Ventral Hernia.
—Ventral hernia is of two types—the spontaneous, usually epigastric, which is an omental escape in the middle line above the umbilicus, occurring most often in fat women, in whom it is likely to be mistaken for a hernia of ordinary umbilical type. By fixation of its contained intestine and omentum there is more or less dragging upon the upper abdominal viscera, with consequent disturbance of function.
Postoperative Hernia.
—Postoperative hernia often also spoken of as ventral, occurs through the cicatrix of the wound which has permitted it, whether this be in the middle line or elsewhere. It is an unfortunately frequent sequel of laparotomy wounds which have required drainage, but occasionally occurs in perfectly clean wounds which have closed satisfactorily in the first place, but which have subsequently parted because of unsatisfactory methods of bringing together their deeper portions. (See [p. 778].) Consequently it should be sufficient here to remind the reader that the more accurate the method of approximating the margins, layer by layer, and effecting a complete and perfect union between them individually the less the tendency to this unpleasant sequel.
Postoperative hernia may be so small as to be kept under subjection with some form of abdominal support, or it may call for operations for radical cure, as do other cases. They are subject to the same dangers of strangulation of their contents.
Diaphragmatic Hernia.
—Diaphragmatic hernia may be congenital, as when occurring through a defect in this partition, or acquired, as when under stress or strain some of the abdominal contents are forced into the thorax, either through natural openings or through a rent or tear. Such escape may include but a small portion of bowel; in congenital cases one-half the abdominal contents have been found within the thorax. The left side seems more often involved than the right. Serious wounds of the diaphragm may be followed by this condition. Under these circumstances the thoracic viscera are more or less displaced, and the heart may be pushed considerably out of place. In cases with a history of violent accident the surgeon may more readily suspect and recognize the condition than in congenital cases, where anatomical relations have long been disturbed, but apparently more or less adjusted or compensated.
Pelvic Hernia.
—In the lower part of the pelvis, under rare circumstances, hernial protrusions occur either through the sacrosciatic foramina, in which case they are known as gluteal or ischiatic ([Fig. 608]), or through the obturator foramen, when they are known as obturator hernias, the latter occurring more often in stout women. Unless these constitute some form of recognizable tumor, or produce acute obstruction by strangulation, they will pass quite unrecognized. A perineal form of hernia is also known, which occurs in Douglas’ cul-de-sac, behind the bladder or uterus, the levator ani muscle being more or less disturbed, and the protrusion occurring somewhere between the labium and the anus. In such hernial sacs the ovary has been found, as well as intestinal loops, and the so-called ovarian hernia includes some anatomical anomaly of this kind.
Fig. 608