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| source: www.everydayhealth.com |
Classification
of Hernia
First:
internal hernias: occur through the hole inside the body
1. Diaphragm
hernia:
Either Congenital
(morgagni hernia, Parasternal hernia, often right) (bochdalek, diaphragm
hernia, posterior, often left( Or acquired (Hiatal hernia(
2. Hernias
within the peritoneum: occur through the hole in the Thorac or mesarica or
foramen of Winslow.
Second:
External hernias: occur through the hole in the abdominal wall towards the
outside:
3. Inguinal
hernia (direct, indirect) - Femoral hernia.
4. Linea
alba hernia: (Epigastric hernia) - Paraumbilical hernia.
5. congenital Hernia or Postoperative hernias
6. abdominal
wall hernia (rare): Spigelian hernia, Lumbar hernia, Obturator hernia.
Areas
of anatomical constriction in the esophagus:
Upper
esophageal sphincter (swallowing function, anatomical sphincter): 15 cm away
from Incisors, the most prone to perforation during upper gastrointestinal
endoscopy.
The
lower esophageal sphincter (function preventing reflux, a physiological
sphincter): is 40 cm away from the Incisors, permanently closed only when
swallowing and burping, pressure about 13 mmHg.
Types of Hiatal Hernias
The
first type: Sliding hernia (commonest)
About
90% of the Hiatal hernia
The
gastroesophageal junction is displaced (The location of Cardia varies),
elevation of the angle of Hess and intervention of the chest cavity, caused by chronic
high pressure in the abdomen (such as from pregnancy, obesity, coughing, or
straining during bowel movements), often not symptomatic, and if demonstrated
symptoms have the same symptoms of reflux
Type
II: Rolling or paraesophageal hernia:
The
gastroesophageal valve remains within the abdomen (without gastric esophageal Displacement),
but the oesophageal hole is wide.
The
fundus ascends to the chest and is located on the thoracic side of the
esophagus, The incidence increases exponentially with age.
Symptoms:
Dysphagia (due to the pressure of the fundus on the esophagus), chest pain, fullness,
heartburn, belching, reflux, Vomiting Blood (Hematemesis), Aspiration
pneumonia, dyspnea.
Note:
Women are more infected than men in the previous two types
Type
III: mixed:
The hole is very wide and the fundus rises with the gastroesophageal valve into the
chest.
Advanced
type (type IV): stomach within the chest:
The
entire stomach is in the chest, and the stomach rotates 180 degrees around its
longitudinal axis.
Symptoms:
Excessive bleeding, intestinal obstruction, Gastric torsion, gastric infarction.
Diagnosing a Hiatal Hernia
- X-ray: useful in paraesophageal hernia and in the chest, while not useful in Sliding hernia.
- Contrast of radiotherapy of the upper gastrointestinal tract (Barium swallow), is useful in hernia of type II and III and If the Sliding hernia is large
- The most important method is upper gastrointestinal endoscopy
Treatment for Hiatal Hernias
Sliding
hernia: 85% pharmacotherapy and 15% Nissen-type fundoplication.
Rolling
or paraesophageal hernia: The treatment is always surgical because of the
complications are fatal.
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| source: www.mayoclinic.org |
Patients who are candidates for surgery: Young patients who have reflux with or without deficiency in sphincter.
Principles
of Surgery:
- Return the contents of hernia to the inside of the abdomen.
- Reset the lower sphincter pressure to twice the pressure of the stomach at rest (the sphincter pressure should be about 30 mmHg), and the sphincter resistance should not exceed the driving force of the esophagus (because this causes permanent dysphagia).
- Sufficient length of the lower sphincter in the abdomen (at least 2 cm)
- Allow the relaxation of the Cardia during swallowing, using the fundus and not the body of the stomach to folding.
- the folding around the bottom of the esophagus and not on the Lesser curvature, because when swallowing food relaxes the fundus and allows the esophagus to move food, and at the height of abdominal pressure press the fundus on the esophagus and close it.
Results
after 360° Nissen-type fundoplication
- Typical symptoms improve in more than 90% of patients after 2-3 years.
- Transient dysphagia is common after surgery as a result of surgical edema and automatically disappears after 3 months, mild-grade.
- Abdominal puffiness: Common, due to increased swallowing seen in patients with reflux.
- Other complications include spleen injury, pneumothorax, esophageal perforation.
There
is also a Thal process that has the same steps as Nissen, but the
fundoplications are partial (270° anterior) only around the lateral and front
faces of the esophagus.
In
addition to the Belsey process, 270-anterior transthoracic fundoplications
(Belsey)
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| source: www.liberaldictionary.com |
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