Tumor protruding from abdominal wall incision

Introduction A prominent mass in the abdominal wall incision is the main symptom of the incisional hernia. Incisional hernia refers to the hernia of the abdominal organs or tissues protruding from the abdominal incision. It is caused by the rupture or non-healing of the fascia in the deep part of the surgical incision, which can be regarded as the delayed incision splitting of the delayed incision or the deep healing of the surface healing. Since the skin and subcutaneous fat layer on the surface of the incision have healed, the fascia layer is split, and under the pressure of the abdominal cavity, the viscera or tissue is exfoliated. The hernia sac may be the peritoneum that has healed, or it may be peritoneal rupture. After gradually crawling formed. The etiology and pathogenesis of incisional hernia is the same as that of incisional hernia.

Cause

(1) Causes of the disease

Incisional hernia is caused by rupture or non-healing of the fascia deep in the surgical incision, which can be regarded as delayed incision rupture or deep incision rupture of surface healing. Since the skin and subcutaneous fat layer on the surface of the incision have healed, the fascia layer is split, and under the pressure of the abdominal cavity, the viscera or tissue is exfoliated. The hernia sac may be the peritoneum that has healed, or it may be peritoneal rupture. After gradually crawling formed. The etiology and pathogenesis of incisional hernia is the same as that of incisional hernia.

Systemic factor

(1) Age factors: Incisional hernias are more common in elderly patients and rarely occur in young adults. The ratio of protease to anti-protease in the serum of the elderly is unbalanced, 1 anti-trypsin is lacking, and tissue degeneration is changed. Especially for long-term smokers, oxides and oxygen free radicals in nicotine can not only cause emphysema, but also accelerate and aggravate the degeneration of the fascia and decidua. The content of collagen and hydroxyproline in degenerative tissue is significantly reduced, the activity of oxidase is low, and the proline can not be hydroxylated to hydroxyproline, resulting in weak abdominal muscles, decidua and connective tissue, healing ability and resistance to the abdomen. The ability to internal pressure is low. In addition, the combined effects of factors such as obesity, malnutrition and intra-abdominal pressure in the elderly are also important causes and predisposing factors for the high incidence of incisional hernia. There are many diseases in the elderly that cause increased intra-abdominal pressure, such as chronic cough, intractable constipation, enlarged prostate and huge intra-abdominal tumors. Sudden intra-abdominal pressure such as violent cough, breath holding and defecation can cause the incision to crack or Partial rupture, or the formation of an incisional hernia or aggravation of the incisional hernia. Obesity not only affects the healing of the incision, but sometimes causes an increase in intra-abdominal pressure, which is also one of the factors that cause incisional hernia.

(2) Abdominal wall strength: Patients with weak abdominal wall are relatively prone to incisional hernia. When the incision is split and the second suture is broken, it can be found that the suture is not broken or opened, but the fascia and the aponeurosis are cut by the suture. The reason for the incision splitting and incisional hernia is actually that the incisional fascia layer does not heal or heal delay, and the suture cuts the fascia and diaphragm. The cutting force of the suture on the fascia and the aponeurosis is like the cutting force of the hanging line on the tissue in the suture therapy of the anal fistula. If the healing effect of the cutting edge is not achieved, the cutting is completed, and the tissue is not healed, that is, the slit is formed. Open or incision. The fascia and decidua are too weak to be easily cut. Some incisions with weak fascia can be used to cut the fascia with a slight force when suturing. If the incision is not sutured, the incision will be split or the incisional hernia will be formed under the continuous intra-abdominal pressure. Obese patients are more prone to incisional hernias, and are also associated with underdeveloped muscles and weak fascia.

(3) nutritional status: malnutrition, such as anemia, hypoproteinemia, vitamin C deficiency, etc. can lead to incision edema, hypoxia, deficiencies in procollagen synthesis, so that the incision or fascia does not heal and cause incision rupture or incisional hernia.

(4) Primary intra-abdominal disease: A large number of clinical observations have found that the primary intra-abdominal disease is closely related to the healing of the incision and the occurrence of incisional hernia. Especially the incidence of elderly gastrointestinal malignant tumors is more, because cancer directly affects digestion and absorption, and late bleeding, obstruction, ascites, etc., have a greater impact on systemic and local healing ability, especially ascites spillover can directly hinder the incision Heal. The incidence of this disease is higher after intra-abdominal suppurative disease surgery, such as acute appendicitis and incision rupture after colon surgery, the incidence of incisional hernia is higher, the reason is that there is bacterial reproduction in the abdominal wall incision, resulting in wound infection , affecting healing.

(5) Comorbidities or complications: Diabetes may have a potential incisional hernia because it may result in delayed healing of the incision and the incision is relatively susceptible to infection. Patients with coagulopathy, respiratory failure, liver dysfunction, jaundice, and uremia may have incisional hernias due to weak tissue regeneration and poor healing of the incision. Increased postoperative abdominal pressure caused by chronic obstructive pulmonary disease or pulmonary infection may also be a cause of incisional hernia.

(6) Others: long-term application of adrenocortical hormone, immunosuppressive agents, anticoagulant drugs, etc., can cause the incision to heal due to poor healing of the incision.

2. Local factors

(1) Incision factors: Most of the lumbosacral occurs in the longitudinal incision, while the transverse incision is rare. Singleton statistical cross-incision surgery in 3147 cases, incision fistula occurred in 29 cases (0.92%); longitudinal incision surgery in 6000 cases, 131 cases of incisional hernia (2.2%). This is because: 1 there is an anatomical basis of the abdominal incision, that is, except for the rectus abdominis muscle, the muscles of the abdominal wall and the fibers of the fascia, sheath and other tissues are mostly lateral, and the longitudinal incision of the abdomen is bound to cut the abdominal wall. These tissue fibers. When these tissues are sutured, they are subjected to the lateral traction force of the muscles, and the sutures are liable to slip between the fibers, so that the slits are likely to be cracked. 2 cut off the nutrient vessels and intercostal nerves near the incision, so that the tissue surrounding the incision loses nerve support and blood supply disorder, thereby reducing its strength, delaying the healing, and easily causing incisional hernia when the abdominal pressure is increased.

In addition, some scholars believe that the location of the incision is also closely related to the occurrence of incisional hernia. Welsh (1966) counted 500 incisional hernias: the lower inferior incisional hernia accounted for 76% (including the Merck's incision 21%), the upper abdominal incisional hernia accounted for 15%, and the other 9%. Domestic Peng Jingsheng et al (2001) reported that of the 72 cases of incisional hernia, 86.11% occurred in the anterior abdominal wall longitudinal incision, 25% occurred in the right lower right median incision, and 23.61% occurred in the right superior rectus abdominis incision. This may be related to the incomplete incision of the rectus abdominis muscle and the relatively high intra-abdominal pressure, which is easy to cause suture cutting, so it is easier to form an incisional hernia.

(2) Infection and drainage factors: Incision infection is one of the main causes of incisional hernia. After infection, the incision healed in the second stage, and there were many scar tissues. The abdominal wall may have different degrees of defects, and the abdominal wall strength of the incision site was significantly reduced. According to statistics, the incidence of incisional hernia after incision infection is 5 to 10 times that of the first-stage healing incision. Incisional hernia after appendicitis in the Mc Burnry incision was almost caused by infection. Prevention of wound infection is an important measure to reduce the incidence of incisional hernia.

In addition, placing the drainage tube through the incision can affect the local healing, increase the chance of infection of the incision, and leave a weak point locally after the drainage tube is removed, which is easy to become a factor of incisional hernia formation.

(3) Technical factors: the intraoperative aseptic operation is not strict, the operation method is rough and the tissue damage is too much, the hemostasis caused by incomplete hemostasis, and the poor suture technique can cause the infection of the incision and the incisional hernia. We found that the incision splitting or incisional hernia in the incision of the abdominal wall sutured by the low-grade physician is relatively more. The reason is that the suture technique is an important factor. For example, the layers of the abdominal wall are not tightly aligned, and the ineffective cavity is formed locally. Infection or rupture; the needle spacing is too sparse or too dense, and the suture is too dense to affect the local blood supply of the incision, thereby affecting healing. The suture is too thin, and the tension of the single needle suture is large when the incision tension is the same, and the fascia is easily cut. Moreover, when the suture is too sparse, the omentum is easily protruded from the line, which not only affects the peritoneal healing, but also causes the internal organs such as the small intestine to be ejected in the future; after surgery, the fascial tissue of the margin is prone to collagen decomposition and weakening. When the point and the needle point are too close to the fascia edge (marginal distance), the tensile strength is weakened, the space for the suture cutting fascia is reduced, and the fascia is more easily cut.

(4) Anesthetic factors: Abdominal surgery with epidural anesthesia may result in poor anesthesia. When closing the abdominal wall incision, it is necessary to forcibly suture the suture, and it is easy to cause tearing of the peritoneum and other tissues. the reason.

(5) Abdominal pressure factors: intestinal obstruction, massive ascites, difficulty in urinary defecation, and postoperative pulmonary infection or cough caused by chronic obstructive pulmonary disease can increase intra-abdominal pressure, increase the incision tension of the abdominal wall, and cause the incision inner layer The incision is caused by tearing.

(two) pathogenesis

Pathophysiology

The incisional ankle ring of the abdominal wall is generally large, and there is little chance of incarceration and strangulation. In the early stage, the hernia sac is incomplete. With the prolongation of time, the peritoneum can crawl to form a complete hernia sac. The contents of the sputum are generally intestinal tract and/or omentum, which often forms difficult refractory sputum due to adhesion. There is also a peritoneal healing and the fascia is split, and the peritoneal bulge forms a hernia sac.

There is no possibility of self-healing in the incision, which has a great influence on the general condition. If not treated in time, most patients gradually increase with the disease course. The muscles around the incision, aponeurosis, fascia and other tissues are becoming weaker, the ankle ring is enlarged, and the internal organs of the abdominal cavity are more and more prominent in the abdominal cavity. In the hernia sac, it gradually develops into a huge incisional hernia, so that the true abdominal cavity volume gradually decreases, and the hernia sac becomes a "second abdominal cavity" or "abdominal abdomen" that accommodates part of the abdominal organs. In this case, if the tension is not adequately prepared, it may affect the respiratory circulatory system, especially in elderly patients with cardiopulmonary complications. Increased intra-abdominal pressure is one of the causes of incisional hernia. After the incisional hernia occurs, the intra-abdominal pressure decreases. Once the tension is repaired, the intra-abdominal pressure rises even higher than the original, causing the diaphragm to rise, resulting in limited ventilation. At the same time, the inferior vena cava is compressed, the reflux is blocked, and even the abdominal cavity syndrome and deep vein thrombosis are caused.

2. Pathological classification

There are three main types of common incisional hernias: common incisional hernia, laparoscopic puncture, and incisional hernia formed by temporary closure of the abdomen. The latter mostly occurred in cases of abdominal cavity syndrome, such as patients with incisional rupture after intestine fistula, due to the inability to suture in time, the skin crawling covered the incision of the intestine itself.

3. Degree classification:

According to the size of the ankle ring, the incisional hernia of the abdominal wall can generally be divided into 3 types:

1 giant: diameter > 10cm;

2 medium: diameter 5 ~ 10cm;

3 small: diameter Breakline.

an examination

Related inspection

Abdominal vascular ultrasonography ascites examination laparoscopy

Symptom

The main symptom of swelling of the abdominal wall is its main symptom. Prominent or obvious when standing and exerting, shrinking or disappearing when lying down. When the sputum block is large and there are more organs and tissues protruding, there may be discomfort such as abdominal pain, pulling and falling feeling. Some patients may be accompanied by loss of appetite, nausea, anxiety and so on. Most incisional hernia contents can adhere to the extraperitoneal abdominal wall tissue and become difficult to relapse, sometimes with incomplete intestinal obstruction. Incarceration can occur in a small number of patients with a small ankle ring.

2. Signs

Masses in the incision scar, most of which are equal to the incision, and there are also incisional hernias formed smaller than the incision area. The content of the sputum can reach the subcutaneous, and the subcutaneous fat layer is thin, and the intestinal type or peristaltic wave can be seen. The paralyzed patient is supine, the tumor is reset, and the finger is inserted into the defect of the abdominal wall, and then the patient's breath can clearly lick the edge of the ankle ring to understand the size of the defect and the strength of the edge tissue.

Differential diagnosis

Differential diagnosis of swelling of the abdominal wall:

1, abdomen "gas-like" mass: abdominal "gas-like" mass is a symptom of colon cancer. Colon cancer is more common in middle-aged and elderly people, and the majority of men aged 30-69 are more than women. Early symptoms are not obvious. Symptoms of common symptoms in the middle and late stage include abdominal pain and gastrointestinal irritation, abdominal mass, bowel habits and fecal trait changes, symptoms caused by anemia and chronic toxin absorption, and intestinal perforation.

2, the abdomen can touch a huge soft mass: the giant bladder - small colon - intestinal peristalsis syndrome patients are still normal weight at birth, later abdominal distension, no meconium, the abdomen can touch a huge soft mass, often susceptible to urinary Is an infection.

3, lower abdomen mass: lower abdomen mass refers to the lower abdomen has a lump, touch has a hard feeling, may be benign or malignant tumor, mostly for gynecological disease symptoms or intestinal, peritoneal diseases.

4, the right lower abdomen can touch the soft sausage-like mass: cecal granuloma with cecal amoebic granuloma and schistosomiasis granuloma. The cecal amoebic granuloma is a complication of chronic colitis caused by Entamaeba Histolytica. The ileocecal schistosomiasis granuloma is a late stage disease of intestinal schistosomiasis. The schistosomiasis egg deposition site is mainly the terminal ileum except the colon. The clinical symptoms are localized abdominal pain and intermittent diarrhea. The right lower abdomen can be touched with soft sausage-like mass. In addition, chronic low intestinal obstruction is often accompanied by acute intestinal obstruction.

5, the midline of the abdomen at the midline: the mass at the midline of the abdomen is a clinical feature of the white line. The bilateral rectus abdominis sheaths are interwoven in the midline of the abdomen to form a belly white line. The abdominal visceral vaginal white line is called the hernia of white line.

6, the abdominal wall outside the mass, there is fixed tenderness: the outer wall of the abdominal wall, fixed tenderness is the main clinical signs of the semilunar hernia. The anterior and posterior layers of the rectus abdominis sheath heal at the lateral edge of the rectus abdominis, forming a semilunar, convex-laterally curved, sacral structure, ie the meniscus (Fig. 1, 2). The peritoneal or intra-abdominal organs protrude through the meniscus of the lateral abdominis, called the spigelian hernia, also known as the lateral abdomen. Spige (1617) first described the anatomy of the meniscus, so it is also known as spiglian.

diagnosis:

1. History: Incisional hernia patients have a history of recent abdominal surgery, often with wound infection, splitting, etc.; or the patient's general condition is poor; or have a history of preoperative smoking and chronic disease.

2. Clinical features: There is a reversible mass in the incision, and the physical examination can detect the ankle ring boundary formed by the abdominal muscle splitting.

3. Auxiliary inspection: visible content image.

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