El uso de neumoperitoneo preoperatorio progresivo en el tratamiento de hernia gigante de la pared abdominal / (The use of progressive preoperative pneumoperitoneum as treatment in giant abdominal wall hernia)

Resumen La cirugía para la corrección de las hernias ventrales gigantes, con pérdida de domicilio abdominal, representa un reto importante debido a la gran cantidad de comorbilidades potenciales. En esta patología se produce una migración de los órganos abdominales hacia el saco herniario; eventualmente, se atrofian los elementos de la pared y al tratar de retornarlos a su posición normal, se puede provocar múltiples efectos adversos en el paciente. Por eso, se debe realizar una cuidadosa planificación, preoperatoriamente. El uso de neumoperitoneo preoperatorio progresivo, permite una adaptación más adecuada desde el punto de vista fisiológico, tanto a nivel sistémico, como en la capacidad abdominal, para tolerar el retorno de los contenidos que han perdido su domicilio. Se presenta aquí el caso de una paciente femenina de 58 años, con una hernia ventral gigante con pérdida de domicilio abdominal, en cuyo manejo se utilizó la introducción preoperatoria progresiva de neumoperitoneo, descrita por primera vez por Goñi Moreno, en 1940.

Abstract Surgery for the correction of giant ventral hernias, with loss of abdominal domain, represents a major challenge due to the large number of potential comorbidities. In this pathology there is a migration of the abdominal organs to the hernia sac; eventually, the elements of the wall undergo atrophy and when trying to return the organs to their normal position, it can cause multiple adverse effects in the patient. Therefore, a careful planning must be carried out preoperatively. The use of progressive preoperative pneumoperitoneum, allows a more adequate adaptation from the physiological point of view, both at a systemic level, as in the abdominal capacity, to tolerate the return of contents that have lost their domain. We present here the case of a 58 year old female patient, with a giant ventral hernia with loss of abdominal domain, in whose management, the introduction of progressive preoperative pneumoperitoneum was used, described for the first time by Goñi Moreno, in 1940.

Hérnia de Spiegel: suspeição diagnóstica e tratamento / Spiegelian hernia: diagnostic suspicion and treatment

As hérnias de Spiegel são raros defeitos da parede abdominal. Apresentam quadro clínico pouco esclarecedor e potencial para complicações. Relatamos um caso de uma paciente de 69 anos de idade, que apresentou quadro clínico compatível com hérnia de Spiegel. O objetivo deste relato de caso é apontar alguns aspectos de seu difícil diagnóstico e salientar a importância do seu correto manejo.

Spiegelian hernias are rare abdominal wall defects. The clinical picture is not very clarifying and there are potential complications. We report a case of a patient of 69 years of age, who presented clinical signs of Spiegelian hernia. The purpose of this case report is to point out some aspects of its diffi cult diagnosis and emphasize the importance of proper management.

Hérnia paraduodenal: relato de caso / Paraduenal hernia: case report

O presente trabalho apresenta um relato do caso, bem como uma revisão de literatura sobre hérnias paraduodenais de paciente de 34 anos, sexo masculino, tratado cirurgicamente por hérnia paraduodenal direita no Hospital Universitário da UFSC. Estas hérnias, raras vezes, são causas de dor abdominal e abdome agudo obstrutivo. A hérnia paraduodenal é também conhecida por vários outros nomes, como: hérnia interna, hérnia mesocólica ou mesentérico-parietal. São definidas como resultantes de uma anomalia de rotação e reduçào do intestino médio, que ocorre na cavidade abdominal durante a vida embrionária. O diagtnóstico pré-operatório é raro devido ao quadro clínico sutil e baixo índice de suspeição, porém, os métodos de imagem podem definí-lo com segurança. É concenso que, uma vez diagnosticada, a hérnia paraduodenal deve ser reparada. O conhecimento da sua patogênese e alterações anatômicas presentes são importantes para o adequado manejo cirúrgico

Hernias suprapúbicas. Un reto para el cirujano / Suprapubic hernia. A challenge for the surgeon

Como parte de los estudios de hernias abdominales se muestra el resultado del tratamiento a un tipo complejo de ellas, la hernia suprapúbica, que requiere un importante conocimiento anatómico en el proceder de reparación. Esta no es frecuente, representa el 2 (por ciento) de todas las hernias. El objetivo del trabajo fue el de evaluar los resultados a corto y a largo plazo, en el Hospital General de Santiago de Cuba, entre el 1ro. de enero de 1994 y el 31 de diciembre de 1998. Se realizó un estudio descriptivo, longitudinal, observacional y clínico de pacientes operados por la técnica de Rives-Bendavit con el uso de bioprótesis, la que fue colocada en el espacio preperitoneal y fijada al ligamento arcuato, a la cara posterior de la sínfisis del pubis, al ligamento de Cooper y lateralmente al músculo recto y su aponeurosis. Fueron operados 39 pacientes con solo 2 recidivas (5,21 por ciento), Y no se presentó rechazo en ningún enfermo. La técnica constituye un excelente medio para la reparación de estas complejas hernias. Los resultados hallados por los autores de este artículo se encuentran en el límite óptimo internacional(AU)

As it leaves from the abdominal studies of hernias is the result of the treatment a complex type of them, hernia suprapúbica, that requires an important anatomical knowledge in the repair behavior. This is not frequent, represents 2 percent of all hernias. The objective of the work was the one to evaluate the results to short and long term, in the General Hospital of Santiago of Cuba, between 1ro. of January of 1994 and the 31 of December of 1998. It was made descriptive, longitudinal, observacional and clinical a study of patients operated by the technique of Rives-Bendavit with the bioprótesis use, the one that was placed in the preperitoneal and fixed space to the arcuato ligament, the later face of the sínfisis of pubis, to the ligament of Cooper and laterally to the straight muscle and its aponeurosis. (5.21 percent) was operated 39 patients with single 2 recidivas, and rejection in any patient did not appear. The technique constitutes excellent means for the repair of these complex hernias. The results found by the authors of this article are in international the optimal limit(AU)

Spigelion hernia: fascia lata repair is an alternative option in absence of prolene mesh.

Spigelian hernia is rare. Seven cases of Spigelian hernia are presented. These include two recurrent Spigelian hernias. Incisional hernias through Spigelian aponeurosis after Pfannensteil incision are not included. Clinical examination is the mainstay of diagnosis. The true incidence is possibly higher, as a low Spigelian hernia is not recognised and often diagnosed as a direct inguinal hernia. Ultrasound scanning is recommended, as it is non-invasive and easily available and can detect the hernial orifice in the Spigelian fascia at an early stage. Recurrence of Spigelian hernia took place in two cases through the site of prolene stitch of a previous repair. Hernioplasty with tension free fascia lata graft/prolene mesh was carried out in all cases. The cost of fascia lata graft is only a scar in the thigh. In a mean follow-up of 3.1 -year no patient has reported back with recurrence This is the ideal substitute for the patients in developing countries where synthetic meshes are still not freely available.

Incisional hernia: an experimental model in rabbits

The aim of this study was to develop an experimental model of incisional hernia in rabbits. Thirty seven rabbits, weighing from 2220 to 2750 g, were submitted to musculoaponeurotic and peritoneum pattern resection of the abdominal wall and distributed in groups of 10 animals according to the postoperative time of 30, 45 or 60 days. The animals were submitted to reoperation at the end of the observation period. In the three groups were observed hernias larger than 60 and 45 cm in transversal and longitudinal measures, respectively, and with volumes greater than 129 ml. Adherences to the internal abdominal wall were present in 13,3 por cento. Seven deaths occurred due to evisceration (5), pulmonary infection (1) and diarrhea(1). There was no significant difference in the three groups studied, according to the statistical methods applied. The experimental model is feasible, and is established at the 30 days of postoperative period.

Hérnia traumática da parede abdominal / Traumatic abdominal hernia

A rare case of blunt traumatic abdominal hernia is presented in which jejunal loops herniated through the abdominal wall. The patient had a serious motor vehicle accident seven years ago, while wearing the seat belt. He developed a traumatic hernia in the anterior lateral abdominal wall, which was operated, and relapsed after some months. The patient was reoperated and we observed the unattachment of the anterior lateral abdominal musculature from the ilium crest. After the hernial sac treatment, the defect was solved with the use of a polypropylene mesh. The postoperative evolution was good and four months later there were no signs of recurrence. Traumatic abdominal hernia remains a rare clinical entity, despite the increase in blunt abdominal trauma. Traumatic abdominal wall hernia falls into two general categories: small lower quadrant abdominal defects, typically the result of blunt trauma with bicycle handlebars, and larger abdominal wall defects related to motor vehiche accidents. The diagnosis may be often established by the physical examination alone. Conventional radiology and computerized tomography usefulness have been proved. In the vast majority of cases, early repair is recommended. The appropriate treatment is the reduction of the herniated bowel into the abdomen, the debridment of nonviable tissues, and a primary tension-free closure of the defect

Hernias internas del abdomen: experiencia en tres casos / Internal abdominal hernias: experience of 3 cases

Las hernias internas del abdomen (HIA) son raras y de difícil diagnóstico clínico. Frecuentemente se presentan complicadas. En la patogenia participan principalmente alteraciones congénitas. Se pueden producir HIA en compartimentos normales de la cavidad abdominal (transcavidad de los epiplones) o por atrapamiento de asas en zonas de adherencias o defectos retroanastomóticos o traumáticos de los mesos. El diagnóstico es casi siempre tardío, por lo que muchas veces, la indicación quirúrgica es por alguna forma de abdomen agudo quirúrgico. Los casos presentados corresponden a dos hernias intersigmoídeas, a través de un defecto, probablemente congénito, en ambas hojas del mesosigmoides, y a una herniación a través de un defecto, probablemente adquirido, en el ligamento ancho izquierdo del útero. Dos de los casos tenían gangrena de las asas comprometidas, mientras que el otro caso presentaba un intestino muy edematoso y friable, en vías de gangrenarse. Esto obligó a realizar resecciones y anastómosis intestinales, una ileostomía, una fístula mucosa de delgado y una operación de Hartmann, con las reconstrucciones respectivas. Los dos enfermos vivos están en control y se encuentran en buenas condiciones. Uno fallece por tuberculosis miliar un año después de su operación. Las tres variedades que motivaron este artículo son infrecuentes dentro de las HIS

Hérnia isquiática: relato de caso / Sciatic hernia: report of a case

A hérnia isquiática é a mais rara entre as raras hérnias do assoalho pélvico. A sintomatologia é escassa, o diagnóstico pré-operatório difícil e o tratamento cirúrgico é o método preferido para tratar essas hérnias. Apresentamos um caso de hérnia isquiática em paciente idoso masculino, que se manifestou como uma massa tumoral na regiäo glútea direita

Hérnias múltiplas da parede abdominal / Multiple simultaneous abdominal wall hernias

Os autores relatam o caso de um paciente adulto portador de hérnias femorais e de Spiegel bilaterais e hérnia umbilical simultâneas, todas de surgimento espontâneo. Apenas um caso semelhante foi encontrado na literatura. Säo abordados aspectos clínicos e diagnósticos de tais situaçöes e ressaltada a raridade do caso

Hérnia intercostal abdominal / Abdominal intercostal hernia

Two cases of abdominal intercostal hernia are presented. One of them contained the colonic hepatic flexure and was caused by a thoraco-abdominal trauma ten months before the patient was referred to us. The second patient noticed the hernia few days after the trauma and the hernial sac content was a loop of small bowel. The clinical presentation of abdominal intercostal hernia is of an uncomplicated hernia, easily diagnosed on clinical examination. Further respiratory and digestive investigations are however essential to determine the content of the hernia sac. Treatment consisted of surgical repair. In one case we prefered the transperitoneal approach with the use of a Marlex mesh to repair the diaphragmatic defect. After one year of the operation the patient had no signs of recurrence. On the other patient we used the same approach and the defect was closed after the approximation of the 10§ and the 11§ ribs with pericostal suture. Nineth days after the operation the patient had no evidence of recurrence

Traumatic abdominal wall hernia.

Two cases of traumatic abdominal wall hernia, produced by impaction of the motorcycle handlebars, are reported. The mechanism of injury, clinical and radiologic diagnosis are discussed. Because of the high incidence of other associated intraabdominal injuries, early exploration and repair through a midline incision is advocated. Adequate debridement and solid repair of fascial planes with non-absorbable sutures are required to prevent recurrence. Primary closure of the musculofascial defect was performed in both reported cases and the recovery was uneventful.

Hernia de Spieghel: relato de caso / Spigelian Hernia: case report

A partir do caso de um paciente com multiplas hernias, onde uma delas era uma hernia de SPIEGHEL, os autores fizeram uma revisao evolutiva da literatura sobre o assunto, principalmente no que concerne a anatomia da regiao onde ocorre a hernia, o diagnostico e os meios semiotecnicos disponiveis para o diagnostico da doenca, a tecnica cirurgica empregada no caso descrito e as complicacoes possiveis, ja que e um tipo incomum de hernia com poucos casos descritos na literatura.

Reconstrucao da parede abdominal / Abdominal wall reconstruction

A luz de modernas tecnicas disponiveis na Cirurgia Plastica Reconstrutiva, realizamos uma sistematizacao da reconstrucao da parede abdominal. Os defeitos a serem corrigidos podem ser de diversos niveis e a possibilidade de utilizacao de retalhos musculares e miocutaneos e enfatizada. A escolha do metodo, seu adequado planejamento e execucao, assim como o momento ideal para submeter o paciente a cirurgia consistem os fundamentos da reconstrucao do continente abdominal

Hernia ventral lateral complicada: diagnóstico tomográfico / Complicated lateral ventral hernia: tomographic diagnosis

Se presenta un caso de hernia ventral lateral complicada diagnosticada por Tomografía Computada. Se analizan los aspectos anatómicos, clínicos, diagnósticos y terapéuticos de esta afección, con especial énfasis en los exámenes complementarios