Hernias , Incisional Hernias , Evisceraţii

1. Hernias – definition and composition pathological exam

Hernia is an organ exteriorization of the abdominal cavity through a weakness in the abdominal wall skin integrity .
The main causes of hernia are represented by small efforts , repeated from chronic bronchitis , chronic constipation , micturition efforts of patients with obstruction subvezical , obesity in repeated tasks , etc. Predisposing factors mention the role of heredity , nutrition conditions , environmental conditions and work ( physical work ) and state – pelvic abdominal wall musculature . But the key factor is the effort in the most active period of life, the majority of those patients are men between 18 and 50. Effort may be unique and brutal, or small but repeated , thus leading to the emergence of points and areas hernia in lower strength of the abdominal wall , pelvic hernia called points or areas .
True hernias are those which are formed at the points or areas hernia anatomy delineated trails or paths of lesser resistance . Each point or area – pelvic abdominal wall hernia , a corresponding terrain variety of hernia .

Classification hernias can be done by various criteria :

⁃ by mode of production, distinguished : congenital hernias and hernia acquired;
⁃ by location, may include: internal or external ;
⁃ by content (any abdominal organ except the pancreas) ;
⁃ after development can be : simple ( reducible ) and irreducible ( incarcerated and throttling ) .
⁃ after surveying can be :
1. Ventral hernias , ventral wall of the abdomen , we group them :
• common hernias : inguinal hernia , femoral and umbilical ;
• rare hernias : white line hernia ;
• hernias very rare hernia Spiegel and the obturatory line ;
2. Hernias dorsal to the dorsal wall of the abdomen : lumbar hernias and hernias ischial ;
3 . Perineal hernias , perianal floor level ;
4 . Diaphragmatic hernia , the upper wall of the abdomen.
Inguinal hernias , femoral and umbilical hernias account for 95 % of the total . Regardless of the particular type of hernia , conferred by its location or visceral contents , all the general characters common hernias .
Pathological anatomy of hernia is composed of three components: path parietal hernia sac and contents of the bag with its sheaths .
Parietal tract , or area of ​​reduced strength of the abdominal wall is represented by a simple hole , a musculo- aponeurotic ring ( epigastric hernia ) or channel consists of a deep hole or internal paths intraparietal a shallow hole or externally located subcutaneous ( external oblique inguinal hernia ) .
Hernia sac consists of peritoneum which pushed mobile abdominal viscera , is committed to the path parietal and gradually lengthens and slides as hernia increases. Shape of the bag is variable , depending on the topography and the stage of evolution of the shape of globular , cylindrical or pear-shaped in form . Totally absent hernia sac ( the embryonic umbilical hernias ) or partial ( when herniates a retroperitoneal organ – bladder , check) . External shells of the bag are made from different anatomical planes parietal , more or less modified .
The hernial sac contents vary by topography hernia . It appears that all peritoneal and subperitoneal covităţii viscera can herniate except pancreas. In most cases, however , the contents of the hernia sac is the small intestine , omentum and colon sometimes .

2 . Hernias – clinical signs and complications

Local functional signs appear in walking, prolonged standing , the effort, and is characterized by the sensation of weight , sometimes local painful embarrassment . Local clinical examination is standing and lying down in effort ( cough, walk) and at rest , making it appear ( or enlarge ) a hernia reduced spontaneously by sores. On palpation appreciate that consistency , depending on content , can be elastic – renitentă ( gut) or soft paste , irregular ( omentum ), sometimes sensitive ( mezou ) . Sounds of percussion and noise -liquid betrays the presence of the small intestine .
The evolution of hernia is generally slow and progressive increasing the volume of the time . It can be well tolerated years, especially when its content is represented by the intestine . Sometimes the babies, small umbilical hernias or inguinal hernias may heal spontaneously , which justifies the attitude of watchful . Bear in mind , however, that hernias generally those with intestinal contents are subject to complications , of which the most serious is strangulated hernia .
Strangulation hernia is accomplished by constriction brutal close and permanent one or more viscera within the hernia sac . Hernia strangulation may be followed by intestinal obstruction and , in severe cases , ischemic necrosis and peritonitis hernia hernial content .

3. Treatment of hernia

Two methods are possible to treat hernias : orthopedic bandages and surgical cure .
Orthopedic treatment is the use of bandages ( belts ) who oppose externalization hernial sac and its contents. In adults or the elderly , orthopedic treatment is not indicated unless the patient’s general condition does not allow surgery.
Surgical treatment aims to reintegrate abdominal viscera herniate , suppression and restoration of abdominal wall hernia sac in the hernia area to avoid relapse.

4 incisional hernias – definition, predisposing factors , clinical signs , treatment

Eventratie is the disease that abdomonale viscera protrude under the skin by a musculo- aponeurotic defect acquired or congenital .
Incisional hernias include: congenital won ( spontaneous ) and traumatic scar ( after laparotomy ) .
If eventrations , herniation of abdominal viscera is the musculo- aponeurotic defects in most cases prior abdominal surgery . Postoperative eventration is also known as the hernia . Functional and pathological disorders are identical to those produced as a result of a strangulated hernia .
Clinic, strangulation is characterized by pain and a feeling of tension , bloating, pseudo formations on the white line is palpate parietal defect
Conservative treatment consists of: abdominal bandage , medical gymnastics , weight loss. Treatment is usually surgical resection eventration bag , reintegration abdominal viscera , musculo- aponeurotic wall restoration . If large eventrations resort to plastic: building ( strengthening ) or replacement .

5. Evisceraţiile – definition, classification , predisposing factors

Evisceraţiile is out of pathologic entities characterized by abdominal viscera outside the peritoneal cavity through an opening full – musculoskeletal peritoneo aponevrotico – skin or without skin. Evisceration no peritoneal sac .
By nature of the cause of the breach parietal generators , there are two types of evisceraţii : traumatic and postoperative . The first does not pose particular challenges in terms of therapy and usually shows a favorable prognosis . Postoperative Evisceraţiile instead a difficult evolution and mortality still high.
Depending interested complication wall layers , we distinguish three types of evisceraţii :
⁃ Subcutaneous ( incomplete ) , occurs in the first week after surgery by opening peritoneo – musculoskeletal aponeurotic plans ;
⁃ Suprategumentară free ( complete ) that is undoing all layers above the wall and settlement intestinal loops operative wound . It is the most serious type of evisceration and usually occurs in the first days after surgery due to the defects especially technical and tactical operative or intra-abdominal pressure surge ;
⁃ exhibiting adherence ( blocked ) all layers of interest , but the abdominal contents get stuck in the wound bed without externalize .
Contributing factors in producing eventrations are two categories:
1 ) General factors with negative response on wound healing :
– Age, poor nutrition , with hypoproteinemia and hypovitaminosis , anemia , obesity , diabetes, malignancy, corticosteroids , clotting or fibrinolysis ;
⁃ factors that increase intra-abdominal pressure : respiratory disease , prostatic dynamic ileus , early lifting effort , inadequate anesthesia in terms of relaxation , etc.
1 ) Local factors : the type of incision , suture technique , wound infection , hematoma and wound sarcomas .

6 . Evisceraţiile – clinical signs and treatment

Free suprategumentară evisceration occurs first in the immediate postoperative intra-abdominal pressure due to surge and defects of surgical technique . The other two types occur later at 7-10 days postoperatively , preceded by minor signs : restlessness, wound pain , flatulence , vomiting and sometimes abrupt in onset, profuse serous secretion , serosanguinolentă or purulent wound .
During an effort to cough or abdominal contractions , the patient feels pain feeling alive and charge a break from the wound . It appears likely wound dehiscence with exposed or covered by skin. In evisceration adherent locked lips appear atonic wound with stitches relaxed and purulent discharge at the bottom of the lesion.

Treatment may be :

1 ) Prophylactic consisting of:

⁃ correct preoperative deficits protein , fluid and vitamins ;
⁃ intraoperative surgical technique will be applied neat , less trauma to the tissues , meticulous haemostasis and antisepsis ;
⁃ postoperative wound suspect any will be supported by tight bandages , inextensible material that goes beyond the wound edges away , it will calm the cough , it will maintain a permanent bladder emptiness by probe.

2 ) – Conservative , rarely used , especially evisceraţiilor adherent addresses . It consists of: wall near the wound with strips of tape or elastic bandages and local tualetă rigorous .

3) – Surgical , Emergency establish if suprategumentare evisceraţiilor free and acceding evisceraţiilor great lack of substance . Anesthesia , preferably trabuie to provide good general muscle relaxation . Propriuzisa surgery includes two timelines: toilet wound and peritoneum and abdominal wall restoration . After surgery will receive : antibiotics and cough medicines to avoid and purging .


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