Generality
The hernia is the escape of a bowel or a part of it from the natural cavity that normally contains it; therefore there are hernias in various parts of the body; the abdominal or inguinal ones are undoubtedly the most frequent.
etiopathogenesis
Congenital hernias occur when a hernial sac is present from birth.
Even in hernias of an acquired nature there is often an anatomical predisposition combined with a weakness of the muscular tissues and especially aponeurotics (tendon - collagens).
On the basis of these assumptions, the fundamental actor in the appearance of herniation is the intra-abdominal pressure which, acting on the areas of weakness, especially during the efforts, tends to push out the viscera.
Pathological anatomy
The hernia, in its evolution, can give rise to a simple internal orifice or to a real channel consisting of an internal and an external orifice.
When the hernia passes through a true canal, it can cross the abdominal wall along an oblique or perpendicular path, therefore one speaks of oblique hernias or direct hernias. The hernia tip (simple engagement of the inner ring) , the interstitial hernia ( when the bowel stops in the thickness of the aponeurotic muscle wall) and the complete hernia (when the outer orifice is crossed) is also distinguished.
The hernial sac is constituted by an extroflexion of the parietal peritoneum (a thin endothelial tissue that wraps around the herniated viscera and engages in the various routes described above). Three regions of the sack are distinguished: the collar, the body and the bottom. The content of the bag varies with the hernial area. The small intestine, the omentum and the colon constitute the most common hernial contents.
symptomatology
In the majority of cases, the patient complains of a gradual appearance of swelling in a given hernial area, but some hernias such as the inguinal or epigastric areas can be immediately painful and aggravated by the erect station associated with physical efforts.
Evolution
An untreated hernia tends to increase and this increases the likelihood of complications.
There are untreated hernias that lead to the so-called "loss of domicile" of the abdominal organs, ie most of the abdominal viscera goes to occupy the hernial sac instead of the abdominal cavity with consequent problems on the thoracic compartment and on respiratory dynamics.
Only surgical treatment can lead to the healing of the hernia.
Complications
The hernial strangulation is the most serious complication, since it is a constriction of the herniated bowel that can culminate with the occlusion-gangrene-peritonitis.
Any effort associated with a sudden increase in abdominal pressure can act as a determining factor in hernial throttling.
Inguinal hernia
Inguinal hernia alone represents more than 90% of abdominal hernias; it appears frequently in the first years of life or at the end of adolescence (often congenital) to reach the maximum peak in old age (often of acquired type). In the female sex it is rare to find, while the crural hernia prevails.
The hernial sac may enlarge until it reaches the scrotum and in this case we speak of inguino-scrotal hernia.
Classic therapeutic solutions
They include all the interventions performed through the open or inguinotomic incision. Two fundamental steps of the intervention are identified: A) dissection and treatment of the sac B) Reconstruction of the inguinal canal.
The reconstruction that until the 70s was prevalent with the non-prosthetic method (Bassini-Posteski-Shouldice-Mcvay method) was burdened with a consistent risk of recurrence. With the introduction of prosthetic materials ( mesh ) and two main techniques called Liechtenstein and Trabucco the recurrence rates have been reduced considerably. The prosthesis therefore satisfies the purpose of strengthening and integrating into the tissues, but at the same time constitutes a foreign body that must be fixed and housed in the tissues.
Of particular clinical interest are the conflicts between the implanted material and the nervous structures, which can give rise to acute and chronic painful complications.
Minimally invasive laparoscopic therapeutic solutions
The most widely used laparoscopic technique currently is TAPP (transabdominal preperitoneal); with this method one has the full videolaparoscopic view of the abdominal wall from the inside, allowing the evaluation of both groins and / or associated abdominal pathologies.
Access is via the umbilical scar, thus limiting cosmetic damage. The prosthesis is inserted and placed on the abdominal wall from the inside avoiding bloody dissections and is housed in a space called pre-peritoneal space; this very thin space is itself devoid of vascular and nervous structures. The prosthesis can be fixed with various other techniques and devices. The staples or spirals called tacks can still give rise to vascular-nervous lesions.
Tissue adhesives, on the other hand, which are true biocompatible adhesives, allow the prosthesis to be fixed in a traumatic manner, greatly reducing the risk of complications.
Crural Hernia
It is a type of hernia less frequent than the inguinal one, which appears more often in women after the age of 30. The crural ring, which is the site of weakness of this hernia, corresponds to an anatomical space immediately below the inguinal ligament and closely related to the femoral vessels (artery and vein).
Therapy
In analogy with inguinal hernias, there are classical techniques that involve open incision and simple plastic (Bassini technique) or prosthetic (Rutkow technique), or laparoscopic video Mini Invasive techniques.
Umbilical hernia - Epigastric hernias - Laparoceli
All these hernias affect the anterior abdominal wall. The umbilical hernia of the adult is found in order of frequency in third place after the groin and the crural; its frequency has increased in the obese.
The dimensions are very variable, from the small hernial sac to the giant hernias with viscera home loss. Epigastric hernia is always a defect in the midline of the anterior abdominal wall that is in the highest position of the navel. Even for this type of hernia the most formidable complication is the throttling. Laparoceli refers to hernias arising from previous surgical operations.
Umbilical hernia
Therapy
The therapeutic principles do not differ from those described so far and include classic or mini-invasive laparoscopic techniques.
Classic techniques
It is necessary to perform an open incision to isolate the hernial sac and reduce it in the abdomen; at this point the reconstruction of the abdominal wall can take place directly (without prosthesis) or prosthetic with the use of "Mesh" to strengthen the surrounding tissues.
Therapeutic Solutions
Laparoscopic Techniques for the Treatment of Abdominal Hernias
Through some millimetric lateral accesses to the abdominal cavity (generally three) it is possible to see the defect of wall from the inside via videoscopica and to introduce a particular type of Mesh named intraperitoneal.
After reducing the hernial contents, it is possible to apply the prosthesis fixing it to the abdominal wall with traumatic mechanical means such as points, metal spirals or treble hooks called Tacks .
Application of a Laparoscopy Mesh. This intervention aims to prevent a new herniation (recurrence) through the weak point of the abdominal wall.
The classic metallic materials used to fix this "artificial mesh" can give rise to complications. For this reason, when circumstances allow, the use of biological fixing adhesives is preferable. Image taken from the site: californiaherniaspecialists.com
Unfortunately these means of prosthetic fixing can give rise to complications of hemorrhagic or algic nature (acute and chronic pain). Alternatively, with the innovative technique developed by dr. Device and its team, the prosthesis can be fixed in a non-traumatic way thanks to the use of tissue adhesives and a special applicator specifically dedicated to this type of intervention.
Luminaire technique
Mini Invasive Technique for Abdominal Hernia Care
Tissue adhesives, being less traumatic, allow the prosthesis to be fixed without causing vascular and / or nerve damage and can reduce the rate of complications in this type of surgery.
This is the innovation introduced by the Italian surgeon Dott. Antonio Dliance, who has developed a laparoscopic technique that allows to treat the hernial pathology of the abdominal wall, in a less invasive way thanks to the use of special "biological glues" for the attachment of the prosthesis, instead of staples or traumatic points, which can cause severe pain or complications.
The technique is based on the use of a single-use, low-cost surgical instrument. This instrument traps the CO 2 gas normally used in laparoscopy inside a thin and transparent plastic flask. The low-pressure inflatable chamber that is created occupies the entire abdominal cavity. At this point the balloon assumes the shape of the abdominal cavity within which it swells and in this way makes the prosthesis adhere to the parietal peritoneum in a total and perfect way. The prosthesis can be fixed to the abdominal wall through surgical adhesives with full efficiency.
Despite the medical progress of the last decade, the surgeon explains, the postoperative complications with the currently most used techniques can be many: the extensive incision of traditional surgery is very invasive, the nails, the metal spirals and the stitches used for fixing the prosthetic retina are foreign bodies that our body can refuse in the long run, the pain can become chronic and the convalescence is very long.
With this technique, through a 12 mm incision it is possible to treat the hernia in a less traumatic way, giving the patient a chance of quick recovery and less risk of complications. In addition, the prosthesis positioned intraperitoneally is resistant to high physical loads and for these reasons it is particularly suitable for patients who practice fitness and body building at a professional level.
For more information, see the website of Dr. Antonio Delettra: www.internationalherniacare.com.
