Information about surgical correction of a hernia of the small intestine or rectum

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An abdominal hernia is a common surgical disease characterized by the protrusion of internal organs located in the abdominal cavity under the skin through cracks and holes in the muscles. This occurs as a result of weakness of connective tissues or as a result of damage (trauma, surgery).

An abdominal wall hernia can be triangular, oval, slit-shaped, round or indeterminate in shape. Most often, the hernial sac may contain loops of the small intestine, fragments of the omentum, the cecum, the appendix, transverse colon, etc. may also end up here.

About small intestinal hernias

A small bowel hernia, also called small bowel prolapse, occurs when the small bowel moves downwards and puts pressure on the upper part of the vagina. This results in a protrusion (see Figure 1).

Figure 1. Internal organs of a woman with and without a small intestinal hernia

A small intestinal hernia occurs when the upper part of the vagina weakens. This may be caused by:

• aging;
• vaginal birth of large children;
• menopause;
• hysterectomy (surgery to remove the uterus) or other gynecological surgery.

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About rectal hernias

A rectal hernia, also called rectal prolapse, is a protrusion of the rectum toward the back wall of the vagina (see Figure 2).

Figure 2. Internal organs of a woman with and without a rectal hernia

A rectal hernia occurs when the muscles of the vaginal walls weaken. This may be caused by:

• aging;
• vaginal birth of large children;
• menopause.

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What will happen if left untreated?

The bulge will gradually increase, will no longer disappear when lying down, and the pain will intensify. The most dangerous complication is strangulation, which can lead to organ necrosis followed by peritonitis, which is a direct threat to life. In case of strangulation, emergency removal of the abdominal hernia is performed.

Important! In this condition, you should not try to correct the defect yourself. It is urgent to call an ambulance.

Other possible complications of hernias:

• inflammation;
• impossibility of reduction;
• coprostasis.

Treatment of hernia of the small intestine and rectum

You will undergo surgical correction. During correction surgery, your vaginal walls will be strengthened with sutures. Surgical repair of a small intestinal hernia stops the small intestine from protruding into the vagina. Surgical repair of a rectal hernia stops the rectum from protruding into the vagina.

Risks associated with surgical correction

Most patients with a hernia of the small intestine or rectum do not experience problems after surgical correction. After surgery you may experience:

• pain;
• vaginal bleeding;
• infection;
• injury to the bladder or ureters (the tubes that carry urine from the kidneys to the bladder);
• incontinence (urine leakage);
• long-term or persistent problems with urination: you may need to have a catheter (thin, flexible tube) inserted into your bladder to drain urine, or you may need other surgery to solve the problem;

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Publications in the media

Regarding the treatment of this disease, you can contact the Surgical Department No. 1 of the Clinic of Faculty Surgery named after. N.N. Burdenko

Abdominal hernias are divided into external and internal • External abdominal hernia is a surgical disease in which, through various openings in the muscular aponeurotic layer of the abdominal walls and pelvic floor, the viscera emerge along with the parietal layer of the peritoneum with the integrity of the skin • Internal abdominal hernia is formed inside the abdominal cavity in peritoneal pockets and folds or penetrates into the chest cavity through natural or acquired openings and slits of the diaphragm.

Frequency. Observed at any age. Peaks of incidence are preschool age and age after 50 years. It is registered more often in men.

Etiology • Congenital defects of the abdominal wall (for example, congenital indirect inguinal hernias) • Enlargement of the abdominal wall openings. Normally existing but pathologically enlarged openings in the abdominal wall can cause protrusion of internal organs (for example, the protrusion of the stomach into the chest cavity through the enlarged esophageal opening of the diaphragm during a hiatal hernia) • Thinning and loss of elasticity of tissues (especially against the background of general aging of the body or exhaustion) lead to the formation of inguinal, umbilical hernias and hernias of the white line of the abdomen • Trauma or wound (especially postoperative), when degenerative changes develop in normal tissues along the incision line, which often leads to the formation of postoperative ventral hernias. Suppuration of a postoperative wound increases the risk of hernia formation • Increased intra-abdominal pressure. Factors contributing to increased intra-abdominal pressure: heavy physical labor, cough in chronic lung diseases, difficulty urinating, prolonged constipation, pregnancy, ascites, abdominal tumors, flatulence, obesity.

Basic concepts. The type of hernia can be determined by objective examination or during surgery • Complete hernia. The hernial sac and its contents exit through a defect in the abdominal wall (for example, a complete inguinal hernia, when the hernial sac with its contents is in the scrotum [inguinoscrotal hernia]) • Incomplete hernia. There is a defect in the abdominal wall, but the hernial sac with its contents has not yet gone beyond the abdominal wall (for example, an incomplete inguinal hernia, when the hernial sac with its contents does not extend beyond the external inguinal ring) • Reducible hernia. The contents of the hernial sac easily move through the hernial orifice from the abdominal cavity to the hernial sac and back • Irreversible hernia. The contents of the hernial sac cannot be reduced through the hernial orifice due to the formed adhesions or large size of the hernia • Strangulated hernia - compression of the contents of the hernial sac in the hernial orifice • Congenital hernia is associated with developmental anomalies • Sliding hernia contains organs that are partially not covered by the peritoneum (cecum , bladder), the hernial sac may be absent • Richter’s hernia is a strangulated hernia of the abdomen. Its peculiarity: infringement of only part of the intestinal wall (without the mesentery). There is no intestinal obstruction (or it is partial) • Littre hernia is a hernia of the anterior abdominal wall containing a congenital diverticulum of the ileum.

Complications mainly arise from delays in seeking medical help and late diagnosis • Obstructive intestinal obstruction develops when a loop of intestine protrudes through a defect in the abdominal wall with the appearance of a mechanical obstacle to the passage of intestinal contents as a result of compression or bending of the intestine (the so-called fecal strangulation) • Strangulated intestinal obstruction with necrosis and perforation of the intestinal loop develops as a result of compression of the mesenteric vessels with impaired blood flow in the wall of the strangulated intestine (so-called elastic strangulation) • Isolated necrosis with perforation of the strangulated area of ​​the intestinal wall with Richter's hernia.

Inguinal hernia

• Indirect inguinal hernia •• Passes through the deep inguinal ring into the inguinal canal. In some cases, it can descend into the scrotum (complete hernia, inguinal-scrotal hernia) •• With congenital inguinal hernias, the processus vaginalis of the peritoneum remains completely open and communicates with the abdominal cavity, inguinal canal and scrotum. Partially obliterated processus vaginalis of the peritoneum can cause hydrocele of the spermatic cord •• Prevalence. 80–90% of all types of abdominal hernias are inguinal. Among patients with inguinal hernias, 90–97% are men aged 50–60 years. In general, it occurs in 5% of men •• In children, there is a significant tendency to incarceration. In 75% of cases, a right-sided hernia is observed •• Can be combined with undescended testicle into the scrotum, its location in the inguinal canal, the development of hydrocele of the testicular membranes or the vaginal membrane of the spermatic cord •• Bilateral nonfusion of the processus vaginalis of the peritoneum is observed in more than 10% of patients with an indirect inguinal hernia .

• Direct inguinal hernia. The inferior epigastric artery and vein serve as an anatomical landmark for recognizing oblique and direct inguinal hernias. A direct inguinal hernia emerges from the abdominal cavity medially from the lateral umbilical fold •• Exits in the area of ​​the bottom of the inguinal canal through Hesselbach’s triangle as a result of thinning and loss of elasticity of tissues •• Direct inguinal hernia is a direct exit of internal organs through the posterior wall of the inguinal canal posteriorly and medially from the spermatic cord; the hernia lies outside the elements of the spermatic cord (unlike an oblique inguinal hernia) and, as a rule, does not descend into the scrotum. The hernial orifice is rarely narrow, so a direct inguinal hernia (as opposed to an oblique one) is less likely to be strangulated •• The hernia is not congenital, it is more often observed in old age. In the elderly, it is often bilateral •• Recurrent hernias occur more often in patients with direct inguinal hernias than in patients with indirect inguinal hernias. Surgical treatment is aimed at strengthening the posterior wall of the inguinal canal.

• Combined inguinal hernias are classified as complex forms of inguinal hernias. The patient has 2 or 3 separate hernial sacs on one side, not communicating with each other, with independent hernial openings leading into the abdominal cavity.

• Femoral hernia exits through the femoral canal along the femoral fascia •• Prevalence - 5-8% of all abdominal hernias. Most patients (80%) are women aged 30–60 years •• Rarely large, prone to strangulation. The contents of the hernial sac are a loop of the small intestine, an omentum •• The appearance of hernias is usually associated with heavy physical exertion, chronic constipation and pregnancy.

• Diagnostics •• Patient complaints about a tumor-like protrusion in the groin area and pain of varying intensity (especially with physical stress) •• Objective examination ••• Examination. Pay attention to the shape and size of the hernial protrusion in the vertical and horizontal positions of the patient ••• Palpation. Determine the size of the hernial protrusion, the degree of reducibility, the size of the internal opening of the inguinal canal, the shape and size of the testicles ••• The symptom of a cough push is the jerk-like pressure of the hernial sac on the tip of a finger inserted into the inguinal canal when the patient coughs ••• Percussion and auscultation of the area of ​​the hernial protrusion . Carry out to identify peristaltic noises and tympanic sound (if there is a loop of intestine in the hernial sac) •• Differential diagnosis: lipoma, inguinal lymphadenitis, abscess, orchiepididymitis, hydrocele of the testicular membranes, varicocele, cryptorchidism.

• Treatment •• The main stages of hernia repair: ••• Access to the inguinal canal ••• Isolation of the hernial sac, opening its lumen, assessment of the viability of the contents and its reduction into the abdominal cavity ••• Ligation of the neck of the hernial sac, its removal ••• Inguinal plastic surgery canal •• Features of hernia repair for oblique inguinal hernias: ••• Ligation of the hernial sac at the level of the parietal peritoneum ••• Suturing of the deep inguinal ring to normal sizes ••• Strengthening the anterior wall of the inguinal canal with mandatory suturing of the deep inguinal ring is used in young men with small indirect inguinal hernias. For sliding, recurrent and large inguinal hernias, the posterior wall of the inguinal canal is strengthened. For large defects of the abdominal wall, it is strengthened using various grafts. Strengthening the anterior wall of the inguinal canal. Girard's method: the internal oblique and transverse abdominal muscles are sutured to the inguinal ligament above the spermatic cord, and a duplicative aponeurosis of the external oblique abdominal muscle is created. Currently, various modifications of this operation are used - the Spasokukotsky method, the Kimbarovsky suture. Strengthening the posterior wall of the inguinal canal. Bassini's method: the edges of the internal oblique and transverse abdominal muscles, together with the transverse fascia, are sutured to the inguinal ligament under the spermatic cord, on top of which the edges of the previously dissected aponeurosis of the external oblique muscle are sutured. Alloplasty. Used for complex forms of inguinal hernias. Skin autografts, dura mater allografts, and synthetic materials are used. •• A feature of hernia repair for direct inguinal hernias is the strengthening of the posterior wall of the inguinal canal after reduction of the contents of the hernial sac. The Bassini method is used •• Hernia repair for femoral hernias can be performed using the femoral and inguinal methods ••• Femoral method. The femoral canal is approached from its external opening. Most surgeons use the method proposed in 1894 by Bassini. Access: parallel to and below the inguinal ligament above the hernial protrusion. The hernial orifice is closed by suturing the inguinal and pubic (Cooper) ligaments. The femoral canal is sutured with a second row of sutures between the edge of the lata fascia of the thigh and the pectineal fascia. Unfortunately, the Bassini operation leads to deformation of the inguinal canal and in some cases contributes to the occurrence of indirect inguinal hernias. Rudzhi's operation does not have this disadvantage ••• Inguinal method according to Rudzhi. The inguinal canal is opened with an incision above and parallel to the inguinal ligament and (after removal of the hernial sac) the hernial orifice is sutured with sutures connecting the inguinal and Cooper ligaments with the internal oblique and transverse muscles. In this way, the inguinal and femoral canals are simultaneously closed •• Relapses after surgical treatment - 3–5% •• Special situations ••• Incarceration of a section of the intestine followed by necrosis. If the diagnosis is established, laparotomy, revision of the abdominal cavity and resection of the nonviable segment of the intestine are performed. ••• Relapses and large defects of the abdominal wall. To eliminate the defect, synthetic prostheses are implanted ••• Children. Krasnobaev’s method is often used: after removing the hernial sac, 2 sutures are placed on the legs of the external opening of the inguinal canal. In this case, 2 folds of the aponeurosis of the external oblique muscle are formed. They are sewn together with several additional sutures ••• A hernia bandage is designed to prevent the exit of abdominal organs through the hernial orifice. It is used if there are contraindications to surgical treatment (concomitant somatic diseases) or if the patient refuses surgery •• Laparoscopic repair for inguinal and femoral hernias ••• Absolute indications: recurrent and bilateral hernias ••• Contraindications: organ strangulation or intestinal infarction within hernias ••• Approaches - intraperitoneal and extraperitoneal ••• Complications: damage to the external iliac vessels, damage to the ilioinguinal and femoral nerves, the formation of adhesions during intraperitoneal surgery can cause small intestinal obstruction.

Other types of abdominal hernia

• Umbilical hernia - exit of abdominal organs through a defect in the abdominal wall in the navel area •• In women, it is observed 2 times more often •• Most often observed in early childhood, in 5% of cases - in older children and adults. As it develops, self-healing is possible at the age of 6 months to 3 years •• Causes of umbilical hernia formation in adults: increased intra-abdominal pressure, ascites, pregnancy •• Umbilical hernia repair ••• In children: Lexer's operation. The umbilical ring is sutured with a purse-string suture ••• In adults: Mayo operation: the hernial orifice is closed with a duplicate of the aponeurosis sheets stitched one on top of the other. Sapezhko's method. First, the peritoneum is peeled off from the posterior surface of the vagina of one of the rectus abdominis muscles. Then, using separate sutures, grasping on one side the edge of the aponeurosis of the linea alba, and on the other hand, the posteromedial part of the rectus sheath, where the peritoneum is separated, a duplication is created from muscular aponeurotic flaps.

• Hernia of the linea alba can be supra-umbilical, peri-umbilical and sub-umbilical •• More often observed in men (3:1). In children they are extremely rare •• Hernias can be multiple •• Plastic surgery by simply suturing the defect in the aponeurosis gives about 10% of relapses. For large hernias, the Sapezhko method is used.

• Postoperative ventral hernia is the most commonly observed type of ventral hernia, resulting from complications during the healing of a postoperative wound •• Predisposing factors: wound infection, hematoma, old age, obesity, high pressure in the abdominal cavity with intestinal obstruction, ascites, pulmonary complications of the postoperative period •• Surgical treatment is performed after eliminating the causes that determined their development.

• A hernia of the semilunar (Spigelian) line is usually located at its intersection with the line of Douglas. Treatment is surgical. For small hernias, the gate is closed in layers by applying sutures. For large hernias, after suturing the muscles, it is necessary to create a duplicative aponeurosis.

ICD-10 • K40 Inguinal hernia • K41 Femoral hernia • K42 Umbilical hernia • K43 Hernia of the anterior abdominal wall • K44 Diaphragmatic hernia • K45 Other abdominal hernias • K46 Abdominal hernia, unspecified

What to expect after surgical correction

• You will have a gauze bandage placed in your vagina to help stop the bleeding. The bandage will be removed the day after surgery.
• Urine will be drained from the bladder using a catheter. Your nurse will remove it the day after surgery.
• After surgery, you may experience some vaginal bleeding. Use regular or panty liners. Don't use tampons.
• You can shower 48 hours after surgery. Do not bathe, swim, or use a hot tub until your doctor or nurse says it is safe to do so.

Take your medications

After surgery you will need to take 3 medications:

• An antibiotic that you must take until all the tablets in the package are gone.
• Medicine to relieve pain after surgery.
• A stool softener to ease bowel movements. You may stop taking it if you develop diarrhea (loose or watery stools).

Follow-up

• Make an appointment with your doctor 2 weeks after surgery.
• Do not lift anything heavier than 10 pounds (4.5 kg) for 3 months after surgery.
• Avoid strenuous physical activity such as running, including jogging, for 3 months after surgery.
• Do not have sexual intercourse or insert anything into the vagina (such as tampons) for 6 weeks after surgery.

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Alarming symptoms

There are some symptoms that are “alarming” in nature, i.e. may indicate the onset of some acute disease.

• Acute onset of pain (the so-called “dagger pain”) - occurs with a perforated ulcer or perforation of a hollow abdominal organ.
• Pain accompanied by an increase in body temperature occurs with acute appendicitis , cholecystitis, peritonitis, etc.
• Cramping pain - when the pain seems to “roll up” and “release” - is characteristic of intestinal obstruction.
• Black stools and vomiting “coffee grounds” are typical for gastrointestinal bleeding.
• Pain is accompanied by a severe general condition - it occurs in many acute surgical diseases.
• The pain is accompanied by repeated vomiting - it happens with acute pancreatitis, pancreatic necrosis, intestinal obstruction.
• The pain in the upper abdomen is of a girdling nature (i.e., radiates to the hypochondrium, back) - it happens with acute pancreatitis, pancreatic necrosis.
• Yellowness of the skin, accompanied by pain in the right hypochondrium, is characteristic of obstructive jaundice.
• The onset of pain in the upper abdomen, sometimes throughout the entire abdomen, followed, within several hours, by localization in the lower abdomen on the right - is characteristic of acute appendicitis.
• The pain is constant and severe and occurs in many acute diseases.
• Pain in the area of ​​the hernial protrusion occurs with a strangulated hernia.