dissection, peeling it out with the fingers, and disengaging it quite up to the neck. It is essential for the later steps of the operation that this be thoroughly done and is complete when Poupart's and Gimbernat's ligaments are well in view. This dissection of the sac takes less time than one might expect and is greatly facilitated if one is able to find a line of cleavage between the tissues. Sometimes bursa intervene between the sac and adjacent tissues and favor a rapid separation.
Third Step.—Open the sac; examine the contents. Once the hernial tumor is well exposed up to the constricting ring, cautiously ines the sac. Caution is required because often it is difficult to when one has penetrated the sac and an adherent intestine be wounded. In this form of hernia the true sac may be a cyst, which may be filled by bloody serum and thus gives appearances of the hernial sac. A moment's examination, peer shows that it is a small closed cavity without communication with the abdomen. The layers are to be cautiously divided one by one: —— the sac is opened into and the opening enlarged. Catch up the lips of the wound of the sac and examine its contents. Usually, in this form of strangulated hernia, one will find the latestine, darkened, tense, and slightly constricted, along with the omentum there may be several loops of small intestine, or the cecum, or the sigmoid flexure.
<Callout type="important" title="Important">Irrigate the cavity and its contents with normal salt solution and prepare to relieve the constriction.</Callout>
Fourth Step.—Relieve the constriction. The first effort should be to relieve the strangulation by stretching the offending fibers, to this end introducing a finger, if possible, into the ring along the inner side of the hernia. Oftentimes the pressure thus exerted will, with little effort, stretch and enlarge the opening sufficiently to relieve the constriction and to permit the necessary manipulation of the bowel.
<Callout type="warning" title="Warning">The use of the herniotomy knife, cutting blindly, should be reserved for exceptional cases, where the subject is fleshy and the obstruction beyond reach and very tight.</Callout>
When the obstruction is removed pull the bowel down and examine it. If it is suspicious or gangrenous, treat it after the manner indicated under Strangulated Inguinal Hernia. If it is sound, reduce it; liberate the sac around the femoral ring, ligate and resect it; and close in some manner the femoral canal, (See operation for radical cure.) The after-treatment is the same as for inguinal hernia.
<Callout type="risk" title="Risk">In exceptional cases it may be necessary, in order to see what to do, to divide Poupart's ligament; or, in the male where the cord is to be avoided, to make another incision along the inguinal canal, exposing the neck of the hernia; or, following the method of Tuffier, to open directly into the peritoneal cavity through the inguinal canal.
Strangulated Umbilical Hernia.—A strangulated umbilical hernia is peculiar in two or three respects. It is likely to be Acute without the characteristic symptoms of intestinal obstruction may be wanting. The site of strangulation is more likely to be in the sac than at the umbilical ring, But because the absolute signs of obstruction are absent and because the opening at the umbilicus seems patent, one has no excuse to delay when an old and long irreducible rupture becomes suddenly painful, with vomiting and partial.
<Callout type="tip" title="Tip">Operating early one may give assurance of excellent results.</Callout>
<Callout type="gear" title="Gear">A grooved director may be slipped up alongside the bowel and the fibers divided with scissors or bistoury; or if the fibers are in plain view, as they should be, they may be nicked with the point of the bistoury and when room is thus made the finger may be introduced as before.
<Callout type="important" title="Important">When the condition of the patient imposes great haste it must suffice to pass interrupted sutures through the whole thickness of the belly wall, and draw the edges of the wound together so that the peritoneal edges point out and the two serous surfaces are thus brought into contact.</Callout>
If more time is available, after the sac is trimmed its edges are sutured as after a laparotomy. The sheaths of the recti muscles are opened up and the inner border of each muscle exposed. The two sides are then brought in contact and three tiers of sutures applied; one waiting the deep layer to its fellow of the opposite side; the second uniting the two muscles; the third uniting the two superficial layers of the sheath. Finally the excess of subcutaneous fat is trimmed away and the skin sutured.
<Callout type="risk" title="Risk">Obturator Hernia must be ruled out before opening the abdomen for intestinal obstruction, Several points help to locate the trouble even when no marked tumor is present.</Callout>
The operation, chiefly as described by Treves, is as follows: The pelvis is elevated, the thigh flexed and adducted, the femoral artery located, and about a finger's breadth of an incision made from the spine of the pubes downward for three or four inches. Incise the skin, the subcutaneous fat and the fascia lata, and expose the adductor longus. Catch up the deep external pudic artery. Retract the adductor brevis and beneath this is the pectineus whose fibers are separated by blunt dissection; or, if necessary, divided in order to expose the sac (Fig. 398).
When the sac is once in view, free it completely up to the neck. The obturator membrane is now to be nicked, observing first the course of the arteries. It is better, however, to open the sac at once, cleanse the contents, and endeavor to insinuate the finger alongside the bowel and stretch the strangulating fibers; failing in this, to divide them.
<Callout type="warning" title="Warning">Precaution, this occurs, tampon firmly against the obturator membrane, and when the tampons are removed one by one, the bleeding points may be recognized and clamped.</Callout>
Finally the intestines, if sound, is reduced, the sac dissected and ligated high up, and the external wound sutured. Lejars remarks that one may find in the sac of a obturator hernia not only bowel and omentum, but also the tubes and ovaries, the bladder and the appendix; and that it is well to be forewarned of these passages, which may greatly complicate an operation at best never simple.
Of strangulation of other forms of hernia—sciatic, lumbar, perineal vaginal—it need only be said that they are too rare to be considered here.
Key Takeaways
- Thorough dissection of the sac is essential before opening it.
- Care must be taken to avoid injuring the bowel during the operation.
- The use of a grooved director can aid in freeing the strangulated contents.
- Sutures should be used carefully to ensure proper closure and prevent complications.
Practical Tips
- Always perform a thorough examination before attempting any surgery, especially when dealing with strangulated hernias.
- Use blunt dissection techniques to avoid damaging delicate tissues during the operation.
- Be prepared for potential complications such as bleeding or infection by having appropriate supplies on hand.
Warnings & Risks
- Avoid using the herniotomy knife blindly; it should only be used in exceptional cases where other methods fail.
- Do not delay surgery when signs of strangulation are present, as this can lead to severe complications.
- Be cautious with the obturator membrane during operations, as it can cause significant bleeding if mishandled.
Modern Application
While the techniques described in this chapter may seem archaic by modern standards, they provide valuable insights into emergency surgical procedures. The principles of careful dissection and avoiding injury to vital organs still apply today, even though many tools and methods have been refined. Understanding these historical practices can help in preparing for emergencies where quick, effective action is crucial.
Frequently Asked Questions
Q: What are the key steps in relieving strangulation during umbilical hernia surgery?
The first step is to carefully dissect the sac and open it to examine its contents. Next, try to relieve the constriction by stretching the fibers or using a finger to enlarge the opening. If necessary, divide the fibers with scissors or bistoury before reducing the bowel.
Q: Why is irrigation important during umbilical hernia surgery?
Irrigation helps clean the cavity and its contents, preventing infection and ensuring that the bowel can be safely reduced without causing further damage.
Q: What are some signs to look for when suspecting an obturator hernia?
Pain over the region of the obturator foramen, pressure there projecting pain down the inner side of the thigh, and a palpable mass in females during vaginal examination can indicate an obturator hernia.