Surgical Handbook PDF

CRIMEAN STATE MEDICAL UNIVERSITY OF S.I. GEORGIEVSKY surgical illnesses Train aid (UNDER ADITION OF PROF. V.V. GEBROVSKY) SIMFEROPOL- 2004 PREFACE Surgery is a creative profession. A true surgeon has to be in a position of search. There are no two identical appendectomies or two identical herniotomies. And how is it possible to teach a young specialist to think creatively not to mention scientific, modern method of approach to business? It is determined that many surgeons who don’t want to think and search, who have no possibilities to try themselves even in a “small” science during their studies at the University, do not know if they are able to do so. And it can be said with certainty that future Pirogovs, Yudins, Spasokukotskiys, Bobrovs, Voyno-Yasinetskiys are going never to return. How to improve the situation? How to help you, dear colleagues? And how to explain that our work is almost the main thing in our life? Who is able to be a surgeon? Can it be anyone who connects his life with medicine? No! Not everyone who had been settled down by his parents in childhood to piano or easel becomes a bright actor or painter. So, not everyone who is attracted by romanticism of the profession can be a good surgeon. It is necessary to have a strong health, versatile mind, excellent vision, hearing and acute sense of smell, strong and adroit fingers, to be able to differentiate correctly all the nuances of color spectrum. Surgery is an art. This idea was perfectly expressed by an outstanding surgeon S.S. Yudin: “Deficiency of knowledge is reparable and is not a great trouble. Knowledge will come with time. Deficiency of natural abilities is difficulty much worse, because it is impossible to fill them up, even with great diligence. And it is entirely hopeless if there is no keen and ascending interest to the work!” It is necessary to take into consideration subjective factors such as moral shortcomings, for example: lack or weakening of call of duty, egoism, cruelty, carelessness, negligence, inaccuracy, lack of discipline, poor self-control, forgetfulness, untidiness, inconsistency, haste at decision-making, imprudence, falsity, self – confidence, self – will, overestimation of personal possibilities, self – sufficiency, intolerance, hot temper, rudeness, malevolence, touchiness. Think it over privately with yourselves. You know all these qualities are controlled; it is possible to get rid of them. Surgery has also shadow sides. The mistakes in work are inevitable. In the performance of our duty we had to converse with the relatives of the patients for hundred times. Grief of a mother of the dead child is boundless, as well as a grief of the son who has lost his mother. Believe, they suffer much more that the doctors have regarded their native man carelessly and indifferently, that he could be rescued, if they have met a good, qualified surgeon. Frequently, we involuntarily destroy families, we settle in houses offence and grief. It is not simple words, which constantly accompanies surgery. Are you ready to all these? Surgery - work round-the-clock. Leaving the work, the true surgeon cannot remove from the soul an idea about the patient in grave condition together with the taken off a white dressing gown. Frequently these ideas prevent to sleep. Frequently, sitting in a cinema, a surgeon catches himself that he does not notice, what happens on the screen. And work at night! Not without reason, world statistics testifies that the myocardium infarctions in surgeons are much more often, than at the doctors of other specialties. What is capable to facilitate emotional state? It is only the feeling of an executed debt and high professionalism. But, believe, the only one nobleness, even in its best displays, is not yet surgery. Better the bad man, but good specialist, than vice versa. As pleasantly it happens to hear: "Doctor, I want you to be the only one to operate me on ". But again a thin psychological feature - it is necessary to correspond to this trust professionally. You see the patient, as a rule, does not know about depth of knowledge of the doctor and his technical skill. The study of faculty therapy is only the first stage in mastering of a surgical profession. Many students of medical high schools become the specialists of other structures - neuropathologists, gastroenterologists, pulmonologists, and cardiologists. But the qualities of a true surgeon, deep knowledge of this greatest science, without any doubt, will be useful in their future daily practical activity of the doctor. Chapter 1. ABDOMINAL HERNIA (etiology, pathogenesis, classification, clinical picture, general principles of treatment) Abdominal hernias are very common. Enough to tell, that in the countries of CIS, in USA, in Great Britain up to 500.000 patients with hernias are operated on annually. Modern herniology is armed with the exact anatomic items of information and huge practical experience. The etiological factors and pathogenesis of hernias are deeply investigated. Numerous operation techniques had been subjected to the critical analysis; among them the most reliable were allocated and proved pathogenically. The achieved results does not settle a problem, does not reduce its urgency. The creative searches of the surgeons proceed both in our country, and abroad. Especially it is necessary to note fundamental works of I.I. Kukudzhanov, N.V. Voskresensky, Y.A. Nesterenko, I.P. Ioffe, K.D. Toskin, V.V. Zhebrovsky, N.N. Volobuyev, I.F. Borodin, M.N. Yatsentyuk, M.Y. Rogomof, F. Fleming, and E. Girard. On the usual tradition, the herniotomy is one of the first operations of the beginning surgeon, and this step is very important, as herniоtomy does not always estimated as a simple one. Even the most widespread surgical interventions on inguinal or femoral hernia, at unskillful traumatic performance of operation, are fraught of incarceration of nerves, injury of large vessels and urinary bladder, development of infection in a wound. The outstanding Russian surgeon S.P. Fedorov wrote: "Hernia is considered to be an easy operation... Actually, from the point of view of correct and good performance, this operation is not an easy one'. BRIEF HISTORICAL SKETCH Information on hernias and first methods of their management came to us from a deep antiquity. The mention of them can be met in works of Hippocrate (5 century BC), Halene (1 century AD), and Сelcius (1 century AD). Celcium gave a classical definition of hernia as protrusion of internal organs through the acquired and congenital rings, and named it hernia. The operative manuals of this period were primitive and crippling ones. And it is natural. You see, anatomic researches have appeared only in the second half of the XX century. They marked the beginning of scientific approach to study the given problem, and created theoretical base of a modern herniology. These are the monographies of A. Cooper (1804), F. Messelbach (1816), C. Yangenbeck (1821), and P. Zabolotsky (1855). Works of A.A. Bobrov (1894), N.V. Bogoyavlenskiy (1901) have appeared later. It is natural, that the progress in surgery of hernias is closely connected with discovery of an anesthesia, and introduction of asepsis and antiseptics in clinical practice. Y. Champinniere performed the first plastic operation at inguinal hernia in 1885 in France. À.À. Bobrov performed the similar operation in Russia in 1892. Great role in development of plastic surgery of hernias of the abdominal wall have played the 1, V1, V111, XV and XV111 congresses of Russian surgeons. The actual questions of treatment of incisional, inguinal, umbilical, femoral, and postoperative hernias were widely elucidated during the work of these congresses. The decisions of these congresses served as a stimulus for further clinical and experimental researches. GENERAL INFORMATION ABOUT HERNIAS, THEIR CLASSIFICATION Abdominal hernias are divided into external and internal ones. The external hernia (hernia abdominalis externa) is a surgical disease, in which a protrusion of internal organs together with parietal layer of the peritoneum occurs through various foramina in a musculoaponeurotic layer of the anterior or posterior abdominal wall and the pelvic bottom, in intact common integuments. These foramina ("weak places") may be the natural anatomic formations, for example: umbilical ring, Pettit’s triangle, Grynfeltt's - Leshaft's space (triangle). They can also arise due to traumas, operations or diseases, for example: postoperative, posttraumatic, neuropathic and artificial hernias. Internal hernias (hernia abdominalis interna) are those abdominal hernias, which are formed inside the abdominal cavity in peritoneal pockets and folds, or penetrate into a thoracic cavity through the natural or acquired foramina and cavities of the diaphragm. Such concepts, as "eventration" and "prolapse" are close to concept "hernia". Eventration - is an acute developing defect of an abdominal wall, results in the orifices for impairment of intact of the abdominal wall and exit of internal organs out of its boundaries. Eventrations may be inherent, traumatic and postoperative ones. The prolapse is such a condition, in which there is a protrusion of an organ or its part, not covered with peritoneum, for example, prolapse of the uterus through vagina or prolapse of the rectum through sphincter ani externum. There are the following components of hernia: hernial ring, hernial sac and hernial contents. Hernial ring is a foramen in a musculoaponeurotic layer, through which a protrusion of parietal peritoneum and internal organs of the abdominal cavity occurs. The shape of hernial ring may be an oval, round, fissural, triangular and uncertain one. Borders of hernial ring are variable - from several cm in diameter in umbilical hernias to 20-30 cm and more in postoperative ones. Exception makes the so-called neuropathic hernia, where the hernial ring is absent; but on the large extent of the abdominal wall, a muscular layer atrophies or loses its tension due to denervation, and aponeurotic tissues of full value are absent. Then this part of the abdominal wall begins to protrude. As an example we can use an esophageal relaxation or a widespread atrophy of muscles of the abdominal wall due to an operational trauma. Hernial sac is a part of the parietal peritoneum, protruded out through the hernial ring. The neck, body and apex of a hernial sac are distinguished. Its size varies greatly. The peritoneum, forming a sac, may have a normal structure, but more often it is dwarfed due to constant trauma and aseptic inflammation; but in postoperative hernias it presents dense fibrous formations lining inside by mesothelium. The mobile organs of the abdominal cavity such as the omentum, the loops of the small intestine, sigmoid, transverse colon, ceacum, etc. usually present a hernial sac contents. The stomach, kidney, spleen, and liver may constitute the contents of diaphragmatic hernia. CLASSIFICATION Abdominal hernias are usually classified by anatomic, etiological and clinical signs. Inguinal, femoral, umbilical, and hernias of the linea alba are distinguished by anatomic signs. Hernias of semilunar line (line of Spigelius) and hernias of xiphoid process, lumbar, schiatic, perineal and diaphragmatic hernias occur much less often. According to their etiology, all hernias are divided into congenital (hernia congenita) and acquired (hernia asgusita). The so-called postoperative hernias, which occur in various sites of the abdominal wall following different operations, constitute the large group. If these operations were performed concerning hernia, recurrent hernias, arising in the same area, are called recurring ones. If the recurrence occurs two and more times, such hernias are termed repeatedly recurring ones. Abdominal hernias following traumas are called traumatic hernias, and those, which have arisen due to some diseases, for example, after a poliomyelitis, are known as neuropathic hernias. Clinical classification Free hernia (hernia reponibilis) is that one in which contents of the hernial sac freely move from the abdominal cavity to the hernial sac and backwards. Irreducible or partially free hernia (hernia irreponibis seu acetera). This condition of hernia is caused by adhesive process inside the abdominal cavity. Strangulated (incarcerated) hernia (hernia incarcerata). The essence of strangulation is that the organs, which have descended into the hernial sac, are constricted in the area of the hernial sac neck. Thus, the frustration of the blood and lymph flow develops, and a real threat of necrosis of the strangulated organs rises. Strangulated hernia is not a local process. Being in most cases one of the forms of an intestinal obstruction, it causes serious frustration of homeostasis, which intensity is connected with duration of strangulation. The incarcerations in hernias are known to be elastic, fecal, retrograde (hernia Maidl) and parietal (hernia Richter). The incarceration of Meckel's diverticulum is called Littre’s hernia (hernia Littre). The inflammation of hernia is a consequence of penetration of an infection to the hernial sac. It may occur in case of inflammation of vermiform process (appendix vermiformis) or Meckel's diverticulum, located in hernia on strangulation, and in perforating intestinal ulcers. An inflammation may result in formation of a hernial sac phlegmon. ETIOLOGY AND PATHOGENESIS The major etiological factor of occurrence of hernias is the disturbance of dynamic balance between intraabdominal pressure and ability of the abdominal walls to counteract it. In a healthy person, despite of presence " of weak places ", muscular tone of a diaphragm and prelum abdominale keep the organs of the abdominal cavity in their natural position, even at appreciable fluctuations of intraabdominal pressure, for example, at a raising of gravities, cough, defecation, dysuria, delivery, etc. The mechanism of herniation is complex and varied. Besides the local predisposing factors, based on the changes of a topographical-anatomic location or physical and mechanical properties of tissues of the hernia area, the general factors also promote the occurrence of hernias of any typical localization. The local factors, which change is necessary for a choice of pathogenically caused method of operation, we shall study in the following lecture. The general factors of herniation are divided into two fundamentally different groups: predisposing and causative agents. Predisposing factors are the following: constitutional features formed on the basis of hereditary or acquired properties. First of all, it is a hereditary predisposition to formation of hernias, as well as typical, sexual and age differences in a structure of a body. The constitutional factors are the following: changes in the abdominal wall associated with pregnancy, unfavorable conditions of work or life, and also various pathological conditions, for example, obesity or cachexia. Causative agents are those, which promote the increase of intraabdominal pressure or its sudden fluctuations, for example, on hard physical labour, often weeping and cry in infancy, difficult labor, cough in chronic diseases, long constipations, disuria in adenoma of prostate, or in stricture of the urethra. The role of hereditary predisposition is undoubtful. It is spoken about hereditary transfer of features of anatomic structure of the abdominal wall. At careful study of anamnesis, the influence of this factor is revealed in 20 - 25 % of the patients (À.Ð. Krymov). R. Berger established, that one of every four patients come from a family, in which one of its members also had a hernia. Persons of hypersthenic constitutional type have predilections to diaphragmatic, epigastric and direct inguinal hernias. In persons with asthenic constitution umbilical, oblique (indirect) inguinal, and femoral hernias are observed more often. In some persons, irrespective of a constitutional type, the true constitutional predisposition to herniation is marked; it occurs on the basis of congenital underdevelopment of the connective tissue, which is of systemic disorder character. The old surgeons named such condition as a weak constitution. It is shown by presence of multiple hernias, for example, by combination of diaphragmatic hernia with inguinal or femoral one, etc. In such patients platypodia, varicose hemorrhoidal veins and veins of extremities, underdevelopment of a skeletal muscular system is observed rather frequently. It is considered, that in men abdominal hernias occur more frequently, than in women. This common opinion is the result of appreciable prevalence of inguinal hernias in men. However, it is known, that constitution of a woman contributes to abdominal hernias to a greater extent. So, diaphragmatic, umbilical, femoral, postoperative, obturator, perineal hernias and hernias of semilunar line (the line of Spigelius) are more frequently in women. The important etiological factor causing weakening of the abdominal wall in women is pregnancy, during which tissues of the abdominal wall (muscles, aponeurosis, and fascias) are subjected to appreciable transformation: they hypertrophy and dilate. The reorganization of a vascular network and peripheral nerves is observed. Only in well-trained sportswomen the abdominal wall completely restores its structure and muscular tonus after labor. In other women the abdominal wall remains atonic and dilated to various degree; stretching of the linea alba and that of the umbilical ring, diastases of the direct muscles of the abdomen is kept. These changes are especially evident in women who experienced labor many times. The herniation is promoted by an obesity or cachexia as a consequence of various pathological conditions. In obesity the abdominal wall muscles are atrophic and flabby. The mechanism of herniation in cachexia is associated with disappearance of fat from tissues; it is accompanied by augmentation of sizes of those fissures and foramina in the abdominal wall, which were filled by fat earlier. As a result, the resistance of weak places is reduced, and favorable conditions for development of hernias are produced. The contributing factors not always result in herniation. The action of any of causative agents, for example, hard physical labour, is necessary; it usually takes place in 60 - 80 % of patients with hernias (P.I. Tikhov, N.I. Kukudzhanov, A.I. Baryshnikov). GENERAL PRINCIPLES OF TREATMENT OF ABDOMINAL HERNIAS Treatment is surgical. The use of a bandage is a palliative measure. It is shown only in those cases when the operation cannot be performed. In the advanced countries of America and Europe, the surgical method is also the basic one. However, the injective method is spread widely enough, especially in the USA. It consists of introduction of irritating and sclerosing agents (solutions of acids and alkalis) into the tissues of hernial ring and into the cavity of a hernial sac, causing a limited aseptic inflammation with formation of a dense unresolving cicatrical tissue. Thus, the obliteration of a hernial sac and cicatrisation of hernial defect is obtained. An essential condition of injective therapy is the ability to complete reducibility of hernia. In injective method there may be serious complications, as necrosis of the spermatic cord, wound of vessels and formation of hematomas, septic abscesses of the abdominal cavity, gangrene of an intestine, chemical peritonitis, etc. The basic principle of surgical treatment of abdominal hernias consists of an individual, differentiate approach to the choice of method of herniotomy. On decision of this task, it is necessary to take into account the form of hernia, its pathogenesis, condition of tissues of the abdominal wall and the size of hernial defect. The operation in hernia should be maximum simple and least traumatic. This principle, however, should be based on reliance, that the chosen intervention would ensure radical treatment. If in many cases of uncomplicated inguinal, femoral and umbilical hernias a surgeon can achieve good results by means of rather simple ways of herniotomies, in complex hernias, such as postoperative, extensive, huge, recurrent, repeatedly relapsing, sliding, combined and diaphragmatic hernias, the operative treatment frequently represents a difficult task. Major principle of operation in hernias is its irreproachable technical performance. Bad surgical technique, by neat expression of V.I. Dobrotvorsky, "... can discredit anyone, even the best way ". Herniotomy in mild cases does not require tops of surgical skill and long-term experience. However, it is in these particular cases when the skill of a surgeon on care of tissues, his ability to orientate easily in topographic and anatomic correlation, to supply maximal asepsis of operation and careful hemostasis is manifested. The deeply intelligent and well-executed operation brings great satisfaction and, in successful outcome, strengthens the self-confidence of a surgeon. The numerous ways of operations in hernias are systematized by a principle of primary use of those or other tissues of an abdominal wall. There are five basic techniques of hernioplasty: 1) fascia - aponeurotic; 2) musculoaponeurotic; 3) muscular; 4) plasty by means of additional biological or synthetic materials (alloplasty, xenoplasty, explantation); 5) combined (use of autogenous and heterologous tissues). The first three techniques are united in autoplastic ones; the other two are called the alloplastic techniques. Each method of plastic repair is investigated in details now. On their basis a number of ways of operations is offered. If the choice of herniotomy is determined by nosotropic (pathogenetic) essence of hernia, the choice of operation procedure should ensure its reliability in the aspect of late results. The advantage of fascia-aponeurotic plastic repair is, that by this technique, the principle of uniting of homogeneous tissues is most completely realized; it results in their reliable accretion. The example of such operations is the techniques of Martynov and Rue-Oppel in inguinal hernias, method of Meyo - in umbilical, and methods of Napalkov, Vishnevsky and Martynov - in treatment of postoperative hernias. As a rule, operations, based on creation of fascia-aponeurotic duplicature, are least traumatic. However, their reliability is in direct dependence on the size of hernial defect, the degree of tension of tissues in their suture, and both firmness qualities of fascias and aponeurosis. When they are thinned, atrophied or disintegrated into separate fibers, and also in cicatrical change of tissues in the area of plastic repair, in extensive defects, the use of fascia- aponeurotic plasty results in frequent occurrence of relapses. The basic technique of treatment of hernia is the musculoaponeurotic plasty. In this technique, building up of the abdominal wall defect is made not only with aponeurosis, but also with muscles. This principle of treatment underlies a plenty of operative procedures. In inguinal hernias – technique of Girard, Spasokukotsky, Bassini, Postemsky, Kirshner, in umbilical hernias - technique of Meyo, in postoperative and incisional hernias - technique of Sapezhko and his numerous followers are widely used. Plastic repair by means of additional biological and synthetic materials is widely applied also. Grafts (transplants), depending on their parentage, are divided into: a) autologic (taken within the limits of the same organism); b) allogenic (taken in an organism of the same species, as organism of the recipient); c) xenogenic (taken in an organism of other species); d) explants (non-biological tissues); e) combined grafts (combination of biological, more often of autologic one, and no- biological tissue). The indications for usage of plastic materials in ventral hernias are: 1) recurring, in particular, repeatedly recurring hernias; 2) primary hernias of large sizes at a flabby abdominal wall, associated with atrophy of muscles, fascias and aponeurosis; 3) postoperative hernias with multiple hernial rings, when suturing of local tissues does not give complete reliance of their firmness; 4) giant hernias with the sizes of defect of the abdominal wall more than 10x10 cm; 5) "complex" inguinal hernias - large direct, oblique with the direct canal, sliding and combined hernias with pronounced atrophy of muscles, with disintegration of aponeurosis into fibers, with hypoplasia of ligaments. Among the biological tissues in surgery of hernias are widely spread the following: autologic grafts of the skin, allogenic grafts of dura mater and xenogenic grafts of the peritoneum. The numerous experimental researches testify, that any biological graft during an implantation undergoes the pronounced inflammatory - destructive changes, degree of which varies from a moderate dystrophy up to necrosis, is in direct dependence on nature of plastic material itself, its antigenicity and way of its processing. The most favorable for replacement of defect of the abdominal wall, undoubtedly, are the autologic tissues. The biological relationship in this kind of transplantation allows to achieve the most reliable implantation of a plastic tissue. However, in this case the structural changes in a graft are also marked - they are caused by denervation and disturbance of blood circulation: histologically, in early terms after transplantation, the pronounced inflammatory changes are observed, but in late terms - the phenomena of partial atrophy and fibrosis occur. Transplantation of allogenic and, especially, of xenogenic tissues is always really accompanied by reaction of transplantation immunity, which results in destruction of heterologous tissue. However, when a plastic tissue has no high risk of rejection, the process of destruction of a graft occurs very slowly and insignificantly, and, simultaneously with destruction, the regenerative processes, replacing lost sites of a graft, develop. As a result, a graft is completely replaced by the tissues of a recipient. It is the most favorable way of morphological transformation of heterologous plastic tissue in the body of a recipient, which ensures the success of transplantation. In those cases, when the plastic tissue has high antigenic activity, the destruction of a graft occurs much faster, than tissues of a recipient replace it. As a rule, the transplantation results in parting of a postoperative wound and rejection of the necrotic remnants of a plastic tissue. All plastic materials used in restorative surgery have advantages and disadvantages. Studying of late results testifies, that by means of grafts it is possible to lower significantly the amount of relapses. And, if now it is possible to deny expediency of application any of plastic material, rejection of this procedure in general means not to notice those positive qualities, which lay in its basis. First of all, it decreases the incidence of operative trauma and raises i ts reliability. Clinical picture of instrangulated hernias will be described in the following lecture. The clinical picture of incarcerated hernia is rather characteristic and, as a rule, is typical. Incarceration is usually accompanied by sudden pain in the hernial protrusion area, and sometimes - through the entire abdomen. Character, intensity and irradiation of pain are various, depending on a kind of incarceration, on an impaired organ, on age of the patient, etc. Sometimes, especially in old and senile age, pains may be insignificant and be endured rather easy; in other cases, especially in young age, pain may be very strong and accompanied by tachycardia and decrease of arterial pressure. In developing acute obstruction of the intestine, pain may be constant, increasing, cramping one. Sometimes pain subsides due to necrosis of the intestine. The detailed elucidation of a pain character and dynamics of a pain syndrome has a great diagnostic value. Cardinal attribute of incarceration of free reducible hernia is impossibility of reduction of hernial protrusion into the abdominal cavity. Hernial protrusion enlarges in volume, becomes intense and morbid. On percussion, dullness is revealed (if hernial sac contains fluid or omentum) or thympanic sound is heard (a dilated loop of the intestine). In irreducible hernia the diagnosis of incarceration is made on the basis of sudden occurrence of pain, morbidity and strain of hernial protrusion. The important attribute of incarceration is the absence of transfer of cough shock symptom into the area of hernial protrusion. Incarceration of hernia is frequently accompanied by vomiting, sometimes repeated. At the beginning vomiting is a reflex one, but later it is caused by intoxication. On incarceration of this or that department of the intestine the phenomena of intestinal obstruction develop. On examination of the abdomen the following is revealed: bloating, intensifying of intestinal peristalsis, antiperistaltic waves. Some patients have an urgent desire to defecation, the gases and feces from a part of an intestine, located more distally from the place of incarceration, may pass. It is characteristic, that bowel emptying does not improve the patient's condition. General condition of a patient at first after incarceration of hernia remains satisfactory. However, suddenness of a pain attack, as a rule, causes anxiety of a patient. Weakness, dryness in the mouth, and thirst occur. Pulse and body temperature change insignificantly. Further, with progress of an acute obstruction of the intestine, state of health and condition of a patient are quickly become worse due to the increase of intoxication and development of peritonitis. Isolated incarceration of the omentum, uterine tube, ovary, urinary bladder or its protrusion is accompanied by a pain syndrome and dysfunction of these organs. The least is revealed not at once and not always. The phenomena of an acute obstruction of the intestine are absent; in this connection in a clinical picture of incarceration the pain syndrome in the area of the hernial protrusion becomes the predominant one. In connection with difficulty of diagnostics, partial hernia of the intestine represents a great danger; the hernial protrusion thus has the small sizes and is revealed with difficulty. Obstruction of the intestine is incomplete, after the conservative measures there comes improvement of health state, and the incarcerated site of the intestine, between that, frequently and rather soon is subjected to necrosis. In case of incarceration in primary occurrence of hernia, a patient can completely reject the presence of hernia in the past. Objectively, the hernial protrusion may not be determined precisely. However, set of signs of acute obstruction of the intestine, localized pain in the area, where hernias are usually situated, together with morbidity of a zone of the canal or the ring on palpation allow to make a correct diagnosis. It concerns as well incarcerations in the internal ring. In the patients of old age the signs of incarceration have no usual evidence and expressiveness. The pains in the area of hernial protrusion and in the abdomen may be ill- defined. People regard to these pains specifically, as they frequently felt unpleasant pain sensations at a long usage of a bandage, became used to them, therefore they cannot pay due attention to recently appeared pains in incarceration. Only in patient and persevering inquiry it is possible to find out, that sudden intensifying of pain in the abdomen and in the area of hernial protrusion nevertheless took place, were accompanied by nausea and vomiting, and then the patient "became absolutely bad”. It is possible also to find out, that at attempt to reduce hernia, the pains “that were not earlier” took place, and that reduction of hernia, as a result, was not possible. In aged persons intestinal obstruction, developing due to incarceration of hernia, has features complicating diagnostics. So, the period, when after incarceration of a bowel, hyperperistalsis of a department, adducting it, is observed, in old people is short; it results in paresis of the intestine with bloating of the abdomen. The abdomen is soft and slightly inflated, the signs of irritation of the peritoneum are absent or are revealed vaguely. A moderate tenderness is determined only at a rather deep palpation. Due to necrosis of strangulated organ (more often - the intestines), the signs of intoxication and peritonitis appear, such as deterioration of a general condition, weakness, thirst, dryness in the mouth, rapid pulse, vomiting, raise of temperature, bloating of the abdomen, etc. In old people all these signs are usually more ill-defined, than in young. It is necessary to remember all these above-mentioned and to estimate correctly, even ill-defined, "vague" clinical signs. The causes of incorrect diagnostics of hernias are inflammatory processes in the inguinal lymphatic nodes, metastases of tumor into these nodes, abscess processes, and varicose nodes in the end department of a superficial femoral vein. SURGICAL APPOACH TO INCARCERATED HERNIAS Strangulated hernia is subjected to immediate surgical treatment. The only one contraindication to operation is the agonal state of the patient. Violent reduction of incarcerated hernia is inadmissible, as it can cause a hemorrhage into soft tissues, into the wall of the intestine and mesentery, thrombosis of vessels, abruption of the mesentery, perforation of the intestine. Besides, such attempt may result in false reduction of hernia. Only in exclusive cases, when the patient categorically refuses to be operated on, or has such diseases, as fresh myocardial infarction, disturbances of cerebral circulation, and from the moment of incarceration has passed not more than 1 - 1,5 hours, a short-term appliance of some conservative measures is allowed: 1) subcutaneous injection of 1 ml of 1 % solution of Atropinum; 2) the urinary bladder emptying; 3) warm cleansing enema; 4) to inject all around the tissues near to hernial hiluses with1,25 % solution of Novocainum; 5) to raise a little the pelvis. It is necessary to carry out this medical complex in conditions of a hospital under medical supervision. If, within one hour, hernia was not reduced, it is necessary to operate on the patient, and, in case of refusal of operation - to insist on its performance. In series of cases patients, having sad experience and because of phobia of operation outcome, reduce strangulated hernia at home. Thus there is a danger of rupture of strangulated organ and false reduction of hernia. Various variants of false reduction are possible. For example, on manual manipulations, it is possible: 1) to separate the whole hernial sac from surrounding tissues and to reduce it together with strangulated organ into the abdominal cavity or preperitoneal fat; 2) to tear off the neck from other departments of the hernial sac and to reduce it together with strangulated organ into the abdominal cavity or preperitoneal fat; 3) to tear off completely the neck of the hernial sac both from its body and from the parietal peritoneum, and to reduce it, together with strangulated organ, into the abdominal cavity; 4) to remove strangulated internal organs in the polyichamber hernial sac from one chamber to another; the latter usually lays more deeply in the preperitoneal fat. It is important to reveal in time false reduction of hernia, as in these cases phenomena of an intestinal obstruction and general peritonitis quickly develop. Thus, typical clinical picture of strangulated hernia is absent. In particular, there is no intense hernial protrusion, positive sign of cough shock symptom and sign of irreducibility. On reduction of hernia under anaesthesia, in making an incision, at other stages of operation, it is necessary to reveal the strangulated organ and to examine it through herniolaparotomy wound after herniotomy. If the organ is not found out, the laparotomy or intraoperative laparoscopy through a hernial sac is shown. The most important stage in strangulated hernia is the isolation of the hernial sac, its dissection, and then, after section of the strangulated ring, - examination and estimation of viable organs. Strangulated departments of the omentum have to be resected in all cases. As if to definition of viability of the intestinal wall, the correctness of the decision in this case depends on experience and qualification of a surgeon. The basic criteria for estimation of viability of the small intestine are: 1) restoration of normal pink color; 2) absence of a constriction mark and dark spots, lucent through the serous coat; 3) maintenance of the mesentery vessels pulsation; 4) presence of peristalsis. At presence of all these signs, the intestine may be recognized as viable and is reduced into the abdominal cavity. At slightest doubt, it is necessary to resect the bowel. Indisputable signs of inviability of the bowel are its dark coloring, flabby dwarfed wall, and absence of intestinal peristalsis and pulsation of the mesentery. It is necessary to pay attention to changes of the strangulated mesentery. Inflammatory edema of the mesentery or extensive hematoma in persons of senile age with sclerotic, fragile vessels may result in the secondary thrombosis with the subsequent necrosis of the intestinal wall. In this connection, in sharp infiltrated mesentery, it is also necessary to perform the bowel resection. It is necessary to pay the special attention to incarceration of sliding hernias, when there is a necessity for estimation of viability of strangulated organ in that part of it, which is not covered with the peritoneum. The caecum and urinary blade slide and are strangulated more frequently. In the first case, in necrosis of the intestinal wall, median laparotomy and resection of the right departments of the colon with placing of iliac transversal anastomosis are performed. After termination of this stage of operation, suturing of the hernial ring begins. In necrosis of the urinary blade wall, its resection with applying of epicystostoma is necessary. In serious cases surgeons are limited to a tamponade of the paravesical fat and applying of a high vesical fistula (Saveliev V.S., 1976). In phlegmon of the hernial sac, one should begin the operation with mid-median laparotomy. It reduces the danger of infection of the abdominal cavity by contents of the hernial sac. One makes a resection of a site of the intestine, which is inside the hernial sac, between the efferent, and adducting (afferent) intestinal loops, anastomosis end-to-end is placed; at the large difference in diameters of lumens of sewed departments of the intestine, anastomosis side-to-side is placed. Mid-median incision of the abdominal wall is closed solidly. Then, with incision above the hernial "tumour" the skin, the fat and the hernial sac are dissected. Purulent exudate is evacuated. The hernial ring incision is made very accurately, as much as to make it possible to isolate and extract the strangulated loop and blind ends of the intestines, left in the abdominal cavity. Isolation of the hernial sac out of surrounding tissues is not performed. A purse-string suture closes the neck of the sac, and then the cavity of the hernial sac is filled with tampons. The formation of an intestinal fistula is allowed only at "desperate operations" in seriously ill patients, when resection of the intestine is impossible. The plastic repair of the hernial ring in the presence of a purulent infection is categorically forbidden. Firstly, it is useless, secondly, - it is dangerous because of a possibility of development of the hardest putrefactive phlegmon of the abdominal wall. In incarceration of giant ventral hernias, a one-stage reduction of the hernial contents into the abdominal cavity sometimes represents the large danger, as can result in stable paresis of the intestine, the increase of intraabdominal pressure with the subsequent impairment of cardiac activity and respiration. In these, very infrequent cases, the double-stage operations are shown. At the first stage, a strangulated ring is excised and, if the loop of the intestine is viable, the hernial sac is excised too, and then the skin is carefully sutured. Having brought out a patient from a serious condition and having made a special preparation, the second stage of operation is performed – the plastic repair of the abdominal wall. In strangulated hernias the performance of complex plastic operations on the abdominal wall should be circumscribed, as there is a real danger of infection of the operative wound, especially at the moment of the hernial sac dissection. GUINAL, FEMORAL, AND UMBILICAL HERNIAS The inguinal hernias occur much more often, than all other hernias of the abdomen. If the patients with ventral hernias make 8 - 18 % from the total number of the patients of surgical hospitals, 75 - 85 % of them are the patients with inguinal hernias. The inguinal hernias occur mainly in men. It is because the inguinal canal in a woman has a fissural form much more often, it is better supplied with muscles and with tendinous layers, is longer and narrower a little, than in men. Ratio of the men and women in inguinal hernias is approximately 6:1. The basic anatomically caused versions are oblique hernias (hernia inguinalis externa s. obligua) and direct hernias (hernia inguinalis interna s. directa). However, alongside with these classical types, knowledge of their variants is important practically, though they occur rather seldom. They are: oblique hernias with the direct canal, preperitoneal, intraparietal, encysted, periinguinal, supravesical, and combined inguinal hernias. During the last years in native and foreign literature the so-called difficult or complex forms of inguinal hernias are persistently distinguished. They are: hernias of large and very large sizes, irreducible, sliding, recurring and repeatedly recurring hernias. Oblique inguinal hernias, depending on origin of the hernial sac, may be congenital and acquired. For deeper comprehension of principal difference between these two forms of oblique inguinal hernias, it is necessary to recollect the features of embryonic development of the inguinal area, which are closely associated with the process of descent of the testis. In oblique inguinal hernias, the hernial sac makes a way from the deep inguinal ring, through the inguinal canal, under the skin near the root of the scrotum and can, in favorable for development of hernia conditions, descend in the scrotum, forming an inguinoscrotal hernia. Oblique inguinal hernia, repeating a course of the inguinal canal, is directed from above downwards, from behind forwards, from outside inside. In its development it passes series of consecutive stages: 1) beginning oblique hernia, when a doctor reaches the hernial protrusion bottom by a finger entered into the external opening of the inguinal canal only at straining effort of a patient and at cough; 2) canal hernia, in which the hernial sac bottom reaches the external opening of the inguinal canal; 3) oblique inguinal hernia of the spermatic cord, in which hernia comes out the inguinal canal and is palpated as tumor-like mass of the inguinal region; 4) oblique inguinoscrotal hernia, when hernial protrusion, following on a course of the spermatic cord, descends into the scrotum. Congenital inguinal hernia, in which the hernial sac is composed by the vaginal process of peritoneum (processus vaginalis peritonei), is quite often combined with hydrocele of the testicle and spermatic cord. The following variants in this case are possible: 1) the vaginal process is partially obliterated; thus, its part, which is immediately adjacent to the testicle, is constricted, becoming the cavity of hydrocele; the superior part of the vaginal process of peritoneum becomes the hernial sac; 2) the vaginal process of peritoneum, remaining patent near internal opening of the inguinal canal, is obliterated at separate sites. It results in a combination of inherent hernia with cysts of spermatic cord. According to the data of N.I. Kukudzhanov, congenital hernias are observed in 1 - 2 % of men, and the various anomalies associated with obliteration of the vaginal process of peritoneum, are observed, on average, in 10 % of men. The modern concept of a choice of way of inguinal hernioplasty Last decades the doctrine about hernias has entered a new progressive stage of its development. The newest technologies, modern plastic and suture materials allow to achieve brilliant results in treatment of abdominal hernias. It is possible to say, that the doctrine about hernias, one of most ancient in medicine, experiences the second youth, the stage of rapid flourish. All this in full measure concerns the surgical treatment of the most numerous group of the surgical patients - patients with inguinal hernias. The International Congresses of Surgeons - herniologists in Amsterdam (1998), Prague (1999). Paris (1997), Moscow (2001, 2002, 2003), and Kiev (2002, 2003) allow to put an end to a long-term discussion and to formulate the renewed modern concept of surgical treatment in inguinal hernias. First of all, about classification. For today, classification by Lloyd M. Nyhus (1995) is generally used; it is the international standard for comparison of results in open (major) and laparoscopic hernioplasty in inguinal hernia. Classification by Lloyd M. Nyhus Gilbert A.I. (1991) has enlarged the division of oblique and direct inguinal hernias to six types. According to his classification, the types 1,2,3 are oblique inguinal hernias, types 3, 4 and 5 - are direct ones. Three types of oblique inguinal hernias differ with the sizes of the internal inguinal ring. In hernias of the 1st type, the internal inguinal ring has the normal sizes. In hernias of the 2nd type, the internal inguinal ring allows to pass one finger following the dissection of the hernial sac and its reduction. In hernias of the 3rd type, the internal inguinal ring passes 2 fingers, and in hernias of the 4th and 5th types have the normal sizes, but hernias themselves differ with the size of defect of the inguinal canal bottom. In hernias of the 4th type, the large fundal defect is present, and in hernias of the 5th type the defect is insignificant, and only one finger is usually passed. The 6th type of inguinal hernias combines the signs of direct and oblique hernias. The femoral hernias according to Gilbert regard to the 7th type. E. Bassini in 1889 and H. Marcy in 1887 formulated the basic principles of treatment of inguinal hernias at the end XIX century. H.Marcy was the first who has paid attention to necessity of restoration of a transversal fascia. The given technique may be applied with success in young men and women. Advantage of this procedure consists of the conservation of natural integrity of an uninjured back wall of the inguinal canal (the 1st type). Eduardo Bassini proposed dissection of the transversal fascia in plastic repair of the inguinal canal in 1890. It is necessary to regard to classical ways of inguinal hernioplasty the technique of Lotheissen-McVay, offered by G. Lotheissen in 1898 and much advanced by C.McVay in 1941. Method of Lotheissen - McVay is universal one. It is suitable for treatment not only inguinal, but also femoral hernias, as it strengthens simultaneously the inguinal space and the internal ring of the femoral canal. It is especially shown in recurring, combined and all complex forms of inguinal hernias. On the basis of classical ways of an inguinal hernioplasty according to H. Marcy, E. Bassini and Lotheisse - McVay, the set of ways of operations is developed. Some of them (Girard, 1984; S.I. Spasokukotskiy, 1902; M.A. Kimbarovskiy, 1928) have only historical interest. Other methods (those of E.E. Shouldice, 1944; N.I.Kukudzhanov, 1938, Postempsky, 1887) have proved their competence and are widely used in surgical practice in Europe and America, and also in the countries of CIS. In the initial forms of oblique inguinal hernias without dilatation of the internal inguinal ring, the plastic repair of the anterior wall of the inguinal canal according to Martynov is applied by now. Its major advantage is the correction of the inguinal canal and its external opening without intervention in deep layers. On modern representations, the method of Martynov may be applied only in oblique inguinal hernia of the 1st type, which occurs mainly in children, teenagers and young people, and also in the women. In this type of hernia the internal inguinal ring, as a rule, is not dilated, and the hernial protrusion is located from the internal inguinal ring up to the middle third of the inguinal canal (oblique hernias). The plastic operations according to Bassini, Kukudzhanov, Shouldice and Postempsky, and also by Lotheissen - McVay are effective enough in inguinal hernias of the 2nd type, that is in small oblique inguinal hernias with dilatation of the internal inguinal ring, but with preservation of the posterior wall of the inguinal canal. Autoplastic techniques may be reliable enough in inguinal hernias of the 3rd type. In these cases, application of method of Nyluis is more preferable. In Russia and in the NIS only individual surgeons applied this technique. However, the opportunity of plastic repair of hernial defect outside of the reproductive zone, the appliance of the puboiliac band (tractus ilioinguinalis) for plastic repair under the control of vision, opportunity of the one- stage building up of the femoral ring (annulis femoralis) allows to consider, that the method of L.M. Nyhus, even in view of its complicacy in comparison with other methods of extensive hernioplasty, is obviously underestimated. Since 1991 laparoscopic hernioplasty (Ger R. with co-authors, 1983, 1990, 1991) progressively develops. It is necessary to notice, that the opinions on indications to laparpscopic treatment of inguinal and femoral hernias are discrepant. Some surgeons do not see essential advantages of laparoscopy in comparison with open operations; they consider this technique as expensive and requiring only general anesthesia. Other surgeons, on the contrary, mark the reliability of endoscopic interventions, which allow the performance a hernioplasty at the out- patient department, and early returning of patients to the practical activities. A. Gilbert in 1995 has published the results of 869 laparoscopic herniographies performed by 21 surgeons, comparing them with results of more than 35.000 open hernioplasties, which have been performed by 18 surgeons. The researches have not confirmed the advantages of laparoscopic method: rather high incidence of relapses (up to 10 %) and considerable number of other complications were marked. But as a whole, the experience of clinics of the USA and Europe shows, that the incidence of relapses from 4 up to 10 % and high cost of new technologies are compensated by cutting by half and more staying in a hospital and rapid restoration of working capacity. In 2002 the European union of the researchers of hernia study the results of modern hernioplasty. The large clinical material covering more than 7.000 patients was subjected to the analysis. It was estimated, that appliance of pathogenically proved methods of an open plastic repair (Bassini, Shouldice, R. Stoppa, I. Lichtenstein, A. Gilbert, L. Nyhus, PHS, etc.) allows to achieve the treatment of inguinal hernia practically without recurrences both in men and in women. Application of laparoscopic techniques of TPPH (transabdominal preperitoneal prosthetic hernioplasty) and EEPH (endovideosurgical extraperitoneal prosthetic hernioplasty) is also quite grounded. Moreover, the indices of restoration of physical activity of the patients here are higher. On the data of studies of late results of laparoscopic hernioplasty, the Russian surgeons (A.D. Timoshin and A.V. Yurasov, 2003) inform about 6 % of relapses; however, they consider this method as more complex one, requiring special training. The complications are rare, but rather serious; the procedure is expensive, and also requires general anesthesia. All abovementioned factors limit the appliance of laparoscopic hernioplasty to the strict indications - in recurring and bilateral hernias, and also if it is necessary to perform combined laparoscopic operations in the abdominal cavity. Autoplasty, alloplasty and explantation in inguinal hernias always were tempting prospect in achievement of good late results. But now, when the choice of perfect synthetic materials and prospects in creation of ideal biocompatible synthetic prostheses for a hernioplasty has appeared, appliance of biological grafts loses its expediency. And the matter is not only that these methods are more labour consuming. Morphological changes in the area of plastic repair with biological transplant not always result in formation of enough firm tissues that reduces efficiency of plastic repair in the late period. It equally concerns autodermal grafts, autogenic grafts of dura mater, allogenic fascial grafts, etc. Major disadvantage of autoplastic operations, even of wittiest of them, is the tension of tissues, which results in development of pathologically changed structures in the area of plastic repair. Quite often laminated (multy-layer) plasty is accompanied by impairment of trophicity of the muscles, fascias and aponeuroses, traumas of n. ilioinguinalis and spermatic cord. The most part of these problems may be decided with tensive plastic repair, in which basis the application of additional plastic materials lays. Tensive plastic repair according to Lichtenstein, offered by him in 1984 (Lichtenstein itself considers L.Newman as the author of this method), has won the greatest popularity in the countries of Europe and in the USA, and also in Russia, in Ukraine and in other countries of CIS. As the synthetic graft in plastic repair according to Lichtenstein settles down on a surface of m. obliguis abdominis internus, under aponeurosis of m. obliguis abdominis externus, it is called the anterior (frontal) plastic repair. On the data of application of the technique according to Lichtenstein in clinics of the USA and Europe, the incidence of relapses following primary hernia makes 2 - 4 %, following primary bilateral hernia - 4 - 5 %, and following recurring and repeatedly recurring hernias - up to 10 - 12 %. It is logically to assume, that reliability of operation is reduced in considerable structural changes on the posterior wall of the inguinal canal. The number of techniques of a hernioplasty without tension is great enough. Wide clinical approbation the techniques according to R. Stoppa (1965), V. Rives (1973), A. Gilbert (1985), J.L. Lichtenstein (1989), E. Trabucco (1993), and I.M. Rutcow - A.W. Robbins have passed. In 1997, by the concept of A. Gilbert, rather original construction of prolen (Prolen Hernia System - PHS) was designed, due to which it is possible to perform plastic repair of the posterior and anterior walls of the inguinal canal simultaneously. PHS combines all the advantages of the most widespread techniques of explantation. The internal flap of PHS provides unconditional building up of the posterior wall of the inguinal canal (sublay mesh), the outside flap is similar to a mesh according to Lichtenstein (onlay mesh) and keeps all of its advantage; a connecting part PHS (connector) is analogous to "a flounce" in plasty by Rutcow - Robbins. Thus, the technique of inguinal hernioplasty should be determined first of all by degree of destruction of the posterior wall of the inguinal canal and the internal inguinal ring. In hernias of the 1st type (according to L.Nyhus) the plastic repair of the anterior wall is allowed). In this case, the striving for excessive radical measures is hardly proved. In hernias of the 2, 3a, 3b types it is necessary to apply this or that variant of building up of the posterior wall of the inguinal canal and formations of the internal inguinal ring. What technique is more preferable: tensive or non- tensive? Wide introduction in clinical practice of modern mesh prostheses, made up of polypropylene, and large gained positive experience gradually overcome some fear of surgeons to explantation. At the same time, the history of herniology keeps memory of the period of general addicting for alloplasty (1975 - 1985), when expansion of indications to application of synthetic materials in simple forms of hernias, use of casual polymers, quite often intended for the technical purposes, as prostheses, has resulted in a plenty of postoperative complications: seromas, infiltrates and suppurations, inhealing fistulas, sequestration of prostheses, etc. The reports about plastics cancerogenesis in their long implantation (E. Oppenheimer et all. 1961, J. Rives et all. 1973) appear. The quality of modern prostheses made up of polypropylene and polyester is rather high. The activity of producer companies outruns the estimation of results of clinical application. The promoted high quality of production and also high cost of explantates does not exclude the occurrence of local and systemic inflammatory reaction, that at the best results in seroma, and at the worst - in suppuration. Such processes in the area of plastic repair, as reduction of a prosthesis (shrinkage) or its stretching ("cigar-shaped deformation"), migration, formation of decubituses, intestinal fistula, etc. are possible. Morphological transformations in tissues, surrounding prosthesis, are characterized by formation of coarse cicatrices. In 2003 the 3rd conference of the experts - herniologists " Meshes-Benefits and Risks " (Saint-Moritz, 2003) was held. It was marked, that one of major tasks is the creation of the perfect materials for plastic repair of hernia. In other words, the search of an "ideal" material for plastic repair proceeds. It concerns not only chemical nature and biocompatibility of prostheses, but also their design, configuration, sizes of pores, thickness of strings. As fairly has noticed one of outstanding herniologists of the present R. Stoppa, " any belief should leave a place to doubt. Belief undoubtedly, as a rule, is a wrong belief ". Choice of a method of plastic repair in inguinal hernias of the 3a and 3b types depends on a degree of destruction (safety) of the posterior wall of the inguinal canal. Here, at kept, though dilated transversal fascia, tensive techniques of E.Shouldice (1944), N.I. Kukudzhanov (1938), Postempsky, Nyhus, Lotheissen, McVay, and also tensive techniques of Lichtenstein, PHS, and Nyhus+explantation are possible; in bilateral direct hernias - techniques of Stoppa, Rives, laparoscopic hernioplasty (TPPH or EEPH). The hernial sac should be excised in all cases. Especially difficult is the question on operative treatment and choice of technique of plastic repair in recurring and repeatedly recurring inguinal hernias. Opinion that at any recurring hernia explantation is necessary (they constitute about 20 % of the total number of inguinal hernias) is incorrect one. The reasons of recurrences are diverse, and even not always morphofunctional failure of tissues or hernial disease lay in their basis. Before operation it is very important to carry out ultrasonic investigation and, certainly, while performing the operation, to estimate a condition of major supporting structures of the inguen: aponeurosis of external oblique abdominal muscle, muscular layers of internal oblique and transversal muscles, transversal fascia, inguinal ligaments, puboiliac band, Cooper's (pectineal) ligament, inguinal aponeurotic fold. It is necessary to determine the character of previous operation. More often recurring hernia is direct one. In the central and medial recurrence (the 4a type) it is possible to apply tensive technique of Shouldice, Kukudzhanov, and McVay. All these techniques at careful, academic performance are reliable enough. In hernia of the 4a type, in complete direct recurrence, and also in repeated (more than 2 times) recurrences the absolute indications to explantation arise (PHS, Lichtenstein 2, Plug-Patch), Rutcow-Robbins, laparoscopic hernioplasty. In hernias of the 4c type, such as recurring femoral hernias, and in hernias of the 4d type, such as combination of recurring oblique, direct inguinal and femoral hernias the operation according to Rives (French technique), Stoppa, Nyhus or laparoscopic hernioplasty are shown. Summarizing all abovementioned, it is necessary to note, that the basis in the modern concept of a choice of method of inguinal hernioplasty is the augmentation of reliability of offered techniques of plastic repair at simultaneous decrease of trauma occurrence. The principles of individualization do not exclude both application of well-approved techniques of tensive plastic repair (techniques of E. Bassini, E.Shouldice, N.I. Kukudzhanov, P. Postepsky, L. Nyhus, L. Lotheissen - McVay), and non-tensive (techniques of I. Lichtenstein, R. Stoppa, J. Rives, A. Gilbert, Rutcow - Robbins, PHS). It is necessary to study separately a question about laparoscopic hernioplasty requiring appropriate material equipment of surgical hospitals and training of the highly skilled experts. The classification of Loil M. Nyhus allows to determine precisely enough a type of hernia and depending on it to choose an adequate technique of operation. Oblique inguinal hernias with direct canal are found mainly in the elderly patients on the basis of sharp atrophy and relaxation of muscular, fascial and aponeurotic structures of inguinal area. As a result, the deep openings of the inguinal canal come nearer to superficial. Canal extends, is shortened, loses an oblique direction, more and more turning into a direct wide opening conducting to the abdominal cavity. Such hernias are of large and very large sizes. The whole posterior wall of the inguinal canal is destroyed. The sizes of the inguinal space may be of 7 - 7,5 cm in length and 3 - 5 cm in height. Intraparietal inguinal hernias are also oblique. They occur very seldom, in 0,1 - 0,3 % of cases from the total number of inguinal hernias. The basic difference is that the hernial sac protrudes from the spermatic cord tunic, penetrating between layers of the anterior abdominal wall. Most frequently it locates above aponeurosis of the external oblique abdominal muscle. Encysted (encapsulated) inguinal hernia differs by two hernial sacs located one inside the other. Only the internal sac is communicated with the abdominal cavity. It is impossible to penetrate into the abdominal cavity from the outside sac, not having opened the internal one. Periinguinal hernia - is a hernia, in which the hernial sac goes out the inguinal canal not through its external opening, but through its fissure in aponeurosis of the external oblique muscle. Direct inguinal hernia is a hernia, which protrudes the peritoneum in the area fovea inguinalis medialis and passes into the inguinal canal outside the spermatic cord, through the inguinal space. This type of hernia is always acquired. Combined inguinal hernias regard to complex ones and are characterized by presence of two or three hernial sacs on one side of the body, which are not communicated with each other, and having independent hernial openings conducting to the abdominal cavity. This type of hernia is dangerous, because during operation one of hernias may be missed. Sliding inguinal hernias are those, in which, except the parietal peritoneum, the visceral peritoneum, covering on a small extent the sliding organ, takes part in the formation of the hernial sac. Sliding inguinal cystoceles, caecum hernia and hernias of female internal genital organs (ovaries, uterine tubes, uterus) are the most widespread. That circumstance, that one of the walls of the hernial sac of sliding hernia is formed by adjoining organ located behind the peritoneum, is the cause of frequent complications both during operation, especially if it is performed by an inexperienced surgeon, and in the postoperative period. Recurring inguinal hernias. It is necessary to distinguish recurring inguinal hernia, which occurs through any interval of time after herniotomy, and repeatedly recurring, when it again occur after 2 - 3 or more operations. It is the most complex form of inguinal hernias, which treatment requires high skill of the surgeon. The basic amount of relapses in inguinal hernias occurs within the first 3 years after operation. Direct, sliding and large inguinal hernias recur more often. The predilection to repeated relapses in patients who had been operated on is very great, and makes about 35 - 40 %. The main cause of relapse in hernia is the wrong choice by a surgeon a technique of surgical intervention disharmonious to a pathogenesis of hernia, and technical errors during the operation. The outstanding Russian surgeon S.P. Fyodorov wrote: " It is considered, that herniotomia is an easy operation... Actually this operation is not easy one from the point of view of correct and good performance ". CLINICAL PICTURE AND DIAGNOSTICS OF INGUINAL HERNIAS The clinical picture in uncomplicated inguinal hernias is rather typical. The complaints of the patient on the presence of a tumorous protrusion in the inguinal area and pain of various intensity, especially on physical exertion, in most cases allow to assume the presence of hernia. The diagnostic difficulties arise when the hernial protrusion is insignificant, for example, in beginning or canal hernias, and also in its atypical localization, for example, in interwall hernias. In these cases the diagnosis is made on the basis of study of anamnesis, examination and palpation of the inguinal area. Inguinal hernias of small sizes may not cause any discomfort and morbid sensations. At the same time, in long-existed hernia, in its large sizes, in sliding and recurring forms the pain is a constant sign and the main complaint of the patients. The pain is localized in the lower departments of the abdominal cavity, in the inguen, irradiate to the pubic region and sacrum. More hernial protrusion, more considerable discomfort it causes on walking and on physical exertion, sharply limiting a working capacity. Frequently patients with inguinal hernia complain of chronic constipations. In sliding cystocele, besides the typical complaints, may be added such signs as pollakiuria, colics in the urethra, pains above the pubic region, disappearing after reduction of hernia. In the elderly patients the retention of urine is observed quite often. Pains, bloating of the abdominal cavity and constipations accompany sliding of ceacum in the hernial ring. The bright clinical picture is observed in inflammation of the vermiform process in hernia. Thus, alongside with intensifying of pain, there is a nausea, vomiting, retention of stool and gases, increase of body temperature, the pulse becomes rapid and the signs of irritation of the peritoneum in the lower departments of the abdomen are determined. It is necessary to emphasize, that chronic inflammation of the vermiform process in hernia introduces some features in its clinical picture: pain in the lower part of the abdomen, constipations, nausea, and loss of appetite appear more often. In women, in involvement of female internal genital organs in the hernial ring, abdominal pain sometimes irradiating to the pubic region are also observed. On examination, the surgeon should pay attention to the form and size of the hernial protrusion in different positions of the patient, both vertical and horizontal. In oblique inguinal hernia, the protrusion has the oblong form, is situated along the course of the inguinal canal, and frequently descends to the scrotum. In direct hernia it is spherical or oval-shaped, lies near at the medial part of the inguinal ligament, near to external edge of the pubic region. When the hernial protrusion is located above the projection of the external opening of the inguinal canal, it is necessary to assume the presence of periinguinal or interwall hernia. If there are two protrusions, combined hernia is possible. In large inguinal hernias in men, a half of scrotum on the side of hernia is considerably enlarged, the skin is stretched, the penis evades to the opposite side, and in giant hernias it disappears in the skin folds. Frequently, at the moment of examination, the hernial protrusion does not demonstrate its contours: it is set in the abdominal cavity or disappears in thickness of fat in obese patients. In this connection, the diagnostic test on examination of the inguinal area, in which a surgeon palpates the hernial protrusion, defines its sizes, the degree of reducibility, sizes of the internal inguinal canal, form and size of testicles is more valuable and informative. The presence or absence of varicocele is fixed; differential diagnostics of direct, oblique and femoral hernias is carried out. Normally, the external opening passes a tip of a finger. In hernia, depending on its size, the diameter is enlarged up to 2 – 3 cm and more, passing 2 or 3 fingers, and sometimes, in giant hernias, all the hand. Not taking off a finger, a surgeon offers the patient to strain himself or to cough. Thus he feels jerky pressure on the tip of a finger – a sign of the cough shock symptom. The definition of this sign is especially important in diagnostics of initial or canal hernias. In considerable dilatation of the inguinal canal, the finger easily advances along the course of the inguinal canal. If hernia is oblique, the dilated passage repeats the direction of the spermatic cord, and in direct hernia, a finger is referred directly, penetrating to the inguinal space. Sometimes it is possible to feel a pulsation of a. epigastrica interna. In direct hernia the pulsation of this artery is felt outside from a finger, and in oblique hernia - from its inside part. Thus, the data received on examination of the patient together with anatomic data obtained earlier allow to differentiate rather precisely oblique inguinal hernia from direct one before the operation. Diagnostics of inguinal hernia in women differs, because introduction of a finger in the external opening of the inguinal canal is practically impossible. It is necessary to be limited by examination and palpation of the hernial protrusion, which in direct hernia is located above the inguinal ligament, and in oblique hernia descends into the large pudendal lip. Diagnostics of sliding inguinal hernias before operation is very important, as it determines the actions of the surgeon during a surgical intervention, giving him an opportunity to avoid a casual wound of organs. The presence of sliding hernia should be assumed: 1) in long - existing hernias of the large sizes with wide hernial ring; 2) in repeatedly recurring hernias, when quite often there is a destruction of the posterior wall of the inguinal canal; 3) in presence of the complaints of the patient, characteristic for sliding of this or that organ; 4) in partial or complete irreducibility of hernia; 5) when on palpation of the hernial sac (after reduction of its contents) its doughy consistence is determined; sometimes the hernial protrusion consists as though of two parts, one of which is more dwarfed; 6) when urination in two stages is observed (in sliding cystoceles at first a patient empties the urinary bladder, and then, after reduction of hernia, he has an urge to urination). In suspection on the presence of sliding hernia, it is necessary to apply the additional methods of investigation, such as irrigoscopy, cystography, cystoscopy, and bimanual gynecologic examination. If there is a suspection on involving of urethra or the kidney in the process, it is necessary to carry out an infusive urography. In presence of tumorous formation in the inguinal area, the lymphadenitis and abscesses should be excluded first of all. Unlike inguinal hernia, inflammatory tumour does not change in its sizes, is irreducible. The inguinal canal is not dilated. Reddening of dermal integuments is observed quite often, the body temperature is increased, and palpation of a tumour is painless. Abscesses are observed in spinal tuberculosis. Dysfunction of the vertebral column and specific rentgenologic changes of bodies of vertebrae are characteristic for this disease. Irreducibility of tumour and absence of the external opening of the inguinal canal dilatation, and presence of fluctuation also allow to exclude hernia. Sometimes, in obese women with pendulous abdomen, difficulties in differentiation of inguinal or femoral hernia occur. In this case, when examining a female-patient in horizontal position, it is important, being guided by bony prominences, to define accurately a projection of the inguinal ligament. Inguinal hernias are above hernial protrusion, and femoral ones are below it. The difference of oblique inguinoscrotal hernia from hydrocele is that hydrocele tumour is spherical or oval-shaped, has distinct borders, and is of compact - elastic consistence. On percussion, in case of hydrocele, the dull sound is revealed, whereas in hernia it is more often accompanied by tympany. In edema the translucent symptom is positive. The patient is placed against a source of light, for example, against an electrical lamp, and a doctor reveals the transparency through a stethoscope, which is put to the scrotum (diaphanoscopy). The content of hydrocele is transparent and passes light, whereas the intestinal loops and omentum do not pass it. However, it is necessary to remember about possible combination of hydrocele or funicular hydrocele hernia. Before operation it is possible to distinguish the acquired oblique hernia from inherent one only presumably, but it has no large practical importance. SURGICAL TREATMENT OF INGUINAL HERNIAS In most cases an operation for free inguinal hernia may be performed under a local anesthesia. The exception is made by children of the first years of life, the patients not bearing Novocainum, and also those cases, when the patient insists on a general anesthesia. The main stages of herniotomy. There is a great amount of operations on inguinal hernia, but all of them differ from each other only by the end stage – plastic repair of the inguinal canal. The main stages of operation are performed identically. The first stage - approach to the inguinal canal. The second stage – isolation of hernial sac out of surrounding tissues and its excision. The third stage - closure of the inguinal opening up to the normal sizes on its dilatation or destruction. The fourth stage – inguinal canal plastic repair. One of the major causes of recurrence of inguinal hernia is the standard application one of the techniques of operation without the account of topographical specificity of the inguinal canal, the type of hernia, age of the patient, sizes of the hernial ring, state of tissues. Such practice is vicious. On the data of native surgeons, standard surgical treatment of inguinal hernias results in recurrences in 6,9 - 28,5 % of cases. At the same time, in clinics specially engaged in this problem, percent of relapses is reduced to a minimum, averaging from 0 till 3. The especially bad late results are observed in complex forms of inguinal hernias, when techniques of Girard, Spasokukotskiy, Martynov, and Kimbarovskiy are applied for their treatment. Thus, in direct inguinal hernias recurrences are observed in 18 -24 %, the inguinal hernias of the large sizes recur in 18- 25 % of cases, and sliding hernias - in 43 %. The frequency of repeated relapses reaches up to 24 - 42 %. The explanation of this fact is that with the help of traditional methods of building up of the anterior wall of the inguinal canal are insufficiently reliably eliminated the main reason of herniation - delicacy of the posterior wall. Only when the inguinal space is reliably covered with muscles, which is observed quite often in oblique hernias of small sizes in young patients, the ways of building up of tissue of the anterior wall of the inguinal canal under condition of closure of deep opening up to a normal diameter can guarantee a successful treatment. In direct inguinal hernias and in complex forms of hernias (oblique with the direct canal, sliding, supravesical, combined, recurring) the primary attention of the surgeon should be directed on building up of the posterior wall of the inguinal canal. In cases of extensive and giant inguinal hernias and in repeatedly recurring hernias, when the inguinal canal is completely decayed, there is a necessity for creation of the new inguinal canal by means of autoplastic reconstruction of its walls or by using of additional plastic materials. Thus, it is necessary to try to keep an anatomic locating of the inguinal canal and its physiological role. In extremely infrequent cases, in very old men, after repeated operations it is expedient to liquidate the inguinal canal, previously having removed the testicle and the spermatic cord. The hernial ring is closed by principles of treatment of postoperative hernias. Technique according to Bassini. It is a clinical way of building up of the posterior wall of the inguinal canal, which has a variety of modifications. In an original way it is carried out as follows. Under the spermatic cord the deep sutures are placed: 1) between edges of the direct muscle and its sheath and the pubic tubercle periosteum; here it is enough 1 - 2 sutures; 2) between the internal oblique and transversal muscles, and also the transversal fascia on the one side, and the inguinal ligament from the other. These sutures completely liquidate the inguinal space. Thus, the transversal fascia and muscles build up a back wall of the inguinal canal. The spermatic cord is placed, and above it the edges of the external oblique muscle aponeurosis are sutured. Technique according to Kukudzhanov. This way is offered basically for the direct and complex forms of inguinal hernias: large oblique with the direct canal, and recurring hernias. After excision of hernial sac and suturing of deep inguinal ring, stitches are put in: a) between sheath of the rectus abdominalis and Cooper's ligament. For this purpose apply a small round pricking needle and surgical synthetic thread. Sutures (3 - 4) are placed in the course of 3 cm from the pubic tubercle up to a fascial case of iliac vessels, protecting them thus with spatula and not squeezing. In case of possible tension, before tying of sutures in the most medial department of the sheath of rectus abdominis, a surgeon makes a hardly slanting relief incision of 2 - 2,5 cm in length. Suturing of tissues with tension is necessary to regard as an appreciable technical error. The described moment of operation is of great importance; it produces a strong bottom of the inguinal canal; a) between connected tendon, and also between superior border of dissected fascia and the inferior border of a transversal fascia and the inguinal ligament. The final stitch is placed at the medial border of the internal opening of the inguinal canal. Operation is completed with placing of duplicature of aponeurosis of the external oblique abdominal muscle. The operation according to Kukudzhanov is a modification of technique according to Bassini. From the point of view of constructive attitude, it is more complex, however its use for the Cooper's ligament plastic repair, suturing of homogeneous tissues without an appreciable tension, full-value use of aponeurosis of the external oblique abdominal muscle raises reliability of this operation, which can be applied for all without exception complex inguinal hernias. The main contraindication to operation is the absence of full-value tissues. Technique aсcording to McVay. It is rather close to technique according to Kukudzhanov. On its basis also lay the narrowing of the deep inguinal ring and reconstruction of the posterior wall of the inguinal canal. Suturing of the transversal fascia forms the deep inguinal ring. Before restoration of the posterior wall of the inguinal canal, on musculus rectus abdominalis sheath, the large relief incision with the length of 4 - 5 cm for the greater mobility of muscular layers and the connected tendon is made; then a transversal fascia together with the connected tendon of internal oblique and transversal muscles is sewed by close stitches to the Cooper's ligament. The author categorically objected to use for this purpose the inguinal ligaments. He considered essentially important to fix the posterior wall to the place of its natural attachment, i.e. to the Cooper's ligament. The stitches are placed on all extent from the жимбернатова ligament up to the femoral vessels. The spermatic cord is packing up, and aponeurotic edges of the external oblique muscle are sewed with duplicature. This technique is recommended to be applied to the complex forms of hernias. Technically it is difficult. There is a danger of damage of femoral vessels; therefore they should be previously exposed. The author of this technique, having applied it in 562 patients with various, including recurring inguinal, hernias has reduced the amount of relapses up to 0,6 %. Technique according to Sholdice (laminated inguinal hernioplasty). Section of the skin is usual. Following the section of the anterior wall of the inguinal canal, the ilioinguinal nerve has to be isolated and taken on a rubber retractor (handle). The fibers of m. cremaster are to be completely crossed and dissected, especially at a place of its transition on the spermatic cord. It is necessary for obtaining a good approach to the deep opening of the inguinal canal. The spermatic cord is isolated and taken aside. The hernial sac is excised. The special importance in plastic repair is given to the transversal fascia, which is dissected from the internal inguinal ring up to the pubic tubercle in parallel to the inguinal ligament on extension of 1 - 2 cm medially it. The medial leaf of the fascia should be mobilized and is exposed of preperitoneal fat up to the posterior wall of the musculus rectus abdominis sheath. Further building up of the posterior wall of the inguinal canal is performed. The first continuous suture begins medially from the pubic tubercle. By means of it the lateral border of the transversal fascia is sutured to the lower surface of the medial one behind musculus rectus abdominalis sheath. This suture is tied at the pubic tubercle, and one end of a thread is left long. The suture is continued in lateral direction, connecting both parts of the transversal fascia up to the internal ring. Then the suture is turned in the opposite direction, and medial border of the transversal fascia is sutured by it to the inguinal ligament up to the pubic tubercle. When the suture reaches the pubic tubercle, it is connected to the left thread. The second continuous suture begins from the internal ring; by means of it musculus obliquus internus abdominalis and the connected tendon is joined to the posterior surface of aponeurosis of musculus obliquus externus abdominalis immediately above the inguinal ligament. This suture continues from the pubic tubercle, and then turns to the internal ring, connecting musculus obliquus internus abdominis with aponeurosis of the oblique muscle, indenting a little from the previous row of sutures. The continuous sutures are placed with atraumatic needle with synthetic thread. The spermatic cord is placed, and the borders of aponeurosis of musculus obliquus externus abdominalis are sutured above it. Then the superficial fascia, subcutaneous fat and skin are also sutured. In special herniotomy specialized hospital in Toronto within 20 years Sholdice and his colleagues had performed 50.000 herniotomies. The relapses were marked in 0,8 % of observations, and the main part of relapses concerns to the period of a beginning of development of the technique. Technique according to Postempsky. This technique provides complete liquidation of the inguinal canal, the inguinal space and creation of the inguinal canal with a perfectly new direction. The spermatic cord is prepared as it is possible further in lateral direction, and the internal ring of the inguinal canal is sutured at the medial side. In some cases, to give the spermatic cord more lateral direction, the oblique and transversal muscles are dissected and the spermatic cord is removed to the formed slit in the superior-lateral direction. The muscles under it are sutured so as they closely, but without compression, cover the spermatic cord (N.I. Kukudzhanov, 1969). Further the building up of the inguinal canal begins. From the medial side the connected tendon of musculus obliquus and musculus transversus and the border of musculus rectus abdominalis sheath are sutured to the pubic tubercle and the superior pubic ligament (Cooper's ligament), which is situated on the upper surface of symphysis and is tightened between both pubic tubercles. Further the transversal fascia, oblique and transversal muscles, and also the superior leaf of aponeurosis of musculus obliquus externus abdominalis are sutured layer-by- layer either at once, or in two stages to the iliopubic cord and the inguinal ligament, and these sutures move away the spermatic cord to the maximum to the lateral side (if earlier the muscles had not been crossed). Sutures above the medial flap fix lateral flap of aponeurosis of musculus obliquus externus abdominalis. Thus newly- formed "inguinal canal " with the spermatic cord should pass through a musculoaponeurotic layer in a slanting direction from behind forward and from within outside, so that its internal and external openings have not appeared one above another in the sagittal plane. The latter is important for the prevention of relapses (I.L. Ioffe, 1968). Then the spermatic cord is placed on aponeurosis, and, layer-by-layer above it, the superficial fascia and the skin are sutured. Sometimes it is expedient to place the spermatic cord between the flaps of aponeurosis. There are also other operations, which provide the replacement of the spermatic cord and, accordingly, the formation of the new inguinal canal. These are techniques according to Felse (1900), Crymov (1929), and Kirshner (1933). All these operations due to their complexity and trauma possibility have not gained ground and now are not applied. Only technique according to Postempsky has withstood the test of time, it is still used for the especially serious forms of inguinal hernias. I.L. Ioffe (1968) considers, that by means of technique according to Postempsky, the strongest and pathogenically proved building up of the posterior wall of the inguinal canal is achieved. Finishing the description of autoplastic ways of operations for inguinal hernias it is necessary to note, that the search of new techniques proceeds. However, each of the offered operations, altering any technical detail, has no principal differences from the classical ways, abovementioned. ALLOPLASTY FOR INGUINAL HERNIAS. In 90 years of the last century in various clinics of the world the wide popularity was received by a technique according to I.L. Lichtenstein, in which basis is the alloplasty without a tension (“free tension”) lays (A.I. Gilbert, 1992; R.E. Stoppa, 1993; G.E. Wantz, 1993). The results of clinical application of this technique are an evidence of its exclusive reliability. Technique according to Liechtenstein. Following a cut of the skin, the hernial sac is exposed by traditional way. On oblique inguinal hernia, after excision of the hernial sac, the deep inguinal ring is restored, and the transversal fascia is sutured. On direct inguinal hernia, the unaffected transversal fascia is dissected only above the hernial sac and is reduced, if it is possible, unopened, and then the transversal fascia is sutured by a continuous suture. For plastic repair of the hernial ring, polypropylene mesh is used, from which a patch by the size 6 x 12 cm is cut out. The implant is placed under the spermatic cord and is fixed from below by interrupted sutures to the inguinal (Poupart's) ligament. The top edge of a mesh is sutured by nodal ligature to the internal oblique muscle. The internal inguinal ring is formed. The rounded lower edge of a mesh is fixed with 2 - 3 stitches to the pubic tubercle together with the superior pubic ligament with the purpose of prevention of development of femoral hernia. For recurring hernias Liechtenstein has developed the second technique, by means of which the hernial ring is obturated with special polypropylene plug (figures 88 b, c, d). Rolled on mesh transplant "plug" is fixed by several stitches in the inguinal canal, preventing the exposure of hernia. The estimation of “plug" technique is ambiguous. Alongside with excellent results (S.E. Stock, 1995; 1999; J.M. Rutkov, A.W. Robbins, 1999; G.E. Wantz, 1999), the dangerous complications connected to migration of a transplant "plug" and relapses are also observed. P.K. Amid (1997) has described perforation of the urinary bladder as a result of migration of transplant. For treatment of bilateral large recurring hernias R.E. Stoppa (1989) has developed a technique of preperitoneal plasty with appliance of mesh polypropylene or Dacron allotransplants. By means of transplant, which is placed in the prepared preperitoneal space at first on one, and then on the other side, all weak, potentially hernial sites of the abdominal wall are covered. The idea of R.E. Stoppa is that the implant is kept in the preperitoneal space due to intraabdominal pressure. Stoppa's operation. Anesthesia is general. The skin incision is made on the middle line below the umbilicus, not reaching a few centimeters up to the pubis. The posterior wall of musculus rectus abdominis sheath is exfoliated by means of blunt dissection, exposing Retzius' (retropubic) space, the internal ring of the inguinal canal and the hernial sac. The inferior epigastric vessels are visualized by removing the peritoneal leaf dorsally and inside. The deferent duct and the spermatic vessels are exposed on an extent up to 8 cm and are freely placed on the pelvic wall; due to this the implant may not contain an opening for the spermatic cord. The allotransplant is cut on represented according to figure 90 form. By means of curved forceps the implant is placed in the prepared preperitoneal space and is sutured along the median line to the umbilical fascia only with one ligature. The operation can be performed from the transversal approach (Pfannenstiel's) that has some cosmetic advantages. FEMORAL HERNIAS. Femoral hernias are those, which prolapse through the femoral canal. They make up 5 - 8 % of all abdominal hernias, are more frequent than inguinal hernias, represent difficulties for diagnostics, are incarcerated more often and have more insidious course. They occur mainly in women in the second half of life. According to our data, among 1830 patients with ventral hernias the femoral hernias were observed in 98 (5,3 %) patients (96 females and 2 males). The absolute prevalence of women is explained by those facts as they have the wider pelvis, i.e. they have more evident muscular and vascular lacunae and less firmness of the inguinal ligament. The femoral ring (anulus femoralis) is the hernial ring in inguinal hernia. It is located in the medial-most department of the vascular lacuna and is bounded medially - with the lacunar ligament, in front - with the inguinal ligament, behind - with the Cooper's ligament, laterally - with the sheath of the femoral vein. The femoral ring is filled with fatty tissue. Here is the large lymphatic node (node of Rosenmuller - Pirogov). The femoral canal (canalis femoralis) is formed on the passage of hernia. Its internal opening is the femoral ring, external - the oval fossa, i.e. the opening in the broad fascia, through which the large saphenous vein (v. saphena magna) passes. The canal has the triangular shape. Its walls are: anteriorly - the posterioinferior surface of the inguinal ligament and the posterior surface of a site a superficial leaf of the broad fascia, posteriorly - the deep leaf of the broad fascia, from the outside - the medial wall of the femoral vein and its fascial sheath. During formation femoral hernia passes 3 stages: 1) initial, when the hernial protrusion does not protrude out the limits the internal femoral ring; 2) incomplete (canal), when the hernial protrusion does not protrude out the limits the superficial fascia, does not penetrate into the subcutaneous fat of Scarpa's triangle; 3) complete, when hernia passes the whole femoral canal, its internal and external openings and emerges into the subcutaneous fat of the thigh. CLINICAL PICTURE AND DIAGNOSTICS OF FEMORAL HERNIA The most typical clinical sign of complete typical femoral hernia is the presence of hernial protrusion in the area of the femoral-inguinal fold. As a rule, this is a smooth hemispheric formation of small sizes locating below the inguinal ligament inside from femoral vessels. Femoral hernias of large sizes may also occur, but rather rare. As a rule, the only reason, which may suggest to the presence of femoral hernia, is the complaint of a patient on pain in the inguen, in the lower abdomen, and the upper departments of the thigh. Rather frequently the first clinical manifestation is incarceration of hernia. On incarceration of the intestine in the intestinal current of incarcerated femoral hernias it is possible to distinguish three periods. The first period: there is no necrosis of strangulated intestinal loops and there are no serious changes in the organism of a patient caused by intestinal obstruction. The second period: necrosis of intestinal loops in the hernial sac or outside its limits (in retrograde incarceration), the signs of intestinal obstruction are marked, but still there are no clear manifestations of peritonitis and severe intoxication. This period usually lasts from the second till the eighth hour from the moment of incarceration. The third period: advanced incarceration, when the phenomena of peritonitis and severe intoxication are clearly determined; it usually happens after 8 - 10 hours from the moment of incarceration. In comparison with other widespread abdominal hernias, the femoral hernias rather frequently cause difficulties on differential diagnostics, especially in obese patients. It is necessary to differentiate it from direct inguinal hernia, inguinal lymphadenitis, benign tumours in the скорновский triangle. In infrequent cases the varicosis in the area of the large saphenous vein opening may be erroneously recognized as femoral hernia. In exclusive cases aneurysm of the femoral artery may be recognized as femoral hernia. THERAPY. All operation procedures for femoral hernia, depending on approach to the hernial ring, are divided into femoral, inguinal and intraabdominal ones, and according to the way of the hernial ring elimination - into simple and plastic ones. The most common way among femoral ones is technique according to Bassini, in which the approach to hernia is performed by a vertical incision on the thigh that passes through the center of hernial protrusion. After excision of the hernial sac, the hernial ring is eliminated by suturing of the inguinal and pubic ligaments. Among the inguinal ways, technique of Rudzhi - Parlaveccio is applied more often. According to this technique, the approach to the hernial sac is performed through the inguinal canal. Then, after excision of the hernial sac, the hernial ring is also eliminated by suturing of the inguinal and Cooper's ligaments. UMBILICAL HERNIAS IN ADULTS. This kind of hernia constitutes about 3 – 5% of all external abdominal hernias, being the 3rd in incidence following inguinal and postoperative hernias. They appear predominantly in women over 30. The umbilical ring is the hernial ring. Usually it is round-shaped. Umbilical ring is rather frequent associated with diastasis of musculus rectus abdominalis and epigastic hernias. Aponeurosis and muscles in the hernial ring and epigastic areas are frequently become thinned, atrophied, and disintegrated into the fibers. It should be taken into consideration on making choice of way and technique of operation. The hernial sac is thin, adhered with the dilated and thinned skin, and the hernial ring borders. In small irreducible hernias, the content of the hernial sac most often is the omentum fixed by adhesions. In large hernias the hernial sac is frequently polychamber. CLINICAL PICTURE. Clinical picture depends on the size of hernia, dimensions of the hernial ring, intensity of adhesive process, either presence or absence of complications, accompanying obesity. Infrequently small umbilical hernias do not trouble patients, especially if they are reducible and have no predisposition to incarceration. The most clear clinical picture is observed, as a rule, in hernias of large sizes. Those patients suffer from constipations, paroxysmal (periodic) pains, frequent nausea and even vomiting. These phenomena are most evident in irreducible hernias. THERAPY. The basic operation techniques are the autoplastic ones, according to Sapezhko and Meyo. On the basis of both techniques lies the creation of musculo-aponeurotic duplicature either in longitudinal (according to Meyo) or transverse (according to Sapezhko) direction. In giant umbilical hernias alloplastic repair is indicated. POSTOPERATIVE HERNIAS. Postoperative hernias of the abdominal wall protrude from the abdominal cavity in the area of postoperative ci

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