Methodical recommendation of practical lessons for 4th year students of the

direction of training "General Medicine"

Practical lesson No. 10 "Hernias of the anterior abdominal wall"

Topic: Hernias of the anterior abdominal wall
The purpose of the lesson: to gain knowledge about the clinic, diagnosis,
complications and methods of treatment of patients with various types of hernias of the
anterior abdominal wall.
Lesson objectives:
1. To consolidate knowledge of the clinical anatomy of the anterior abdominal wall
2. Anatomy of the venous circulation of the abdominal organs
3. Portocaval and kavacaval anastomoses
4. Causes and classification of portal hypertension syndrome
5. Acquire the skills of assessing the results of clinical, X-ray, ultrasound, laboratory
methods of research in patients with portal hypertension syndrome.
6. To study the clinical picture in uncomplicated forms of portal hypertension
7. To study the clinical picture with intense ascites
8. To study the principles of providing emergency care for portal hypertension
syndrome
9. To study the principles of surgical treatment of portal hypertension syndrome.

Methodical instructions for self-preparation for the lesson

Requirements for the initial level of knowledge. To master the topic, you must repeat:
- from the course of normal anatomy, topographic anatomy and operative surgery:
topographic anatomy of the abdominal and retroperitoneal organs, syntopy, holotopy
and skeletotopy of the parenchymal and hollow organs of the abdominal cavity, blood
supply and innervation of the parenchymal and hollow organs of the abdominal cavity
and retroperitoneal space.
- normal and pathological physiology: the main functions of the parenchymal and
hollow organs of the abdominal cavity and retroperitoneal space.
- normal and pathological anatomy of hernias of the anterior abdominal wall

Test questions from related disciplines:

1. Deontological bases of examination and treatment of surgical patients
2. Technique for physical examination of the abdominal cavity
3. Features of palpation, percussion, auscultation of the anterior abdominal wall
4. Technique for determining the weak points of the anterior abdominal wall
5. Anatomical structure of the anterior abdominal wall.
6. Method for determining the cough thrust
7. Features of sliding hernias
8. Methods of drainage of the abdominal cavity in complicated forms of hernias of the
anterior abdominal wall
9. Technique of surgical treatment of umbilical hernias
10. Technique of surgical treatment of inguinal hernia

Guided by the recommended literature, students should:

know the topographic anatomy of the abdominal organs and retroperitoneal space, the
clinical picture, modern methods of clinical, laboratory and instrumental examination,
methods and methods of treatment of complicated and uncomplicated hernias of various
forms of the anterior abdominal wall. Principles of tactics at the prehospital stage.

Control questions on the topic:

1. To get acquainted with the general symptomatology, diagnosis, basic principles of
surgical treatment of hernias
2. To study the anatomy of the groin area, inguinal hernia, the main methods of surgical
treatment.
3. Get acquainted with the anatomy of the femoral canal, femoral hernias, the main
methods of surgical treatment
4. To study the clinic and the main methods of treatment of umbilical hernia and hernia
of the white line of the abdomen.
5. To get acquainted with the concept of "restrained hernia", clinic, diagnosis,
differential diagnosis of restrained hernias, as well as the features of the surgical
technique

An indicative basis for action in a practical class (APC)

1. Prepare homework and lectures on the topic for testing.
2. Control of students' theoretical training.
3. Clinical anatomy of the anterior abdominal wall.
4. The questions of pathogenesis and clinical picture of hernias of the anterior
abdominal wall are examined
5. The issues of clinical and instrumental diagnostics of various forms of the anterior
abdominal wall are discussed
6. The issues of surgical treatment of various forms of hernias of the anterior abdominal
wall are discussed

Independent work of students under the supervision of a teacher:

Students examine in wards patients with abdominal pathology, who have phenomena
that may be characteristic of hernias of the anterior abdominal wall, specify the general
clinical manifestations of this pathology,
Students solve situational tasks on the topic of the lesson, form a preliminary diagnosis,
carry out a differential diagnosis, determine urgent measures to provide assistance to a
surgical patient, outline an examination plan using laboratory and instrumental methods,
interpret the data obtained, outline a conservative treatment plan, determine indications
for surgical treatment, analyze the main methods of surgical treatment, preparation of
the patient for surgery, postoperative management of the patient, possible complications
in the postoperative period, patient rehabilitation and follow-up.
Form the ability to correctly fill out an outpatient card and medical history
Students draw up the solution of situational problems in writing and submit them to the
teacher for checking.
The teacher answers questions, monitors the end
knowledge.

Upon completion of the lesson, students should be able to:

1. Examine a patient with hernias of the anterior abdominal wall,
2. To identify the common symptoms of hernias of the anterior abdominal wall, to
explain the causes of their occurrence.
3. To identify specific symptoms in hernias of the anterior abdominal wall (various
forms of the disease)
4. Draw up a plan for the examination of a patient with suspected complicated forms of
hernias of the anterior abdominal wall.
5. Determine the indications and contraindications for surgical intervention for hernias
of the anterior abdominal wall
6. Draw up a plan of preoperative preparation for complicated and uncomplicated forms
of hernias of the anterior abdominal wall
7. Draw up a plan of postoperative management of the patient, draw up a plan of
rehabilitation measures.

Questions for self-control:

1. Definition and classification of hernias of the anterior abdominal wall.
2. Etiology of hernias of the anterior abdominal wall. Predisposing factors.
3. Clinical manifestations of hernias of the anterior abdominal wall.
4. Diagnosis of hernias of the anterior abdominal wall.
5. Treatment of hernias of the anterior abdominal wall.
6. Umbilical hernia. Anatomical prerequisites for the occurrence of an umbilical hernia.
7. Terms and principles of surgical treatment of umbilical hernia.
8. Inguinal hernia. Anatomical prerequisites for the occurrence of an inguinal hernia.
9. Terms and principles of surgical treatment of inguinal hernia.
10. Complication of inguinal hernia - infringement. Clinic and diagnostics.
11. Features of surgical tactics for strangulated inguinal hernia.
12. Rare forms of hernias of the anterior abdominal wall
 Topic content:
A hernia of the abdomen is called the exit of the internal organs covered with the
parietal peritoneum from the abdominal cavity beyond its limits through the natural or
artificial openings of the anterior abdominal wall. A hernia should be distinguished
between eventration and prolapse.
Eventration is the exit of organs from the abdominal cavity through an acutely
developed defect in the abdominal wall without preserving the integrity of the parietal
peritoneum.
Types of events
By origin - congenital, post-traumatic, postoperative.
By the nature of the abdominal wall defect - complete (defect through all layers) and
incomplete or subcutaneous (the integrity of the skin is preserved). Prolapse (prolapse) -
the exit of an internal organ not covered by the peritoneum, or part of it through a
natural opening.
Classification
By localization:
1. External - come out through the holes in the musculo-aponeurotic layer of the
anterior or posterior abdominal wall and pelvic floor.
• inguinal (oblique, straight);
• femoral;
• umbilical;
• white line of the abdomen (epigastric, paraumbilical, hypogastric);
• Spigel and Douglas lines;
• lumbar;
• locking;
• sciatic;
• crotch;
• xiphoid process, etc.
2. Internal - formed inside the abdominal cavity, in the abdominal pockets or penetrate
into the chest cavity through the natural and acquired apertures of the diaphragm.
intra-abdominal hernia;
diaphragmatic hernia.
By the degree of development:
• initial - the leaf of the parietal peritoneum and the contents of the abdominal cavity are
just beginning to penetrate into the deepening of the abdominal wall (preperitoneal
lipoma)
• canal - hernia within the hernial canal.
• complete - hernias that have come out under the skin.
• large sizes - the volume of the hernial sac is a significant part of the volume of the
abdominal cavity.
By origin:
• congenital;
• acquired (including postoperative, recurrent, traumatic, neuropathic).
By clinic:
• reducible;
• irreducible: a) complete irreducibility; b) partial irreducibility.
• restrained: a) elastic restraint; b) fecal infringement; c) parietal infringement; d)
retrograde infringement (Maydl's hernia); e) infringement of the Meckel diverticulum
(Littre's hernia); f) Broca's hernia.
• inflammation of the hernia (from the skin or coming from internal organs).
• hernia trauma;
• foreign bodies of hernias;
• neoplasms of hernias.
Components of a hernia:
• hernia gate;
• hernial sac (mouth, neck, bottom). With sliding and diaphragmatic hernias, as a rule,
the hernial sac is partially or completely absent;
• hernial contents

Etiology of hernias of the anterior abdominal wall

1) Predisposing factors - connective tissue weakness syndrome, damage to the nerves
that innervate the abdominal wall, the presence of postoperative scars.
2) Producers - factors contributing to the increase in intraperitoneal pressure - hard
physical labor, prolonged constipation, difficulty urinating.

Common Symptoms of Uncomplicated External Abdominal Hernias

• the presence of hernial protrusion, hernial orifice;
• pain in the area of hernia;
• dysfunction of the organs that make up the hernial contents

Treatment of uncomplicated hernias of the anterior abdominal wall

1) Surgery is the only way to radically eliminate a hernia. The complexity of the
operation, its trauma, the likelihood of complications is proportional to the size of the
hernia and the duration of the disease. A small hernia is usually a small, aesthetic
surgery that is well tolerated by patients. In contrast to small hernias, the treatment of
giant hernias of the anterior abdominal wall is a serious surgical problem, 5 requiring in
some cases non-standard and even risky solutions. Naturally, the manufacturability and
trauma of such operations, and the likelihood of complications increases significantly.
Based on this, an indication for planned surgical treatment is the presence of a hernia of
the anterior abdominal wall, of any size, for any (even with small) periods of the
disease.
Contraindications to surgery should be narrowed as much as possible.
2) Conservative treatment (limiting physical activity, using a bandage with or without a
pelot) is used if there are contraindications to the operation or the patient has
categorically refused it.
3) Contraindications to planned operations:
• absolute - severe concomitant chronic diseases, clinical malignant tumors.
• relative (temporary) - acute diseases, pregnancy.

Stages of a planned operation

1. Access.
2. Revision of the hernial sac: discharge from the surrounding tissues -> opening and
revision of the hernial sac
assessment of the condition of the contents of the hernial sac
stitching and excision (or intussusception into the abdominal cavity) of the hernial sac.
3. Plasty of the hernial orifice - elimination of the defect of the muscular-aponeurotic
layer. Numerous methods of hernia orifice repair for hernias are systematized according
to the principle of the predominant use of certain own tissues of the abdominal wall or
allografts:
1) Autoplastic methods of hernia orifice repair:
• fascial-aponeurotic plastics;
• muscular-aponeurotic;
• muscular.
2) Alloplastic methods:
• plastic using additional biological or synthetic materials;
• combined plastic (use of autologous tissue and foreign tissue)

Oblique inguinal hernia (differential diagnostic signs)

• it is more common in males, mainly in children, young and middle age.
• can be congenital and acquired.
• located above the groin fold.
• as a rule, it is one-sided.
• has an oblong or oval shape, repeats the course of the spermatic cord
• can descend into the scrotum.
• the spermatic cord on palpation is determined medial to the hernial protrusion.
• a cough push is defined lateral to the finger inserted into the external opening of the
inguinal canal.
• if a finger inserted into the inguinal canal manages to determine the pulsation of the
inferior epigastric artery, then it is located medially from the finger.
• when the inner inguinal ring is clamped, the hernial protrusion does not appear when
the patient is straining (negative symptom of Krymov).

Differential diagnosis of oblique inguinal hernia

An oblique inguinal hernia most often has to be differentiated:
• direct inguinal hernia;
• femoral hernia;
• dropsy of the testicle or spermatic cord communicating with the abdominal cavity;
• cyst of the spermatic cord;
• cryptorchidism;
• cyst of the round ligament of the uterus;
• lipoma of the anterior abdominal wall;
• inguinal lymphadenitis or cancer metastasis;
• answer the question: acquired or congenital oblique inguinal hernia.

Direct inguinal hernia (differential diagnostic signs)

• more common in women;
• in men, mainly of elderly and senile age, weakened and emaciated;
• there is no congenital;
• like an oblique hernia, it is located above the inguinal fold;
• is often bilateral;
• has a rounded shape;
• does not descend into the scrotum;
• the spermatic cord is located lateral to the hernial protrusion;
• cough impulse during the examination is determined directly under the finger inserted
into the external opening of the inguinal canal;
• if a finger inserted into the inguinal canal manages to determine the pulsation of the
inferior epigastric artery, then it is felt outward from the finger;
• despite the compression of the inner inguinal ring, when the patient strains, a hernial
protrusion appears (positive symptom of Krymov).

Дифференциальный диагноз прямой паховой грыжи

Прямую паховую грыжу чаще всего приходится дифференцировать
• косая паховая грыжа
• бедренная грыжа
• водянка или киста семенного канатика,
• киста круглой связки матки,
• липома передней брюшной стенки
• лимфаденит или метастаз рака

inguinal hernia surgery tapas

The most important of the recent advances in herniology is the evidence of the decisive
importance in the genesis of the inguinal hernia - the morphostructural weakness of the
posterior wall of the inguinal canal.
Therefore, in any type of inguinal hernia, one of the main points of a radical operation
should be a thorough revision of the posterior wall with the aim of its subsequent
anatomically and biomechanically substantiated strengthening.
1. Access to the inguinal canal.
2. Revision of the hernial sac: isolation from the surrounding tissues, opening and
revision of the hernial sac> assessment of the state of the contents of the hernial sac>
suturing and excision (or intussusception into the abdominal cavity) of the hernial sac.
3. Revision of the posterior wall of the inguinal canal and suturing of the inner inguinal
ring - suturing of the inner inguinal ring is performed to normal size (up to a diameter of
0.6-0.8 cm) when it expands or collapses.
4. Autoplasty or alloplasty of the inguinal canal: students need to know the basic
methods of plastic surgery of the inguinal canal, depending on the type of inguinal
hernia: the method of Girard-Spasokukotsky-Kimbarovsky; methods of Potempsky,
Kukudzhanov, Shouldice, Lichtenstein, Nyhus, PHS (prolen hernia system).

Femoral hernia (differential diagnostic signs)

• More common in women.
• As a rule, always purchased.
• Located below the groin fold.

Differential diagnosis
• femoral hernia - inguinal hernia;
• lipoma of the anterior abdominal wall;
• inguinal lymphadenitis;
• cancer metastasis;
• aneurysm of the femoral artery.

Plasty of the femoral canal is performed by suturing the scallop fascia to the pupar
ligament: femoral access - Bassini's operation; inguinal access - Ruggia's operation -
Parlavecchio.

Umbilical hernia (differential diagnostic signs)

Differential diagnosis.
• Umbilical hernia - paraumbilical hernia.
• Lipoma
• Cancer metastasis (usually stomach).
• Umbiliscitis.

Methods of surgical treatment of an umbilical hernia (methods of plastics of the

umbilical ring)
• plastic surgery of the umbilical ring according to Shpizi - preserving the navel in
children,
• plastics of the umbilical ring according to Lexner - applying a purse string suture to
the umbilical ring,
• plastic surgery of the umbilical ring according to Mayo - creating a duplication of the
aponeurosis in the transverse direction
• plastics of the umbilical ring according to Sapezhko - creating a duplication of the
aponeurosis in the vertical direction.

Hernia of the white line of the abdomen (differential diagnostic signs)

• More often located between the navel and the xiphoid process.
• More often acquired.
• With a few exceptions, it is equally common in men and women

Differential diagnosis of hernia of the white line of the abdomen

• Lipoma;
• cancer metastasis;
• germination of a cancerous tumor.

Methods of plastic hernia orifice for hernias of the white line of the abdomen
• Sapezhko.
• Napalkov.
• Martynov.

Complicated hernia
1) An irreducible hernia is a hernia that was previously easily adjusted into the
abdominal cavity, and ceases to partially or completely adjust.
The cause of irreducibility is the fusion of organs between themselves and the hernial
sac due to inflammation; narrowing of the neck of the hernial sac.
Predisposing factors are old age, hard physical labor, prescription and large size of
hernias, wearing bandages.

The clinical picture depends on how much of the contents of the abdominal cavity has
moved into the hernial sac. The most common symptoms are dyspepsia, flatulence,
constipation, pain.

Differential diagnosis of irreducible hernia

• restrained hernia;
• lipoma;
• cancer metastasis;
• phlegmon of the hernial sac;
• inguinal lymphadenitis with femoral hernia.

Treatment is operative, depending on the location and type of hernia.

2) Injured hernia With a sharp increase in intra-abdominal pressure (when lifting
weights, coughing, defecation), the mobile organs of the abdominal cavity exit through
the hernial orifice into the hernial sac, and due to irritation of the peritoneum, the
hernial contents are compressed in the hernial orifice.
Strangulated hernias account for 4.5-5.0% of all acute surgical diseases of the
abdominal cavity.

The clinical picture of a strangulated hernia

• sudden onset with new or existing hernia during increased intra-abdominal pressure;
• irreducibility of previously reducible hernia;
• sudden sharp, gradually increasing, sometimes paroxysmal pain in the abdomen;
• nausea, hiccups, excruciating repeated vomiting;
• stool and gas retention;
• general severe, often collaptoid condition of the patient;
• tension, sharp soreness of hernial protrusion;
• negative symptom of a cough shock;
• the further development of the symptoms of the disease is associated with an increase
in symptoms caused by the infringement and progression of the phenomena of intestinal
obstruction and peritonitis.

The mechanism is distinguished:

• elastic restraint;
• feces;
• combined infringement.

Pathogenesis of elastic restraint

• rapid introduction of viscera into the hernial sac;
• reflex muscle spasm in the area of the hernial orifice;
• violation of venous outflow in the restrained organs;
• edema of the wall of the restrained organs;
• cessation of arterial inflow ischemia of the walls of organs, their necrosis and
gangrene;
• a picture of strangulated intestinal obstruction with peritonitis, phlegmon of the hernial
sac and abdominal wall develops.

The pathogenesis of fecal impaction

• compression of the organs in the hernial sac as a result of their overfilling with feces,
gases.
• the development of pathological changes occurs relatively slowly, the bowel loops are
overstretched, losing the ability to peristalize - evacuation of contents is disturbed,
obstructive intestinal obstruction develops.
• as a result of compression of the mesenteric vessels, venous outflow is disturbed, and
subsequently, with the occurrence of edema, and arterial inflow, the wall of the
strangulated intestine is necrotic, phlegmon of the hernial sac and abdominal wall,
peritonitis develops.

Pathogenesis of combined infringement

• its occurrence and clinical manifestations consist of signs of elastic and fecal
impairment.

Special types of infringement

Retrograde (Madia's hernia) - “reverse” infringement of three or more loops of the
small intestine, in the form of the letters “V” or “W”, and the loops located in the
hernial sac may be viable, while the loops located in the abdominal cavity are necrotic.

Parietal (Richter's hernia) - the antimesenteric edge of the intestinal wall is infringed.
Most often, this type of infringement is observed with femoral, inguinal, less often
umbilical and hernias of the white line of the abdomen.

Imaginary or false (infringement of Broca) - peritonitis of various genesis, not

associated with infringement of the hernia, as well as ascites can simulate infringement
of the hernia due to filling the hernia sac of a reducible or irreducible hernia with
exudate or transudate, accompanied by the appearance of pain, tension in the area of the
hernial sac.

Littre's hernia - an infringement of Meckel's diverticulum - the pathogenesis and

clinical picture resemble parietal infringement (Richter's hernia).

Differential diagnosis of strangulated hernia

• irreducible hernia; • coprostasis;
• acute inguinal lymphadenitis;
• acute umbiliscitis;
• the presence of vulgar inflammatory infiltrates in places corresponding to the
localization of hernias.

Surgical treatment.
A strangulated hernia is an absolute indication for emergency surgery.
It is unacceptable forcible reduction of strangulated hernias, as it is possible:
• reduction of non-viable intestine;
• imaginary reduction;
• rupture of the intestine in the hernial sac with the subsequent development of
peritonitis;
• rupture of the vessel and bleeding into the abdominal cavity.

Features of surgical treatment of strangulated hernias

"Without dissecting the restraining ring, open the hernial sac, remove the effusion,
revise the vitality of the restrained organ!"
The intestine is viable: pink or red, the serous membrane is smooth, shiny; slightly
edematous wall; vascular pulsation is preserved; visible peristalsis in the restrained area.

The intestines are not viable:

black-earthy or black;
the wall is edematous with areas of subserous hemorrhage;
there is thrombosis of large vessels;
there is no pulsation of small vessels;
there is no peristalsis, and it is not restored;
under the action of hypertonic solutions, it "falls through".

Operation options
The intestine is viable - the restraining ring is dissected, the intestine is immersed in the
abdominal cavity, hernia repair and plastic hernia orifice are performed.
The intestine is not viable - midline laparotomy, intra-abdominal resection of the
intestine, retreating proximally not less than 40 cm, and distally - not less than 15-20 cm
with a side-to-side anastomosis, possibly “end-to-end”. Removal of the contents of the
hernial sac to the outside, hernia repair and plastic of the hernial orifice.

Complications during surgical treatment of hernias

A. Intraoperative
1. Damage to large vessels, more often - of the femoral vein, less often - arteries with
deep stitching of the pupar ligament with an inguinal hernia or dissection of the femoral
ring in the lateral direction - with a femoral hernia; damage to the obturator artery in
cases of anomalies in its position with a femoral hernia (it is necessary to isolate the
vessel along the length, apply a vascular suture).
2. Injury of the bladder or bowel - with sliding, restrained, irreducible large
postoperative umbilical and recurrent hernias (it is important to timely detect and suture
the defect).
3. Damage to the spermatic cord and injury to the vas deferens in inguinal hernias.
4. Damage to the ilio-inguinal and ilio-celiac nerves.
B. Postoperative
1. Cardiopulmonary insufficiency in patients operated on for large postoperative
umbilical and strangulated hernias without sufficient preparation.
2. Pneumonia.
3. Intestinal paresis.
4. Bleeding into the abdominal cavity, hematoma in the operation area (insufficient
hemostasis).
5. Inflammatory infiltration, usually associated with rough operation.
6. Wound suppuration - more often as a result of aseptic disturbance.
7. Thrombosis of mesenteric vessels is more common in elderly people suffering from
atherosclerosis.
8. Thrombosis of the veins of the thighs and pelvis - caused by this embolism.
9. Edema of the scrotum, spermatic cord, testicular atrophy (funiculitis, epididymitis,
orchitis) due to trauma to the spermatic cord, excessively tight suture.
10. Neuritis and neuralgia due to entrapment of branches of the external pudendal or
femoral nerves in the seams.
11. Early, usually the so-called "false" relapses due, as a rule, to an irrational choice of
the method of plastic surgery and poor performance of the operation.

Situational tasks
Task 1
Patient M, 36 years old, was admitted to the clinic with complaints of a tumor-like
formation in the epigastric region. The tumor-like formation arose 3 years ago and is
gradually increasing in size. Objectively: in the epigastric region, a tumor-like
formation of 8x6 cm, elastic consistency, painless, adjusted into the abdominal cavity is
determined. There is also a defect in the aponeurosis up to 3 cm in diameter. There is no
other pathology.
Questions
1. What is your “working” or clinical diagnosis?
2. Based on what clinical symptoms and other data available in the task, did you make
this diagnosis?
3. What methods of examination (laboratory, instrumental) will you prescribe to the
patient. What are your goals with this appointment?
4. Expected examination results for your clinical diagnosis.
5. Methods for the treatment of this pathology

Task 2
Patient P., 36 years old, was admitted to the clinic with complaints of a tumor-like
formation in the left groin area. Ill for 5 years, the formation is gradually increasing in
diameter. Objectively: on the left, just below the pupar ligament, there is a tumor-like
formation 5x3 cm in size, which fits into the abdominal cavity. No other pathology was
found
Questions
1. What is your “working” or clinical diagnosis?
2. Based on what clinical symptoms and other data available in the task, did you make
this diagnosis?
3. What methods of examination (laboratory, instrumental) will you prescribe to the
patient. What are your goals with this appointment?
4. Expected examination results for your clinical diagnosis.
5. Methods for the treatment of this pathology

Task 3
Patient M, 46 years old, was admitted to the clinic with complaints of the presence of a
tumor-like formation in the area of the surgical scar along the midline of the abdomen. 3
years ago underwent surgery for destructive cholecystitis, peritonitis. The wound healed
by secondary intention. Objectively: along the midline of the abdomen, from the
xiphoid process to the navel, there is an operating scar, in the center of which is a
tumor-like formation with a diameter of up to 15 cm, elastic consistency, which can be
adjusted freely into the abdominal cavity. An objective study did not reveal any other
pathology.
Questions
1. What is your “working” or clinical diagnosis?
2. Based on what clinical symptoms and other data available in the task, did you make
this diagnosis?
3. What methods of examination (laboratory, instrumental) will you prescribe to the
patient. What are your goals with this appointment?
4. Expected examination results for your clinical diagnosis.
5. Methods for the treatment of this pathology

Task 4
Patient K., 35 years old, complains of a tumor-like formation in the right groin area,
which tends to increase with straining, physical exertion and descends into the scrotum,
which causes pain and decreased ability to work.
Questions
1. What is your “working” or clinical diagnosis?
2. Based on what clinical symptoms and other data available in the task, did you make
this diagnosis?
3. What methods of examination (laboratory, instrumental) will you prescribe to the
patient. What are your goals with this appointment?
4. Expected examination results for your clinical diagnosis.
5. Methods for the treatment of this pathology

Task 5
Patient Sh., 48 years old, complains of sharp pain in the area of tumor-like formation in
the left groin area. Carrier hernia for 5 years. Pain appeared after lifting the weight 8
hours ago, after which nausea appeared, vomiting occurred up to 6 times. Urination is
not disturbed. Body temperature 37.2 ° C. Apparently, the patient had an infringement
of the inguinal hernia.
Questions
1. What is your “working” or clinical diagnosis?
2. Based on what clinical symptoms and other data available in the task, did you make
this diagnosis?
3. What methods of examination (laboratory, instrumental) will you prescribe to the
patient. What are your goals with this appointment?
4. Expected examination results for your clinical diagnosis.
5. Methods for the treatment of this pathology

Task 6
Patient 3., 56 years old, was admitted to the clinic with complaints of pain in the navel.
Five years ago, she noted the appearance of a tumor-like formation in the navel, which
was gradually increasing in size. First, the formation was set into the abdominal cavity.
Three months ago, was stopped adjusting. Objectively: in the area of the navel, a tumor-
like formation 10x10 cm is determined that does not fit into the abdominal cavity,
elastic, slightly painful. On auscultation, peristalsis is heard over it. On clinical
examination, no other pathology was found.
Questions
1. What is your “working” or clinical diagnosis?
2. Based on what clinical symptoms and other data available in the task, did you make
this diagnosis?
3. What methods of examination (laboratory, instrumental) will you prescribe to the
patient. What are your goals with this appointment?
4. Expected examination results for your clinical diagnosis.
5. Methods for the treatment of this pathology

Test tasks
1. A patient has 40 years of age a year after surgery for inguinal hernia, a hernial
protrusion appeared again. Your actions?
1) observation, surgery for hernia infringement
2) operate with a progressive increase in the hernia
3) observation with the exclusion of heavy physical activity
+4) elective surgery before complications develop or increase
hernia
5) wearing a bandage
2. Tactics for irreducible hernia:
1) wearing a bandage
2) the appointment of physiotherapy
+3) planned surgery
4) emergency operation
5) observation by a surgeon
3. Plasty of a hernial defect with an umbilical hernia is performed according to
methodology:
1) Bassini
2) Martynova
3) Spasokukotsky
+4) Mayo
5) Girard
4. What are the characteristic symptoms of impingement in a urinary hernia?
bubble:
1) pain in the area of hernial protrusion
2) tenesmus
3) stool and gas retention
+4) dysuria and hematuria
5) dyspepsia
5. Tactics for coprostasis hernia:
1) emergency surgery
2) planned surgery
3) introduction of the probe into the stomach with its lavage
+4) the appointment of laxatives and siphon enemas
5) performing perirenal blockade
6. Tactics for hernia inflammation:
1) emergency surgery
2) wearing a bandage
+3) conservative treatment
4) opening the hernial sac
5) the appointment of physiotherapy
7. Femoral hernias are more common:
1) in men
+2) in women
3) in children
4) old people
5) gender and age don't matter
8.Tactics for spontaneous reduction of a hernia in the emergency room;
1) the patient can be released home
2) emergency surgery - hernia repair
+3) hospitalization of the patient in the surgical department for
observation
4) the appointment of antibiotics and siphon enemas
5) emergency laparotomy with bowel revision
9. The most common cause of hernia formation:
1) unstable stool
2) dysuric disorders
3) dyspeptic disorders
+4) heavy physical activity
5) frequent overeating
10. When the hernial sac was opened, about 100 ml of urine was released.
What kind of hernia are we talking about?
1) reducible
2) irreducible
3) Richterovsjoy
+4) sliding
5) false
11. A 70-year-old patient has left-sided oblique inguinal hernia with a tendency to
infringement. There is a prostate adenoma with urinary dysfunction. Your
recommendation:
1) wearing a permanent bandage
2) emergency operation with the next infringement
3) surgical treatment with a rapid increase in the size of the hernia
+4) elective surgery after examination by a urologist and correction
violations
urination
5) simultaneous hernia repair and removal of adenoma
12. What to recommend to a 80-year-old patient without gross somatic pathology
with frequent infringements of an inguinal-scrotal hernia?
1) conservative treatment aimed at stool regulation
2) emergency surgery - hernia repair
+3) elective surgery after outpatient examination
4) hospitalization with supervision in the surgical department
wearing a bandage
13. Why do elderly patients with hernias of the white line of the abdomen and
with umbilical hernias before surgery should the stomach be examined?
1) to determine the nature of the organ in the hernial sac
2) to identify the size of the hernia orifice
for the diagnosis of intra-abdominal hypertension
+4) to exclude stomach tumors or peptic ulcer
5) to exclude gastrostasis
14. A free man with a strangulated inguinal-scrotal hernia was admitted on the 3rd
day from the onset of the disease, temperature 39 degrees, hyperemia, infiltration
and edema of the scrotum. What complication is observed in the patient?
1) testicular necrosis
2) funiculitis
+3) phlegmon of the hernial sac
4) acute orchitis
5) dropsy of the testicle
15. Sign indicating the non-viability of the restrained hernia:
1) delayed peristalsis
2) normal gut color
+3) absence of pulsation of mesenteric vessels
4) the collapsed bowel loop
5) spasmodic bowel loop
16. Which wall of the inguinal canal is weakened with a straight inguinal hernia:
1) top
2) front
+3) back
4) bottom
5) none
17. Signs of hernia infringement, except:
1) sharp pain
2) sudden irreducibility of the hernia
+3) high fever
4) acute onset of the disease
5) soreness of hernial protrusion
18. Specify which wall of the femoral ring is dissected in case of a strangulated
femoral hernia?
1) front
2) back
3) lateral
+4) medial
5) no
19. Inguinal hernia in children is associated with:
+1) unliterated vaginal process of the peritoneum
2) hyperproduction of aqueous humor
3) violation of lymphatic drainage
4) weakness of the anterior abdominal wall
5) increased physical activity