notes by dr Claudio Italiano
Hernia refers to the escape of a viscera from the cavity that normally
contains it, a passage that occurs through an orifice or an anatomical canal or
in any case through a continuous solution. The term hernia, therefore, refers to
the three cavities of the body: abdominal, cerebral, thoracic.
A particular hernia is that which takes shape after a surgical operation, due
to the abdominal wall muscles collapsing, after the exploratory laparotomy, ie
after the surgeon has engraved the muscles and anatomical structures of the
abdominal wall creating a locus minoris resistantiae: we speak of laparocele or
post-laparotomic hernia or incisional hernia of the English-speaking authors.
In our case we want to talk about abdominal hernias, subdivided into congenital
or acquired:
congenital hernias: of the navel which allows the passage of the umbilical
cord, of the vaginal peritoneum duct, where the testis migrates from the
abdominal cavity descending into the scrotal bag. If after this passage, the
orifice is left, then we will have:
Omphalocele and neonatal umbilical hernia in the case of the navel
congenital inguinal hernia when the residual vaginal peritoneum is engaged
acquired hernias: they are those that make their way through areas of weakness
of the abdominal wall.
In the pathogenetic mechanism of the hernia two conditions must be met:
In the hernia of weakness, a predisposing cause, is the abdominal wall that
yields because of its weakness or because it becomes thinner in malabsorption or
constitutional magtrices, in old age, during pregnancy
In stress hernias, the triggering cause is due to the increase in
endo-abdominal pressure: in ascites, severe obesity, chronic constipation,
coughing efforts.
In any case, the hernia is the result of the engagement of the abdominal mobile
viscera, which pressing against the walls that contain them, push themselves
into orifices or anatomical channels of the internal wall of the abdominal
cavity, practically they engage through the "herniaian doors" .
Depending on the door crossed by the hernia, we can have:
Inguinal hernia. It is formed in the inguinal region. He prefers male sex
and is the most frequent hernia. It is found in early childhood (congenital form)
but particularly in adulthood (stress hernia) and in old age (weakness hernia).
Crural hernia. It is formed in the crural region and is the second in order of
frequency. It affects mainly the female sex due to the shape of the pelvis.
Umbilical hernia. It engages the navel. It is found in both sexes and at all
ages. Very common in obese people and in the presence of ascites.
Epigastric hernia. It forms along the sunrise line.
Semilunar hernia. It is called Spigelio hernia or lateral ventral for the
position that occupies the right side of the muscle at the point where the
epigastric vessels meet the Spigelio semilunar line.
Obturatory hernia. It makes its way through the obturator foramen, at the root
of the thigh.
Lumbar hernia. Not to be confused with lumbar disc herniations.
The content is given by the type of mobile bowel, most often small intestine and
epiploon, present in the sac. In general, the bowel, except in the case in which
it has synechiae, can re-enter the abdominal cavity and the hernia is said to be
"reducible"; if it remains in the abdomen, once pushed by the doctor's hands (squeezing
maneuver, by taxis) it is called "contained hernia". Otherwise, it is defined as
"irreducible" and "irrepressible", respectively.
We say "permagne" the particularly voluminous and irreducible hernias, like that
of our patient, because the quantity of the exiled intestine is so large that it
has lost, as they say, the right of domicile in the abdomen.
The patient, often aware of his hernia, or other times, does not believe that
the swelling that shows, for example, in the scrotal bag is related to a
herniation of the bowel. Hernias, when small, can remain long asymptomatic.
Other times, even in the absence of evident swelling, they can manifest
themselves with symptoms also relevant: belt pain, dyspepsia, gastralgia, which
require a differential diagnosis with some important diseases such as
pancreatitis or peptic disease. He usually comes to the emergency room, because
he accuses violent abdominal pain, worsening constipation, or, for a purely
surgical emergency, if in the meantime the hernia has become choked. The
symptomatology of the hernia is greatly aggravated in the case of complications:
Inflammation. It is quite rare and involves the formation of adhesions between
the herniated viscera and the saccular wall, especially if the patient has
suffered a trauma.
Irreducibility. It is characteristic of permagne hernias and of those that
have undergone inflammatory phenomena with adhesion formation.
Clogging. It is a typical complication of inguinal hernias, when the faecal
mass accumulates progressively in the herniated loop, extending and obstructing
it. The consequent blockage of intestinal transit causes a mechanical intestinal
obstruction, a pathology that requires timely treatment. In the initial phases
and in the presence of particularly compromised general situations (in which a
temporary postponement of the surgical intervention is required), a reduction
per taxis can also be attempted, which must be carried out with due caution, to
avoid excessive pressure on the the extended intestine can determine the rupture.
Throttling. It intervenes when the structures that form the collar of the bag
suddenly exert a strangulation action on the segment of intestine that crosses
it and on the vascular peduncle contained in its mesentery with serious
consequences on the circulation of the organ.
This complication is particularly fearful because, if it is not resolved
promptly, it leads to ischemic necrosis with consequent perforation of the
intestinal wall.
In these cases we can have signs of peritonitis in case of perforation with
pouring of the septic content into the abdominal cavity. In these cases, you
first arrive at the hospital and work on it and it is better, otherwise there is
the risk that in the abdominal cavity can spread feces or pus, for the already
suffering gut rupture.
Inguinal hernia, when the hernia runs through the inguinal canal, the one run by
the spermatic cord and the round ligament of the woman, entering the inguinal
region, delimited triangular area:
at the bottom of a line that identifies with the inguinal ligament,
medially from the lateral edge of the rectus abdominis muscle
from a third ideal line that connects the upper anterior iliac spine to the
edge of the rectus muscle.
But the herniation of the bowel is not always complete, since the pictures of
the "hernia tip" can be obtained, that is, the viscera engages in part only in
the internal orifice of the inguinal canal and is neither visible nor
appreciable. Or we also have the clinical picture of "interstitial hernia", if
the sac and then the hernia have invaded the inguinal canal. It is not visible
but appreciable.
Instead, we speak of a real "inguino-scrotal hernia", if the viscera is
herniated into the scrotal bag, this is a very advanced and evident form. Here
the doctor needs to diagnose differential with other diseases of the testis:
varicocele, hydrocele, testis tumors.
This hernia, which mainly affects women because of their wider pelvis that
determines a broadening of the door of the crural region. It is also called "femoral
hernia" from the name of the femoral vasculonervous bundle, ie the crural
orifice passes the artery and femoral vein, from the abdominal cavity towards
the thigh. The clinical diagnosis is simple in the established forms and the
position of the swelling that remains constantly below the inguinal line of
Malgaigne (which ideally connects the anterior superior iliac spine to the pubic
tubercle) serves to distinguish it from the inguinal hernias in which the
swelling appears instead above. On the other hand, the differential diagnosis
with respect to the swelling of the Cloquet lymph node is more problematic, a
large lymph node present in the crural site and which may be affected by various
pathologies, even serious ones.
It represents the third in order of frequency among abdominal hernias. It
manifests itself in the umbilical region making its way through the umbilical
orifice. There are various forms:
They are both of a congenital nature being linked
to a defect of closure of the abdominal wall present at birth.
It is observed in the newborn for a defect of closure of the
navel after the fall of the umbilical cord. It tends to regress spontaneously,
usually within the first year of life, otherwise it must be treated surgically.
A typical hernia of weakness can manifest itself at all ages and
in the two sexes with a predominance for women and for the black race. It can
also become very voluminous.
It is localized in the epigastric region, then median and supra-umbilical. It
makes its way through the small gaps present in the dawn line and which serve
the passage of local vessels and nerves. It can simultaneously present itself in
more than one point. It reaches at most the volume of a small egg and contains
mostly epiploon.
The hernia must be considered the classic disease of surgical relevance, in the
sense that it can and must only be treated operatively. The intervention, with
the current techniques simple and rapid, is practiced under local anesthesia, in
a day hospital (hospitalization of a few hours) and allows a rapid recovery of
their social and work activities. The risks of recurrence are minimal as well as
post-operative complications. In recent years the number of advocates of
laparoscopic or minimally invasive technique has been increasing in the surgical
treatment of hernia. However, it is clear that it is more invasive and laborious
for this pathology and compared to traditional open techniques.
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