Perineal hernia in women. Endoscopic technologies in the treatment of disease

This type of hernia is quite rare and occurs mainly in women. The protrusion is divided into anterior and posterior. While anterior hernias occur only in women and represent a protrusion through the urogenital diaphragm, the posterior type of hernia occurs in both sexes and is present as a mass below the lower border of the gluteus maximus muscle or between the anus and the gluteal prominence.

Hernias of this type are often congenital and hereditary, and their development increases with age. In rare cases, they may be associated with diseases such as Marfan syndrome ( genetic disease connective tissue, characterized by disproportionately long limbs). Acquired perineal hernias are also quite rare and occur due to an increase in intra-abdominal pressure, vaginal birth, obesity or chronic pelvic diaphragm disease.

A perineal hernia can be caused by prostate and urinary tract disease, which in turn weakens the pelvic floor. They are often also caused through pelvic floor reconstruction surgery. Such reconstruction becomes even more difficult if the coccyx or distal sacrum had to be removed through this operation. Also the cause of of this disease There may be constipation and diarrhea.

Symptoms of perineal hernia

Early symptoms of a perineal hernia include discomfort and pressure around the rectum. The main signs of the occurrence of these protrusions is the presence of a tumor-like formation in the perineum. If the protrusion includes the bladder, then the patient will have a clearly defined dysuric disorder. The symptoms of these protrusions are quite similar to other types of disease, such as a Bartholin gland cyst (inflammation of the gland and its ducts), lipoma (a benign tumor of adipose tissue), and therefore, to determine a perineal hernia, it is necessary to conduct a detailed diagnosis. Other symptoms include discomfort and pain during shrinkage, erosion of the skin over the hernia, intestinal obstruction, and difficulty urinating.

Diagnosis of a pelvic floor hernia

When diagnosing, a very important step is to separate the symptoms from other diseases in the area. Since this type of protrusion occurs predominantly in women, one of the diagnostic methods is a digital examination through the vagina, since during this procedure it is possible to determine the type of protrusion by first palpating the area between the vagina and the ischium.

Treatment of perineal hernia

There are two methods for removing a protrusion in the pelvic area, such as transperitoneal and perineal. Surgical approaches to the treatment of perineal hernia in women include the use of a transabdominal method (removal through the peritoneum) through a lower midline incision, which provides an excellent opportunity for reconstruction of the pelvic floor. After removing the hernial sac, the damaged area is sutured using local tissue or a special mesh using alloplasty.

The approach to removing a hernia using the perineal method provides less impact compared to the transabdominal technique, but at the same time is less painful. As an isolated technique, it may be most useful for congenital hernia repair, as this method causes almost no recurrence in patients.

Perineal hernia in women

A perineal hernia in women is a protrusion that passes through the urogenital septum (diaphragma urogenitales) or between the muscle fibers of the levator anus muscle, or between it and other perineal muscles. The anatomical features of the structure of the perineum with the formation of peritoneal depressions can serve as predisposing factors in the formation of this hernia.

Winkel suggests distinguishing 3 types of hernial formations in women:

• anterior (Hernia perinaealis anterior), which extends between mm. constrictor cunni, m. ischio-cavernosus,
• middle (Hernia perinaealis media), which comes out between mm. constrictor cunni, m. transversus perinei profundus
• posterior (Hernia perinaealis posterior) - emerges from the uterorectal recess of the peritoneum.

Posterior hernial protrusions are usually larger than the anterior ones. They are accompanied by frequent prolapse of the rectum, and with an anterior hernia, prolapse of the vagina or uterus. Perineal hernial formations are also divided into complete and incomplete, the latter remaining in the tissues of the perineum.

The contents of perineal hernias in women include the bladder and genitals; posterior hernias most often contain the intestines and omentum.

Symptoms of perineal hernia in women

Symptoms vary, depending on the size of the hernial protrusion, its contents and reducibility. With incomplete hernias, complaints are vague. In any case, pain in the perineum that is not explained by a disease of the rectum and genital organs should force the doctor to examine the patient regarding the possible presence of a perineal hernia. Being in a herniated bladder is accompanied by dysuric phenomena.

Anterior hernial formations extend into big lip, which may give rise to confusion with an inguinal hernia. Perineal hernias in women extending to the perineum do not create difficulties for their recognition, but posterior hernias can be located under the edge of the buttock and then resemble a sciatic hernia, although examination of the hernial orifice with a reducible hernia easily allows for a correct diagnosis. Reducible perineal hernias rarely give rise to misdiagnosis. But with irreducible hernias, the hernial protrusion was sometimes mistaken for a neoplasm even during surgery, which caused damage to the intestines, omentum and other organs.

Recognition of irreducible hernia formations is difficult and requires examination through the vagina, rectum, additional research bladder, x-ray examination of the intestines.

Treatment of perineal hernias in women

Treatment can only be surgical. Surgical interventions are performed by the perineal route, using laparotomy and a combined method. With all methods of surgery, the latter consists of 2 moments - isolation and resection of the hernial sac, and the second - closure of the hernial orifice. It is easier to close them through the perineum by suturing the gap in the muscles. For muscular atrophy, aponeurotic plasty or muscle plasty from the gluteus maximus muscle, alloplasty, are used.

Of the complications, the main one is strangulation, which most often gives rise to surgery by laparotomy. For strangulated and irreducible hernial protrusions, it is recommended combined operation- laparotomy and perineal method.

Features, symptoms and treatment of perineal hernia

A perineal hernia is a rare pathology in people of any age, characterized by prolapse of a certain organ of the pelvic cavity through the diaphragm or pelvic floor muscles. This type of hernia occurs more often in women than in men, which is explained by features in the anatomical structure. Let's look at how you can identify and treat a perineal hernia.

Mechanism of hernia development

In the absence of deviations, the omentum, bladder and part of the intestine are held in their anatomical location using the pelvic diaphragm. If its integrity is violated or the pelvic floor muscles are damaged, the support becomes unstable and the internal organs, under the influence of their weight, penetrate under the skin. This is how a perineal hernia is formed, which has the code Q-00 – Q-99 according to the international classification of diseases ICD-10.

The pathology most often occurs in women. The female perineum is characterized by a special structure of the urogenital diaphragm and the muscles adjacent to it. In men, the genitourinary septum has a small opening through which the urethra passes, so pathology is much less common and occurs in the back of the perineum.

The structure of the perineum in men

The causes of a perineal hernia can be the following factors:

• weakening of the pelvic floor;
• violation of the integrity of the genitourinary diaphragm during surgical interventions;
• the formation of a benign or malignant tumor in the pelvic cavity;
• pregnancy and childbirth;
• some diseases (in men - prostate adenoma or prostatitis) and obesity.

A perineal hernia in humans is formed, like an inguinal hernia: from a section of the intestine, omentum or bladder. In very rare cases, pathology may develop in women from the internal genital organs.

Classification of perineal hernias

In total, two types of hernias of the described localization can be distinguished: posterior and anterior. Each has its own characteristics.

Anterior perineal hernia occurs only in women. In this case, the internal organ passes in front of the transverse perineal muscle, pushing apart soft fabrics and comes out, most often, under great labia. At the same time, the anterior wall of the vagina protrudes. The pathology looks like a small lump and is often not detected visually, but only by palpation.

Posterior perineal hernia occurs in people regardless of gender. In this case, the internal organ passes behind the transverse perineal muscle through the gaps between the muscle tissue starting from the coccyx and the sphincter. A posterior perineal hernia manifests itself as a slight swelling in the area of ​​the edge of the buttocks. In women, the pathology is often complicated by rectal prolapse.

In addition to classification according to the nature of occurrence and localization, grouping of hernias according to their course can be used. The most dangerous in this case are strangulated perineal hernias, which are difficult to treat surgically due to the complex surgical approach.

Symptoms of perineal hernia

It is not enough to know what a perineal hernia looks like - the inguinal and sciatic types have similar localization. Therefore, it is difficult for doctors to make a diagnosis without additional examination. This is especially true for small hernias located under the subcutaneous tissue and not manifested by protrusion.

Anatomy of the female perineum

The main symptoms are the same as for other types of hernias:

• pain aching character lower abdomen;
• feeling of heaviness and pressure in the perineum;
• violation of the act of defecation - constipation;
• problems with urination if the hernia is formed by the bladder.

If a perineal hernia is strangulated, body temperature may increase. In some cases it develops sharp pain, especially during bending and squatting.

Diagnosis of perineal hernia

The diagnosis is made based on the collected history, palpation and instrumental examination data. The doctor will ask you about what preceded the development of the pathology, what measures were taken independently, and will ask you about your symptoms. Then he will begin to feel the protrusion.

In some cases, it is not possible to determine the location of the hernial orifice and the nature of the hernia by palpation of the perineum. Therefore, examination of the vagina in women and the rectum in men will be required. A perineal hernia puts pressure on these organs, so it can be detected.

For a more accurate diagnosis, radiography and computed tomography are used. Using these methods, you can obtain information about the nature of the hernia and the contents of the hernial sac. After collecting all the data and excluding similar pathologies, the doctor makes a decision on treatment.

Surgery for perineal hernia

Perineal hernia can only be treated surgically. Emergency surgery is only necessary in case of complications that threaten the patient's life, for example, a strangulated hernia. In all other cases, the operation is performed as planned.

Posterior perineal hernia

The operation is being carried out combined method under general anesthesia. In some cases, the perineal approach can be used, but it has a significant drawback - with a strangulated hernia and necrosis of the intestine, it is impossible to remove adjacent healthy tissue. Therefore, the doctor makes the final decision on the surgical technique based on preliminary diagnosis.

Perineal hernia is often accompanied by relapses. This is due to the peculiarities of the anatomical structure of the pelvic floor, in which it is impossible to perform hernial orifice repair. Therefore, throughout the life of a person who has undergone surgery to remove pathology, he needs to undergo examinations.

Prevention of perineal hernia

There are no measures that can prevent the formation of a perineal hernia. You can prevent complications from developing. To do this, you need to regularly visit the doctor and not ignore pain in the lower abdomen.

Perineal hernia is very rare. Most often, the pathology is diagnosed in women, which is associated with anatomical features structures of the pelvic floor and perineum. Surgery is the only treatment method, but it is also associated with a high relapse rate. Therefore, people who have been diagnosed with a perineal hernia should be periodically checked by a doctor and, if necessary, undergo an examination.

Veterinary clinic of Dr. Shubin

Balakovo, st. Trnavskaya, no. 4. tel.-46-58

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Perineal hernia

Definition

Perineal hernia is a violation of the integrity of the muscles of the pelvic diaphragm with subsequent prolapse of the contents of the pelvic and/or abdominal cavity V subcutaneous tissue crotch.

Depending on the location of the diaphragm muscle defect, a perineal hernia can be caudal, sciatic, ventral and dorsal (see below). Also, a distinction is made between unilateral and bilateral perineal hernia.

Etiopathogenesis

The exact causes of the disease have not been determined. An imbalance of sex hormones is considered as a probable cause, due to the predisposition to the disease in non-castrated males. Also, probable predisposing factors include various pathological conditions accompanied by tenesmus, such as chronic constipation and prostate hyperplasia. In cats, perineal hernia can develop as a rare complication of previous perineal urethrostomy.

The development of perineal hernia is caused by degenerative changes muscles of the pelvic diaphragm, which leads to a displacement of the anus from its normal physiological position, which causes a violation of the act of defecation, tenesmus and coprostasis, which further worsens the situation. There is likely to be displacement of abdominal organs such as the prostate, bladder, and small intestine into the hernia cavity. If the urinary tract is strangulated, life-threatening renal failure is likely to develop.

Diagnosis

Perineal hernia is typical for dogs; it is quite rare in cats. In dogs, the vast majority of cases (about 93%) occur in non-neutered males. Possible predisposition in dogs with short tail. In cats, perineal hernia is more common in neutered cats, but female cats are more often affected compared to female cats. Age predisposition – middle-aged and elderly animals, with the average age of onset of the disease in both dogs and cats being 10 years.

The main primary complaints are difficulties with defecation; sometimes animal owners note swelling on the side of the anus. With strangulation of the urinary tract, signs of acute postrenal renal failure are likely to develop.

Physical examination findings

Upon examination, one- or two-sided swelling in the anal area is likely to be detected, but it is not always detected. The results of palpation of this swelling depend on the contents of the hernia; it can be hard, fluctuating or soft. Diagnosis is based on the detection of weakness of the pelvic diaphragm on rectal examination. Also, during a rectal examination, rectal overflow and changes in its shape are likely to be detected.

Imaging tools for this disease are used only as auxiliary methods. Plain radiography can reveal displacement of organs into the hernial cavity, but for these purposes it is better to use various methods contrast radiography (eg contrast urethrogram, cystogram). Also, ultrasound is used to assess the position of internal organs.

Differential diagnosis

Rectal diverticulum without perineal hernia

Treatment

The goals of treatment are to normalize bowel movements, prevent dysuria and organ strangulation. Normal bowel movements can sometimes be maintained through laxatives, stool softeners, feeding adjustments, and periodic evacuation of the colon through enemas and manual bowel movements. However, long-term use of these methods is contraindicated due to the likelihood of developing internal organs, and the basis of treatment is surgical correction.

For surgical correction, two herniorrhaphy techniques are most often used: the traditional technique (anatomical reposition technique) and transposition of the internal obturator (obturator internus muscle). With the traditional method, greater tension is created in the zone surgical wound and certain difficulties arise when closing the ventral edge of the hernial orifice. The technique of transposition of the obturator internus muscle requires more professionalism on the part of the surgeon (especially with severe atrophy of the obturator), but creates less tension in the defect area and makes it quite easy to close the ventral edge of the hernial orifice. Other herniorrhaphy techniques may include the use of the superficial gluteal, semitendinosus and semimembranosus muscles, fascia lata, synthetic mesh, small intestinal submucosa, or a combination of these techniques.

For bilateral perineal hernia, some doctors prefer to perform two consecutive operations on each side with an interval of 4-6 weeks, but it is also possible to perform simultaneous closure of the defect. With sequential closure of the defect, the likelihood of temporary deformation of the anus is reduced and postoperative discomfort and tenesmus are reduced, but the choice of technique often depends on the preferences of the surgeon.

Although the data on effectiveness are somewhat contradictory, castration is still indicated in non-castrated male dogs during surgery in order to reduce the likelihood of recurrent hernia and also to reduce the size of the prostate in case of benign hyperplasia. Suturing the rectum in case of suspected diverticulum is performed extremely rarely, due to a significant increase in the risk of developing postoperative infection. Colopexy may reduce the likelihood of postoperative rectal prolapse. It is also possible to perform cystopexy, but this procedure is performed quite rarely due to the likelihood of developing retention cystitis.

It is recommended to prescribe stool softeners and laxatives 2-3 days before surgery. Immediately before the operation, the contents of the large intestine are evacuated through manual bowel movements and an enema. If the bladder hernia is displaced into the cavity, it is catheterized. Antibiotics are administered intravenously for prophylactic purposes, immediately after sedation of the animal.

Preparation surgical field and styling

The surgical field is prepared at a distance cm around the perineum in all directions (cranially above the tail, laterally behind the ischial tuberosities and ventrally behind the testes). Laying the animal on its stomach with the tail pulled back and fixed. It is optimal to perform surgery on an animal with an elevated pelvis.

In addition to the fascia, the pelvic diaphragm is formed by two paired muscles (the levator anus and the caudal muscle) and the external sphincter of the anus. The levator anus (m. levator ani) originates from the bottom of the pelvis and the medial surface ilium, passes laterally from the anus, then narrows and attaches ventrally to the seventh caudal vertebra. The caudal muscle (m. coccygeus) begins on the ischial spine, its fibers run laterally and parallel to the levator anus, and is attached ventrally on the II-V caudal vertebrae.

The rectococcygeus muscle (m. rectococcygeus) consists of smooth muscle fibers, starts from the longitudinal muscles of the rectum and is attached ventromedially on the caudal vertebrae.

The sacrotuberal ligament (l. sacrotuberale) in dogs connects the end of the lateral part of the sacrum and the transverse process of the first caudal vertebra with the ischial tubercle. In cats this education absent. The sciatic nerve lies immediately cranial and lateral to the sacrotuberous ligament.

The obturator internus is a fan-shaped muscle covering the dorsal surface of the pelvic cavity, it begins on the dorsal surface of the ischium and pelvic symphysis, passes over the lesser sciatic notch ventral to the sacrotubercular ligament. The internal pudendal artery and vein, as well as the pudendal nerve, pass caudomedially on the dorsal surface of the obturator internus, laterally to the caudalis muscle and levator ani. The pudendal nerve is located dorsal to the vessels and divides into the caudal rectal and perineal nerves.

In most cases, a hernia is formed between the external levator anus and the anus itself, and is called caudal. When a hernia forms between the sacrotuberous ligament and the gluteal muscle, the hernia is called sciatic. When a hernia forms between the levator anus and the caudal muscle, it is called dorsal. When a hernia forms between the ischiourethral, ​​bulbocavernosus and ischiocavernosus muscles, the hernia is called ventral.

The skin incision begins under the tail in the area where the tail muscle passes, then follows the hernia swelling 1-2 cm lateral to the anus and ends 2-3 cm ventral to the pelvic floor. After dissection of the subcutaneous tissues and the hernial sac, the hernial contents are identified and the fibrous attachment to the surrounding tissues is dissected, followed by its reduction into the abdominal cavity. Maintaining the reposition of organs in the abdominal cavity is carried out using a damp tampon or sponge located in the hernia defect. Then the muscles involved in the formation of the pelvic diaphragm, internal pudendal arteries and veins, pudendal nerve, caudal rectal vessels and nerves and the sacrotuberous ligament are identified. Next, herniorrhaphy is performed depending on the chosen technique.

Traditional (anatomical) herniorrhaphy

With this technique, the external anal sphincter is sutured with the remnants of the tail muscle and levator anus, as well as with the sacrotubercular ligament and the internal obturator. The defect is sutured with an interrupted suture, monofilament non-absorbable or long-term absorbable thread (). The first sutures are placed on the dorsal edge of the hernial orifice, gradually moving ventrally. The distance between suture stitches is no more than 1 cm. When applying sutures to the area of ​​the sacrotubercular ligament, it is optimal to pass through it and not around it, due to the likelihood of entrapment sciatic nerve. When placing sutures between the external sphincter and the internal obturator, the involvement of the pudendal vessels and nerve should be avoided. The subcutaneous tissue is collected in the usual manner using absorbable sutures, and the skin is then sutured with non-absorbable material.

Herniorrhaphy with transposition of the obturator internus muscle.

The fascia and periosteum are dissected along the caudal border of the ischium and the site of origin of the obturator internus muscle, then, using the periosteal elevator, the internal obturator is raised above the ischium and this muscle is transposed dorsomedially into the hernial orifice with its location between the external sphincter, the remnants of the pelvic diaphragm muscles a and sacrotubercular ligament. It is possible to cut off the internal obturator tendon from its insertion to facilitate closure of the defect. After which, interrupted sutures are applied as in the traditional technique, medially the internal obturator is connected to the external sphincter, and laterally to the remnants of the pelvic diaphragm muscles and the sacrotubercular ligament.

To reduce pain, straining and the likelihood of rectal prolapse, adequate postoperative pain relief is provided. If rectal prolapse occurs, a temporary purse-string suture is applied. Antibacterial therapy, in the absence of significant tissue damage, is stopped 12 hours after surgery. Also, after the operation, the condition of the sutures is monitored for possible infection and inflammation. Within 1-2 months, diet adjustments are made and medications are prescribed to soften the stool.

Forecasts

The prognosis is often favorable, but largely depends on the professionalism of the surgeon.

Valery Shubin, veterinarian, Balakovo.

Perineal hernia in a dog: causes, complications, therapy

A perineal hernia in a dog is a pathology in which prolapse, one- or two-sided protrusion of internal organs occurs, namely the 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 uncastrated males of middle and older age, 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.

Etiology, causes

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 a weakening of muscle tone, degenerative-destructive changes in the muscular structures of the pelvic diaphragm, and impaired tissue trophism. This leads to a displacement of the anus from its natural anatomical position.

• 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 is 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.

Hernias are observed in dogs aged five to ten years. 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:

• At the initial stage, a decrease in the tone of the muscle structures of the perineum and their gradual atrophy are noted.
• The second stage of 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 moving to the third stage, a painful, non-disappearing protrusion appears near the anus on one or 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 a displacement of the outlet of the rectum. The remaining organs gradually shift, protruding into the resulting hernial cavity.

As a rule, the prostate, rectal loop, and omentum prolapse into the hernial sac. The bladder often protrudes into the formed cavity. When pressing on the pathological protrusion, urine is released spontaneously. In case of complete pinching of the urinary tract, the act of urination is absent.

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.

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

At the initial stages of development of the 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, body temperature may increase, weakness, fast fatiguability after a short physical activity, loss of appetite, intoxication. 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. A hernia may be strangulated, so treatment should be started as soon as possible to avoid serious complications.

Treatment

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

If the bladder is pinched, catheterization is performed to remove urine using a 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.

In therapeutic therapy, depending on their type, in veterinary medicine they use:

• intra-abdominal fixation of organs;
• resection (excision) of the hernial sac;
• suturing the hernial sac.

During the operation, the hernial sac is most often excised, the contents are reduced, and the hernial sac is closed. muscle defect bottom of the crotch. Strengthening is carried out with special surgical materials to prevent relapses. Considering the possibility of injury to internal organs, surgery is prescribed only for large hernias.

In the treatment of perineal hernias in animals, the Magda method (MoltzenNielsen.) is most often used. The hernial defect is closed through a small surgical approach from the side of the perineum with slowly absorbable surgical sutures (catgut, polyglactin, polydioxanone). The thread is passed through the caudal lateralis muscle around the sacrotuberous ligament. The rectum is sutured. The anal sphincter is sutured to the sacral ligament. To prevent perforation of the intestines, a temporary purse-string suture is applied.

If the pathology has reached the third stage, they resort to muscle plastic techniques. To close a hernia defect, special alloplastic (synthetic) materials are used, for example, polypropylene.

With bilateral protrusion, the operation can be performed in two stages with an interval of 4-6 weeks. In this case, the likelihood of temporary deformation of the anus is reduced and the rehabilitation period is shortened.

In the postoperative period, four-fingered patients are prescribed enzyme, anti-inflammatory, restoratives, antibiotics, prescribe a special therapeutic diet, food. Food should be light and easily digestible. In the first month after surgery, intense exercise is contraindicated. Do not allow the body to overheat or hypothermia. The condition of the seams is constantly monitored.

The prognosis after treatment of a perineal hernia depends largely on proper care, attentive attitude towards the pet, the level of professionalism of the treating veterinarian.

Rare forms of abdominal hernia, pudendal hernia, herniae perineales, herniae lumbales, hernia obturatoria, other abdominal hernia, hernia retroperitoneal, hernia sciatic

Version: MedElement Disease Directory

Other specified abdominal hernia without obstruction or gangrene (K45.8)

Gastroenterology

general information

Short description

Note. This subheading includes the so-called “rare hernias”:

Abdominal hernias, specified localization, not classified elsewhere;
- lumbar hernia;
- obturator hernias;
- hernias of the female external genitalia;
- retroperitoneal hernias;
- sciatic hernia.

Hernial protrusions in the lumbar region on the posterior and lateral walls of the abdomen. There are congenital and acquired (traumatic, muscle atrophy, etc.) lumbar hernias.

Obturator hernias exit through the obturator canal, the walls of which are formed pubic bone with a locking groove running along its lower surface; the lower border is formed by the internal and external obturator membranes and the fatty tissue located between them. The channel has anterior and posterior openings. In addition to the hernial sac, the canal contains the obturator nerve, vein and artery.

Perineal hernia(hernias of the female external genitalia) extend to the perineum from the abdominal cavity through defects in the pelvic diaphragm. There are congenital and acquired perineal hernias. Congenital hernias are a consequence of abnormalities in the development of the pelvic floor muscles, are detected immediately after birth and are coded in the block of headings “Congenital anomalies [malformations], deformations and chromosomal disorders” - Q00-Q99.

Retroperitoneal hernias(retroperitoneal) - a variant of hernias that form inside the abdominal cavity in peritoneal pockets and folds and prolapse into the retroperitoneal space. Resemble external hernias of the abdominal wall. They have a hernial orifice and hernial contents (usually the small intestine, omentum). They do not have a hernial sac.

Sciatic hernias - abdominal hernias extending onto the posterior surface of the pelvis through the greater or lesser sciatic foramen.

Classification

1. Congenital ("Others" congenital anomalies abdominal wall" - Q 79.5) - are detected immediately after the birth of a child or during the first months of life. Their appearance is associated with anomalies in the development of the muscles of the lumbar region or developmental defects.

2. Acquired - develop under the influence of factors that sharply weaken or destroy the posterior wall of the abdomen.

Obturator hernias:

1. The obturator hernia itself does not extend beyond the canal.

2. Posterior pectineal hernia - the hernial sac exits through the anterior opening and remains lying under the pectineal muscle.

3. Anterior pectineal hernia - located under the fascia lata or in the subcutaneous tissue.

Perineal hernia

1.Front- hernias that extend in front of the intersciatic line or the deep transverse perineal muscle.

In women, an anterior perineal hernia forms in the vesicouterine cavity of the peritoneum and passes into the gap between m. sphincter ani externus (m. constrictor ani s. orbicularis ani) and m. ischiocavernosus. After this, it exfoliates the tissue and passes into the labia majora, protruding its central part.

In men, anterior perineal hernias almost never occur, due to the presence of an obstruction in the dense urogenital septum with an opening only for the urethra.

2. Rear- hernias that extend behind the deep transverse perineal muscle.

In men, a posterior perineal hernia develops from the vesico-rectal recess of the peritoneum, in women - from the uterorectal recess. Then the hernia passes posteriorly from the intersciatic line and through the interintestinal fissures enters the cellular space of the ischiorectal cavity.

The most common places where a hernia passes through the pelvic diaphragm:

The gap between the iliococcygeus muscle and the levator ani muscle;

The gap between the iliococcygeus and coccygeus muscles;

Gaps in the levator ani muscle.

Classification retroperitoneal hernias by location:

1. Paraduodenal (the most common) or Treitz hernia - an internal abdominal hernia in which any abdominal organ enters the duodenojejunal cavity (Treitz's pouch). Can be right- or left-sided.

2. Pericecal (periocecal hernia).

3. Hernia of the foramen of Winslow.

4. Intersigmoid (intersigmoid) hernia.

5. Paracolic hernia (right-sided, left-sided).

6. Ilioascial hernia.

Sciatic hernias:

1. Sciatic hernia extending above the piriformis muscle (hernia suprapiriformis).

2. Sciatic hernia emerging under the piriformis muscle (hernia infrapiriformis).

3. Sciatic hernia emerging through the lesser sciatic foramen (hernia spinotuberosa).

Etiology and pathogenesis

The origin of lumbar hernias is the upper and lower lumbar triangles between the XII rib and the iliac crest along the lateral edge of the latissimus dorsi muscle. Also, lumbar hernias can emerge through defects in the aponeurosis due to rupture or inflammation, without a specific localization.

With a lower lumbar hernia, the hernial orifice is located within the lower lumbar triangle, the base of which is formed by the internal oblique and transverse abdominal muscles. This is a relatively thin muscle plate, perforated by the ilioepigastric nerve and lumbar vessels.

With an upper lumbar hernia, the hernial orifice is located within the upper lumbar triangle, the base of which is transverse muscle belly; the outside of the triangle is covered vastus muscle backs.

Contents of a typical lumbar hernia usually becomes small intestine. With a sliding hernia, the contents become the ascending or descending colon.
Often, lumbar hernias have no hernial sac. Retroperitoneal tissue and sometimes a kidney can emerge through the hernial orifice. In this case, the hernia is considered false.

Obturator hernias in women, according to most surgeons, are explained by the peculiarities of the anatomical structure female pelvis: its more pronounced slope, larger size of the obturator foramen, more vertical position of the obturator canal. The older a woman gets, the smaller the mass of fatty tissue in the obturator canal, thus the aspiratory muscles undergo atrophy. This causes the gap to increase by about neurovascular bundle, creating conditions for the formation of a hernia. This, in particular, explains the fact that obturator hernias are often bilateral.
The hernial sac contains intestinal loops and the omentum; less often - appendix, bladder, female genital organs.

Perineal hernia arise under the influence of various reasons, including:

Weakness of the pelvic floor;

Violation of the integrity of the pelvic floor after surgery or injury;

The presence of an intrapelvic, subperitoneal tumor.

As a rule, the contents of the hernia are the small intestine, but the hernial sac may also contain the omentum or bladder. For more information about the structure of perineal hernias, see the “Classification” section.

Retroperitoneal hernias are mainly congenital, arising as a result of DST syndrome and/or incomplete intestinal rotation. In adults, they usually occur as a result of chronic perivisceritis and/or after surgical interventions, accompanied by a violation of the normal position of the abdominal organs. The most common such provoking interventions are the performance of various anastomoses (for example, Roux-en-Y gastric bypass), liver transplantation, intestinal or bladder resection. With the development of surgery, the list of such surgical interventions increases.

Reasons for education sciatic hernias:

Congenital existence of a peritoneal diverticulum;

The presence of abnormally enlarged orifices;

Atrophy of the muscles of the sciatic region due to physiological (pregnancy, childbirth) and pathological (tumors of the pelvic organs and its walls) phenomena.

Epidemiology

Sign of prevalence: Extremely rare

All hernias classified in this subheading are extremely rare. In total, they occupy about 1% of all abdominal hernias.

are found at any age, most often in men.

Obturator hernias usually occur in older women. Most often on the right side, but they can be bilateral.

Perineal hernia occur in both men and women. Any age.

Retroperitoneal hernias. The age is predominantly young and adult. In general, no gender differences were found, although types such as paraduodenal hernias are 3 times more common in men than in women.

Sciatic hernias occur at any age, equally often in both men and women.

Risk factors and groups

- pregnancy;
- obesity;
- surgical interventions in the abdominal cavity;
- congenital developmental defects;
- female.

Clinical picture

Clinical diagnostic criteria

Protrusion, pain in the area of ​​protrusion, pain decreases when lying down, pain increases with physical exertion, pain is associated with eating, constipation, dysuria, pain in the epigastrium, pain to the left of the navel, pain in the lower back, pain in the lower abdomen, pain in the perineum, pain in the gluteal region

Symptoms, course

Recognizing lumbar hernias is not very difficult. A common sign of such a hernia is the presence of a hernial protrusion in a typical location (in the area of ​​the lumbar triangles) or in other points of the lumbar region (for example, along the course of postoperative scars).
Patients complain of pain in the hernia area. If the hernial protrusion comes out through the gap where the nerve passes, the pain is constant. With physical stress, the pain intensifies. Lumbar hernias can grow in size and become irreducible.

Obturator hernias

They can be asymptomatic for a long time. Sometimes they manifest as pain along the obturator nerve. There are painful sensations of a very different nature, the pain radiates Irradiation is the spread of pain beyond the affected area or organ.
down along or on the lower half of the abdomen, worsens with movement. The pain may have the character of real neuralgia or only mild paresthesia Paresthesia is a spontaneously occurring unpleasant sensation of numbness, tingling, burning, or crawling.
.

During the examination, pay attention to the configuration of the hip. It is necessary to examine the patient in both lying and standing positions, with different positions of the limbs. Detection of tympanitis Tympanitis (tympanic percussion sound) - a loud, medium-high or high percussion sound that occurs when percussion over a hollow organ or cavity containing air
percussion helps to make a diagnosis.

An obturator hernia is characterized by the Howship-Romberg symptom: stabbing pain neuralgic in nature, which spreads along the inner surface of the thigh down to the knee joint. The occurrence of the symptom is due to the pressure of the hernial protrusion on the obturator nerve; the pain increases sharply when the hernia is strangulated.

It is necessary to conduct a rectal and vaginal examination with palpation of the area of ​​the posterior end of the obturator canal.

Perineal hernia
Main manifestations:

Aching pain in the lower abdomen;

Feeling of heaviness in the perineum;

Constipation;

Difficulty urinating.

It is very difficult to recognize perineal hernias, especially in cases where the hernial protrusion is small and does not reach the subcutaneous tissue.
To clarify the diagnosis, it is necessary to examine patients through the vagina and rectum. With anterior perineal hernias, the anterior wall of the vagina protrudes; with posterior hernias, the posterior wall of the vagina and the anterior wall of the rectum protrude.

Retroperitoneal hernias
If there is no strangulation, retroperitoneal hernias do not have specific symptoms. As a rule, they manifest themselves as abdominal pain or a feeling of fullness and distension, most often in the epigastrium Epigastrium is an area of ​​the abdomen bounded above by the diaphragm and below by a horizontal plane passing through a straight line connecting the lowest points of the tenth ribs.
or to the left of the navel, after eating.
Cramping pain of varying frequency and severity is possible (dull, colicky, cramping, severe, convulsive, unbearable).
Retroperitoneal hernias are characterized by a change, relief or elimination of an attack of pain after a change in body position, for example, in a supine position. Pain can appear suddenly and disappear just as suddenly after physical exertion.
Vomiting, nausea, belching, constipation, and increased peristalsis may occur (not constantly).

Sciatic hernias
A large sciatic hernia is easily recognized. Preoperative diagnosis is extremely difficult when the hernial protrusion does not extend from under the edge of the gluteal muscle.
The main complaints are related to pain in the gluteal region, which is especially aggravated by physical work.
With a pear-shaped hernia, pain may be noted along the sciatic nerve (along the back of the thigh).
For hernias that extend above the piriformis muscle, the pain is usually localized in the upper outer quadrant of the buttock.
For hernias extending above the piriformis muscle and through the for. ischiadicum minor pain is noted in the outer parts of the lower inner quadrant of the buttock.

Diagnostics

1. With visible hernial protrusions, the diagnosis is established clinically.

Additional physical signs:
- symptom of cough impulse;
- reducibility of protrusion;
- soft, slightly elastic, heterogeneous consistency of the protrusion;
- auscultation of peristalsis over the protrusion (rare).

Factors that significantly complicate clinical diagnosis: patient obesity, inadequacy, development of complications.

2. Retroperitoneal hernias are most often diagnosed intraoperatively, based on the incorrect location of intestinal loops.

3. X-ray contrast methods and computed tomography are the main methods of visualization and diagnosis.
X-ray semiotics of rare abdominal hernias is diverse. 3. Neuralgia - for small obturator, lumbar and sciatic hernias.
4. Stomach diseases, duodenum, intestines for retroperitoneal hernias.
5. Diseases causing dysuria, for perineal hernias.
6. Tumors of the abdominal organs.

An inguinal hernia in women, as in men, occurs as a result of weakening of the muscles in the abdominal wall.

When these muscles weaken, the abdominal wall loses its ability to support organs. Which in turn leads to protrusion and the appearance of a hernial sac.

In most cases, this pathology is acquired, but there are also cases where the cause is heredity. In this case, we mean genetic predisposition. The disease itself occurs only with accompanying factors that provoke the appearance of pathology.

If you notice symptoms of the disease, you should immediately consult a doctor. Ignoring it can lead to complications, and subsequently treatment will be more difficult and longer.

Inguinal hernia in women: characteristics of the disease

An inguinal hernia is an exit of the abdominal organs through the inguinal canal (paired slit-like formation in the lower abdominal wall, inside which the round ligament of the uterus normally passes in women).

In case of a hernia, loops of intestine (large or small), omentum, bladder, ovary, fallopian tubes, and rarely, ureter, kidney, and spleen emerge through the inguinal canal. Inguinal hernia in women is most often an acquired condition, although congenital forms also occur. It can occur on one or both sides at once.

The inguinal region consists of several fascial layers, between which the inguinal canal is located. In women, it contains a nerve bundle, artery and round ligament of the uterus. Like any other, the channel has an inner and outer ring (inlet and outlet).