strangulated intestine). Difficulties in recognition are greatly aggravated in cases where the strangulated hernia is relatively small, especially in patients with a significantly developed subcutaneous fat layer. Examination and palpation of places of possible hernial protrusions (inguinal rings, femoral canal, navel, scars after previous operations) is a mandatory element of the examination of patients with abdominal pain.

In the first hours after the infringement of the hernia, the skin covering the hernial sac remains unchanged, however, in cases where patients apply for medical care very late, on the 2-3rd day after the development of infringement, phlegmon phenomena in the hernia area are possible (skin hyperemia, tissue infiltration, severe pain, fever, local temperature increase). This is due to the necrosis of the strangulated loop, its necrosis and the transfer of infection to the surrounding tissues (hernial sac and skin covering it).

Symptoms of strangulated internal abdominal hernia

In addition to external hernias, there are so-called internal hernias, which can also be infringed. special attention deserve a hernia of the dome of the diaphragm, almost always the left. Infringement of the abdominal organs (most often the stomach or large intestine) in them when they penetrate into the left pleural cavity accompanied by sharp pains in the left side chest, painful vomiting (often with blood) or signs of intestinal obstruction. In addition to the symptoms of hernia incarceration in the form of damage to the abdominal organs, respiratory disorders, severe tachycardia, a drop in blood pressure, pallor, cyanosis, caused by compression of the lung and displacement of the mediastinum by the abdominal organs that have fallen into the left pleural cavity, are just as acute.

On examination, the patient reveals:

displacement of the heart to the healthy side,

dullness of percussion sound or tympanitis,

weakened breathing or its absence,

sometimes - peristaltic noises over lower divisions chest on the left

moderate soreness on palpation of the upper abdomen.

infringement diaphragmatic hernia, as a rule, is not recognized or diagnosed with a significant delay (in patients, spontaneous pneumothorax, hemopneumothorax are suspected, extremely dangerous and contraindicated in these cases are taken pleural punctures).

It should be remembered about the possibility of infringement of a diaphragmatic hernia of the abdomen in persons with a history of chest injuries or pelvic fractures. With these fractures, "closed" ruptures of the left dome of the diaphragm sometimes occur without damage to the outer integument. Free diaphragmatic hernias formed as a result of this can exist asymptomatically for several years and manifest themselves only as a formidable picture of sudden infringement. The diagnosis of diaphragmatic hernia in the hospital can be clarified by x-ray examination of the chest.

Symptoms of infringement are an indication for emergency hospitalization in surgery department hospital. The general condition of the patient may initially remain satisfactory, then progressively worsens due to the development of peritonitis, hernia phlegmon and manifestations of signs of pathology. With the advanced form of parietal infringement in the femoral hernia, the inflammatory process in the tissues surrounding the hernial sac can simulate acute inguinal lymphadenitis or adenophlegmon.

Diagnosis of strangulated abdominal hernia

Clinical manifestations depend on the type of infringement, the infringed organ, the time elapsed since the onset of the development of this complication. The main signs of pathology are pain in the area of the hernia and irreducibility of a hernia that had previously been freely reduced.

The intensity of pain is different, a sharp pain can cause a state of shock. Local signs infringements are sharp morbidity at a palpation, consolidation, tension of hernial protrusion. The symptom of cough shock is negative. With percussion, dullness is determined in cases where the hernial sac contains an omentum, bladder, hernial water. If there is an intestine containing gas in the hernial sac, then a tympanic percussion sound is determined.

Thus, the diagnosis is made on the basis of the following clinical criteria:

Sharp pain in the area of a pre-existing hernia or in the abdomen.

The appearance or increase, compaction, soreness of an irreducible hernial protrusion.

Lack of transmission of cough shock to hernial protrusion.

The symptoms of infringement have to be differentiated from an irreducible hernia, which usually has many years of prescription, and is a bag fused with the abdominal organs that have entered it. However, even with an irreducible hernia and persistent indications of patients on the stability of the type and size of the hernia, the appearance of sharp pains should be regarded as a possible infringement of the abdominal organs in it. In such cases, patients should also be urgently hospitalized.

The differential diagnosis of incarceration of the inguinal and femoral hernia is carried out with inguinal or femoral lymphadenitis (comes gradually, proceeds against the background of high fever and chills, often has an entrance gate on the thigh or lower leg, is not accompanied by symptoms of intestinal obstruction). In addition, the strangulated inguinal hernia of the abdomen is differentiated with acute hydrocele and acute orchiepididymitis (according to the same clinical signs) and with torsion of the testicle and spermatic cord (occurs at the age of 16-21 years, is characterized by a high standing of the painful testicle on palpation, the presence of a cough impulse and absence of hernia gates).

Infringement may occur in the internal opening of the inguinal canal. Therefore, in the absence of a hernial protrusion, it is necessary to conduct a digital examination of the inguinal canal, and not be limited to examining only its outer ring. With a finger inserted into the inguinal canal, you can feel a small sharp painful induration at the level of the internal opening of the inguinal canal. This type of abuse is rare.

Forms of infringement of a hernia and their manifestations

Symptoms of retrograde infringement

More often, the small intestine is retrogradely infringed, when two intestinal loops are located in the hernial sac, and the intermediate (connecting) loop is located in the abdominal cavity. The binding intestinal loop is subjected to infringement to a greater extent. Necrosis begins earlier in the intestinal loop located in the abdomen above the infringing ring. At this time, the intestinal loops in the hernial sac may still be viable.

It is impossible to establish a diagnosis before the operation. During the operation, having found two intestinal loops in the hernial sac, the surgeon, after dissecting the infringing ring, must remove the connecting intestinal loop from the abdominal cavity and determine the nature of the changes that have occurred in the entire strangulated intestinal loop. If the retrograde infringement during the operation remains unrecognized, then the patient will develop peritonitis, the source of which will be the necrotic binding loop of the intestine.

Parietal hernial infringement in the abdomen

Parietal infringement occurs in a narrow infringing ring, when only a part of the intestinal wall is infringed, opposite to the line of attachment of the mesentery; observed more often in femoral and inguinal hernias, less often in umbilical. The disorder of lymph and blood circulation in the strangulated area of the intestine leads to the development of destructive changes, necrosis and perforation of the intestine.

The diagnosis of infringement of this form presents great difficulties. In terms of clinical manifestations, parietal pathology differs from incarceration of the intestine with its mesentery: there are no shock phenomena, symptoms of intestinal obstruction may be absent, since the intestinal contents pass freely in the distal direction. Sometimes diarrhea develops, there is constant pain in the area of the hernial protrusion. In the area of the hernial orifice, a small sharply painful dense formation is palpated. It is especially difficult to recognize parietal infringement when it is the first clinical manifestation of a hernia that has arisen. In obese women, it is especially difficult to feel a slight swelling under the inguinal ligament.

Complications of hernial infringement

The onset of the complication is associated with an increase in intra-abdominal pressure ( physical labor, cough, defecation). When the intestine is infringed, signs of intestinal obstruction join. Against the background of constant acute pain in the abdomen, caused by compression of the vessels and nerves of the mesentery of the strangulated intestine, there are cramping pains associated with increased peristalsis, there is a delay in the passage of stool and gases, and vomiting is possible. Without emergency surgical treatment, the condition of a patient with a hernia of the abdomen deteriorates rapidly, symptoms of intestinal obstruction, dehydration, and intoxication increase. Later, puffiness, hyperemia of the skin in the area of the hernial protrusion appears, phlegmon develops.

Complications of self-reduced strangulated hernias

A patient with a restrained spontaneously reduced abdominal hernia should be hospitalized in the surgical department. Spontaneously reduced previously strangulated intestine can become a source of peritonitis or intra-intestinal bleeding.

If during the examination of the patient at the time of admission to the surgical hospital, peritonitis or intra-intestinal bleeding is diagnosed, then the patient must be urgently operated on. , in which no signs of peritonitis or intra-intestinal bleeding were detected during dynamic observation, hernia repair is indicated in planned.

Forced reduction of a strangulated hernia, produced by the patient himself, is now rarely observed. In medical institutions, the forced reduction of a hernia is prohibited, since this can damage the hernial sac and the contents of the hernia up to rupture of the intestine and its mesentery with the development of peritonitis and intra-abdominal bleeding. With forcible reduction, the hernial sac can be displaced into the preperitoneal space, along with the contents incarcerated in the neck of the hernial sac (imaginary reduction). When the parietal peritoneum is torn off in the region of the neck of the hernial sac, the strangulated loop of the intestine, together with the strangling ring, may be immersed into the abdominal cavity or into the preperitoneal space.

It is important to recognize the imaginary reduction of the hernia in a timely manner, because in this case, intestinal obstruction and peritonitis can quickly develop. Anamnestic data:

forced reduction of a hernia,

abdominal pain,

signs of intestinal obstruction,

sharp pain on palpation of soft tissues in the area of the hernial orifice,

subcutaneous hemorrhages

All these symptoms suggest an imaginary reduction of the hernia and urgently operate on the patient.

Late Complications infringement of the hernia of the abdomen, observed after spontaneous reduction, are characterized by signs of chronic intestinal obstruction (abdominal pain, flatulence, rumbling, splashing noise). They arise as a result of the formation of adhesions and cicatricial strictures of the intestine at the site of rejection of the necrotic mucosa.

The irreducibility of a hernia of the abdomen is due to the presence in the hernial sac of adhesions of the internal organs between themselves and with the hernial sac, formed as a result of their traumatization and aseptic inflammation. Irreducibility may be partial, when one part of the contents of the hernia is reduced into the abdominal cavity, while the other remains irreducible. Contributes to the development of irreducibility prolonged wear bandage. Irreducible are more often umbilical, femoral and postoperative hernia. Quite often they are multi-chambered. Due to the development of multiple adhesions and chambers in the hernial sac, an irreducible hernia is more often complicated by the infringement of organs in one of the chambers of the hernial sac or by the development adhesive obstruction intestines.

Coprostasis is one of the complications of strangulated abdominal hernias.

Coprostasis - stagnation of feces in the large intestine. This is a complication of a hernia, in which the contents of the hernial sac is the large intestine. Coprostasis develops as a result of a disorder motor function intestines. Its development is facilitated by the irreducibility of the hernia, a sedentary lifestyle, plentiful food. Coprostasis is observed more often in obese patients of senile age, in men with inguinal hernias, in women with umbilical hernias.

The main symptoms of this type of complication of incarcerated hernia are:

persistent locks,

stomach ache,

nausea,

rarely vomiting.

Herniated bulge slowly increases as the colon fills up stool, it is almost painless, slightly tense, pasty consistency, positive cough symptom. General condition of patients of moderate severity.

Features of the treatment of strangulated abdominal hernias

Patients with strangulation should be urgently hospitalized in the surgical department, since circulatory disorders in the strangulated loop develop very quickly, and the operation to be performed depends on the timely recognition of the strangulated hernia and the speed of delivery of the patient to the surgical department: dissection of the strangulated ring and release of the compressed, but preserved the viability of the intestine or its resection with developed necrosis. Any attempts to reduce the hernia without surgery when it is infringed are unacceptable, since it is extremely often complicated by trauma to the strangulated intestine up to its rupture. Patients in whom a strangulated hernia has reduced on its own are also subject to hospitalization due to the risk of developing peritonitis. Antispasmodics are not shown.

The diagnosis of the symptoms of infringement of abdominal hernias is confirmed during the operation. When dissecting tissues under the inguinal ligament, a strangulated hernia or enlarged inflamed lymph nodes are found.

Stages of therapy for infringement of abdominal hernias

In case of infringement, it is necessary emergency operation. It is carried out in such a way that, without cutting the infringing ring, open the hernial sac, prevent the incarcerated organs from slipping into the abdominal cavity.

The operation is carried out in several stages.

The first stage of treatment is a layer-by-layer dissection of tissues up to the aponeurosis and exposure of the hernial sac.

The second stage of therapy is opening the hernial sac, removing the hernial water. To prevent the strangulated organs from slipping into the abdominal cavity, the surgeon's assistant holds them with a gauze pad. It is unacceptable to dissect the restraining ring before opening the hernial sac.

The third stage of treatment is the dissection of the infringing ring under the control of vision, so as not to damage the organs soldered to it from the inside.

The fourth stage of treatment is the determination of the viability of the restrained organs. This is the most critical stage of the operation. The main criteria for the viability of the small intestine are the restoration of the normal color of the intestine, the preservation of the pulsation of the mesenteric vessels, the absence of a strangulation groove and subserous hematomas, and the restoration of peristaltic contractions of the intestine. The indisputable signs of the non-viability of the intestine are dark color, dull serous membrane, flabby wall, absence of pulsation of the vessels of the mesentery and intestinal peristalsis.

The fifth stage of treatment of infringement of abdominal hernias is resection of a non-viable bowel loop. From the border of necrosis visible from the side of the serous cover, at least 30-40 cm of the leading segment of the intestine and 10 cm of the outlet segment are resected. Resection of the intestine is performed when a strangulation groove, subserous hematomas, edema, infiltration and hematoma of the mesentery of the intestine are found in its wall.

In case of infringement sliding hernia it is necessary to determine the viability of the part of the organ not covered by the peritoneum. If necrosis of the caecum is detected, resection of the right half of the large intestine is performed with the imposition of ileotransversoanastomosis. With necrosis of the bladder wall, resection of the altered part of the bladder is necessary with the imposition of an epicystostomy.

The sixth stage - plastic hernial ring. When choosing a plastic method, preference should be given to the simplest one.

Treatment of complicated infringements of abdominal hernias

With a strangulated hernia complicated by phlegmon, the operation begins with a median laparotomy (first stage) to reduce the risk of infection of the abdominal cavity with the contents of the hernial sac. During laparotomy, the intestine is resected within viable tissues and an interintestinal anastomosis is applied.

Then a herniotomy is performed (second stage) - the strangulated intestine and the hernial sac are removed. Plastic surgery of the hernia gate is not done, but surgical treatment is performed festering wound soft tissues, which is completed by drainage.

Required component complex treatment of hernia incarceration is general and local antibiotic therapy.

Forecast. Postoperative mortality increases with the lengthening of the time elapsed from the moment of infringement before surgery, and is in the first 6 hours 1, 1%, in the period from 6 to 24 hours - 2, 1%, after 24 hours - 8, 2%; after resection of the intestine, mortality is 16%, with hernia phlegmon - 24%.

In the treatment of infringement complicated by coprostasis, it is necessary to achieve the release of the colon from the contents. With reducible hernias, one should try to keep the hernia in the reduced state - in this case, it is easier to achieve restoration of intestinal motility. Apply small enemas with hypertonic saline sodium chloride, glycerin, or repeated siphon enemas. The use of laxatives is contraindicated due to the risk of developing fecal incarceration.

Inflammation of a hernia can occur due to infection of the hernial sac from the inside when the intestine is strangulated, acute appendicitis, diverticulitis of the ileum (Meckel's diverticulum, etc.). The source of hernia infection can be inflammatory processes on the skin (furuncle), its damage (maceration, abrasions, scratching).

In acute appendicitis in the hernia of the abdomen, an emergency appendectomy is performed, in other cases, the source of infection of the hernial sac is removed.

chronic inflammation hernias with tuberculosis of the peritoneum are recognized during surgery. Treatment consists of hernia repair, specific anti-tuberculosis therapy. In case of inflammatory processes on the skin in the area of a hernia, an operation (hernia repair) is performed only after they have been eliminated.

Prevention of complications of the disease consists in the surgical treatment of all patients with hernias in a planned manner before the development of complications. The presence of a hernia is an indication for surgery.

A strangulated hernia acts as a gradual or sudden compression in the ring of the hernial orifice - the hole through which the hernial formation exits to the outside - the area of \u200b\u200bany organ belonging to the abdominal zone. In view of such compression, a violation of the process of blood supply to this organ occurs, and subsequently its necrosis is established - the necrosis of damaged tissues of a living organism, which is accompanied by the final cessation of their functioning. A pinched hernia can involve both internal hernias (occur in the diaphragmatic openings as well as pockets that form the abdominal cavity) and external hernias (observed in a variety of defects and crevices that cover the walls of the pelvic floor and abdomen). To find out how to treat hernias with strangulation , it is necessary to study in detail the essence of this pathology, its signs, the manifesting symptomatic picture and the developed methods of disposal.

The mechanism of occurrence, which determines the disease in question, and the classification of its types

A strangulated hernia, if we consider the mechanism of its appearance, is differentiated into two fundamentally different varieties, which include elastic infringement, as well as fecal. For hernias with incarceration of the first type, the following situation is typical: an infringement is formed after an unexpected exit through the zone of narrow hernial orifice of a large number of abdominal viscera at a time when, under the influence of high physical exertion, the degree of intra-abdominal pressure sharply increases. Due to strangulation - compression - in the area of \u200b\u200bthe narrow ring representing the hernial orifice, ischemia of those organs that have been infringed occurs, as a result of which the sick person begins to experience acute pain. An elastic strangulated hernia that has not been eliminated leads to rapid necrosis, which affects all hernial contents and which occurs over several hours, at least two. , advancing in the leading section of the intestinal loop. A strangulated hernia of the first variety occurs if there is a narrow hernial orifice, as for fecal incarcerations, they are often observed with a wide hernial bulge. With elastic infringements great importance has physical tension, while with fecal strangulations, the determining factor is a violation that is associated with intestinal motility, as well as a slowdown in peristalsis - a wave-like contraction of the walls that form the esophagus, intestines, stomach and promote promotion to the outlets of their contents. Strangulated hernia is characterized by spread to various organs, which are hernial contents. In medicine, another classification of hernial protrusions with infringement has been developed, which is based on criteria such as their localization, that is, location. The strangulated inguinal hernia accounts for up to sixty percent of cases relative to the total number of detected pinchings, respectively, the frequency of inguinal hernias in surgical practice is the highest. Diagnosis is difficult in case of infringement of a canal hernia in the region of the deep inner ring of the inguinal canal; such a pathological process can only be detected if a very thorough examination is made. It is necessary to distinguish between an incarcerated inguinal hernia and inguinal lymphadenitis - one of the types of inflammation that affects the lymph nodes, acute orchiepididymitis - male urological a disease characterized by extensive inflammation in the area of the testicles and appendages, a tumor of the testicle, a tumor of the spermatic cord, dropsy of the testicle - the latter is also called hydrocele and implies a disease in which accumulation of fluid is noted in the testicle, dropsy of the spermatic cord - funiculocele, is released by the process of accumulation of fluid along the spermatic cord , as well as strangulated femoral hernial bulge. In the case of inguinal lymphadenitis and acute orchiepididymitis, as a rule, there are no anamnestic (anamnesis is understood as the totality of information that was obtained during medical examination by questioning the patient himself and / or persons who know him) indications of a previous hernial formation, neither pronounced pain symptoms nor vomiting are present, and the pain is accompanied by an early increase in body temperature. Diagnosis of the disease is carried out with the help of a physical examination of the patient.

Important: as for orchiepididymitis, it always reveals an enlarged painful testicle along with its affected appendage!

Oncological diseases, which are associated with the testicle and spermatic cord, are not accompanied by the sudden onset of a symptomatic picture indicating a strangulated inguinal hernia. With careful digital examination zones of the inguinal canal, such a pathological condition as a hernial exit with infringement is excluded without any difficulties.

An incarcerated femoral hernia is recorded on average in twenty-five percent of people in relation to all clinical cases of incarcerated hernias. To confirm the development of this type of herniation with pinching, a differential diagnosis between the strangulated inguinal hernia described earlier, acute femoral lymphadenitis and varicothrombophlebitis - the most common form of thrombophlebitis, in which a thrombus, that is, blood clot, clogged veins transformed by varicose veins (subcutaneous swelling). In order to establish acute femoral lymphadenitis, anamnesis data are used along with the results of an objective study, which indicate the absence of a strangulated femoral hernia. Attention is focused on ulcers, abrasions, abscesses, which are localized on lower limbs, since they serve as an entrance gate for infection. Diagnosis of varicothrombophlebitis also does not cause significant difficulties for the attending specialist. Signs are taken into account that signal the course of a thrombotic process in the saphenous veins located below, and are expressed in hyperemia, soreness and cord-like cord along the vein. Surgical intervention, which is carried out for a strangulated femoral hernia, is technically recognized as the most difficult, since the operative access to the neck of the hernial sac is too narrow and anatomically important formations, such as the inguinal ligament, femoral joints, are closely located. A strangulated umbilical hernia is diagnosed in ten percent of cases from the total the number of hernias with pinching. The clinical picture of such an infringement, which arose against the background of a reducible hernial bulge, is so characteristic that it is practically impossible to make a diagnosis of any other pathology. The presence or absence of the cough impulse transmission process is the only distinguishing diagnostic manifestation. Incarcerated postoperative ventral hernia is rarely recorded in surgical practice. In view of the extensive adhesions of the intestine, as well as its deformations and kinks in the area of postoperative hernial formations, an acute pain syndrome often appears along with adhesive intestinal obstruction, these signs are attributed to the result of a pinched hernial protrusion, but such an erroneous diagnosis does not affect the patient in principle, because in both cases require emergency surgery. Surgical intervention for a strangulated ventral hernia formed after surgery is performed under anesthesia. A strangulated internal hernia is often characterized as a false strangulated hernia, since the absence of a hernial sac has been established. Strangulated internal hernial outlets can be manifested by the symptoms that are characteristic of acute intestinal obstruction, that is, pain in the abdomen, gas and stool retention in the patient, as well as other radiological and Clinical signs. Carried out before surgical invasion, the diagnosis of parietal entrapment to which hollow organs are exposed is extremely difficult.

Pathogenesis in hernial exits with infringement

At the moment when the infringement is carried out, a closed cavity begins to form in the area of the hernial sac, which contains separate body or several organs with impaired blood circulation. In the place where the omentum, intestinal loop or other organ is compressed, a groove appears, which is defined in medicine by the term “strangulation”. At the first stages, due to the fact that blood circulation is disturbed, venous stasis appears in the intestinal cavity, which soon leads to edematous phenomena in all layers that form the intestinal wall. Simultaneously with the described process, diapedesis is observed - the exit - of uniform blood elements, coupled with plasma, which is directed both into the lumen of the previously strangulated intestine and into the hernial sac. In the area of the closed lumen of the intestine, which was ischemic, decomposition of the intestinal contents starts, this process is characterized by the active formation of toxins. The pinched bowel loop rather quickly (if elastic infringement occurs, then within a few hours) undergoes necrosis, covering first the mucous membrane, then affecting the submucosal layer, then the muscular membrane, and on last stage- serous. With infringement, in addition to the section of the intestine located in the hernial sac, the leading section of this intestine, which is concentrated in the abdominal cavity, also suffers.

Attention: the factors listed above determine the high level of mortality, which determines strangulated hernias, for this reason it is advisable not only early operation, but also the implementation of vigorous postoperative rehabilitation therapy!

Retrograde strangulation and parietal strangulation are considered as special types herniation with pinching. Retrograde strangulated hernias, which are also known in medicine as W-shaped, are distinguished by the presence of at least two intestinal loops in the area of the hernial sac, while the condition of the latter can be described as relatively favorable. As for the third loop, which is located in the abdominal cavity and serves to connect the two mentioned, significant changes are established in it. This type of pinching is recorded infrequently, however, its course is much more difficult than the development of ordinary infringement, since the progression of the main pathological process is concentrated not in the hernial sac, which is closed, but in the open abdominal cavity. What is Richter's infringement? Richter's hernia, or parietal infringement, is a pathological condition in which the intestine is compressed partially, and not to its full extent. Mechanical intestinal obstruction is not observed, but there is a risk of necrosis of the intestinal wall. Richter's hernia does not occur with hernial bulges, which are large in size, it is typical for hernial formations of small size and with narrow hernial orifices. Richter's incarceration of a hernia in a sliding hernia affecting the bladder leads to dysuric-type disorders, suggesting painful frequent urination, as well as hematuria - the presence in the urine of an amount of blood that exceeds physiological norm.

General symptoms that indicate the progression of hernial protrusions with infringement

When the patient complains of pain that suddenly appeared in the abdomen, especially if they are accompanied by symptoms that indicate intestinal obstruction, it is always necessary to exclude the possibility of hernia pinching, using the signs of hernia pinching, characterized by the following four conditions:

a sharp pain syndrome affects the hernia area or the entire abdomen;
hernial formation cannot be reduced;
hernial bulging is marked by soreness, coupled with tension;
cough impulse is not transmitted.

Symptoms of a strangulated hernia are primarily expressed in pain. The level of intensity of pain symptoms is so high that it becomes very difficult for a sick person to resist screaming and moaning. In the vast majority of clinical cases, the severity of pain does not change until the necrosis of the organ that was pinched occurs, with the accompanying death of intramural - intramural, localized in the walls of hollow organs - nerve elements. An unreduced hernial formation acts as such a symptom , which is of decisive importance in the presence of a pinched free hernia, previously amenable to reduction. The tension that spreads in the hernial protrusion, together with some growth of the latter, is accompanied by pinching, which can cover both irreducible and reducible hernia, in this regard similar sign is more essential for the successful recognition of the infringement by the doctor than such a symptom as the irreducibility of the hernia. Usually, bulging, in addition to tension, acquires a noticeable soreness, which is also referred to by the patients themselves in the process of palpation examination of the hernia, that is, its palpation with fingers, as well as in any attempt to reduce the resulting hernial formation.

The fact of the absence of transmission in the area of the hernia of the cough shock is recognized as the most important sign informing about the infringement that has occurred. A cough push to the area of the hernial protrusion cannot be transmitted because at the moment of pinching, the hernial sac is dissociated from the free zone of the abdominal cavity and turns into an isolated fragment. For this reason, the pressure inside the abdominal cavity, which increases during coughing, ceases to be transmitted to the area of the hernial sac, this condition is called negative symptom cough impulse. Sick elderly people suffering from a strangulated hernia for many years tend to use a special medical bandage for many years. They develop a gradual habituation to pain sensations and other uncomfortable conditions in the area of hernia formation, therefore it is fundamentally important, in the event of a suspicion of pinching, to establish whether there are any changes in the nature of the pain syndrome they experience, whether such patients experience moments of intense pain, which may indicate pinching, and when exactly they occur, as well as whether other unusual symptoms appear. The symptomatic picture that is mainly inherent in the elastic type of infringement has been outlined above. As for fecal infringement, it has the same patterns of pathogenesis, but its course is characterized as less bright. With fecal pinching, the degree of pain syndrome is not so pronounced, the phenomena of intoxication develop more slowly, the onset of necrosis of the intestine that was strangulated is recorded later.

Carefully: the infringement of the fecal species is recognized as as dangerous as its elastic variety, and since the end result of both diseases is the same, the treatment tactics in case of their diagnosis are the same!

Treatment of hernial bulges with the process of infringement

Surgical tactics with a strangulated hernia indicates the need emergency surgical treatment, it does not matter what type this hernial formation belongs to and what is the period of the detected pinching. As the only contraindication to committing surgical treatment strangulated hernia, the agony of the patient appears, that is, a condition in which, due to severe hypoxia - a reduced content of oxygen in individual tissues and organs or the body - vital functions are deeply inhibited, and the person's pain sensitivity disappears, he loses consciousness, his pupillary, corneal (corneal) - a reflex that belongs to the unconditioned and due to which the palpebral fissure closes when the cornea of the eye is irritated - as well as skin, tendon reflexes. Any attempts to reduce hernial formations both in the prehospital phase and directly in the hospital itself are strictly prohibited, since there is a threat of moving into the abdominal cavity of the organ that was subject to irreversible ischemia. However, in some clinical cases performing a surgical intervention can be even more dangerous for the patient than the reduction of a hernial formation, for example, this applies to those sick people whose nature of the course of the disease, due to the presence of any concomitant diseases, can be assessed as extremely severe and who, after establishing a pinching that occurred at the attending physician, no more than one hour passed. AT similar situations careful attempts at reduction may well be made. If the infringement was recorded a small amount of time ago, then the reduction of the hernial protrusion is possible even in children, and especially in those whose age is early, since in them, unlike adults, the abdominal wall is more elastic, and destructive-dystrophic changes affect the pinched organs much less frequently. Sometimes patients who have ever tried to repair their own hernia and are afraid of the upcoming surgical intervention, begin to produce often quite rough and repeated attempts reduction of pinched hernial formations, doing this at home. In this regard, a condition may arise that is described as an imaginary reduction of a hernia and is recognized as one of the most serious complications of the pathological process under consideration. Preoperative preparation of a sick person involves removing urine from the body, shaving hair from the area operating field and conducting its hygienic preparation. The process of anesthesia by many surgeons is carried out using local anesthesia, since it is believed that it does not provoke unwanted reduction of hernial bulging, but preference, regardless of the location of the hernia with infringement, should be given either spinal anesthesia, or anesthesia, used in case of need to expand the volume of surgical invasion, which is associated with peritonitis or intestinal obstruction.

Primary infringement of a hernia is quite rare. It appears as a result of a very strong physical momentary stress, if a person is predisposed to the appearance of such a protrusion. That is, in a person, as a result of such an effort, a hernia appears and is infringed at the same time.

Diagnosing a strangulated hernia is quite difficult. This can only be done by an experienced doctor who does not forget about the possibility of his appearance.

This is the danger of an insidious disease. The patient is simply unable to understand what is happening to him, and may miss precious time.

As a result of this, peritonitis begins, the death of tissues of internal organs, as well as severe intoxication.

Secondary infringement of a hernia is detected much faster, as it develops against the background of an already existing protrusion. That is, the patient can already explain the situation to the emergency doctor.

With elastic infringement, a very intense constant or growing pain of a cutting nature suddenly appears in the area of hernial protrusion with irradiation in epigastric region and waist.

With fecal infringement, the pain appears gradually, but progresses rapidly and within 1 to 2 hours also reaches a significant intensity. The pain may be accompanied by a single or repeated vomiting and severe weakness.

Hernia before an attack of pain, reducible or partially reducible, ceases to be reduced, increases in size

A hernia in medicine refers to a condition when body organs or tissues protrude outward or move from their usual place. This happens through the weakness of the abdominal wall and connective tissues of the human body.

It manifests itself as a noticeable bulge at the point of the protrusion. It can be noticed by the surgeon during examination, and a common person will note the appearance of a strange tubercle on his body.

Often, this bulging of the insides can be painful and cause discomfort. Especially when touching or interacting with clothing. Not to mention the moral pressure due to the bashfulness of the appearance of a painful defect on the body.

Infringement of a hernia in the area of the white line of the abdomen is quite rare. According to statistics, this infringement occurs infrequently due to anatomical features. And the classic infringement in a situation with a hernia of the white line of the abdomen is not always reliable.

Very often in medical practice, the suspicion of incarceration of a hernia in the area of the white line of the abdomen is confused with the infringement of the preperitoneal fat layer. This is not a dangerous clinical picture, compared with a real complication of the disease.

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This condition is the most severe complication of a hernia and poses a great danger to the patient. Infringement of a hernia of the abdomen mainly occurs with the so-called external hernias of the anterior abdominal wall (inguinal, femoral, umbilical, postoperative).

Infringement occurs in the area of the hernial ring, therefore, large hernias emerging from relatively small defects in the anterior abdominal wall are much more likely to be infringed.

Elastic infringement occurs at the moment of a sudden increase in intra-abdominal pressure during physical exertion, coughing, straining. In this case, overstretching of the hernial orifice occurs, as a result of which more than usual internal organs enter the hernial sac.

The return of the hernial orifice to its previous state leads to infringement of the contents of the hernia. With symptoms of elastic infringement of a hernia of the abdomen, the compression of the organs that have entered the hernial sac occurs from the outside.

Symptoms of retrograde infringement

More often, the small intestine is retrogradely infringed, when two intestinal loops are located in the hernial sac, and the intermediate (connecting) loop is located in the abdominal cavity.

The binding intestinal loop is subjected to infringement to a greater extent. Necrosis begins earlier in the intestinal loop located in the abdomen above the infringing ring.

At this time, the intestinal loops in the hernial sac may still be viable.

Any attempts to reduce the hernia without surgery when it is infringed are unacceptable, since it is extremely often complicated by trauma to the strangulated intestine up to its rupture.

Patients in whom a strangulated hernia has reduced on its own are also subject to hospitalization due to the risk of developing peritonitis. Antispasmodics are not shown.

Stages of therapy for infringement of abdominal hernias

In case of infringement, emergency surgery is necessary. It is carried out in such a way that, without cutting the infringing ring, open the hernial sac, prevent the incarcerated organs from slipping into the abdominal cavity.

The operation is carried out in several stages.

The first stage of treatment is a layer-by-layer dissection of tissues up to the aponeurosis and exposure of the hernial sac.

The second stage of therapy is opening the hernial sac, removing the hernial water. To prevent the strangulated organs from slipping into the abdominal cavity, the surgeon's assistant holds them with a gauze pad. It is unacceptable to dissect the restraining ring before opening the hernial sac.

The third stage of treatment is the dissection of the infringing ring under the control of vision, so as not to damage the organs soldered to it from the inside.

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The fourth stage of treatment is the determination of the viability of the restrained organs. This is the most critical stage of the operation.

The main criteria for the viability of the small intestine are the restoration of the normal color of the intestine, the preservation of the pulsation of the mesenteric vessels, the absence of a strangulation groove and subserous hematomas, and the restoration of peristaltic contractions of the intestine.

The indisputable signs of the non-viability of the intestine are dark color, dull serous membrane, flabby wall, absence of pulsation of the vessels of the mesentery and intestinal peristalsis.

Resection of the intestine is performed when a strangulation groove, subserous hematomas, edema, infiltration and hematoma of the mesentery of the intestine are found in its wall.

When a sliding hernia is infringed, it is necessary to determine the viability of the part of the organ that is not covered by the peritoneum. If necrosis of the caecum is detected, resection of the right half of the large intestine is performed with the imposition of ileotransversoanastomosis.

With necrosis of the bladder wall, resection of the altered part of the bladder is necessary with the imposition of an epicystostomy.

The sixth stage - plastic hernial ring. When choosing a plastic method, preference should be given to the simplest one.

Treatment of complicated infringements of abdominal hernias

During laparotomy, the intestine is resected within viable tissues and an interintestinal anastomosis is applied.

Then a herniotomy is performed (second stage) - the strangulated intestine and the hernial sac are removed. Plastic surgery of the hernia gate is not done, but the surgical treatment of a purulent wound of soft tissues is performed, which is completed by drainage.

A necessary component of the complex treatment of hernia incarceration is general and local antibiotic therapy.

Forecast. Postoperative mortality increases with the lengthening of the time elapsed from the moment of infringement before surgery, and is in the first 6 hours 1.1%, in the period from 6 to 24 hours - 2.1%, after 24 hours - 8.2%; after resection of the intestine, mortality is 16%, with hernia phlegmon - 24%.

Four symptoms are characteristic of a strangulated hernia. They occur with any form of pinching. These include:

Pain of a sharp nature, manifested in the area of the hernia;
The protrusion cannot be reduced even in lying down;
The hernia is painful and constantly tense;
The cough impulse is not transmitted.

In operational practice, strangulated hernia is the fourth most common pathology. It can be primary and secondary.

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The risk of infringement threatens any kind of pathological protrusion, regardless of its location, anatomical location and hernial contents. The main provoking factor is a rapid and strong contraction of the abdominal muscles, in which the pressure on the hernial ring from the inside increases sharply.

Incarcerated hernias are clearly classified according to various indicators. This helps the surgeon accurately determine the type and extent of the operation.

1. By anatomical location

2. According to the organ, restrained in the hernial orifice

3. By the nature of the infringement

4. According to the degree of compression of the prolapsed organ

When clarifying the nature of the hernia and the type of infringement, the patient's complaints are important.

The main symptom of any type of strangulated hernia is pain, which differs depending on the location, type and degree of infringement. The pain can capture only the area of the hernia or spread throughout the abdominal cavity.

A patient with signs of hernia incarceration is referred for surgery in urgent order. Surgical intervention has the status of "according to vital indications”: this means that the only contraindication is the obvious near-death state of the patient.

What Doctors Say About Joint Treatment

Infringement of a hernia usually occurs in the hernial opening, less often in the neck of the hernial sac, which is congenitally narrow or became callused and unyielding after the previous inflammatory process, even more rarely in the diverticulum of the hernial sac or in the hernial sac itself. The narrowness of the hernial opening and the inflexibility of its edges contribute to the infringement.

The mechanism of infringement is not always clear. There are elastic and fecal infringement. Only the mechanism of elastic infringement is quite clear. With this form of infringement, the intestinal loop, due to a strong and rapid contraction of the abdominal press, is immediately squeezed under great pressure into a narrow hernial opening or into a narrow congenital hernial sac.

The hole and the bag initially stretch, and then, after the cessation of tension in the abdominal press, they contract and squeeze the intestinal loop that has fallen into them. The compression is so strong that the entire contents of the intestine are forced out and not only the veins, but also the arteries are compressed. The restrained loop bleeds and dies.

Infringement of hernias in childhood observed rarely, it is more common in adults and the elderly. The femoral and umbilical hernia. Infringement occurs more easily in small hernias, in which the edges of the hernial opening have not lost resistance.

pathological changes. In the usual form of infringement, only easily collapsing veins are compressed, while the flow of blood through the arteries continues. In the restrained loop of the intestine develops venous congestion, the loop becomes more voluminous, cyanotic, swollen.

Due to an increase in intravenous pressure, sweating occurs, firstly, into the tissue of the intestinal wall, as a result of which the latter becomes edematous, secondly, into the cavity of the restrained loop, as a result of which the amount of its liquid contents increases, thirdly, into the cavity of the hernial sac, due to which accumulates in it "hernial water", often having a hemorrhagic character.

The vessels of the intestine are thrombosed, the mucosa ulcerates, the peritoneal cover loses its luster and becomes covered with a fibrinous coating, the intestine turns black, its wall becomes passable for bacteria, and the hernial water becomes purulent. Most of all, the strangulation furrow suffers.

The wall of the strangulated loop soon dies, breaks through, and the contents of the intestine enter the hernial sac. Then a phlegmon of the hernial membranes develops, turning into an abscess, which opens outwards and leaves behind a fecal fistula. Opening of the intestine or abscess into the abdominal cavity with subsequent fatal peritonitis is observed infrequently, since the abdominal cavity usually has time to delimit itself by adhesions by this time.

The afferent section of the strangulated intestine is overflowing with contents that do not have an outlet and continue to enter it from the overlying sections of the intestine and gases formed during the putrefactive decomposition of the contents. The wall of the adducting segment of the intestine comes into a state of paresis, the vessels thrombose, nutrition is disturbed, and it becomes passable for microbes in the same way as the wall of the strangulated loop, but later. As a result, diffuse peritonitis develops.

clinical picture. Symptoms of a strangulated hernia usually appear immediately, often immediately after abdominal tension. The hernial tumor becomes painful, especially in the neck, tense, irreducible and increases in volume.

Later, with the development inflammatory phenomena she gets hot. With incomplete hernias, the tumor may be absent, and then there is only local pain. The pain sometimes reaches considerable strength and can cause shock.

The abdomen is initially soft and painless, but soon the phenomena of intestinal obstruction join, i.e., bloating and increased peristalsis overcrowded leading segment of the intestine, vomiting, hiccups, complete retention of gases and stools. It is possible to empty the intestines from the department located below the infringement.

At the beginning of the infringement, there is often an early reflex vomiting, later - repeated vomiting with an admixture of bile due to intestinal overflow. Then the vomit acquires a fecal odor. With the onset of peritonitis, when the abdomen is felt, protective muscle tension is determined.

The general condition of the patient is rapidly deteriorating, the pulse quickens, becomes arrhythmic, blood pressure falls. The temperature rises and then falls. The reason for the drop in temperature and severe general condition is poisoning with intestinal toxins, most often leading the patient to death.

Extremely toxic substances, histamine, etc., were isolated from the contents of the strangulated intestinal loop. The body is dehydrated, the amount of urine excreted is greatly reduced. Urine is concentrated and contains indican. The cause of death may also be acute peritonitis due to perforation of the intestine. If the patient does not receive timely prompt assistance or the fecal abscess does not open spontaneously, the disease ends in death.

The diagnosis is hampered by infringement of hernias that are inaccessible to palpation, hidden under a thick layer of tissues, for example, obturator, ischial, hernia of the Spigelian line, parietal. In order to avoid viewing the infringement of the hernia in case of obstruction, it is necessary to examine all hernial areas.

A clinical picture similar to incarceration of a hernia is given by a torsion of the intestines with a hernia, appendicitis in the hernial sac, twisting of the spermatic cord of the testicle, acute epididymitis with inguinal ectopia of the testicle.

When the intestines are twisted, part of the wrapped loops, with a large hernia, is sometimes located in the hernial sac and feigns infringement, since the hernia becomes painful and irreducible. In this case, after opening the hernial sac, next to the cyanotic wrapped loop, unchanged intestinal loops are visible.

Appendicitis in the hernial sac is observed in inguinal hernias from slippage when the caecum with the appendix is the hernial contents. The hernia at the same time becomes painful and increases, as if infringed. An attempt at repositioning can have fatal consequences.

Treatment of strangulated hernias should in principle be only operational. Each patient with a strangulated hernia must be immediately sent to a surgical hospital for surgery, since the pathological process proceeds very quickly.

The operation of the strangulated hernia, in appropriate cases, ends with the plastic closure of the hernial opening.

After the operation, patients who are in a state of intoxication are given an intravenous hypertonic saline solution or a blood transfusion.

Manual reduction of strangulated hernias as a therapeutic measure is unacceptable, as it threatens a number of mortal dangers.

The latter include:

Injury or rupture of the strangulated intestinal loop, followed by peritonitis;
Reduction of a dead intestinal loop with the same outcome;
Reduction of the hernia as a whole (en masse), i.e. e. contents together with the hernial sac, while maintaining the restraining ring;
Separation of the restraining ring, hernial sac and adjacent parietal peritoneum and its reduction into the abdominal cavity together with the restrained loop.

In the last two cases, only an imaginary reduction is achieved and the formidable dangers of infringement are not eliminated.