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Lecture notes, cheat sheets
Детская хирургия. Ущемленные паховые грыжи (конспект лекций)
Directory / Lecture notes, cheat sheets Table of contents (expand) LECTURE No. 9. Strangulated inguinal hernia Incarcerated inguinal hernia occurs in children of various age groups. The internal organs of the abdominal cavity with a slight tension can go into the hernial sac. The resulting spasm of the muscles creates an obstacle to their return to the abdominal cavity. It should be noted that in younger children, for the same anatomical and physiological reasons, spontaneous reduction of a hernia often occurs, and strangulated organs rarely undergo irreversible changes. In older children, the outer inguinal ring thickens, becomes fibrous and, when a spasm occurs, does not stretch, holding the restrained organs. clinical picture The most constant sign of strangulated hernia in infants is anxiety, which occurs in the midst of complete well-being and is permanent, periodically intensifying. However, this symptom is often assessed incorrectly, since infringement in 38% of cases occurs against the background of other diseases that have a similar course. In addition, in some children (often premature), the anxiety may be minor, and the behavior of the child - without noticeable disturbances. Sometimes the swelling appears for the first time and may go unnoticed for some time due to the small size and pronounced subcutaneous fat layer in the inguinal regions in newborns. All this complicates the diagnosis and gives rise to late recognition of strangulated hernia. In older children, the clinical manifestations of infringement are more distinct. The child complains of sudden sharp pains in the inguinal region and a painful swelling that appears (if the hernia was incarcerated at the first appearance). In those cases when the child knows about the presence of a hernia, he indicates its increase and the impossibility of reduction. Soon after the infringement, many children (40-50%) have a single vomiting. Stools and gases first depart on their own. When the loop of the intestine is infringed, the phenomena of intestinal obstruction develop (70% of observations). In rare cases, intestinal bleeding is noted. The general condition of the child in the first hours after the infringement does not noticeably suffer. Body temperature remains normal. When examining the inguinal regions, swelling is revealed along the spermatic cord - a hernial protrusion, which often descends into the scrotum. In girls, the hernia may be small and hardly noticeable on examination. Feeling the hernia is sharply painful. The protrusion is smooth elastic consistency, irreducible. Usually, a dense cord is palpated, going into the inguinal canal and filling its lumen. When a child is admitted late from the onset of the disease (2-3rd day), the following are revealed: a serious general condition, fever, severe intoxication, clear signs of intestinal obstruction or peritonitis. Locally, hyperemia and swelling of the skin appear, associated with necrosis of the strangulated organ and the development of phlegmon of the hernial protrusion. Vomiting becomes frequent, with an admixture of bile and fecal odor. There may be urinary retention. Differential diagnosis The differential diagnosis in young children, first of all, has to be carried out with an acutely developed dropsy of the spermatic cord. In such cases, accurate anamnestic data are important - with dropsy, swelling occurs gradually, increases over several hours. Anxiety at the beginning of the disease is little expressed, but in the following hours there are general symptoms characteristic of a strangulated hernia. Vomiting is rare. The basis for differential diagnosis is palpation data: a tumor with dropsy is moderately painful, oval in shape, with a clear upper pole, from which a dense cord characteristic of a hernial protrusion does not extend into the inguinal canal. Quite often, an acutely developing cyst of the spermatic cord can be extremely difficult to distinguish from a strangulated hernia. In such cases, the diagnosis is made during surgery. Incarcerated communicating dropsy of the spermatic cord sometimes gives rise to an erroneous diagnosis. In such cases, it is known from the anamnesis that the boy had a swelling in the inguinal region, which periodically decreased (especially in the morning), but became painful and tense in the following hours. In contrast to a strangulated hernia, the child has no symptoms of intestinal obstruction, and a thin cord is determined, coming from the swelling into the inguinal canal. In doubtful cases, an operation should be prescribed. Torsion of the spermatic cord ("torsion of the testicle") is also manifested by the sudden anxiety of the child. Other general phenomena (refusal of the breast, reflex vomiting) may also occur. Palpation of the swelling in the inguinal region is sharply painful, the spermatic cord is thickened due to twisting, palpable in the inguinal canal, resembling the neck of a hernial sac. It is extremely difficult to distinguish testicular volvulus from a strangulated hernia in a newborn, but this is of no practical importance, since both diseases require urgent surgical intervention. Inguinal lymphadenitis in children of early and preschool age (especially girls) is sometimes impossible to distinguish from a strangulated hernia. An incomplete history of the disease, the child's anxiety during the examination, and difficult palpation of the external inguinal ring (tissue infiltration) suggest inflammation of the strangulated hernia. The absence of general symptoms and phenomena of obstruction does not exclude infringement of the uterine appendages or parietal incarceration of the intestine. Thus, with pronounced symptoms of inguinal lymphadenitis, even the slightest suspicion of a strangulated hernia should be regarded as an indication for immediate surgery. Treatment The presence of a strangulated inguinal hernia is an indication for urgent surgery. However, it should be clarified that in children of the first months of life, infringement usually occurs when the child cries, strains or anxiety, which are accompanied by tension in the abdominal muscles, which are of primary importance in the mechanism of infringement. The pain that occurs when the infringement increases the child's motor anxiety and intensifies muscle spasms. If you create conditions under which the pain decreases, then the child calms down, the muscles surrounding the inguinal canal relax, and the hernia self-reduces. In addition, strangulation in young children rarely leads to necrosis of the hernia contents, which, however, can occur, but not earlier than 8-12 hours from the moment of complication. This allows some surgeons to recommend non-surgical reduction of the strangulated hernia in children (manual reduction, repeated baths, irrigation hernia with ether, giving anesthesia). In infants, a strictly individual approach to the treatment of a strangulated hernia should be followed. In newborns and children of the first months of life, emergency surgery is absolutely indicated: 1) in cases where the anamnesis is unknown or more than 12 hours have passed since the infringement; 2) in the presence of inflammatory changes in the area of hernial protrusion; 3) in girls, since they usually have appendages with hernial contents, which are not only infringed, but rotated, which leads to their rapid necrosis. Normally developed older children who do not have serious comorbidities should be operated on following diagnosis. Conservative treatment. All children who do not have absolute indications for surgery, upon admission to the surgical hospital, undergo a set of conservative measures, creating conditions for spontaneous reduction of the hernial protrusion. The patient is given a single age dose of pantopon, then a warm bath (37-38 C) lasting 10-15 minutes is taken or a heating pad is placed on the area of the hernia. Gradually, the child calms down, falls asleep, and the hernia is spontaneously reduced. Non-operative reduction, according to experts, is observed in 1/3 of infants. Conservative treatment is carried out for no more than 1 hour. If during this time the hernia has not reduced, then the child is subjected to surgical intervention, and the measures taken will be preoperative preparation. In those cases when the hernia spontaneously reduced before the onset of anesthesia (or the infringement was eliminated by conservative measures), the child is left in a surgical hospital, the necessary studies are carried out and the operation is planned. Preoperative preparation. Children who have absolute indications for surgery do not receive special preoperative preparation. The exception is patients admitted late from the onset of the disease (3-4 days). The general condition of such children is extremely difficult due to intoxication against the background of peritonitis and dehydration. Prior to surgery, such a child must be intravenously administered a 10% glucose solution, blood transfusion, and antipyretic and cardiac drugs. For 2-4 hours the child's condition noticeably improves, the body temperature decreases, and then proceed to the operation. Surgical treatment consists in the elimination of infringement and radical plastic surgery of the inguinal canal. Surgical intervention is performed under general anesthesia. postoperative treatment. The child is prescribed antibiotics for 2-3 days. To prevent edema, the scrotum is pulled anteriorly with a bandage, physiotherapy (sollux) is used. The child's activity is not limited, they are allowed to turn in bed, sit up on their own on the 2-3rd day after the operation. The patient is prescribed a normal (by age) diet. Children of the first months of life are applied to the mother's breast 5-6 hours after the operation. To prevent complications from the wound in infants, the sticker should be changed when contaminated. The sutures are removed on the 5-6th day after the operation, the next day the child is discharged. In the postoperative period, an infiltrate is sometimes observed in the suture area. The appointment of UHF currents and the extension of the course of antibiotics stop the complication. With suppuration of the postoperative wound in a child, the general condition sharply worsens, the body temperature rises. The data of blood tests (leukocytes with a shift of the formula to the left) are changing. However, local changes are initially expressed slightly - slight infiltration of the scar, sometimes swelling of the scrotum. If you suspect the occurrence of suppuration, you should (except for antibacterial and restorative measures) dilute the gluing edges of the wound with a bellied probe and put a thin rubber graduate on the first day. This is usually enough to eliminate the complication. In some cases, the removal of sutures and dilution of the edges of the entire wound is required. School-age children after being discharged home are exempted from classes for 7-10 days and from physical activity for 2 months. Subsequently, dispensary observation of the surgeon for the child is necessary, since in 3,8% of cases there are recurrences of the hernia, requiring a second operation. Authors: Drozdov A.A., Drozdova M.V. << Back: Hernia of the umbilical cord >> Forward: Gastric obstruction (Prepyloric gastric obstruction. Pyloric stenosis)
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