Hernia: is it worth rushing with surgery? Cholecystectomy or what the stones are silent about...

There are no safe gallstones and harmless abdominal and inguinal hernias. All of these diseases require surgery.

Unfortunately, most of our citizens end up on the surgeon’s table not as planned, but in emergency situations, literally on the verge of life and death. And not only the patients themselves are to blame for this, but, often, also the general practitioners whom such patients go to see. Many of these would-be specialists “allow” their patients to coexist with their deadly diseases for a long time and not rush into operations. The surgeons are sure that for such imaginary kindness these doctors should be deprived of the right to practice medicine. After all, cholecystitis (or cholelithiasis), as well as abdominal and inguinal hernias, are not just diseases, but time bombs that people suffering from these ailments carry within themselves. No one knows when it will explode, but if it happens, it won’t seem too bad.

Insidious organ: surgical treatment only

The gallbladder plays a supporting role in the body: bile settles in it, which, when a person eats fatty foods, comes from there and helps to absorb the eaten kebabs or smoked sausage. But due to various circumstances, stones can form in this organ.

Unfortunately, there is no other way to combat this disease other than surgery. Treatment with bile acid preparations, injection of special chemicals into the gallbladder (through a puncture), and crushing of stones with ultrasound (lithotripsy) do not lead to a cure. Even if there is only one stone in the gallbladder, this means that the organ will never be able to cope with its function as before. Therefore, the main method of treating cholecystitis today is surgery to remove the entire gallbladder (cholecystectomy).

Umbilical.

What are the symptoms of an umbilical hernia?

A hernia looks like a soft bulge near the belly button. It may be visible when you cough or tense your stomach, but it can also be noticeable when you are at rest. Umbilical hernias in adulthood can cause discomfort, pain in the abdomen and in the area of the hernia itself.

Causes of occurrence?

The formation of an umbilical hernia is promoted by too much intra-abdominal pressure. Causes may include excess weight, pregnancy, a tendency to constipation, difficulty urinating, excessive exercise, and fluid accumulation in the abdominal cavity (ascites). Such hernias most often require surgical intervention.

Acute cholecystitis means that the patient is late for surgery

Formations in the gallbladder may not bother their owner for some time. But, alas, much more often their movement leads to inflammation of the gallbladder wall - cholecystitis.

If microbes are added to the inflammation, acute cholecystitis occurs, which requires urgent surgical treatment. It is especially dangerous if the stone blocks the bile duct. In this case, jaundice, chills, and pain occur - this is a consequence of the rapid destruction of the liver. Stones can block the flow of secretions from the pancreas, causing a deadly disease - acute pancreatitis. This means only one thing: the patient was late for the operation.

Of course, it is not a fact that gallstones will definitely “speak,” but if this happens, good things cannot be expected, especially if it happens somewhere far from home, or even in a foreign country. Therefore, it is better not to wait for a dangerous outcome. By the way, the number of stones also does not play any role in the development of the disease. Even a single stone in the gall bladder can become a gravestone for a person. The small size of the stone should not be reassuring either - precisely such stones are the most dangerous, since they can get stuck in the duct.

On the verge of life and death

Endoscopic gallbladder removal: no scars or pain

Removal of an essentially useless gallbladder - cholecystectomy - is today carried out in the most gentle way possible, using laparoscopy, after just 3-4 punctures on the body. A few hours after the operation, the patient can already get up, and after 2 days he goes home. At the same time, he does not experience pain, there are no scars left after the intervention - only barely noticeable traces of punctures. There are also no restrictions after the operation.

Of course, you shouldn’t overeat on fatty foods and drink alcohol, but this is not useful not only for those who have undergone surgery, but also for all other people. The quality of life of patients after cholecystectomy does not suffer at all - it’s just that the bile no longer settles in the bladder, but directly leaks into the duodenum.

What diagnostic methods may be needed?

In most cases, visual examination and medical history, including the date of surgery and the nature of rehabilitation, are sufficient to make a diagnosis. A general blood and urine test is required, and radiography and ultrasound of the abdomen may also be useful.

A hernia after abdominal surgery most often appears unexpectedly, and the patient’s task is to find his bearings in time and consult a doctor. “The First Family Clinic” is open every day at the address: Kolomyazhsky Prospekt, 36/2 (Udelnaya metro station, Pionerskaya).

Dangerous gap. Surgical treatment of hernias in Vladivostok

Another common surgical problem is hernia. This is a defect, or more simply put, a hole in the anterior abdominal wall through which internal organs fall out under the skin. According to statistics, 4 out of a thousand people suffer from this disease. In men, inguinal hernias occur more often, in women - umbilical hernias. People of any gender can develop incisional hernias. They are the most common - they occur in a third of patients who have undergone surgery on the abdominal organs.

As you know, the abdominal wall consists of muscles that normally support the internal organs, preventing them from protruding outward. But as soon as this natural framework weakens, a person faces the threat of a hernia. The disease is provoked by congenital abnormalities of the abdominal wall, weakness of connective tissue, trauma (during operations), and excessive physical activity. In addition, the cause of hernias is often an increase in intra-abdominal pressure due to obesity, pregnancy and diseases of the colon, especially those accompanied by constipation. Hereditary predisposition also plays an important role.

Postoperative ventral hernia - symptoms and treatment

For the surgical treatment of PIH, a huge number of different methods have been proposed, differing mainly in the technique of closing and strengthening the hernial orifice (hernioplasty).[24] All methods of PIH hernioplasty can be divided into two groups: plastic using local tissues and plastic using additional plastic materials. A combination of these methods is also possible.

Hernioplasty with local tissues

There are several methods of hernioplasty using local tissues:

aponeurotic methods of hernioplasty;
muscular-aponeurotic methods of hernioplasty;
muscular methods of hernioplasty;
plastic surgery using a hernial sac.

Despite the high risk of relapse, plastic surgery with local tissues takes place in surgical practice. Most often, these methods are used in children and young women.

Plastic surgery of the hernial orifice using additional plastic materials

Plastic surgery using preserved dura mater

Among homoplastic techniques, the most relevant was the use of the dura mater, and many surgeons, especially in Russia, used preserved dura mater for plastic surgery, especially for large and giant PIH.[2] Dura plastic surgery was widely used in the clinic of K. D. Toskina, where this plastic surgery has been used since 1972. Good results can be noted, for example, in 252 operations it has only 1.8% relapses and 5.6% wound complications. In modern herniology, this technique is not used, since the problems associated with the preparation and storage of implants have been joined by the problem of HIV infection and hepatitis.

Plastic surgery using autoderma

Due to the ease of implementation and less trauma (compared to the use of autofascia), only autodermal plastic surgery remains relevant among autoplastic techniques. These methods and alloplasty with the use of artificial prostheses form the basis of modern plastic surgery using additional plastic materials. The first experience of using skin for hernioplasty belongs to G. Simon in 1881. The skin was cut around the hernial protrusion, the inner edges were stitched together, and the hernial sac with a sutured skin flap was immersed by suturing the outer edges of the skin incision. This technique was accompanied by a large number of relapses and specific complications, such as the formation of dermoid cysts. With autodermal plastic surgery, an important point is the fixation of the skin flap with some tension, as well as early activation of patients. This degeneration of the skin flap was actively used by supporters of autodermal plastic surgery to widely promote this method. One of the main problems remains the problem of complications of the wound area and graft engraftment. Another obstacle was that the skin flap degenerates not into dense aponeurotic tissue, but into scar-like loose connective tissue, which has much less resistance to physical stress. The use of autodermal plastic surgery in the treatment of large hernias with intestinal and/or ligature fistulas is generally inappropriate.[12]

Use of synthetic material

Since the 40s of the 20th century, a new stage in herniology began, associated with the synthesis of high-molecular polymers suitable for implantation into the tissues of the human body. The development, implementation and use of modern polymer materials have significantly expanded the possibilities of prosthetic hernioplasty of PIH of almost any size.[10] Currently, prosthetic hernioplasty is the basic treatment method for patients with PIH. However, with prosthetic hernioplasty, the question arises about specific complications - seromas, due to prolonged exudation of the reactive fluid in the area of the prosthesis.[18] The incidence of complications may depend on many factors, ranging from the prosthesis used to the method of its implantation. Today, in addition to the surgeon’s technique, it is necessary to take into account the characteristics of synthetic polymer materials to increase the efficiency of prosthetic methods, since complications associated with low quality prostheses can ruin even the most advanced surgical technique. The use of materials such as nylon, foam rubber, polyvinyl alcohol, fluoroplastic and many others has increased the frequency of infiltrates, seromas and suppurations, long-term non-healing fistulas, and sequestration of grafts.[14] Some authors have written about the carcinogenicity of plastics when they remain in the body for a long time.[3][17][24] Considering all of the above, the synthetic material for hernioplasty must be chemically inert, durable, elastic, convenient for sterilization and affordable; the prosthesis must not have carcinogenic or pro-inflammatory properties.

With the development of laparoscopic herniology, an additional requirement has recently emerged - the ability to form a barrier to the development of adhesions from the abdominal cavity. JP Amid (1997) identifies four types of synthetic materials:

Type No. 1 - total microporous endoprosthesis (atrium, Marlex, Prolene, Trelex). The micropore diameter of this type is more than 75 microns. Macrophages, fibroblasts, capillaries, and collagen fibers freely penetrate through these pores.

Type No. 2 - total microporous prosthesis (Gore-Tex; surgical membrane and double network) with a micropore size of less than 10 microns.

Type No. 3 - macroporous endoprosthesis with a multifilament component (Teflon, Mersilene, Dacron, woven polypropylene network).

Type No. 4 - materials with submicroscopic pores. Type 4 materials are practically unsuitable for plastic surgery, but in some cases they are used in combination with type 1 prostheses for intra-abdominal implantation. In cases of infection of the material when the porosity of its fibers is less than 10 microns, the dentures have to be completely removed, since leaving it leads to the formation of a chronic focus of infection. The properties described above are found in braided and twisted threads, as a result of which a good prosthetic material should consist of monofilament threads. The main material that meets the requirement is polypropylene, the study of which showed no signs of rejection, carcinogenicity or resorption over time. On its basis, monofilament polypropylene mesh Marlex, bifilament polypropylene mesh Prolene, multifilament polypropylene mesh Surgipro, which are still used today, were created. Also, the pore diameter of the material determines the speed and quality of its implantation into the body tissue. It has been proven that with a pore size of more than 75 microns, the implant grows throughout its entire thickness with collagen fibers and fibrocytes within a month, while with smaller pores, histiocytic infiltration prevails and, as a result, weaker fixation of the synthetic material in the body tissues.

The use of Marlex and Prolene prostheses, whose pore sizes are 100 microns, has reduced the incidence of wound infectious complications compared to lavsan (mersilene) from 15% to 5%, and the formation of fistulas from 15% to 2%. It has been experimentally proven that the optimal pore size is 2-3 mm.[22] Prostheses made of polytetrafluoroethylene (Gore-Tex) are quite inert, comparable to polypropylene, but their adhesive properties are lower, which means they are less firmly implanted into the body tissue. In addition, their use is often complicated by chronic tissue infection. JJ Bauer et al. (2002) reports the use of Gore-Tex during operations for extensive hernias, the result was wound suppuration in 7.1% and recurrence of the hernia in 10.7% of patients; in one patient the prosthesis had to be removed. Therefore, Gore-Tex is used exclusively for laparoscopic hernia repairs, in which the likelihood of infection of the prosthesis is minimized due to the tense carboxyperitoneum.[10]

A more delicate connective tissue scar allows the use of so-called “lightweight” meshes (Vipro, Vipro-2, Ultrapro), that is, meshes with a reduced amount of polypropylene per unit area of the prosthesis, which reduces the intensity of the inflammatory reaction. Currently, polypropylene meshes PMS (6-11 cm), PMM (15-15 cm), PML (30-30 cm), PMH, produced by are widely used; polypropylene mesh SPMM-35 (7 13 cm), SPMM-66 (15 15 cm), SPMM-135 (22 33 cm), produced by the TYCO corporation, as well as monofilament polypropylene mesh produced by St. Petersburg. [22] Use of other synthetic materials materials is undesirable, since it increases the risk of chronic infection of the prosthesis, which inevitably requires its complete removal.

About 1 million mesh implants for hernia repair are used annually in the world. In some countries, up to 90% of all hernias are operated on using polypropylene mesh prostheses.[22]

Among the methods of prosthetic hernioplasty, two large groups can be distinguished: “tension-free” methods and combined ones. The essence of tension-free repair is to use the patient’s own tissues to close the hernia defect without complete adaptation (contact) of the edges of the hernia defect in combination with a mesh prosthesis. In this case, the grid can be placed and fixed in various ways, according to the onlay, inlay, online+inlay, sublay principles. With combined prosthetic plasty, the hernia defect is eliminated completely by local tissues, by matching and layer-by-layer complete adaptation of its edges (tension plasty), due to which the normal topographic-anatomical structure of the abdominal wall and its function is restored, and is additionally strengthened by a prosthesis, which can be positioned according to the on-lay principle or sublay. Based on the above, many herniologist surgeons call tension plasty radical, and non-tension plasty palliative. However, a complete, layer-by-layer comparison of the topographic-anatomical structure of the abdominal wall in extensive and giant hernias, unfortunately, is not always possible.

Non-tension methods of prosthetic hernioplasty

The essence is plastic surgery of the hernial orifice with exogenous material without any adaptation of the edges of the defect. There are a large number of different methods of tension-free hernioplasty, differing both in the methods of placing the prosthesis and in the methods of their fixation. The main methods of tension-free hernioplasty:

over the muscular aponeurotic frame (or the second name is “onlay”): with this type of plastic surgery, the defect in the aponeurosis is closed edge to edge, an endoprosthesis is placed on the suture, after peeling off 4-6 cm in different directions of the subcutaneous fatty tissue, and sutured to aponeurosis;
under the muscular aponeurotic frame (retromuscular, preperitoneal, another name is “sublay”): with this method, after fixing the prosthesis to the peritoneum, the opened sheaths of the rectus abdominis muscles are sutured together edge to edge;
With the “inlay” technique, hernioplasty of the abdominal wall is performed with an endoprosthesis without covering it with aponeurosis tissue. This can only be done in cases where it is impossible and dangerous to compare the edges of the hernial orifice due to the risk of developing compartment syndrome.

In the nineties, various methods were proposed for the repair of giant hernias:

In 1990, the Ramirez method appeared, which consisted of dissecting the aponeurosis of the external oblique muscle on both sides, which is necessary to reduce the hernial orifice.
In 1996, the Devlin method appeared, in which the mesh graft is placed and fixed using the “onlay” method, while it is necessary to achieve minimal tension on the edges of the hernia defect.[12]

Combined methods of prosthetic hernioplasty

In cases of using “combined methods” of plastic surgery, closure of the hernial defect includes one of the above methods of aponeurotic plastic surgery using only local tissue, and the prosthesis is fixed above or below the aponeurosis. The choice of one or another plastic method is made by the surgeon individually, depending on the type and size of the hernia, the condition of the local tissues, the patient’s age and the presence of concomitant pathology.

Based on the experience of surgical treatment of 188 patients with extensive and giant hernias, V.G. Lubyansky et al. (2008) found that patients before surgery had dysfunction of the abdominal-caval pump associated with destruction of the anterior abdominal wall and decreased mobility of the dome of the diaphragm. Part of the intestine is located outside the abdominal cavity. All this causes low intra-abdominal pressure, which, in turn, leads to obstructive and restrictive lung diseases. When reconstructing the anterior abdominal wall, the work of the abdominal-caval pump is restored, this ensures an increase in the speed of venous blood flow in the femoral vein and is the basis for the prevention of thromboembolic complications.

The above determines the advantage of using combined methods of prosthetic hernioplasty of ventral hernias over non-tension hernias, which consists in eliminating the preoperative pathological relative position of the anatomical structures of the anterior abdominal wall and restoring the physiological properties of the abdominal press. To prevent inhibition of intestinal motility, elevation of the diaphragm and displacement of the chest organs, which can lead to disruption of cardiac activity, breathing and the development of abdominal compartment syndrome, clear indications for one or another type of operation are determined. Of particular importance is the preoperative preparation of patients and timely prevention of cardiopulmonary complications in the early postoperative period. According to V.N. Egieva and D.V. Chizhova (2004), the use of combined plastic surgery results in up to 20% of disease relapses.[22] Most domestic and foreign authors note from 15 to 35% of relapses during prosthetic hernioplasty of extensive and giant PIH.

Endovideosurgical techniques for prosthetic hernioplasty

New horizons in herniosurgery are opened by minimally invasive laparoscopic techniques, which make it possible to eliminate many of the disadvantages of traditional hernioplasty. A revolution in hernioplasty in 1993 was made by Karl LeBlanc, who proposed a new method of laparoscopic hernioplasty, in which a mesh endoprosthesis was installed intraperitoneally and its fixation was carried out laparoscopically. This tactic in the world literature is called IPOM (intraperitoneal onlay mesh). The IPOM technique involves closing the hernia defect using special mesh endoprostheses, the distinctive feature of which is a two-layer structure. One side of the mesh is coated with a special solution that does not cause adhesion upon contact with internal organs, the second, on the contrary, has adhesive properties in order to connect with the peritoneum as firmly as possible. The mesh is suspended using non-absorbable ligatures in the abdominal cavity and fixed around the perimeter using tackers. The original LeBlanc technique had metal tackers. However, with the classical IPOM technique, the risk of the formation of postoperative seromas and granulomas of the hernial sac increases, so this technique is modified.

Advanced techniques in surgery of umbilical and ventral hernias with the Ventralex ST endoprosthesis

To perform an operation using this technology, an umbilical or ventral hernia must not have been previously operated on and the hernia orifice size must not exceed 6 square meters. see. Surgical intervention is performed through a small herniotomy incision and another additional trocar access of 5 mm. Under endotracheal anesthesia, a 5 mm trocar is installed on the left flank. Afterwards, a herniotomy incision of up to 1.5-2 cm is made in the area of the protrusion and the hernial sac with its contents is resected. Removing the contents of the hernial sac is safe, since laparoscopy was performed before and it was found that there is no risk of damage to internal organs. The Ventralex endoprosthesis is inserted into the abdominal cavity, resembling a mushroom in shape, which, as mentioned earlier, has two surfaces - a fixing and a protective one. After installation of the Ventralex endoprosthesis, laparoscopy is performed again to check the quality of the installation of the prosthesis. Afterwards, several skin sutures are applied, and the operation is completed.

Treatment of umbilical and ventral hernias using this method has a number of advantages:

minimal trauma;
duration of intervention - 15-20 minutes;
there is virtually no pain after surgery;
rapid rehabilitation (discharge from hospital after 24-48 hours);
pronounced cosmetic effect.

According to many authors, the rate of complications after laparoscopic hernioplasty ranges from 2 to 26%, and the rate of relapse of the disease varies from 0 to 17%. One of the main concerns when using laparoscopy to treat PIH is the presence of a prolonged adhesive process in the abdominal cavity. When installing ports, there is a high probability of damage to the abdominal organs involved in the adhesive process.

Don't embarrass yourself. The only way out in case of infringement is immediate surgery

For the time being, the hernia may not bother the patient. And visually, the protrusion is not always noticeable, but, as a rule, only with pressure and when a person has to strain and strain. However, even a “silent” hernia can pose a great danger. If for some reason internal organs are injured, the outcome can be very tragic. Infringement occurs due to compression of blood vessels. Just a few hours of delayed blood circulation is enough for gangrene to develop in the tissues, so a delay in surgery can cost the patient his life. No one knows when this terrible complication may occur. According to statistics, up to 40% of hernias are strangulated. This often happens after heavy lifting and excessive physical activity.

The only way out in case of infringement is immediate surgery. However, the mortality rate after such an emergency intervention is 5–6 times higher than with planned surgery. Therefore, it is better not to wait for a dangerous outcome and to operate on the hernia on time. The sooner this is done, the better the results will be, including long-term ones.

In the Middle Ages, there was only one method of treating hernias - cauterization with a hot iron. Our contemporaries were much more fortunate - today such defects can simply be “patched.” Plastic surgery using mesh composite prostheses, similar to a patch, is a modern and effective way to treat hernias.

There are practically no complications after implantation of such a “patch”, since the synthetic material does not cause a rejection reaction. After it, there are practically no relapses, since the prosthesis forms a particularly strong frame in the leaky tissues of the abdominal wall, much stronger than natural muscle tissue. Thus, this method is not only therapeutic, but also preventive. Thanks to its mesh structure, the polypropylene flap soon grows with the patient’s own cells and after a while it cannot be distinguished from native tissues.

Implantation of mesh prostheses can be performed on all patients over 16–18 years of age. Even diabetes mellitus is not a contraindication for this method - such patients simply need more thorough preoperative preparation.

This operation is also performed using laparoscopy, through three barely noticeable punctures. Patients do not experience any pain or any unpleasant sensations afterwards. After such an intervention, you do not need to wear a bandage for six months or limit weight lifting, as is the case with traditional hernia operations. Within 2–3 days after installing the patch, the patient is discharged home, and after a month they can even engage in weightlifting.

Recommendations from specialists in the early postoperative period

During the first 4-6 hours after surgery, you should not drink or get out of bed. Until the morning of the next day after the operation, you can drink plain water without gas, in portions of 1-2 sips every 10-20 minutes with a total volume of up to 500 ml. The patient can get up 4-6 hours after surgery. You should get out of bed gradually, first sit for a while, and, in the absence of weakness and dizziness, you can get up and walk around the bed. It is recommended to get up for the first time in the presence of medical personnel (after a long stay in a horizontal position and after the action of medications, orthostatic collapse - fainting) is possible.

The next day after the operation, you can move freely around the hospital, start taking liquid foods: kefir, oatmeal, diet soup and switch to the usual regime of drinking liquids. In the first 7 days after surgery, the consumption of any alcoholic beverages, coffee, strong tea, drinks with sugar, chocolate, sweets, fatty and fried foods is strictly prohibited. The patient's diet in the first days after laparoscopic cholecystectomy may include fermented milk products: low-fat cottage cheese, kefir, yogurt; porridge with water (oatmeal, buckwheat); bananas, baked apples; mashed potatoes, vegetable soups; boiled meat: lean beef or chicken breast.

In the normal course of the postoperative period, the drainage from the abdominal cavity is removed the next day after surgery. Removing the drainage is a painless procedure; it is performed during dressing and takes a few seconds.

Young patients after surgery for chronic calculous cholecystitis can be sent home the next day after surgery; other patients are usually in the hospital for 2 days. Upon discharge, you will be given a sick leave certificate (if you need one) and an extract from the inpatient card, which will outline your diagnosis and features of the operation, as well as recommendations on diet, exercise and medication. A sick leave certificate is issued for the duration of the patient’s stay in the hospital and for 3 days after discharge, after which it must be extended by the clinic surgeon.

Care of postoperative sutures

In the hospital, special stickers will be applied to postoperative wounds located at the places where instruments are inserted. It is possible to take a shower with Tegaderm stickers (they look like a transparent film), while Medipore stickers (a white patch) must be removed before showering. You can shower starting 48 hours after surgery. Getting water on the seams is not contraindicated, but you should not wash the wounds with gels or soaps or rub them with a washcloth. After taking a shower, you should lubricate the wounds with a 5% iodine solution (or betadine solution, or brilliant green, or 70% ethyl alcohol). Wounds can be treated using the open method, without dressings. Taking baths or swimming in pools and ponds is prohibited before the sutures are removed and for 5 days after the sutures are removed.

Sutures after laparoscopic cholecystectomy are removed 7-8 days after surgery. This is an outpatient procedure, the sutures are removed by a doctor or a dressing nurse, and the procedure is painless.

Classification of postoperative hernias

Hernial protrusions are classified by size. Highlight:

a small postoperative hernia,
which is located in any one area of the abdomen and does not change its configuration. Determined only by palpation or ultrasound examination with the size of the hernial orifice up to 5 cm;
medium postoperative hernias
, which occupy part of one area of the abdomen with the formation of a visible protrusion and the size of the hernial orifice from 5 to 10 cm;
large postoperative hernias,
completely occupying any area of the anterior abdominal wall, changing the shape of the abdomen, with the size of the gate from 10 to 15 cm;
giant postoperative hernias
, occupying two or three areas of the abdomen or more, sharply deforming the abdomen, interfering with everyday life, with the size of the hernial orifice more than 15 cm. In 2006, the Society of Herniologists of Russia recommended adhering to the SWR Classification, recognized in Madrid at the XXI International Congress herniologists.

This classification takes into account three main parameters: the localization of the hernia in relation to the navel (median, lateral and combined), the size of the hernia orifice and the presence of relapses.