Hernia of the white line of the abdomen in an adult: surgery, symptoms, treatment, removal of hernia of the white line of the abdomen

The linea alba is an anatomical structure that is formed by the fusion of the fascia and aponeuroses of the muscles of the anterior abdominal wall. The linea alba is located along the midline of the abdomen (dividing it into two symmetrical halves) and is named so because of its white color, which is caused by connective tissue.

Normally, the linea alba has small openings through which blood vessels and nerve endings pass. These gaps are a “weak” point, and under certain conditions, internal organs and fatty tissue located in the abdomen can prolapse through them. Such protrusions are called hernias. Most often they are localized in the upper third of the linea alba.

Types of hernias of the white line of the abdomen

Depending on the origin, a hernia of the white line of the abdomen can be congenital or acquired. A congenital disease manifests itself either immediately after the birth of a child, or a little later, but in early childhood. It occurs due to insufficient development of the tissues of the abdominal wall and can disappear on its own as the child grows. Acquired hernias of the white line of the abdomen occur with age. The reason for their development is the thinning and loss of tone of the aponeurotic tissues.

Hernias of the white line of the abdomen are divided into free (reducible) and irreducible. The contents of reducible hernias can move freely from the abdominal cavity to the hernial sac and back. With an irreducible hernia, such migration is impossible.

There is such a thing as a strangulated hernia. This condition occurs if the hernial contents are subjected to compression. As a rule, it occurs at the level of the hernial orifice, is life-threatening and requires immediate treatment.

In addition, complete hernias and incomplete hernias of the white line of the abdomen are distinguished. With a complete hernia, its contents extend beyond the abdominal wall. With an incomplete hernia, this does not yet happen.

Types of operations:

Plastic surgery using your own tissues

The incision is made in the midline above the hernial protrusion.
The hernia defect is sutured with a non-absorbable thread, thereby eliminating the possibility of separation of the abdominal muscles.

This type of operation is used for small hernial orifices and the patient does not have conditions and diseases that cause failure of the connective tissue structures of the body.

The disadvantages of this type of operation include the need to create tension in the tissues of the anterior abdominal wall, which can lead to relapse of the disease. Another disadvantage is the long incision along the midline and a long rehabilitation period with limited physical activity.

Plastic surgery using synthetic prostheses and meshes

This is also a traditional (open) intervention performed through an incision over the hernial protrusion. However, with this type of operation, tension is not created on the native tissues of the abdominal wall, and the defect is closed using a prosthesis made of synthetic material. Artificial implants and meshes grow over time with a person’s own tissues and create a strong support; in this regard, the possibility of recurrence of the disease is reduced to almost zero.

Laparoscopic hernia repair of the linea alba.

With the advent of high-tech devices, this technique in the treatment of hernias is becoming increasingly popular. The operation does not require a long skin incision.

Several punctures are made in the abdominal wall, located mainly in the lateral sections, through which the hernial sac is exposed, adhesions are separated, if any, and a special mesh prosthesis is installed.

Laparoscopic surgery involves fewer traumatic factors than open surgery. The period of rehabilitation and recovery after laparoscopy is much shorter than with other techniques. Even with large hernias, after a month you can return to your usual rhythm of life and usual loads. In addition, the postoperative period does not require wearing a bandage. The distance of skin punctures from the site of installation of the mesh prosthesis reduces the risk of purulent-inflammatory complications, which can be of great importance in people with reduced immunity (for example, diabetes, obesity) and significantly reduces the risk of hernia recurrence.

A relative disadvantage of laparoscopic hernia repair of the linea alba can be considered the lack of correction of diastasis of the rectus muscles and, consequently, incomplete restoration of the shape of the anterior abdominal wall, especially in thin people. The widespread use of this technique is also limited by the significant cost of the implant, which has a special coating that prevents adhesions, and instruments for its laparoscopic installation. Such operations are also not suitable for patients with severe diseases of the cardiovascular and respiratory systems. All surgical interventions are performed under general anesthesia. Postoperative hospital stay depends on many factors and concomitant diseases and ranges from 2 to 10 days.

Rehabilitation after surgery

With traditional plastic surgery methods, wearing a bandage is recommended in the postoperative period. In addition, during the period of convalescence, it is important to follow all the recommendations of the attending physician: follow a special gentle diet and avoid any physical activity. Ignoring a disease such as a hernia and a lax attitude towards one’s health can lead to life-threatening conditions and, in the future, to serious complications. Despite the fact that the only method of treating this disease is surgery, the variety of types of operations that currently exist makes it possible to select the optimal type of plastic surgery for each patient, taking into account his individual characteristics.

Causes

The main reason for the development of acquired hernias of the white line of the abdomen is the loss of elasticity and thinning of the aponeurotic and fascial tissues. Various reasons can lead to this:

Age-related changes.
General exhaustion and cachexia.
Traumatic damage, including during surgical interventions, when degenerative processes begin to occur in initially unchanged tissues along the incision line.
Postoperative complications - inflammatory processes, seromas, hematomas. Most of all, the structure of the connective tissue of the aponeurosis is affected by purulent-necrotic processes that develop during infectious complications.
Pregnancy.
Obesity, in particular its abdominal form.
Heavy physical activity.
Prolonged constipation.
Ascites.
Problems with urination.
Chronic lung diseases leading to persistent hacking cough (accompanied by tension).

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What to pay attention to during rehabilitation?

To ensure a sufficiently strong fusion during the rehabilitation period, restrictions are established. They concern:

ability to carry heavy loads - 2 months, not more than two kg;
playing sports and training - only from the third month with the permission of a doctor;
food - only boiled, light dishes, milk porridges, juices, low-fat soups, kefir, cottage cheese (the rest is in accordance with the above dietary requirements).

The photo shows a neat postoperative suture on days 2–3

Classification and stages

A hernia of the linea alba does not occur suddenly. One way or another, it is preceded by certain processes that lead to an increase in the size of the aponeurotic fissures. Preperitoneal fatty tissue begins to proliferate in them, leading to the formation of a lipoma. If you squeeze it, you will experience severe pain, which many patients and even doctors can mistake for an ulcer or other diseases of the gastrointestinal tract, accompanied by acute pain. Most often, the process ends at this stage and many people do not even suspect that they have such a pathology, especially if the disease is asymptomatic.

If the condition of the aponeurosis worsens, the situation may worsen. The peritoneum begins to stretch behind the fatty tissue, and when it gets into the aponeurotic fissures, a true hernia occurs. Following this, the greater omentum, a fragment of the intestine, or even the wall of the stomach may be pulled into the hernial sac.

Based on location, the following types of hernias of the white line of the abdomen are distinguished:

Supraumbilical. As the name suggests, they are located above the navel, in the so-called epigastric region. This is the most common pathology, found in 80% of hernias of the white line of the abdomen.
Peri-umbilical hernias (not to be confused with umbilical hernias). They form around the umbilical ring and are very rare, occurring in less than 1% of patients.
Subumbilical hernias, accordingly, are formed in the hypogastric region. They account for about 9% of all hernias.

A hernia of the linea alba is usually single. But there are also multiple formations located on top of each other.

What happens when a hernia forms?

The hernial canal in the linea alba forms gradually. The tendon fibers diverge over a distance of up to 12 cm. A hernial orifice is formed, resembling a circle, oval or diamond. There are stages of development. A hernia begins with stretching of the cracks in the fibers of the aponeurosis and the release of fatty tissue under the skin. It forms preperitoneal lipomas. The holes are still small.

With further expansion, an anatomical hernial orifice appears, into which the peritoneum protrudes in addition to the tissue. Normally, the role of the peritoneum is to cover and protect the inside of the abdominal wall and the outside of the abdominal organs. Here it forms the shell of the hernial sac.

At the stage of complete formation, the disease has all the classic signs:

hernial orifice - represented by an opening where organs protrude;
peritoneal sac;
components of the hernial sac are the intestinal loop, omentum, stomach wall, ligaments of internal organs.

Trauma to the contents of the sac causes swelling. The hernial orifice becomes narrow for self-reduction of the prolapsed omentum, pinching occurs with all the negative consequences.

Symptoms

At the stage of preperitoneal lipoma, the hernia can exist asymptomatically for a long time. If touched, acute abdominal pain develops, which can be confused with pathology of the gastrointestinal tract. It often happens that the hernia is in a stable state and exists at this stage for years without progression of the process.

If it increases, a protrusion forms along the midline of the abdomen. It causes painful sensations that intensify with palpation, after eating, when straining, etc. The pain can radiate under the shoulder blade, under the ribs or in the lower back. When the impact on the hernia stops, or intra-abdominal pressure normalizes, the pain subsides and may even stop for a while.

A serious complication of a hernia is strangulation, when the contents of the hernia are compressed by the hernial orifice. In this case, the patient experiences severe increasing pain. After some time, vomiting occurs, stool retention develops and symptoms of intestinal obstruction increase. In this case, the hernia cannot be repaired.

A strangulated hernia is a life-threatening condition and requires immediate hospitalization in a hospital followed by surgical care.

List of sources

Grubnik V.V., Parfentiev R.S., Vorotyntseva K.O. Laparoscopic methods of hernioplasty in the treatment of ventral hernias // Almanac of the Institute of Surgery named after. A.V. Vishnevsky. - 2010.- T 5, No. 1. - P. 152.
Dibirov M.D., Torshin S.A., Izmailov M.I. Problems of treatment of ventral hernias in the elderly and senile age // Mat. VII All-Russian Conference of General Surgeons. Krasnoyarsk, 2012. - P. 307-309.
Egiev V.N. Experience of intra-abdominal repair of ventral hernias / V.N. Egiev, A.L. Sokolov, V.S. Volkoedov, N.A. Ermakov // Almanac of the Institute of Surgery named after. A. V. Vishnevsky. - 2010.- T. 5, No. 1. - P. 153.
Morphological and functional changes in the muscles of the anterior abdominal wall in postoperative ventral hernias / Shpakovsky N.I., Filippovich N.F., Volodko Ya.T., Zuev V.S., Rylyuk A.F. // Journal of Healthcare of Belarus, 1983.- No. 5.- P.39-42.
Dibirov M.D., Torshin S.A., Izmailov M.I. Problems of treatment of ventral hernias in the elderly and senile age // Mat. VII All-Russian Conference of General Surgeons. Krasnoyarsk, 2012. - P. 307-309.

Diagnostics

The main symptom of hernia is the formation of a protrusion, accompanied by pain or discomfort at the site of its localization. In this case, the pain has a pulling or aching character and occurs or intensifies when pressure is applied to the hernia or when the abdominal muscles are tense. The intensity of pain does not depend on the size of the protrusion.

As for the protrusion itself, upon palpation you can determine that it has a soft consistency. When the position of the body changes, it can change its configuration and size. For example, with a vertical position of the body and straining, it increases. When lying down, it may decrease or disappear altogether.

Examination for hernias of the white line of the abdomen includes the following techniques:

The linea alba of the abdomen is palpated along its entire length, starting from the xiphoid process and ending with the suprapubic region.
To determine the hernial contents, palpation and percussion are performed. In the presence of intestinal loops, rumbling and a ringing tympanic sound will be detected. If there is a seal, the sound will be muffled.
The reducibility of the hernia is determined with the patient lying on his back.
The cough impulse symptom is examined. A finger is inserted into the hernial opening and the patient is asked to cough. If it is a hernia, then tremors will be detected during coughing.
The patient is also asked to push. This will allow you to determine the maximum possibility of a hernial protrusion, if it is large, or to detect small hernias that may not yet appear.

Diet

There is no special diet for postoperative hernias, but the diet should be adjusted towards limiting the amount of food taken at the same time (that is, 5-6 meals in small portions are indicated). constipation are excluded from the diet - saturated meat broths, cabbage, spicy, fatty and spicy foods, legumes, rice, brown bread, milk/dairy products, fresh baked goods, flour products, astringent fruits/berries, carbonated drinks .

The diet should be based on dietary meats, lean fish, chicken eggs, cottage cheese, cereals, baked vegetables, fruits, rosehip decoction, dried fruit compote, weak tea.

Treatment methods

All hernias of the white line of the abdomen can be cured exclusively with surgery. Elective operations are performed for uncomplicated hernias. At the same time, it is possible to fully examine the patient and choose the optimal tactics for hernioplasty. Emergency operations are performed when complications develop (strangulated hernia), and in some cases several stages with delayed repair are required.

The choice of hernia repair method is determined based on the reasons for its formation, as well as the shape and size of the hernia. Sometimes it is impossible to carry out a full-fledged operation, in which case palliative interventions are limited. Such situations arise when the patient is old, in the presence of giant hernias, after closure of which suffocation may develop due to a sharp decrease in the volume of the abdominal cavity. Also, suturing is contraindicated in the early period after a strangulated hernia complicated by phlegmonous inflammation.

There are several ways to operate on hernias of the white line of the abdomen:

Fascial-aponeurotic plastic surgery. This method implements to the maximum extent the principle of stitching homogeneous tissues, which, under certain conditions, ensures their reliable fusion and reproduction of the natural anatomical relationships of the tissues of the abdominal wall.
This method is implemented in two ways:
- Simple suturing of the edges of the aponeurosis. This method is considered unreliable because it often causes relapses. Can be used in the treatment of young people.
The second method is suturing the aponeurosis with strengthening with muscle tissue . It is assumed that the muscle, due to its elasticity, will counteract the increase in intra-abdominal pressure. In practice, this method is also rarely used due to the technical difficulties of the operation. The main point is to preserve muscle function during muscle transplantation, and this is not always possible.
And the last method is plastic surgery using artificial reinforcing materials that strengthen the white line. Such techniques are used for recurrent hernias, for large hernias, for atrophic changes in the structures of the abdominal wall, as well as for multiple hernias of the white line of the abdomen. Polymer meshes are used as reinforcement. They are chemically inert, non-toxic, elastic and durable. Their use has made it possible to sharply reduce the likelihood of relapses and achieve good treatment results.

In addition to the traditional method of performing surgery using skin incisions, endoscopic technologies are increasingly being used. They involve carrying out all surgical procedures through small punctures. The advantage of this technology is that the intervention is less traumatic, has a good cosmetic effect and a quick recovery period. The disadvantage of this method is the need for special equipment and trained personnel. To date, this is not available in every clinic.

Pathogenesis

The pathogenesis of the development of a postoperative hernia involves changes in the structural organization of the aponeurosis . Characteristic is remodeling of connective/muscular tissue caused by dystrophic/restorative processes. Recovery processes are considered as replacement compensatory processes in response to the death of part of the aponeurosis tissue. The trophic function of the aponeurosis is significantly reduced, which is due to a reduction in the microvasculature, which contributes to destructive trophic changes in the connective tissue. As a result of a metabolic disorder in the connective tissue, the aponeurosis becomes thinner, the collagen bundles become unfibered, and spaces filled with adipose tissue are formed between its fibers. The ratio of collagen types I and III decreases. The architecture of the scar has multidirectional elastic/collagen fibers running in different planes, forming a structure of unformed dense connective tissue. This significantly reduces the strength of the anterior abdominal wall and its adaptation to mechanical loads, promoting the formation of hernias .

Prevention

In order to prevent the formation of a hernia, it is recommended to adhere to the following rules:

Train your abdominal muscles.
Organize a proper diet to avoid constipation and diarrhea.
Maintain your weight at an optimal level.
Try not to lift heavy objects.
During pregnancy you need to wear a bandage.

As for the occurrence of recurrent hernias after their repair, the likelihood of relapse will be determined by the method of hernioplasty, the age of the patient and the condition of the tissues of the abdominal wall. The best results are achieved when strengthening the abdominal wall with synthetic materials in young patients.

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Features of the postoperative period

After the operation, the patient is observed and wound infection is prevented (a course of antibiotics, dressings with disinfectants). Men often have difficulty urinating. Walking is allowed on the second day. It is recommended to wear a bandage.

They are discharged home on days 8–10, immediately after the stitches are removed, but complete restoration of the tissue and wound will occur only after several months. At home, it is recommended to treat the wound with brilliant green. Dieting. Showering is allowed after two weeks. The doctor may prescribe physical therapy.