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External and internal hernias

  1. Gastroepato
  2. Gastroenterology
  3. External and internal hernias
  4. Abdominal hernia
  5. Palpation of the intestine

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External abdominal hernias

In external hernias the viscera migrate out of the abdominal cavity through areas of least resistance of the wall. They can be congenital or acquired; reducible or irreducible. Route: it can be a simple orifice of the muscle-aponeurotic wall (hernia linea alba) or a canal with internal orifice towards the abdominal and external cavity emerging on the subcutaneous plane (inguinal and crural hernias). Sacco: extroflection of the parietal peritoneum involved in the journey and enveloping the hernia viscera. External enclosures: they are represented by the different anatomical planes of the region pushed forward, up to the skin. Content: depends on the hernia zone; accustomed, epiploon, small intestine, colon; more rarely bladder, uterine appendages, appendix (hernial appendicitis !!).

Hernial thrombus

More serious complication. Close constriction of the viscera contained in the hernial sac, with immediate circulatory disorders, epiploic necrosis, mechanical ileus with possible peritonitis; if he is choked, he goes into gangrene. Symptomatology. It depends largely on the strangled organ. Intestinal thrombus more severe than epiploic. Locally tensefazione hernia tesa with sudden irreducibility and simultaneous appearance of pain; carefully examine herniae sites: they often escape negligent observation. small, cramped, chronic hernias. If intestinal throttling: nausea, vomiting before feeding then biliary, later signs occlusion. intestinal with abdominal wall tension, hyperperistalsis, pulse and frequent breathing. and also defense if peritonitis; finally fecaloid vomiting, hiccups, collapse. If epiploic choking: same symptoms, but less resounding. Reflex vomiting, mostly preserved canalization; possible omental necrosis, abscess formation with elimination on the outside or propagaz. at the abdominal cavity with peritonitis. Therapy. In the first hours try manual reduction. Surgery: emergency intervention.

Inguinal hernia

External oblique: more common. Protrusion of the abdominal contents in a peritoneal extroflexion (sac) through the inguinal canal; it usually runs. (e) acquired externally to the elements of the funiculus. If congenital, the sac results from the lack of obliteration of the peritoneo-vaginal canal that accompanies the descent of the testicle in the male and the fixation of the ovary in the female: it runs in intimate connection with the elements of the funiculus inside the common vaginal. We talk about: tip of hernia if the herniated part protrudes just from the deep inguinal ring; intraparietal hernia if the engagement has already progressed between the deep inguinal ring and the superficial ring; inguino-scrotal hernia if the scrotum is reached.

Direct: it is formed by the weakening of the "weak area", corresponding to the mean inguinal dimple; shorter and more direct route to reach the superficial inguinal ring. Collar of the bag is usually very large with less chance of throttling. Internal oblique: more rare than the previous ones, it forms in the dimple in the internal or vesico-pubic guin- tions and protrudes medially to the superficial inguinal ring, ie in the pubis area.

Symptomatology

The patient is usually seen for the presence in the inguinal area of ​​a more or less marked swelling, soft, indolent, which in the typical cases disappears in a horizontal position and reappears in an upright position or following a cough or a effort. The palpatory and plutiful characters of the hernial content allow to establish whether enteroceles or epiplocels. Common a local sense of annoyance and pain, more pronounced in hernias of a certain volume and after efforts or marches. In the hernia tip the finger inserted into the inguinal canal feels impulse and sense of expansion under cough.
Differential diagnosis. Inguinal adenopathies, hydro cele (distinguishable by means of transillumination), ectopic testis, serous cyst of the man's funicular, cysts of Nuck's duct and tumors of the leg. round in the woman; easy confusion with crural hernias by proximity to the seat. Complications: throttling. Therapy. The repair Surgical is the only effective treatment and can be performed with minimal risk at all ages. The girdles and the other means are nothing but palliatives to reserve for those cases where a surgical provision is absolutely unworkable.

Crural hernia

Less frequent than the previous ones, it is more common in the average age, it is observed almost exclusively in the female sex. It emerges from the abdomen under the inguinal ligament at the oval fossa, becoming subcutaneous in the triangle of Scarpa, making its way as a rule in the medial (or weak) space of the Gimbernat lacuna; more raram. the viscera may engage between the vein and the artery (and the prevascular) or between it and the ileopectinous band (ie external crural): sometimes the sac is inside the sheath of the vessels (and intravasal). The collar of the bag is usually small, so it should not be choked. Symptomatology. Tumefaction, usually modica, medially to the femoral vessels, at the base of the Scarpa triangle, with peduncle continuing under the femoral arch, reducible, with a cough pulse. Because of its small size it easily escapes observation, especially in obese subjects. In the obstructive obstructions from an unknown cause always suspect a crural hernia (explore the hernia doors !!). Diagnosis diff. Inguinal hernia in women: observe Malgaigne line, which connects the anterior superior superior iliac spine, to the pubic tubercle; the crural hernia is located inferiorly and, externally to it, beats the femoral artery. Oxifluent abscess (vertebral origin research). Ectasias of the saphenous. Femoral lymphadenitis can simulate strangulated crural hernia: look for lesion inflammation of the lower limbs, genitals, perineum. Therapy: surgical.

Umbilical hernia

There are two varieties. Umbilical hernia of children, congenital, favored by delayed closure of the umbilical ring, manifests itself at the fall of the umbilical cord or in the first weeks of life, exceptionally later. Capable of spontaneous regression in relationship with the conserved ability to close the umbilical ring. Umbilical hernia of the adult, acquired, in third place for frequent after inguinal and crural; frequent in the elderly and obese pluriparous; progressive, incapable of re-gression; often irreducible, due to saccular adhesions, susceptible to incarceration and throttling. Very variable dimensions, from a hazelnut to gigantic hernia, whose sack contains most of the epiploon and loops of the tenuous. The umbilical hernia secondary to ascites is easy to observe. Frequent complication of hernial epiploitis due to infection of the overlying, eczematous, thin and close-fitting skin; the tumefaction becomes irreducible, painful with reddening of the overlying skin. Therapy. In the child: compressive bandage or belt with a flat pad (non-tapered which delays healing !!) for a few months; do not operate, if not after the fifth year. In the adult: compressive bandage or girdled in very marked obese, cardiopathic, advanced age; otherwise intervention.

Epigastric hernia

It appears in adulthood, in the stretch of dawn line between the ensiform and navel process. Favored by the small foramen of passage of the terminations of the last intercostal vessels and nerves: for this reason it is never median but paramedian. It can herniate only the adipose tissue properitoneal (adipose) or have a real sac with almost epiploic content.
Symptomatology. Epigastric swelling of moderate size, visible in the skinny, not always reducible. Often functional disturbances of imposing reflexes (tractions on the large omentum or round ligament of the liver) simulate a peptic ulcer, a cholelithiasis or cardiac disorders, the so-called "flat heart", for the irregularity in the appearance of symptoms.

Internal abdominal hernias

Very rare. One or more viscera engage in natural or abnormal orifice of the peritoneum and remain so dislocated, while remaining in the cavity of the abdomen. They can occur, through the Winslow foramen, in the paraduodenal pits (e. Of Treitz), through an anomalous hiatus of the mesocolon, the great omentum or the small omentum. The hernia ring may consist of laceraz. omentals or mesenteriali produced by previous laparatomic interventions. Internal hernia must be considered in the differential diagnosis of an intestinal obstruction.

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