Perineal hernia. Perineal hernia (Perineal hernia). Surgical treatment of inguinal hernia

Hernias- protrusion of an organ in whole or in part under the skin, between muscles or into internal pockets and cavities through openings in anatomical formations. These can be existing normally and increased in pathological conditions holes or gaps, as well as holes that appear at the site of a tissue defect, thinning of a postoperative scar, etc.

According to localization they distinguish brain, muscle, diaphragmatic hernia and abdominal hernia. Among the latter, there are inguinal, femoral, umbilical hernias, hernias of the white line of the abdomen, xiphoid process, sternum, lateral abdominal hernia, obturator, sciatic, perineal, postoperative, etc.

For abdominal hernia protrude from the abdominal cavity internal organs together with the parietal layer of the peritoneum through the “weak” places abdominal wall(hernial orifice) under the skin (external hernias) or into other cavities and various pockets of the peritoneum (internal hernias).

There are:
hernial orifice- the hole through which the hernia comes out,
hernial sac- plot parietal layer peritoneum, covering the hernial contents, which can be any abdominal organ or part thereof.
More often the hernial contents are part greater omentum and small intestine.

In the hernial sac there are:
- the mouth connecting the hernial sac with the abdominal cavity,
- neck - its narrowest section between the mouth and the body of the bag, which ends at the bottom.

The hernial sac may partially cover the exiting organ (sliding hernia).

The reasons causing the formation hernias , are increasing intra-abdominal pressure(for constipation, cough, difficulty urinating, childbirth, heavy lifting, etc.) and weakening of the abdominal wall as a result of its stretching and thinning (for repeat pregnancies, injuries, age-related changes, diseases, etc.). Hereditary predisposition, age, gender, body type and anatomical structure areas of hernia appearance.

Most characteristic feature hernias - the presence of swelling that appears in a standing position or when straining and disappears in a lying position or after manual reduction.

Inguinal hernia are more common in men, which is due to the peculiarities of embryogenesis and anatomical structure groin area.

There are:
congenital and acquired,
oblique (external),
direct (internal) inguinal hernias.

Indirect inguinal hernia exits through the deep inguinal ring, located in the lateral inguinal fossa, into the inguinal canal along with the spermatic cord, often descending into the scrotum, and in women, into the labia majora.

Direct inguinal hernia protrudes from the abdominal cavity through the medial inguinal fossa, located opposite the superficial inguinal ring(the finger inserted into it goes in a straight direction, while with an oblique it deviates to the side).

Femoral hernia occupy the second place in frequency after the inguinal ones, occur mainly in women 40-60 years old, and are often bilateral.

Predispose to the development of a femoral hernia increase in size and weakness of the deep femoral ring. A femoral hernia is located just below the inguinal ligament, which distinguishes this hernia from the inguinal hernia, which lies above the ligament.
A complete femoral hernia protrudes through the femoral and subcutaneous rings; an incomplete hernia does not extend beyond the superficial fascia and is located in the femoral ring, making it difficult to establish clinically.

Patients usually complain of pain in the lower abdomen, groin area, and thigh. When the hernial content is the wall Bladder, dysuria is observed. When compressed femoral vein swelling of the leg is possible, developing towards the end of the day.
During digital examination, the finger passes below the inguinal ligament, and it is possible to determine the relationship of the hernia to the femoral vessels. A femoral hernia sometimes needs to be differentiated from a varicose node, lymphadenitis, or lipoma, especially in the case of an irreducible hernia.

Umbilical hernia occurs more often in women, because pregnancy and childbirth weaken the umbilical ring.

The formation of a hernia is promoted the presence of a peritoneal diverticulum in the umbilical ring. Large hernias often have a multi-chamber hernial sac, the contents of which may include, in addition to the omentum and loops of the small intestine, the large intestine and stomach.
An irreducible umbilical hernia often causes pain and nausea. Diagnosis umbilical hernia is simple, but in case of irreducible formation, it is necessary to exclude a primary or metastatic tumor of the navel.
An umbilical hernia can imitate a protruding navel, in which there is a peritoneal diverticulum, but there is no content and no symptom of a cough impulse is felt.

Hernia of the white line of the abdomen more often observed in men.
Hernial orifices are cracks and holes in the linea alba of the abdomen, through which preperitoneal fat passes, gradually pulling the peritoneum along with it.

There are:
supra-umbilical,
periumbilical,
and infraumbilical hernia of the white line of the abdomen.

A hidden hernia is possible when the hernial protrusion is located in the thickness of the white line of the abdomen, without going beyond its limits. Multiple hernias are observed, located one above the other. The hernial contents are sometimes the large intestine, stomach, round ligament liver and gall bladder.

Most often these hernias are asymptomatic , less often there are complaints of pain in the epigastric region, worsening after eating, nausea and even vomiting. Pain is associated with compression of organs or tension of the omentum. Differential diagnosis is made with preperitoneal lipoma. The appearance of protrusion of the abdominal wall in vertical position patient or upon straining and its disappearance in the supine position during reduction indicates the presence of a hernial sac. Often such a hernia is accompanied peptic ulcer, cholecystitis and other diseases. Therefore, in the presence of a hernia of the linea alba, a thorough clinical examination is necessary.

Postoperative hernias are formed in the area postoperative scars after appendectomy, operations on biliary tract and other interventions, mainly after suppuration of a postoperative wound or the introduction of tampons into it.
The hernial orifice has different shape and size, often slit-like or semicircular; they are formed by the edges of diverged muscles and aponeurosis. The diagnosis is based on the presence of a protrusion in the area of ​​the postoperative scar, which appears when intra-abdominal pressure increases.

Rare forms of hernias
These include:
hernia of the xiphoid process of the sternum,
lateral abdominal hernia,
obturator,
ischial,
perineal hernia, etc.

Hernia of the xiphoid process of the sternum - protrusion of internal organs through an opening in the xiphoid process. A lateral abdominal hernia can occur in the area of ​​the rectus sheath. Diagnosis of small protrusions is difficult; they can be mistaken for a tumor of the abdominal wall.

Lumbar hernia (usually left-sided) appears on the posterior or lateral surface of the abdomen through the lumbar Petit triangle and the Greenfelt-Lesgaft gap. Recognizing a lumbar hernia usually does not cause difficulties: the hernial protrusion appears in the position on the affected side, and disappears when turned to the healthy side.

Obturator hernia. It occurs predominantly in older women and exits through the obturator canal. In the absence of visible protrusion, it manifests itself as pain along the obturator nerve, radiating to inner surface hip, hip and knee joints. Characterized by increased pain during abduction and rotation of the hip (Treves' symptom).

Sciatic hernia goes to back surface pelvis through the greater or lesser sciatic foramen, usually on the right; occurs predominantly in men. The hernial sac descends along the way sciatic nerve and squeezing it can cause pain.

Perineal hernia protrude through a defect in the urogenital diaphragm, more often observed in women. Anterior perineal hernias in women extend onto the labia majora and are difficult to distinguish from inguinal hernias, while posterior ones extend onto the perineum and resemble sciatic hernias. These hernias are recognized And during vaginal and rectal examinations.

Internal abdominal hernias are formed as a result of internal organs getting into various intra-abdominal pockets.
Treitz's hernia (perioduodenal) is more common. It occurs at the transition point duodenum into the skinny one in the area of ​​Treitz's pocket.

Clinical picture with an unstrangulated internal hernia, it is characterized by cramping pain in the abdomen, radiating to epigastric region and occurring after eating or significant physical activity. Depending on the location of the hernia, pain on palpation is determined above the navel, to the right or left of it.

Patients often complain of belching, flatulence, and persistent constipation. When pinched, a clinical picture develops high obstruction intestines. The diagnosis is difficult, and often a Treitz hernia is recognized only during surgery.

HERNIA IN CHILDREN

Hernias in children are often congenital or appear soon after birth. The most common are inguinal hernias (usually oblique), followed by umbilical hernias.

An indirect inguinal hernia occurs in boys when the processus vaginalis of the peritoneum is not closed; it is often combined with retention of the testicle in the abdominal cavity or inguinal canal.
In girls, oblique inguinal hernia is much less common; its development is associated with non-closure of the nucova diverticulum. When screaming or straining, a painless protrusion appears in the groin area, which is easily retracted into the abdominal cavity when lying down. Differential diagnosis inguinal hernia in boys it is carried out with hydrocele of the testicular membranes and varicocele.

When a hernia is strangulated, the child is restless, he experiences sudden severe pain and muscle tension in the area of ​​the hernial protrusion, which ceases to be reduced into the abdominal cavity. After a few hours, the pain may subside, the child becomes lethargic, and symptoms of intestinal obstruction develop. If a hernia is strangulated, the child is sent to surgery department. The main treatment method is emergency surgery. However, in the first 10 hours from the moment of infringement, according to indications, conservative measures are possible (warm bath, raising the foot end of the bed, administration of antispasmodics, etc.), which should be carried out for no more than 2 hours.

Umbilical hernias in children appear from the moment of birth in the form of swelling in the area of ​​the umbilical ring when the child screams, is restless, or strains. As a rule, they are easily reduced into the abdominal cavity. Incarceration of an umbilical hernia is extremely rare.
Conservative treatment of umbilical hernia — physiotherapy, massage. You should be careful when using adhesive bandages on the umbilical ring, since the skin of newborns is easily vulnerable and the resulting macerations can serve as an entry point for infectious agents. Usually, by the age of 3-5 years, the umbilical ring decreases and closes on its own; at older ages, surgical treatment is indicated.

COMPLICATIONS

The main complications of a hernia are infringement, less often inflammation, damage and neoplasms.

Strangulation of a hernia is usually caused by sudden compression of its contents in the hernial orifice, resulting from lifting weights, strong straining, coughing, etc.
Cause of strangulated hernia can be spastic contraction tissues surrounding the hernial orifice, their narrowness, scar constrictions in the hernial sac. More often infringed small intestine, in the place of compression of which a strangulation groove is formed (sharp thinning of the intestinal wall). Poor circulation of the intestinal wall is caused by compression of its vessels.

Usually squeezed first venous vessels, as a result of which plasma leaks into the thickness of the wall and lumen of the intestine. The volume of the intestine increases, its arterial blood supply is disrupted, and the wall undergoes necrosis. The plasma sweats into the hernial sac. The resulting so-called hernia water is initially sterile, but can later become infected. Necrosis of the intestinal wall ends with its perforation. When intestinal contents spill into the hernial sac, phlegmon develops, and when it breaks into the abdominal cavity, peritonitis develops.

Clinically, the infringement manifests itself sharp pain in the area of ​​the hernial protrusion, which increases in volume, becomes irreducible, and sharply painful on palpation. Often, especially when the intestine is strangulated, vomiting occurs and the passage of gases and feces stops. Signs of intoxication appear - tachycardia, weak pulse, dry tongue, cold extremities, confusion.

Special forms of strangulated hernia are retrograde (reverse) and parietal (Richterian).
With retrograde infringement in the hernial sac there are two slightly changed intestinal loops, and the greatest circulatory disorders occur in the loop connecting them, located in the abdominal cavity.

Parietal infringement usually affects a limited area of ​​the intestinal wall. The size of the hernial protrusion, as a rule, does not change, Clinical signs There are no intestinal obstructions, and therefore the diagnosis of this type of strangulation is made only during surgery for peritonitis. Incarceration of the omentum can also manifest itself mainly as pain and increased intoxication.

Any attempts to reduce a strangulated hernia are unacceptable. Even if a strangulation is suspected, the patient should be hospitalized in the surgical department.

Acute inflammation of the hernia more often occurs in acute appendicitis and the clinical picture differs little from strangulation. Chronic inflammation may be a consequence of constant trauma to the hernia or have a specific nature, for example, with peritoneal tuberculosis.
Chronic inflammation of the hernia is accompanied by the formation of adhesions between the hernial sac and its contents, which leads to the occurrence of an irreducible hernia.

Hernia damage observed with injuries or a sharp increase in intra-abdominal pressure. They can cause rupture of internal organs located in the hernial sac.

Neoplasms of hernia are rare, they can come from the hernial sac or its contents, as well as surrounding organs and tissues. Lipomas of the hernial sac are more common.

TREATMENT

Treatment of hernia is surgical. The presence of a hernial protrusion and especially its enlargement, pain, disability and the risk of complications are indications for surgical intervention.

Conservative treatment only possible with uncomplicated hernias, in the presence of serious contraindications to surgery or the patient’s categorical refusal, as well as in small umbilical hernias in children early age.
Conservative treatment consists of limiting physical activity and wearing a bandage. Surgical intervention can be performed either under local or under general anesthesia. The latter is especially indicated when large sizes hernial sac and hernial orifice in easily excitable patients and young children.

Contraindications to elective surgery are spicy infectious diseases, dermatitis, eczema in the area surgical field, diseases of cardio-vascular system and respiratory organs in the stage of decompensation, late dates pregnancy, old age and etc.

The operation consists of isolating and opening the hernial sac (hernia repair), immersing its contents into the abdominal cavity, after which plastic surgery of the hernial orifice is performed. For oblique inguinal hernias, plastic surgery of the anterior wall of the inguinal canal according to the method of Girard and Spasokukotsky is often used. Universal method, used for both oblique and direct inguinal hernias, is plastic back wall inguinal canal using the Bassini method.
For large, especially recurrent inguinal hernias, accompanied by significant destruction of both walls of the inguinal canal, it is repaired using the Kukudzhanov method.
For umbilical hernia, transverse repair according to Mayo or longitudinal repair according to Sapezhko is used. For large recurrent hernias, abdominal wall defects are closed using allografts (nylon, dederon, etc.).

Strangulated hernia is absolute indication to an emergency operation, the volume of which may be greater than during a planned operation, due to the need for resection of the intestine or omentum, drainage of the abdominal cavity, etc.

With phlegmon of hernia the abdominal cavity is opened outside the hernial sac, and after resection of the altered intestine, its section along with the hernial sac is removed through a separate incision as a block. Obturator, sciatic, perineal and internal hernias with strangulation are operated on through laparotomy or combined access.

Working ability after hernia repair is restored on average after 1 month. Persons performing heavy physical work, according to the conclusion of the Supreme Labor Commission, they are transferred to light labor for a period of up to 6 months. Recurrent and major postoperative G. in in some cases may serve as a basis for referring the patient to VTEC.

Inguinal hernia is the process of the viscera of the abdominal cavity, covered with the parietal (parietal) layer of peritoneum, emerging into the inguinal canal. This prolapse occurs through a congenital or acquired gap in the abdominal wall. In men, the hernia extends into the scrotum, and in women, into the subcutaneous space around the labia majora.

Most often, inguinal hernia is observed in children. Boys suffer the most from it. It usually bulges out on one side. This occurs 3 times more often on the right than on the left. After 10 years, the disease rarely develops. Main surgical complication « acute abdomen"are precisely strangulated inguinal hernias.

About the structure of the inguinal canal

The internal cavity of the abdomen is lined with peritoneum - a thin connective tissue film. It “wraps” the walls and almost all the organs in the abdomen.

In the appearance of a hernia, a specific anatomical formation plays a huge role - the inguinal canal, which receives the hernial contents. This is a small gap (about 4.5 cm) located in the groin between the muscles, connective tissue fascia and ligaments. Its origin lies in the abdominal cavity, then goes forward, down, inward. And the external opening is located outside in the groin, surrounded by a strengthening group of muscles. In women, the round uterine ligament enters the area of ​​this canal, in men - elements spermatic cord, including vessels, nervous tissue, vas deferens.

Mechanism of development of congenital inguinal hernia

The testicles of male fetuses develop in the abdomen. Their usual location during the first three months pregnancy - behind the peritoneum. Closer to the fifth month, the developing testicles begin to descend and approach the entrance to the inguinal canal, enter it and, until the seventh month, slowly move along it, forming the so-called “vaginal process”. At normal development in the ninth month, the boy’s testicles completely enter the scrotum along with a stretched peritoneal “pocket” that maintains communication with the abdominal cavity.

When a child is born, it “closes” and then heals. But sometimes a malfunction occurs, and the passage from the abdomen to the scrotum remains open. This anatomical defect is the first “bell” signaling the possibility of developing an inguinal hernia. With an increase in intra-abdominal pressure, intestinal loops and even some organs can “fall” into this appendix.

The formation of an inguinal hernia in girls is similar to the above-described process of hernia formation in boys. In developing female embryos, the uterus is located higher than usual. In the process of development, it descends to “its” place along with the fold of the peritoneum, forming the same “vaginal process”, the failure of which subsequently provokes a hernia.

A congenital inguinal hernia is a defect of the developing fetus. It is formed from birth.

How does an acquired inguinal hernia occur?

Acquired inguinal hernias appear due to heavy loads and in connection with the pathology of the abdominal press, its weakening.

Factors contributing to the occurrence and development of hernias include:

• premature pregnancy, as a result of which the vaginal process with other organs has not yet completed its development cycle and remains “open”;
• heredity, the presence of hernia in family members and close relatives;
• the presence of anatomical weakness of the abdominal wall muscles;
• excess weight, causing increased stress on the abdominal organs;
• injuries in the groin area that provoked weakening of the ligamentous apparatus;
• severe emaciation. The absence of fatty layers in the canal leads to the formation of empty volumes into which the outer layer of the peritoneum can be pressed;
• pregnancy, which often results in increased intra-abdominal and mechanical pressure on organs, intestines, which contributes to the formation of a hernia;
• physical inactivity, in which flabby and atrophied muscles are unable to perform their functions, as a result of which the peritoneum, without meeting muscular resistance, can be “pushed” into the canal;
• physical overloads that create constant increased pressure in the abdominal cavity;
• chronic, coughing, providing additional load on the “weak” areas of the peritoneum;
• intestinal diseases accompanied by constant constipation, which also cause an increase in pressure.

Types of inguinal hernias

The disease is classified according to the location of the hernial sac.

Types of pathology:

Symptoms of an inguinal hernia, what it looks like

The main features include:

• The appearance of a protrusion in the groin area, which increases with coughing, sneezing, any physical stress, as well as when standing in an upright position.
• The existing swelling in most cases, when pressed with fingers, returns to the peritoneal cavity. At the same time, a characteristic rumbling sound is heard.
• There is usually no pain. Sometimes it can appear in the groin and radiate (give) to the lumbar region.
• When fallopian tubes or ovaries prolapse, painful menstruation develops.
• With a sliding form of inguinal hernia that involves the bladder, there are symptoms of dysuric disorders (pain in the lower abdomen, frequent and (or) painful urination).
• If the cecum enters the hernial sac - flatulence, pain, constipation
• When an inguinal-scrotal hernia forms, the scrotum enlarges on the side of the formation.

IN supine position the hernia seems to hide and becomes invisible outwardly.

What is an inguinal hernia strangulation?

This is one of the unpleasant and frequent ones. A section of the intestine that gets into the hernial sac (or the fallopian tube and ovary in girls and women, the spermatic cord in boys and men) becomes pinched in the inguinal canal, disrupting trophism and blood circulation, which can subsequently provoke necrosis (death) of tissue.

The reasons for this situation may be problems in the functioning of the intestines, flatulence, sudden overexertion with increased pressure in the intraperitoneal space.

The patient has complaints about:

• intense pain in the groin;
• tension and density of the hernia;
• inability to reduce the protrusion;
• symptoms of intoxication: pallor, nausea, vomiting, stool retention.

In this case, after examination by a doctor, immediate hospitalization and surgical intervention are required.

Diagnosis and examination for inguinal hernia

Any suspicion of a hernia is a reason to contact a surgeon.

The doctor, with the patient standing, examines the hernial protrusion, palpates it, performs a straining test, then a cough test. Assess the jerk symptom. By finger examination, the external opening of the canal is found. Sometimes this hole can be identified without a hernial sac; in surgery this symptom is called “weak groin”.

Additionally, an ultrasound scan of the scrotum, canals, abdominal cavity and pelvic organs, in which a hernial sac with all anatomical formations and hernial contents, the size, position and condition of the inguinal canal are assessed.

Very important information can be obtained with x-ray examination with the introduction contrast agent. Also, to clarify the location of the intestinal hernia, irrigoscopy (examination of the large intestine) and cystoscopy (x-ray visualization of the bladder) are performed.

Treatment of inguinal hernia

There is no self-healing of an inguinal hernia without surgery. Surgical method – the only way getting rid of this pathology.

Surgical treatment is not performed:

• weakened elderly patients;
• at strong types exhaustion (cachexia);
• in case of serious illness;
• during pregnancy;
• to prevent the hernia from returning after removal.

Treatment and prevention of inguinal hernia by wearing a bandage

If there are contraindications to the operation, wearing a bandage is used. Also, this type of treatment is indicated for preventive purposes for people who, due to their occupation, face physical overload.

The doctor selects a bandage for an inguinal hernia and its size individually for each patient. These devices can be double-sided or left-right.

Note:The use of a bandage does not cure an inguinal hernia, but serves as a means of preventing prolapse of the intestines and organs into the hernial sac and prevents strangulation.

After selecting a bandage, you should follow the rules for wearing it:

• put it on only while lying on your back;
• make sure you find the inserts. They must correspond to the site of the hernial protrusion.

Important: The use of a bandage is contraindicated in cases of strangulated hernia and diseases skin, in contact with it.

Surgical treatment of inguinal hernia

As mentioned above, there are no alternatives to surgical treatment of inguinal hernias. If there is an infringement, the operation is performed as an emergency. In other cases, planned surgical intervention is indicated after preparing the patient.

The preparation process includes examining the patient and prescribing a clinical blood and urine test. Before the operation, the patient is not allowed to eat or drink. It is also necessary to treat existing chronic diseases in order to minimize the risk of complications (for example, prostatitis,).

To answer the question that worries many patients: “Is it worth doing surgery for an inguinal hernia?” answers by Dr.Med.Sc. Korotky I.V.:

Methods of surgical operations:

• laparoscopy – suturing of a hernia with an endoscope through puncture of the abdominal wall using a mini-camera, microendoscopic instruments and installation of a mesh;
• surgical hernia repair. Apply various techniques surgical treatment of inguinal hernia (Bassini, Matrynov, Rudzhi, etc.)

General stages of surgery to remove an inguinal hernia:

• isolating the hernial sac and separating it from the tissues;
• incision of the bag with reduction of the contents;
• cutting off the sac and plastic restoration of the integrity of the wall,
• suturing the gate and surgical wound.

Surgical treatment of inguinal hernia in children

In children, removal of an inguinal hernia must be performed under general anesthesia (anesthesia). Most often used quick access about 1.5 cm long. The hernial sac is separated from the spermatic cord, then sutured and excised. At the same time, the bag is inspected for the presence of abdominal contents. The external opening of the canal in the child is not strengthened.

A pediatric surgeon talks about the causes of inguinal hernia formation in children, symptoms of strangulated hernia in children and treatment methods:

Emergency surgery to remove a strangulated hernia

The danger of this complication is that necrosis (necrosis) may occur in the strangulated intestine or other organ due to impaired blood circulation in the tissues. This leads to a life-threatening condition and sometimes to the death of the patient.

When treating an inguinal hernia complicated by strangulation, the surgeon has to carefully examine the strangulated organ after dissecting the hernial sac. If there are signs of necrosis, the affected area is removed, the ring in which there was infringement is dissected. The operation then continues as planned. After such an operation, the patient must be prescribed antibiotics for several days.

What is a recurrent inguinal hernia?

In some patients, inguinal hernias recur. Relapses occur in 5-10% of cases.

The causes of a new hernia can be:

• surgical errors and incorrectly selected type of plastic surgery;
• non-compliance with recommendations in postoperative period: intense physical overload, heavy lifting, etc.;
• coughing;
• diseases accompanied by constipation;
• suppurative processes in the area of ​​the postoperative suture;

In men, recurrence of an inguinal hernia occurs due to untreated before planned operation adenomas.

Preventive measures to prevent the development and progression of inguinal hernias

To prevent the possibility of the appearance and development of acquired inguinal hernias, you need to:

• lead active image life with normal physical activity;
• eat foods with sufficient plant fiber content;
• wear a brace during heavy work and activities involving heavy lifting;

The dog has a pathology in which prolapse occurs, one or two-sided protrusion of internal organs, namely contents of the pelvic and abdominal cavity into the subcutaneous tissue of the perineum. Occurs when the integrity of the muscular structures of the pelvic diaphragm is disrupted.

Most often in veterinary practice, perineal hernia is diagnosed in middle-aged and older male dogs, as well as in representatives of short-tailed breeds. This pathology also occurs in females, especially after 7-9 years. As a rule, animals are prescribed surgery . Drug therapy is ineffective for this pathology.

Unfortunately, the exact etiology of perineal hernias in dogs is not fully determined. The prolapse of internal organs into the subcutaneous layer of the perineum is caused by weakening muscle tone , degenerative-destructive changes in muscle structures pelvic diaphragm, disruption of tissue trophism. This leads to a displacement of the anus from its natural anatomical position.

Possible reasons:

• hormonal imbalance of sex hormones;
• rectal prolapse;
• difficult, prolonged labor;
• strong mechanical damage, injuries;
• increased intraperitoneal pressure during defecation;
• phenotypic, age-related, genetic predisposition;
• congenital, acquired chronic pathologies, diseases of the genital organs.

Important! In males, one predisposing factor in the development of this pathology can be called extensive vesico-rectal excavation. In addition, the muscle structures in the perineal area, which are formed by the muscles of the tail, do not form a single tissue layer with the medial edge of the superficial gluteal muscle. Therefore, its delamination is possible.

Congenital weakness of the muscular structures of the pelvic diaphragm, age-related changes in the body of animals, pathological conditions accompanied by tenesmus - a painful false urge to defecate. Chronic constipation, prostate diseases in male dogs (hyperplasia, neoplasia of the prostate) can also cause this pathology in pets.

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Hernias are observed in dogs aged from five to 11-12 years old. In puppies, young individuals under 5 years of age, in representatives of decorative miniature breeds this pathology occurs in extremely rare cases.

Symptoms

Clinical manifestations of perineal hernias depend on age, general physiological state pet, stage of development, their location.

Depending on the location, there are: abdominal, sciatic, dorsal, anal hernia. The swelling can be unilateral or bilateral. Symptoms increase gradually as the disease progresses. The appearance of protrusion of the subcutaneous layer at the location of the hernial sac is noted.

Stages of formation of perineal hernias:

• On initial stage note a decrease in the tone of the muscle structures of the perineum, their gradual atrophy.
• For second stage The development of the pathology is characterized by the formation of a small round soft swelling in the perineal area. May disappear as the dog moves.
• When going to third stage a painful, non-disappearing protrusion appears near the anus on one/both sides.

With constant pressure on a certain area, destructive and degenerative processes occur in the muscular structures of the pelvic diaphragm. As this pathology progresses, the tension weakens. The muscles are not able to maintain the natural anatomical position of the internal organs, which will lead to displacement of the outlet of the rectum. The remaining organs gradually shift, protruding into the resulting hernial cavity.

As a rule, it falls into the hernial sac prostate, rectal loop, omentum. The bladder often protrudes into the formed cavity. When pressing on the pathological protrusion, urine is released spontaneously. In case of complete pinching urinary act there is no urination.

Important! The danger of perineal hernias lies in the possibility of rupture of prolapsed organs, which will invariably cause the death of a pet. The rapid development of purulent peritonitis is facilitated by the proximity of the rectum. Prolapse of the urinary tract will lead to acute renal failure.

Symptoms:

• deterioration general condition;
• the appearance of swelling, a characteristic round protrusion in the perineal area;
• difficult painful defecation;
• chronic constipation;
• difficulty urinating;
• lethargy, apathy, drowsiness.

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On initial stages development of pathology, the swelling in the perineal area is painless, easily reducible, and has a soft, flabby consistency. Animals do not feel discomfort or pain. As the pathology progresses, there may be an increase in body temperature, weakness, fatigue after short physical exertion, loss of appetite, etc. The protrusion becomes painful and tense. The dog may limp on its paw, especially with a unilateral hernia.

It is worth noting that muscles are constantly contracting. May happen strangulated hernia, therefore treatment should be started as soon as possible so as not to provoke serious complications.

Treatment

At the initial stage of development of perineal hernias, dogs can be prescribed supportive care. drug therapy, which is aimed at normalizing the act of defecation and urination. It is necessary to exclude factors that disrupt tissue trophism. If the dog is scheduled for surgery, veterinarians It is recommended to castrate male dogs, since only in this case it is possible to eliminate the root cause of the pathology and avoid possible relapses in the future. After castration, the prostate atrophies in about two to three months.

If the bladder is strangulated, catheterization is performed to remove urine using urinary catheter. In some cases, the peritoneum is pierced, after which the organ is set.

If defecation is disrupted, dogs are given enemas and mechanical bowel movements are used. Animals are switched to soft food and given laxatives.

At later stages of development of this pathology, the dog’s condition can only be normalized by surgical intervention. The purpose of the operation is to close the defect of the perineal floor. It is performed in a hospital setting under general anesthesia. Before surgical treatment, the dog is kept on a semi-starved diet for two days.

Perineal hernia, or pelvic floor hernia, protrudes under the skin, passing through the gap between the levator ani muscle and the coccygeus muscle. Passing through the muscular part of the pelvic floor, the hernia protrudes the pelvic fascia, penetrates the ischiorectal fossa and protrudes into the perineal fossa, the anterior wall of the pelvis, the wall of the vagina or bottom part labia majora. A perineal hernia is often combined with PC prolapse and is more common in women.

Anterior perineal and posterior perineal hernia in women (according to Kirschner):
1 - m. ischiocavernosus; 2 - m. bulbocavernosus; 3 - m. transversus perinei superflcialis; 4 - m. levator ani; 5 - m. sphincter ani ext.; 6 - m. glutaeus max.; 7 - anterior perineal hernia; 8 - posterior perineal hernia

A posterior perineal hernia is more common in men and exits through the rectovesical recess of the peritoneum. In women, it exits through the rectouterine cavity. Passing posteriorly from the intersciatic line through the gaps in the levator ani muscle, the posterior perineal hernia extends into the subcutaneous fatty tissue and is located in front or behind the anus.

The hernial sac most often contains the bladder and its diverticula, female genital organs, intestinal loops, and omentum. Posterior hernias often contain intestinal loops and omentum.

Clinical picture of perineal hernias largely depends on the location of the hernial protrusion. Small hernias usually proceed without any clinical symptoms. The presence of a bladder in the hernial sac is often accompanied by frequent painful urination. An objective examination reveals a mobile hernial “tumor”, which increases with straining.

An anterior perineal hernia in women is differentiated from an inguinal hernia, especially in cases where the latter descends into the labia majora. Diagnosis is helped by digital examination through moisture-lich. A hernial protrusion in a perineal hernia is palpated between the vagina and the ischium. Sometimes a perineal hernia has to be differentiated from a sciatic hernia.

Serious difficulties in diagnosis arise with irreducible hernias. Such a hernia is often mistaken for a tumor. If a perineal hernia is suspected, in addition to the vaginal one, a rectal examination must also be performed.

Treatment is surgical. Optimal access to the hernial sac and hernial opening laparotomy or perineal approaches are considered. A combination of these approaches is also considered appropriate. Plastic surgery of the hernial orifice is performed using the surrounding tissues.

Hernial protrusion of the abdominal or pelvic organs into the soft tissue of the perineum. It is manifested by the presence of an elastic formation in the perineal area, periodic or constant nagging pain, discomfort when walking, disturbances in urination and defecation. Diagnosed using a physical examination, vaginal, digital rectal examination, ultrasound of the hernial formation, abdominal organs, and pelvis. It is eliminated by performing perineal, abdominal or combined hernioplasty with suturing of the defect, using auto- or allografts.

ICD-10

K45 Other abdominal hernias

General information

Perineal (perineal) hernias belong to the category of rare hernia formations, localized in the tissues of the pelvic floor. They usually occur between the ages of 40 and 60; they are detected 5 times more often in women than in men. According to the observations of specialists in the field of general surgery, herniology, gastroenterology, andrology, obstetrics and gynecology, anterior perineal hernias predominate in women, and posterior ones in men, which is associated with the anatomical features of the structure of the genitourinary diaphragm in representatives of different sexes. The main features of perineal hernial formations are predominantly small size, difficulty in diagnosis due to the atypical location and developed fatty tissue in the area of ​​the gluteal fold, perineum, frequent recurrence, tendency to strangulation due to insufficient elasticity of the hernial orifice.

Causes of perineal hernia

The occurrence of perineal hernial protrusions is caused by the failure of the pelvic muscles, unable to withstand normal or increased pressure in the abdominal cavity. The likelihood of the formation of a hernia defect in the perineal area increases if the patient has relatives with various hernias, obesity or exhaustion, and an asthenic physique. The risk group includes patients with stigmata of congenital connective tissue dysplasia (myopia, subluxation and dislocation of the lens, scoliosis, flat feet, clubfoot, varicose veins, hemorrhoids, etc.). The anatomical prerequisite for perineal hernia formation is the presence of a vesicouterine, uterorectal fossa in women, and a vesico-rectal fossa in men. Immediate reasons the formation of a perineal hernia becomes:

• Weakening of the pelvic floor muscles. Probability of beam divergence muscle fibers, the formation of defects in the ligamentous-fascial formations that form the genitourinary and pelvic diaphragm increases with frequent childbirth, carrying a multiple pregnancy or a large fetus. This is due to the increased mechanical load on the pelvic floor that occurs during gestation and childbirth.
• Damage to the perineal muscles. The integrity of the pelvic muscles is disrupted during perineotomy, episiotomy, and perineal ruptures during childbirth. Pelvic floor hernias are observed in patients who have undergone operations with abdominal-perineal and perineal access - abdominoperineal extirpation of the rectum, excision of dermoid cysts, radical prostatectomy, etc.

The release of abdominal contents through weakened areas of the perineum is facilitated by significant one-time, periodic or constant increase intra-abdominal pressure. A hernial protrusion can form during pushing during childbirth, straining due to constipation, difficulty urinating in patients with prostate adenoma, hacking cough, or heavy lifting. The formation of a hernia is possible in the presence of large and giant space-occupying formations in the abdominal cavity (retroperitoneal schwannomas, nephroblastomas, hemangioepitheliomas of the liver, etc.).

Pathogenesis

The mechanism of formation of a perineal hernia is based on the gradual thinning of the layers of the pelvic floor in weak areas with increasing pressure in the abdominal cavity. Under the pressure of its own weight, internal organs with covering them parietal peritoneum penetrate into areas of the genitourinary or pelvic diaphragm, stratify their muscles, stretch the fascia, penetrate the subcutaneous tissue, forming a hernial orifice and protrusion. A formed hernia has a hernial sac represented by the parietal serosa, contains pelvic or abdominal organs and often has a tendency to increase in size. Typically, the peritoneum that extends beyond the hernial orifice thickens and undergoes fibrous degeneration due to an aseptic inflammatory process.

Classification

Systematization of perineal hernias is carried out taking into account their location. The anatomical approach takes into account as much as possible the peculiarities of the formation of the hernial protrusion and its contents. Like other hernias, perineal formations can be incomplete or complete, reducible or irreducible. The guideline for classifying a protrusion to a specific anatomical type is the intersciatic line dividing the perineal area into anterior and posterior sections. Accordingly, they distinguish:

• Anterior perineal hernia. They begin in the vesico-uterine pelvic fossa, pass between the ischiocavernosus, anterior perineal, bulbocavernosus muscles, protruding into the labia majora. The hernial sac most often contains the bladder and female genital organs.
• Posterior perineal hernia. They originate from the utero-rectal or vesical-rectal recess of the pelvic peritoneum. They pass through the levator ani muscle into the ischiorectal fossa. Usually contain intestines, omentum, and can be combined with rectal prolapse.

Symptoms of perineal hernia

The clinical picture of the disease develops gradually. A soft elastic protrusion appears in the center of the labia majora or near the anus. In the initial period, the patient periodically experiences nagging pain in the perineal region or lower abdomen, which become permanent over time and can radiate to the leg and lower back. As the formation increases in size, discomfort when walking is sometimes noted. In women there are painful sensations during sexual intercourse. The symptoms of a hernia depend on the organs filling the hernial sac. When the bladder protrusion gets into the bladder, dysuric disorders, urinary incontinence, and pain when urinating are detected. Chronic constipation often develops due to the involvement of the rectum in the process. The general condition of patients with a perineal hernia is not impaired.

Complications

If the contents of the hernia is a loop of intestine, intestinal obstruction may form, manifested severe pain in the abdomen, retention of stool, gas, repeated vomiting. With a long course of the disease, injury to the protrusion, infection, perineal phlegmon is possible, which is characterized by a violation of the general condition of the patient (the occurrence of febrile fever, chills, headache, nausea), the appearance local signs inflammation. Most serious complication disease - strangulation of a perineal hernia, which leads to ischemia and necrosis of the contents of the hernial sac. If left untreated, the risk of secondary infection with the development of peritonitis increases.

Diagnostics

Making a diagnosis can be difficult initial stages diseases when the hernial sac is small and cannot be visually identified. The presence of a perineal hernia should be suspected in representatives of the risk group if there is a characteristic clinical picture. The diagnostic search is aimed at a thorough examination of patients to exclude other pathologies. For diagnosing a hernia, the most informative are:

• Physical examination. Palpation and percussion are the main methods by which the location and size of the formation are determined. In men, a digital examination of the rectum is additionally performed to identify a posterior perineal hernia, as well as concomitant pathology (prostatitis, prostate adenoma).
• Vaginal examination. Examination of a woman’s genital organs in a gynecological chair is necessary to detect an anterior perineal hernia, which is palpated as a small protrusion on the anterior wall of the vagina. During the examination, a smear is taken for bacteriological analysis of the microflora in order to exclude an infectious process.
• Ultrasound perineal protrusion. An ultrasound examination is performed to confirm the diagnosis and allows the doctor to assess the size and contents of the hernial sac, and the condition of the organs that make up it. Sonography has a high diagnostic value when conducting differential diagnosis with other volumetric formations.

Changes in laboratory tests blood (increased leukocyte levels, increased ESR) are observed only in the event of complications. If the bladder gets into the hernial sac in clinical analysis urine may contain protein, mucus, increased content leukocytes and erythrocytes in the field of view. To exclude pathology from the abdominal and pelvic organs, it is performed.

Treatment of perineal hernia

The only method of eliminating the defect is hernioplasty. Surgical intervention usually carried out as planned. Emergency surgery required for strangulated hernia. In case of uncomplicated course of the disease, the perineal approach is preferable, through which, after isolation and excision of the hernial sac, it is more convenient to close the hernial orifice. If the pelvic muscles are well preserved, the defect between the muscles is sutured. In case of muscular atrophy, autoplasty is performed with a fragment of the gluteus maximus muscle, aponeurotic tissue, or alloplasty with the installation of a mesh synthetic implant. Possible strangulation of the hernial protrusion becomes an indication for laparotomy or a combined intervention, which allows for a high-quality inspection of the organs and, if necessary, their resection within healthy tissues.

Prognosis and prevention

At timely diagnosis and adequate surgical treatment, most patients recover. The prognosis is favorable. In some cases, a recurrence of the perineal hernia is observed. Measures to prevent perineal hernia formation in patients at risk are nonspecific; they involve limiting the weight of heavy lifting and regular physical exercise, aimed at strengthening the pelvic muscles, reducing body weight, timely emptying the bladder, normalizing stool, adequate treatment of diseases accompanied by increased intra-abdominal pressure.