Features of surgical treatment of strangulated postoperative abdominal large and giant hernias
Background. Strangulation of postoperative abdominal hernias (PAH) of large and giant size occurs in 6.2-25.1 % of cases. Elderly and senile patients predominate among patients with strangulation. The clinical course of strangulated PAH depends on the size of the hernial protrusion and its location, the nature and duration of strangulation, and the severity of comorbidities. In PAH of large and giant sizes with a multi-chamber bag, strangulation can occur in one of the chambers, which makes it difficult to diagnose. Mortality from PAH strangulation in the elderly and senile patients is 25-30 %.
Objective. To describe the features of surgical treatment of PAH strangulation.
Materials and methods. Analysis of literature sources on this issue.
Results and discussion. Strangulations can be elastic, parietal, fecal and retrograde. Elastic strangulation occurs when there is an acute increase in intra-abdominal pressure, during which the hernia gate is excessively stretched, and when the intra-abdominal pressure is reduced, the organs in the hernia sac are compressed. In retrograde compression, the intestinal loop in the abdominal cavity is strangulated and necrotized. Under conditions of parietal compression, the intestinal wall opposite the mesentery is strangulated. Fecal strangulation occurs as a result of compression of the efferent loop by the overfilled afferent loop. Acute pain that occurs in the area of the postoperative scar during exercise allows to suspect PAH strangulation. For the purpose of differential diagnosis, radiography and ultrasound examination of the abdominal cavity are performed. The main principle of treatment of strangulated PAH is to carry out an urgent surgery. Short-term preoperative preparation for 2 hours is mandatory. Preoperative preparation includes detoxification (saline solutions, Reosorbilact, “Yuria-Pharm”), correction of fluid and electrolyte metabolism and disorders of the cardiovascular and pulmonary systems, prevention of thromboembolic complications. The viability of the strangulated loop is determined by its color, the condition of the mesentery, and the reaction to irritation with warm saline. If the small intestine is not viable, it is resected with removal of the afferent loop at the distance of 30-40 cm from the necrosis zone and the efferent loop at the distance of 20 cm from the necrosis zone, followed by creation of a side-to-side or end-to-end anastomosis. If the large intestine is not viable, it is resected within the above limits with the formation of colostoma. At the stages of herniotomy, hernioplasty and before drainage and suturing antiseptic washing is performed with a help of Dekasan (“Yuria-Pharm”); 800-1200 ml are used depending on the area of the wound surface. When there is a phlegmon of the hernia sac, one should perform laparotomy outside the inflammatory process, resect the necrotized organ, and then remove the hernia sac with its contents. After washing with antiseptics solutions (Dekasan) and drainage of the abdominal cavity, it is covered with the own tissues. Alloplasty is contraindicated in such cases.
Conclusions. 1. Strangulations of PAH of big and giant sizes require urgent surgery after short preoperative preparation. 2. Surgical treatment of such strangulations should be performed with separation of the anatomical components of the abdominal wall in combination with alloplasty. 3. In case of strangulation of PAH and extremely severe condition of the patient, operation is aimed at the elimination of strangulation without defect closure.
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