Possibilities of Ultrasonic Technologies in the Diagnosis of Incarceration in Patients with External Abdominal Hernias

The dissertation is dedicated to studying the diagnostic capabilities of ultrasonic technologies in cases of incarceration of external abdominal hernias. The research is motivated by high postoperative mortality rates in patients with incarcerated hernias and a significant number of diagnostic errors ranging from 11% to 30%. For the first time, ultrasonic signs of incarceration of hernia contents in B-mode, hemodynamic signs, and criteria for assessing the viability of incarcerated organs using Doppler techniques have been identified. An algorithm for comprehensive ultrasonic examination of patients with ambiguous clinical pictures of incarceration has been developed, along with differential diagnosis of incarcerated hernia from other acute diseases presenting with similar clinical symptoms.

The relevance of the problem of diagnosis and surgical treatment of incarcerated hernias is due to the large number of patients admitted to surgical hospitals with this pathology (they are surpassed only by patients with acute appendicitis, pancreatitis, and cholecystitis), as well as high postoperative mortality. In the structure of acute surgical diseases, hernia incarceration accounts for 6% [Abumakov M.M., et al., 1998, Feleshtinskiy Ya.P., 2001, Mikhailov A.P., 2002]. Despite more than 100 years of experience in the surgical treatment of incarcerated hernias, postoperative mortality, according to domestic and foreign authors, has shown no tendency to decrease for the past 30 years and ranges from 3% to 40% [Abumakov M.M., et al. 1998, Zhebrovskiy V.V., et al., 2000, Savelyev V.S. et al., 2004, Waldhaussen J.H., 1996, Rath A.M., et al., 2000].

In most patients, there is a fairly typical clinical picture of hernia incarceration, and the diagnosis raises no doubts. However, in some cases, establishing the diagnosis of an incarcerated hernia is associated with certain difficulties that arise during differential diagnosis with other diseases, irreducible and incarcerated hernias, or in obese patients. The greatest difficulties arise in the diagnosis of parietal incarceration. Furthermore, it is not easy to diagnose incarceration in the presence of large postoperative multichamber hernias, when incarceration of an internal organ occurs in one of the chambers of the hernia sac. A particular difficulty is presented by the timely diagnosis of retrograde hernia incarceration, which is practically impossible to diagnose before surgery [Briskin B.S., et al., 1998].

In connection with the features of the manifestation of incarceration, the number of diagnostic errors remains quite significant and amounts to 11–30% [Buyanov V.M., et al., 1998, Saenko V.F., et al., 2001, Feleshtinskiy Ya.P., 2001]. All this forces surgeons to repeatedly analyze the results of diagnosis and search for ways to improve them.

The severity of the pathological condition in the context of hernia incarceration is explained by the fact that intestinal incarceration is a special form of intestinal obstruction and is presented in most cases as the most dangerous strangulation form. In this case, not only the passage of intestinal contents is violated, but also the blood supply to the intestine due to compression of its mesentery.

One of the features of surgical interventions for incarcerated hernias is the large number of intestinal resections reaching 50%, which, as a rule, is a consequence of acute strangulation intestinal obstruction [Turko A.P., et al., 1998].

The percentage of errors in assessing the viability of the incarcerated intestine reaches 60%, and in 18% of cases, intestinal resection in the postoperative period is complicated by insufficiency of intestinal sutures, and in 16% of cases, necrosis of the intestine submerged in the abdominal cavity is noted [Briskin B.S., et al., 1998, Rath A.M., et al., 2000].

At the disposal of surgeons are clinical diagnostic methods, with the help of which one can hardly confirm the presence of a hernia in a patient, suggest its character, and in most cases conduct a presumptive differential diagnosis [Zhebrovskiy V.V., et al., 2000, Nyhus L.M., et al., 1978].

With the appearance of publications on herniography and studies of the inguinal region in infrared thermal radiation, scientists began attempts to objectify the assessment of structural changes associated with inguinal hernia [Yurykhin I.A. et al., 1983, Dubrov E.Ya., et al., 1998, Zhebrovskiy V.V., et al., 2000].

These methods did not satisfy practicing physicians due to their complexity and invasiveness, so the balance between the necessary informativeness and acceptable invasiveness was achieved in instrumental diagnosis only after the development of high-frequency ultrasonic sensors [Buyanov V.M., et al. 1998, Boyiv L., et al., 1998]. With their appearance, ultrasonic diagnosis of anatomical structures of soft tissues began to develop, which received wide distribution in various branches of medicine, and yet did not acquire proper methodological support in the surgery of incarcerated inguinal hernias and other diseases of this anatomical area. At present, there is no clear description of characteristic changes and echosemiotics in incarcerated hernias of the anterior abdominal wall.

At present, the ultrasonic examination method is actively being introduced into wide surgical practice, allowing comprehensive assessment of both the state of abdominal organs and the hernia sac, as well as the state of regional hemodynamics. However, despite the high informativeness of the method, to date, the diagnostic significance of ultrasonic symptoms of incarceration has not been determined, the algorithm for conducting comprehensive examination with the application of Doppler techniques has not been developed, and ultrasonic criteria for violations of hemodynamics in incarcerated organs remain unstudied.

The topic of possibilities and indications for the use of ultrasonic diagnosis remains open for discussion and requires further research.

THE AIM of this research is to study the possibilities of ultrasonic technologies in the diagnosis of incarceration in patients with external abdominal hernias.

To achieve the stated goal, the following tasks were determined.

RESEARCH TASKS:

1. To study the capabilities of ultrasonic scanning (B-mode) in the diagnosis of incarceration of hernia contents in external abdominal hernias.

2. To investigate the features of regional blood flow in organs of hernia contents using Doppler methods of ultrasonic examination and to establish hemodynamic signs of the incarceration syndrome.

3. To study the possibilities of ultrasonic technologies in determining the viability of incarcerated organs.

4. To determine the possibilities of comprehensive ultrasonic examination in the differential diagnosis of incarcerated hernia from other acute diseases presenting with similar clinical symptoms.

SCIENTIFIC NOVELTY.

The clinical material presented in the work was evaluated from the standpoint of both clinical and special instrumental examination data.

For the first time, signs of incarceration of hernia contents were identified on ultrasonic scanning in B-mode.

For the first time, hemodynamic signs of incarceration of external abdominal hernias were determined using ultrasonic technologies.

For the first time, ultrasonic criteria were determined that allow predicting the degree of impairment of circulation in incarcerated organs.

For the first time, ultrasonic signs of necrosis of hernia contents were established.

For the first time, a diagnostic algorithm for conducting ultrasonic examination with the application of Doppler techniques in patients with incarcerated external abdominal hernias was developed.

PRACTICAL SIGNIFICANCE.

The work resolves relevant scientific and practical tasks associated with the objectification of determining the degree of incarceration.

The diagnostic significance of individual ultrasonic signs of hernia incarceration has been established.

Indications for the use of Dopplerography in patients with incarcerated hernia have been determined.

Ultrasonic signs allowing assessment of the viability of organs incarcerated in external abdominal hernias have been determined.

A rational algorithm for conducting ultrasonic examination in patients with a doubtful clinical picture of incarceration has been developed.

VALIDATION OF THE WORK.

The materials of the dissertation were reported and discussed at the international forum "EMERGENCY MEDICINE IN A MEGACITY" (Moscow, 2004), at the 3rd International Conference "Actual Questions of Herniology" (Moscow, 2004), at a joint meeting of the Department of General Surgery of the Faculty of Postgraduate Education, PIIL of Surgery and Traumatology of the State Educational Institution of Higher Professional Education "Russian State Medical University" (GOOU VPO "RGMU FASZR") with doctors of surgical departments and physicians of the ultrasound diagnostic department of City Clinical Hospital No. 13 of the Department of Health of Moscow.

PUBLICATIONS.

Six scientific papers on the dissertation research topic have been published in the central press and scientific collections.

STRUCTURE AND SCOPE OF THE DISSERTATION.

The dissertation consists of an introduction, a literature review, three chapters of original research, conclusion, conclusions, practical recommendations, and a list of references comprising 207 items, including 104 domestic and 103 foreign authors.