Abdominal hernia

　　Since there are cavities in the abdominal cavity, hernial rings that can form internal hernias can be formed, which is the basis for the formation of abdominal hernias. The hernial ring cavities of abdominal hernias have primary and secondary types.

　　1. Primary abdominal hernia

　　Caused by congenital abdominal cavities. During the process of embryonic development, a residual cavity between the mesentery and the posterior parietal wall may occur during intestinal rotation, with abnormal rotation and poor fixation of the colon, and the mesentery of free intestinal segments such as the small intestine, mobile ascending colon, transverse colon, and sigmoid colon can develop congenital hernial rings, forming internal hernias. The normal posterior peritoneum has several recesses, but they are generally shallow and small, and do not cause internal hernias. If the peritoneal recesses are too deep, and the intestinal tract enters and is difficult to self-reposition, a recess hernia may form.

　　(1) Diaphragmatic hernia and esophageal hiatus hernia: Abdominal organs such as the stomach or transverse colon, which protrude into the thoracic cavity through a congenital defect in the diaphragm, are called diaphragmatic hernia. In addition to gastrointestinal obstruction, such diaphragmatic hernias often have symptoms of compression of chest organs such as the heart and lungs. Esophageal hiatus hernia is a relatively common type of diaphragmatic hernia.

　　(2) Omental hernia: Free intestinal loops, occasionally an abnormally long transverse colon of the mesentery, may sometimes pass through the omental foramen into the lesser omentum sac, known as an omental hernia. Because the anterior wall of the hernia sac is the hepaticoduodenal ligament, most cases will occur strangulation.

　　(3) Peritoneal recess hernia: If the peritoneal recess is too deep, it can be formed by the intestinal tract entering and not easily复位自行, forming a recess hernia. For example, the duodenal recess around the duodenojejunal flexure, the mesentery abdominal wall recess, the intermesenteric cleft of the colon mesentery, the ileocecal pouch, the post-cecal pouch, the post-sigmoid pouch, the paravesical space, etc.

　　(4) Mesenteric hernia: The mesentery of the small intestine may sometimes have congenital defects or clefts, and the transverse mesocolon may occasionally have defects. The small intestinal loops can pass through this hole to cause obstruction or incarceration.

　　2. Secondary abdominal hernia

　　It refers to abdominal hernia formed after surgery or trauma, except for traumatic diaphragmatic hernia, the common ones are as follows:

　　(1) Gaps caused by subtotal gastrectomy: The existence of post-anastomotic gaps after Billroth II or gastrojejunal anastomosis may become a cause of abdominal hernia. Especially when performing an anterior colonic anastomosis, and the input jejunal loop is too long, and the gap between the jejunal mesentery and the transverse mesocolon is not closed, sometimes an internal hernia may occur due to the output loop or intestinal tract passing through this gap. A too long input loop can form a larger post-anastomotic gap, which is an important cause of hernia.

　　(2) Gaps caused by radical rectal cancer surgery: After abdominal perineal resection for rectal cancer, two gaps may form in the abdominal cavity. One is the gap between the intestinal tract brought to the abdominal wall stoma and the left lateral abdominal wall, which may cause intestinal hernia into the side of the stoma intestinal tract if not closed during surgery and postoperative abdominal distension. The other gap is due to improper suture of the pelvic peritoneum, or postoperative abdominal distension causing the pelvic peritoneum to rupture into a gap, through which the intestinal tract can enter and form an internal hernia.

　　(3) Gaps caused by biliary tract surgery and biliary-enteric drainage: After T-tube drainage of the common bile duct or gastroenteric catheterization, if the position of the catheter is not properly placed, the intestinal loops may also enter the gaps between these drainage tubes and the lateral abdominal wall, forming an internal hernia.

　　Common complications of abdominal hernia include a large amount of mesenteric or intestinal hernia into gaps that cannot be复位自行，and can be accompanied by intestinal strangulation. At this time, the passage of intestinal contents and the blood circulation of the intestinal wall are obstructed. The patient has obvious intestinal distension, disorder of water and electrolyte metabolism, acid-base imbalance, and severe peritonitis and sepsis. When intestinal necrosis occurs, toxic shock is more pronounced.

　　Abdominal hernia can occur from neonates to the elderly, with clinical manifestations of a series of symptoms and signs caused by gastrointestinal obstruction.

　　1. Abdominal pain

　　Postoperative internal hernia following abdominal surgery is characterized by severe abdominal pain, accompanied by symptoms of strangulated intestinal obstruction, with persistent and intermittent exacerbation of abdominal pain. Omental sac hernia and recess hernia can cause chronic simple intestinal obstruction, usually manifested as mild abdominal pain that recurs frequently.

　　2, Vomiting and constipation

　　Para duodenal hernia, partial gastrectomy after surgery and other high internal hernias have frequent vomiting and constipation. Crypt hernia, omental bursa hernia and other non-occlusive abdominal hernias have little nausea, vomiting, and constipation.

　　3, Abdominal distension and mass

　　Incisional abdominal hernia of low intestinal loops can cause abdominal distension. Omental bursa hernia, para duodenal hernia can occasionally form a mass and localized abdominal distension in the upper abdomen, and percussion sounds like a drum, and other types of internal hernia are often not palpable.

　　4, Abdominal postoperative internal hernia

　　It often occurs when the intestinal function recovers and starts to eat, with sudden severe abdominal pain, vomiting, and cessation of defecation and anal排气, accompanied by pale complexion, rapid heart rate, and cold extremities, and signs of peritoneal irritation.

　　Congenital (typical hernia) abdominal hernia cannot be prevented, but some atypical hernias caused by surgery can be prevented, such as Billroth II gastrojejunostomy, biliary-enteric Roux-Y anastomosis, colostomy, Mile operation, etc. The abnormal anatomy formed by iatrogenic trauma is an important factor causing secondary abdominal hernia, and it is easy to cause intestinal obstruction, so targeted effective measures should be taken: the incision at the surgical site should be smooth and without gaps; various anastomoses should meet physiological requirements and be tension-free; perfect preoperative preparation and effective postoperative treatment should be ensured to ensure the smoothness of gastrointestinal decompression; it is strictly forbidden to overeat and carry heavy loads in a short time after gastrointestinal surgery; avoid long-term bed rest and get out of bed as soon as possible, etc., and anti-adhesion drugs can also be used in abdominal surgery.

　　Firstly, X-ray examination

　　Abdominal radiography, abdominal plain film, or CT scan, etc., in addition to general intestinal obstruction signs, an abnormal accumulation of gas can be seen in a certain part of the peritoneum, a mass of small intestinal loops is gathered together, not easy to be moved, as if in a bag, while other parts of the small intestine in the abdomen are rare. Wislow hernia can be seen with the stomach displaced to the left and backward, the colon displaced downward, a cluster of small intestinal fluid levels accumulating in the omental bursa area, the mesentery located between the inferior vena cava and the portal vein, and a gas-liquid level in the omental bursa, multiple intestinal loop shadows visible in the subhepatic space.

　　Para duodenal hernia can be seen with small intestine twisted together, accumulating in the hernia sac, located in the midline, cannot be moved or dissolved, the body of the stomach is pulled down, the colon is behind the small intestinal loop mass, the small intestine in the hernia sac is dilated and呈淤滞状态. On the left side, para duodenal hernia can be seen with a mass of entangled intestinal loops between the stomach and pancreas, at the level of Treitz's ligament or behind the pancreas, the entangled intestinal loops lack the normal inter-digitation space between the intestinal loops (inter-digitation), and the intestinal tract is dilated with a gas-liquid level; On the right side, para duodenal hernia can be seen in the right upper abdomen with dilated intestinal tract and gas-liquid level, jejunal arteries and veins are behind the mesenteric artery.

　　Secondly, Ultrasound

　　An abnormal mass echo can be seen in a certain part of the peritoneum, with or without intestinal peristalsis, and the tubular or cystic shape of the mass internally changes with time and diet.

　　III. Other examinations

　　If selective mesenteric angiography shows abnormal course and distribution of mesenteric vessels, it is helpful for diagnosis.

　　Patients are often supplemented with vitamin C, such as kiwi, orange, tomato, asparagus, etc., and patients can eat more high-fiber staple foods to improve their defecation. At the same time, more high-protein foods such as eggs, eel, black fish, turtle, yogurt, and milk should be consumed. Hernia patients should avoid eating foods that can easily cause constipation and abdominal distension, cold and spicy foods, and drinking beer and carbonated beverages.

　　Acute bowel obstruction caused by intra-abdominal hernia may lead to bowel strangulation and necrosis in the short term. Once this disease is suspected, surgery should be performed immediately.

　　1. Preoperative preparation:Gastrointestinal decompression, sufficient fluid replacement, and correction of water, electrolyte, and acid-base balance disorders.

　　2. Key points of surgery:Gently dilate the hernia ring with hands, carefully and slowly reduce the bowel loops with a combination of compression and traction; if the bowel is severely distended, the hernia sac can be incised to aspirate gas and fluid from the bowel loops and separate adhesions to aid in reduction. Repair the expanded hernia ring or mesenteric defect.

　　All intra-abdominal hernias require surgical treatment. The edges of congenital intra-abdominal hernias often have important blood vessels or organs, and the bowel should not be forcibly expanded or arbitrarily cut or trimmed at the hernia ring during reduction to avoid injury. The Winslow foramen hernia can be treated by performing a Kocher incision to fully mobilize the duodenum to expand the hernia ring. Paraduodenal hernias can only be opened below the hernia ring, and it is absolutely not permissible to injure the superior mesenteric vessels at the anterior margin of the hernia ring in the right paraduodenal hernia. In summary, attention must be paid to the anatomical relationship adjacent to the hernia ring during surgery.

　　The true congenital intra-abdominal hernia sac is a vascular peritoneum, omentum, or mesentery, which can only be incised at locations without blood vessels or non-vascular trunks, and the incarcerated bowel is to be reduced and examined. If it is difficult to reduce the bowel that has expanded without necrosis, it can be reduced after performing enteric decompression under strict anti-contamination measures. If it has been strangulated and necrotic, the bowel at the normal entrance of the hernia ring should be cut, the necrotic bowel segment inside the hernia sac should be removed, and then the cut ends should be anastomosed. The surgical principles for congenital or acquired intra-abdominal false hernia are: after the hernia contents are reduced, adhesions should be cut or all fissures should be sutured to prevent recurrence.