Ministry of health of Ukraine

anorectal malformations
Congenital malformations vidhidnyka and rectum are in the ratio of 1:5000 births. It should be noted that the combined defects anorectal area, cardiovascular, urinary, digestive system, musculoskeletal system, central nervous system occur in 27% of cases.
These defects are more common in girls (relative to boys 2:1).
Anorectal malformations are formed on the 4th week of intrauterine embryo development when there is separation of the cloaca into 2 parts: the front, which formed the bladder and ureters, and back, which is formed by the upper part of the rectum. Anal department is formed by wrapping ectodermal layer from the surface inward. Defect formation and division inside the cloaca and the perineum underdevelopment caused by disturbance stages of embryogenesis, which ends up to the 8th week.

Clinical manifestations, diagnosis and treatment of anorectal malformations largely depend on the species. If atresia vidhidnyka on the first day after birth, the newborn state is satisfactory. The first symptoms appear after 10-12 hours after birth: the child is concerned, poor sleep, natuzhuyetsya, not leaving meconium. If no qualified supervision, then after the first day there bloating, vomiting gastric contents first, and then mixed with bile and intestinal contents.

Baby refuses the breast. If late to help, the phenomenon of intestinal obstruction in the dynamics of progress, vomiting becomes uncontrollable, growing phenomenon exsicosis and toxicity. In later stages of the disease is complicated by aspiration pneumonia, intestinal perforation and peritonitis, the child quickly dies.
For early diagnosis of defects conduct routine inspection crotch baby immediately after birth, especially if there is no discharge of meconium in the first 6.10 h.
Atresia vidhidnyka without difficulty find during the initial examination: vidhidnyk absent, in its place showing umbilicus, which ends blindly.

For a correct determination of the height atresia using ultrasound or invertohramu by Kakovychem - Vanhenstynom (Fig. 4).

Previously a plot vidhidnyka impose opaque objects (coin, clip). Do survey radiographs in the lateral projection of the baby head down. Level atresia is determined by the distance between the blind end of the colon (as evidenced by the gas bubble) and a metal tag in the crotch. This method is valid only after the 1st day because the gases in the area atrezovaniy colon appear only after 15 hours after birth.
The second auxiliary method of determining atresia - Puncture (for Pelerinym-Syitkovskym), which was used because of the possibility of infection fabric crotch. Thick needle syringe pierce the skin of the perineum at the point of natural vidhidnyka and slowly pulling the plunger, the needle is introduced to the intestine, while in the pen will not drop meconium. In the distance, which entered the needle, make
conclusion about the height atresia. In this same needle injected contrast material (10 - 15% solution verohrafinu) transmitting marking locations vidhidnyka and perform radiography in two projections (antero-posterior and lateral) in the upright position. This study helps to clarify the distance between the skin and the perineum blind end of the colon. The presence, location and full external muscle - the latches vidhidnyka determined using electromyography. In recent years, increasingly used ultrasonic diagnostic methods.
Fistulas in the reproductive system found only in girls. In most cases, it opens in prysipok vagina, at least - in the vagina and very rare - in the uterus. Clinical atresia vidhidnyka the presence of voles in reproductive system largely depends on the location and diameter of the hole fistula. A characteristic feature is its selection of meconium, and feces and gases through the gender gap in the first days of life, vidhidnyk while absent. If the fistula is short and broad, and signs of underdevelopment rectum minor, the child's point regular self-emptying in the first months of life. During the introduction of complementary foods and switch to bottle-feeding stools are rare, there is constipation, which leads to the development of megacolon syndrome.
When atresia with fistula in the vagina fistulas hole in this case is narrow, open on the medial surface of the posterior vaginal wall slightly above the hymen, fistula diameter less than 0.5 cm Douglas prysinkova (rektovestybulyarna) fistula is localized in the region of the navicular fossa and is different diameter. There is a pattern: when rektovestybulyarnyh fistulas rectal atresia mostly low sex organs developed normally. If you have a rectal-vaginal (rektovahinalna) fistula, atresia usually high and often accompanied by hypoplasia of the external genitalia, ziyannyam gender gap. The higher the location of the fistula, the clearer clinical signs.
To clarify the height of the final section of the rectum and the study of anatomical and functional state located above the colon conduct x-ray with contrast barium sulphate through the fistula.

Enough is informative introduction metallic urethral catheter through the fistula towards predictable vidhidnyka, second hand finger through the skin of the perineum grope end of the catheter and roughly determine the level of atresia in thickness of tissue between the end of the catheter and finger.

Vidhidnyka atresia and rectal fistula in the urinary system (bladder, urethra) is observed only in boys.
Diagnosis of urinary fistulas in the system is much more complicated than the diagnosis of fistulas in the reproductive system. Clinical symptoms may be absent or remain undetected because fistulas move often blocked with mucus or meconium. Therefore, in some children by the end of the 2nd day the picture of low intestinal obstruction, the main clinical manifestations of which are discharge of meconium and gases through the external opening of the urethra. When combined rectal bladder urine is painted in green throughout urination, the last portion of urine stained more intensely and are accompanied by a discharge of gases accumulated in the bladder.
In the case when the rectum communicates with the urethra, discharge gas and meconium excretion are scarce. Undissolved meconium released at the beginning of urination, the last portion of urine clear. Strip away through the urethra and no act of urination as sphincter apparatus does not deter them.
Think about the presence of urinary fistulas must for every high atresia, whereas narrow "asymptomatic" fistula is more than 40%.
The diagnosis is confirmed during catheterization urethra. If spivustya rectal wide urethra and fistula ukuporit meconium, introduced along the back wall of the urethra metal catheter pushes content fistulas move into the lumen of the rectum and "falls" there. Thus fistula diagnosed in the membrane of the urethra.
Diagnosis of urinary fistulas system facilitates uretrotsystohrafiyi. Under radiological control in the initial section of the urethra to a depth of 1.5 cm through the catheter impose 10-15% solution verohrafinu. On radiographs in lateral projection shows that the contrast agent is in the rectum.
Voles on the perineum occur in boys more often than girls. In girls, they are wide and short. In boys, the length and width of the fistula can greatly vary - external opening can be opened directly from the vidhidnyka, the root of the scrotum and even in the area of ​​the penis. In general fistula function vidhidnyka in the first days of life compensated sufficiently. Shortness act of defecation occurs later. Constipation occurs after 1 year. If fistulas course narrow stool hampered from the first days of life.
Diagnostic perineal fistula conducted during the external inspection. Regardless of the length of the course fistulas atresia of the rectum is always low.
Alberto Pena (2007) found that expected for anorectal anomalies in infants in utero characterized calcificates in the kidneys of the fetus, which is called "calcium nephritis," which is accompanied by thickening of meconium and colorectal formation of defects such as high position vagina fake neutrymannya chair cesspool and other defects. Nowadays when establishing such vices performed prenatal surgery. Yes, particularly when performed kloatsi separation uterus, bowel and bladder. In the diagnosis of defects using rear laparoscopy under traditional operations Pena. Laparoscopy allows the diagnosis and eliminate fistula without complications.
Ectopia vidhidnyka called atypical location (close to the genitals) full vidhidnyka. There perineal and vestibular ectopic. Real ectopia must be differentiated from a wide perineal fistula, which requires further surgical correction. The difference lies in the visual detection of muscle contractions external - vidhidnyka latches or using electromyography. When he reduced ectopic near vidhidnyka, functional abnormalities are not detected.
Congenital narrowing vidhidnyka and rectum are defined in section comb lines vidhidnykovoho ring. Length and shape narrowing can be varied - in the form of a thin membrane or dense fibrous ring. Clinical occur after administration bait when frequent constipation. In acute degree of stenosis constipation arises from the first days of life, emptying in a narrow band. Child restless, belly swollen, appetite decreased, the child is not gaining weight, subsequently formed secondary megacolon.
Diagnosis narrowing simple, is digital rectal examination, where in place of constriction determine elastic ring. Pronounced acute stenosis can not even hold a finger tip. To confirm the diagnosis spend colonoscopy radiocontrast study and rectum.
Treatment. All kinds atresia vidhidnyka and rectum requiring surgical correction. Emergency surgical care in the first 1 - 2 days of life carried out in the case of all kinds of complete atresia, fistulas as well as in the urinary system, rectal-vaginal and rectal-perineal fistulas with a narrow passage. When fistulas in the reproductive system and the perineum without evidence of low intestinal obstruction surgery is carried out in terms from 1 month to 2 years of life. During the operation moved vidhidnyk the usual place (Stone and Dyffenbahom). It is important not to damage the outer muscle - vidhidnyka contactor. To improve the adaptation of the neuro-reflex apparatus anorectal department in recent years, surgical correction of congenital defects is carried out in an earlier date. When rectal-vesical and rectal fistulas sechivnykovyh-separation conduct anastomosis immediately after diagnosis.
In recent years preferred cherevnopromezhynniy proktoplastytsi, even if a fistula in the membranous part of the urethra. In prostatic fistula of urethra only rational method of surgery - abdominal-perineal intrarektalna proktoplastyka (for Romualdi, Rehbein in modification Lonyushkina OI).
At low forms atresia vidhidnyka and rectum perform perineal momentary proktoplastyku by Dyffenbahom in modifying AI Lonyushkina.
In secondary forms of atresia (height more than 1.5 - 2 cm from the perineal skin) in recent years widely implemented sakropromezhynnu proktoplastyku with rear access for sagittal A. Peng, which enables mobilized rectum to her through pubokoktsyhealnu communications and external muscle - contactor vidhidnyka with electromyography muscle structures.
At high forms atresia requires mobilization of significant parts of the intestine. This is only possible during surgery abdominoperineal sakropromezhynnoyi proktoplastyky. Given the scope and trauma of the operation, surgeons divide it into three phases. In the first days of life in the left groin impose unnatural vidhidnyk by Mikulychem or unnatural vidhidnyk on different parts of the colon or end kolostomu on distal sigmoid colon closer to atresia - the first stage.
After 3 months - 1 year performing radical surgery - the relegation of the rectum from the posterior sagittal access by A. Pena - second stage. Third stage - closing colostomy.
Yu.V.Basylashvili, V.B.Davydenko, Yu.V.Paschenko and others. (2007) suggest a method original Sacre abdominal perineal proktoplastyky, which is what demukozatsiyu peripheral section bowel spend with posterior sagittal access downlink direction, eliminate fistula, and incrementally - above transitional folds of peritoneum without vskryttya intestinal lumen in the abdominal cavity. Nyzzvedennya mobilized colon is made through a tunnel in the tissues of the perineum, which is formed by a tube-conductor conducted visually through the center of the sphincter apparatus without dissection after suturing sacral access.
To prevent cicatricial stenosis used bouginage newly vidhidnykovoho channel on the 10-15th day after the operation extender Gegara, increasing the diameter from number 8 to number 12. The procedure is carried out to the full bouginage wound epithelization in the future continue to preventive bouginage 1 every day, then every other day. At home parents continue bouginage under medical supervision weekly for 5 - 6 months.
Weather data blemish treatment largely depends on their severity, the combination of anomalies and rationally chosen tactics of surgical correction and adequate rehabilitation measures in the postoperative period.

Materials for self-

Situational tasks:
Task 1. Patient K., aged 3 hours from the moment of birth, born to a mother 19 years old, weighing 2100h, body length 45cm, aged 32 weeks. At birth: early discharge of amniotic fluid, anhydrous period of 6 h., Entanglement umbilical cord, Apgar score 5 points. At the time of the inspection the skin moderately cyanotic, reflexes weakened, reduced physical activity, breathing self, saturation within 90%, in the area fontanel Cephalhematoma to 4cm in diameter, 2.0 ml of urine, meconium discharge from the genital slit, baldly, anus No, vestibular fistula were found.
1. Formulate a preliminary diagnosis.
2. Determine the degree of prematurity
3. Make a plan of survey.
4. Methods of invertohramy by Vanhistinom
5. Therapeutic tactics.

Task 2. On the 4th day postoperative period in a child who was operated on anorectal malformation - rektopromezhynnoyi fistula in the first days after birth, using minimal posterior sagittal anorectoplasty marked redness and swelling of the wound, sero-purulent discharge from under stitches fever to 37 , 80S, reducing the discharge of meconium, moderate bloating, discharge by nasogastric tube light yellow-green content in small amounts, up to 7 ml. per day. A child born in the period 34-35 weeks, body weight 3000h, body length 51 cm, with no signs of hypoxia.

1. What kind of complications in the postoperative period should consider?
2. What is the basis of classification of anorectal malformations?
3. What changes in intrauterine fetal ultrasound indicate the presence of anorectal malformations rozkytku?
4. What are the methods of examination should be used?
5. What measures should be conducted?
Problem 3. The child at 3 days after birth, when properly formed anus self emptying missing. Setting cleansing enemas ineffective. Abdomen swollen, visible peristalsis, by nasogastric tube is allocated to 25 ml. content, dark green. On the first day of life poorly meconium discharge from the rectum, to 2-3 ml. The general condition of severe shortness of breath and 65 for 1 min., Tachycardia - 160 sec. for 1 min.
1. What kind of birth defect should be suspected in a patient?
2. What is necessary to carry out a survey?
3. What diseases should be to the differential diagnosis?
4. What surgery when necessary to confirm the diagnosis?
5. What complications can occur in the postoperative period

Problem 4. In the child in '11 marked periodic constipation from birth, bloating, loss of appetite, and sometimes nausea, muscle hypotrophy. In iryhohrami narrowing seen in the area of ​​the rectum with suprastenotychnym extension colon above this place. When anomanometriyi anorectal reflex negative.

1. Your preliminary diagnosis?
2. What is necessary to test to confirm the diagnosis?
3. What diseases are eastern clinical picture?
4. Spend the differential diagnosis of chronic constipation?
5. Develop a plan for treatment of the patient?

Problem 5. Boy 5 years is from constipation from birth, from remote rural areas. In the field of children's surgeon still did not get. Significantly enlarged abdomen, behind in physical development. Often constipation vary diarrhea.

1. What preliminary diagnosis can be suspected?
2. Which test should be conducted?
3. What is the solution used to siphon enema?
4. As the divided bowel disease on the clinical course?
5. What treatment should be patient?

Problem 6. The child is 3 years since the birth of observed delay emptying every 3-4 days does have a cleansing enema. Boy behind their peers in physical development. It is noted pale skin, bloating.

1. What's disease in a child should suggest?
2. Which test should be conducted?
3. What is the basis of classification of chronic constipation, who invited her?
4. What is the preparation of the large intestine to Proctologic test?
5. Your treatment strategy in this case?

Problem 7. Girl on the third day after birth delivered to the clinic about the lack anus. Urination is not broken, with the gender gap periodically released small amounts of meconium. On examination, the child's crotch positive "symptom shock" when irritated anal holes marked reduction in the external sphincter.

1. Ask a preliminary diagnosis?
2. What method of diagnosis, you can set the option anatomical malformations?
3. Determine the timing of surgical treatment in the absence of the anus?
4. What classification of anorectal malformations.
5. Who is the most efficient method of surgical intervention in this wadi development?

Task 8. By the admissions department delivered a baby 6 months delayed emptying and gases. Noted bloating, vomiting twofold. Coming second, the difficulty of leaving gas and defecation occur from birth. Has conservative therapy. Now ordinary cleansing enema and putting flue tubes give no relief. Severe intoxication and changes in metabolism, decreased total protein and dysprotenemiya.

1. Your preliminary diagnosis?
2. Which clinical stage should include this disease?
3. What complication arose in this patient?
4. What diseases should make the differential diagnosis?
5. At what age is best to radical surgery in this disease?

Problem 9. Baby 5 months complaints of constipation from birth stool only after repeated enemas, intermittent bloating, weight 6kg., Frequent agitation, loss of appetite, periodically - vomiting - 1-2 times a week.

1. What is the preliminary diagnosis can be spotted patient?
2. With which diseases similar clinical picture?
3. Which test should be conducted?
4. Which anatomical shape isolated in Hirschsprung's disease?
5. What kind of surgery should be performed?

Problem 10. The boy 9 years old about 2 years ago appeared constipation lasting 2-3 days Stool independent, calformed. Abdomen not tender to palpation, somewhat enlarged, symmetrical.

1. What is the preliminary diagnosis can be spotted patient?
2. With which diseases similar clinical picture?
3. What do you know kind of constipation that occur in children?
4. What examination is necessary to make the diagnosis?
5. What treatment should be patient?

Tests
1. Identify operational tactics in norodzhennoyi child with acute form of Hirschsprung disease after failure of conservative therapy:

A. Colostomy
B. Operation Swenson
C. Operation Duhamel
D. Operation Soave
E. Enterostoma

2. In the newborn child is absent anus, urine sometimes leaves clean, sometimes with a touch of meconium. What kind of bug?

A. atresia anus
V. atresia anus with fistula in sechovypusknyy channel
S. atresia anus with fistula in the vagina
D. Atresia anus and rectum
E. Atresia anus with fistula in the bladder

3. In iryhorami a child aged 3 years with Hirschsprung's disease shows a narrowing in the area of ​​direct and sigmoid colon. Which anatomical shape Hirschsprung disease observed in this patient?

A. Rectal
V. Rektosyhmoidalna
C. Subtotal
D. Total
E. Anal

4. The mother that stradzhdaye chronic pancreatitis, a girl who has 5 days after birth marked bloating. Bowel loops konturuyut on the anterior abdominal wall. After the enema went meconium in small quantities and baby zryhnula. In iryhohrami narrowing in rectal area, and above - the diameter of the colon significantly increased. What nayimovirnyy diagnosis?

A. Acute Hirschsprung disease
B. Dynamic ileus
C. Ladd Syndrome
D. Mechanical obstruction
E. Intussusception

5. In pediatric surgery clinic from the hospital moved novonarordzhenyy lack of anal 3 hours after birth. What should be the diagnostic tactics Children surgeon?

A. Plain radiographs of the abdomen
B. Emergency X-ray examination by Vanhestinom immediately after admission
C. X-ray examination by Vanhestinom 8 hours from receipt
D. Ultrasonography of the abdomen
E. Investigation of urine for the presence of meconium

6. In the newborn shortly after birth seen vomiting stagnant, whether intestinal contents. Meconium is missing. Stool as thin mucous streakings. What diagnosis may be suspected?

A. Low intestinal obstruction
V. Pilorospazm
S. Hirschsprung's Disease
D. Sepsis
E. Mukovistsedoz

7. In child 1.5 years of age constipation, bloating, malnutrition, choking. In iryhohrami narrowing seen in the area of ​​the rectum with suprastenotychnym extension colon above this place. When anomanometriyi anorectal reflex negative. Your diagnosis:

A. diaphragm hernia
V. Dolihosihma
S. Mehakomen
D. Hirschsprung's Disease
E. Atresia of the colon

8. On examination, the baby in the delivery room found that a child weighing 2600h abdomen - common throughout, in probing the stomach received 10ml transparent content. Meconium not depart. Catheter introduction through the anus, went to 2cm. On plain radiographs - pneumatization intestine throughout, gas and liquid level. For what defect you are dealing with?

A. Atresia of rectum
V. Atresia 12 duodenal ulcer
S. Atresia ileum
D. Atresia anus and rectum
E. Esophageal Atresia

9. All wadi development, manifested congenital intestinal obstruction, grouped into four main groups, depending on the violation utero. To one of these defects are caused by disturbance of embryogenesis intestinal wall. Name of bug, which belongs to this group?

A. Ladd Syndrome
V. Mekoniyeva obstruction
S. Ring shaped pancreas
D. The acute form of Hirschsprung disease
E. form membranous atresia

10. Determine the optimal age of the patient for surgical treatment of acute forms of Hirschsprung disease:

A. 3-5 years
V. 1year
C. After 3 years
D. After 7 years
E. After 10 years

List of theoretical issues:

1. The etiology of malformations of the colon and rectum.
2. Characteristics of transit and yevakuatornoyi functions of the colon.
3. Classification of chronic constipation by ML Bush and OI Lonyushkinym. What underlie it?
4. Reasons for different types of constipation. How to share the clinical course constipation?
5. Spend the differential diagnosis of constipation caused by defects colon (constipation organic origin).
6. What information do you get from such ancillary diagnostic methods as rectal digital examination, iryhohrafiya, sigmoidoscopy, kolonofibroskopiya, electromyography?
7. What is fecal intoxication and how to fight it? Biochemical changes in the body of patients with chronic constipation clinic.
8. Conservative treatment of nutritional constipation in children depending on the reasons that led them.
9. Pathogenesis of congenital colon.
10. Pathogenesis of anorectal malformations.
11. The main clinical manifestations of disease in various forms of Hirschsprung disease.
12. The main external clinical signs of anorectal malformations.
13. Methods of diagnosis of Hirschsprung disease.
14. What is a biopsy of the colon and in some cases it is conducted?
15. What types of enemas you know methods of siphon enema.
16. Principles of treatment of Hirschsprung disease.
17. Methods of diagnosis of anorectal malformations.
18. Preparation of the colon to Proctologic inspection and for operations.
19. Of surgical methods of treating Hirschsprung disease.
20. Motivation of landmark transactions in children with anorectal malformations.
21. Methods of anorectoplasty by A. Peng
22. Rehabilitation of children after surgery for colon.

Practical tasks.

1. Demonstrate abdominal examination and review of cutaneous mucosal folds and rectum using rectal mirror.
2. Interpret auxiliary methods (endoscopic, radiological, biohomichni, histochemical)
3. Technique of iryhohramy and invertohramy.
Malformations of the anterior abdominal wall.

1. Background.

Hernia of the umbilical cord - severe malformation, mortality from which to present remains very high (from 9.1% to 65%). As a proportion of acute childhood diseases incarcerated inguinal hernia occupies the 3rd place after acute appendicitis. Chastist and a large percentage of complications that accompanied the above defects require timely diagnosis and the correct treatment strategy.

2. The specific objectives.

1. Master the list of diseases that are associated with impaired formation of the anterior abdominal wall and peritoneal obliteration of the process, the process of lowering the testicles.
2.Rozpiznaty major clinical manifestations of defects of abdominal wall and inguinal region.
3. Differentiate malformations of abdominal wall and inguinal areas, depending on the clinical manifestations.
4. Interpret helper methods (ultrasound, plain film, fistulography).
5. Demonstrate palpation of the scrotum and identify symptom "cough shock" method of conservative treatment of umbilical hernia in children during the first months of life.
6. Identify features of malformations of abdominal wall.
7. Analyze Cause - effect relationships of complications related to violation of obliteration of vaginal appendix and lowering the testicles.
8. Submit algorithm of the physician in violation appendix and vaginal obliteration of strangulation.
9. Submit tactics of patients with malformations of abdominal wall and inguinal region.
10. Identify indications for conservative or surgical treatment of patients with impaired obliteration of vaginal appendix.
11. To interpret the general principles of treatment of children with impaired testicular descent.
12. Master the principles of rehabilitation after surgery, be able to assess the prognosis of life possible violations associated with this pathology.

4.2. Theoretical questions to studies.

1. Peculiarities of the abdominal wall.
2. Classification embryonic hernia umbilical cord. Clinic. Diagnostics. Indications for surgical treatment. Conservative treatment. Complications.
3. Gastroschisis. Clinical manifestations, diagnosis. Clinical management and treatment.
4. Umbilical hernia. Features and indications for conservative treatment. Operative intervention methods plastics.
5. Etiopathogenesis, classification, clinical presentation, diagnosis and treatment of fistulas navel.
6. Hernia of abdominal white line. Clinic. Diagnosis and treatment.
7. Etiopathogenesis, classification, clinical presentation, differential diagnosis of inguinal hernias. Complications of inguinal hernias.
8. Choice of surgical treatment in inguinal-scrotal hernia.
9. Differential diagnosis of strangulated inguinal hernia in children. Conservative and surgical treatment.
10. Classification and clinical picture of cryptorchidism and testicular ectopia. Tactics doctor. Methods of treatment.

4.3 Practical work (tasks) to be performed in class.

1. Identify the leading symptoms umbilical, strangulated inguinal hernia.
2. Determine the type and cause damage to the testicles.
3. Assess the degree of violations that result in zaschepleni inguinal hernia.
4. Master technique palpation of inguinal region and scrotum.
5. Identify and demonstrate symptom hernial protrusion or symptom "cough impulse."
6. Conduct differential diagnostics of diseases related to violation of obliteration of vaginal process and the process of lowering the testicles.
7. Master the tactics of treatment umbilical hernia and fistula navel.
8. Master the tactics of treatment available and strangulated inguinal hernias.
9. To be able to define the indications for surgical intervention, the timing and amount of preoperative preparation with inguinal hernia and cryptorchidism.
10. Demonstrate knowledge of the postoperative management of patients with anterior abdominal wall hernias and cryptorchidism.
Contents subject.
Malformations anterior abdominal wall associated with disruption of embryogenesis its layers and elements at different stages of fetal development. Among them - aplasia muscles of the anterior abdominal wall hernia embryonic, umbilical, inguinal, white line of the abdomen and other sites. Others are very seldom.
Classification hernias:
a) Location:
• external - cord (embryonic), axillary, umbilical, thigh, abdomen white line etc.
• internal - diaphragm, pinching of the abdomen in natural openings;
b) etiology:
• birth;
• acquired - hernia underdeveloped anterior abdominal wall trauma (real, traumatic, violent - inIf dramatic tension of abdominal wall hernia scars, artificial - just inguinal);
c) the state of the internal organs in the hernia sac: free (internal organs freely go in hernial mi ¬ shock and independently reduce the abdominal cavity);
• skilled (exercised in the case of small efforts);
• awkwardly (not exercised even if you try to let into ¬ tion, pain and clinical signs of intestinal speaktheir ¬ hidnosti not). This condition is caused by the presence of adhesions between the hernia sac and internal organs as a result of previous incarcerated;
• strangulated (hernial protrusion does not reduce a pain during reduction);
• slide - a special kind of hernia, when one of the walls of the game ¬ zhovoho bag is wall of the abdomen, which is not covered by peritoneum (in the case of inguinal hernia on the right - cecum and bladder, and left - bladder).
Gastroschisis
Gastroschisis (from the Greek. - The difference abdomen) - a eventeratsiya that occurs in utero period. The umbilical cord is attached properly, so pathology related to defects ekstraumbilikalnoyi front che ¬ zealous wall. Found it at a frequency of 1:6000 novonarod ¬ bridegroom, 40% of which - premature. Defect of the anterior abdominal wall looks small gap sizes is localized to the right of the umbilical cord. Described rare cases of left-side location of the defect. Its occurrence is associated with blood circulation in the distal part of the right omfalomezenterialnoyi artery development of necrosis anterior abdominal wall to the right from the base of the umbilical cord and the formation of abdominal wall defects. Through defect eventerovanyy stomach falls short section of the midgut three times larger diameter than defect. Sometimes falls bladder and ovaries in girls. Intestinal loops soldered together, matt coated fibrinous coating, thick, swollen, enlarged in violation of the outflow of venous blood and lymph. This state eventerovanoho intestine associated with bowel strangulation in a narrow abdominal wall defects or twisting of the "midgut" and recommended expanding defect immediately after birth (NL Zakharov, 1986). Fibrinous layers on intestinal loops associated with changes in the composition of amniotic fluid after the commencement of the kidneys in the fetus. But this is interpreted as a defensive reaction from exposure to urea, a chemical that causes inflammation of the intestines (Ashkraft, Holder, 1997). This period is characterized hipoperystaltyka malabsorption and intestines, their lumen filled with thick and sticky meconium.
Gastroschisis combined with intestinal abnormalities - atresia, stenosis, Meckel diverticulum in 10-14% (S.A.Karavayeva and others., 1998), sometimes with visual nervous system, kidneys, heart, diaphragm (up to 1-6% of cases).
Diagnostics of defects must be carried out in the antenatal period, in this case carried cesarean. Gastroschisis be differentiated from umbilical cord hernia and rupture of membranes hernial sac, in the case of Gastroschisis hernial sac absent.
All children performed ultrasound and neyrosonohrafiya to identify other congenital anomalies and comorbidity.
Treatment. In the maternity hospital after the birth of Gastroschisis necessary to anesthesia baby central analgesics, warming, ensure adequate temperature. A must is the decompression of the digestive tract regular probe. When a child to the neonatal intensive care unit for 1-2 days preparing for surgery. A correction of hypovolemic shock by infuzivnoyi therapy using fresh frozen plasma glucose-saline solution in the ratio 1:1, is injected as vikasol, kontrikal. To stabilize Geodynamics used dopamine infusion, to prevent infectious complications prescribe antibiotic therapy.
Surgical treatment depends on the severity of the defects. In newborns with viscero-abdominal disproportion I level defect is closed after the withdrawal of the shock. If underdeveloped abdominal cavity does not contain swollen and thickened bowel loops (viscero-abdominal disproportion II-III degree), then spend 2 of staged surgical correction. The first stage of surgical correction is performed using synthetic polymers rozsmoktuvalnyh or vidseparovannoyi skin formed ventral hernia. At the 2nd stage conduct relaparotomy, divisive seam between the loops of intestines and form the anterior abdominal wall. Using modern mesh allograft - polypropylene mesh biotransplantat Tutoplast-pericardium, which is implanted firmly to the body tissues and is gradually replaced by fibroblasts recipient that stabilizes the abdominal wall and save her strength for a long time.

Cons urinary duct. As you know, the bladder combined with alantoyisom urinary ducts - urahusom. By birth urahus obliteruyetsya - formed median ligament of the bladder, coming from its top to the navel. Depending on the type of violation reduction of urinary duct distinguished flaws: 1) complete fistula urinary duct, 2) incomplete fistula urinary duct, 3) bladder diverticulum, 4) cyst urahusa, 5) persistent umbilical-mesenteric artery.

If urahus neobliterovanyy entire length of the umbilical cord after dropout hole fistula secreted urine drops, and during natuzhuvannya - jet. If fistulas large diameter hand pressing on the anterior abdominal wall can remove all urine from the bladder. Such complete fistula are rare. If small diameter fistula, urine is not, but by pressing the plug on the anterior abdominal wall appears urine. Complete fistula urahusa complicated urinary tract infection.
Diagnosis of complete fistula urinary duct is not difficult, if it stands urine, in other cases should be investigated for the presence of urea excretion or enter into se ¬ chovyy bubble solution of methylene blue. Isolation of dye fistula indicates the presence of a complete cleft of the urinary duct. In some cases helps sensing fistula, if not enter a thin tube into the bladder, it indicates fistula urinary duct.
Most neobliterovanoyu is only the part that is adjacent to the navel (outside), then fistula incomplete. In this case, it is differentiated from the vitelline duct fistulas - hold sensing fistula, and in some cases - fistulography. These studies show that duct goes down to the bladder in the back of the anterior abdominal wall. Urine clear, stands a few drops. If there is infection fistula, urine becomes purulent character. Near its external opening is often formed granuloma. Macerated skin.
Treatment of fistulas only operative (after conservative treatment of inflammation of the urinary duct and the skin around its outer hole).
Neobliterovana Yolk duct may be the source of some birth defects. Depending on the degree of obliteration distinguished: 1) complete fistula navel, 2) incomplete fistula navel, 3) Meckel diverticulum, 4) enterokistomu, 5) fibrous cord. Variations of these anomalies is shown in Fig. 2.
If Yolk duct neobliterovana the entire length, then the navel is fistula, which leaves in the mucous membrane of bright red. Depending on the size of the fistula it stands colorless liquid intestinal contents. With a wide combination of these fistulas constantly secreted intestinal contents, which irritates the skin and causes its purulent inflammation in severe cases, there are signs exsicosis. Also, sometimes when natuzhuvannya and weeping through the belly button falls outside Inverted part of intestine (evahinatsiya).
Most neobliterovanoyu is only part of the yolk ¬ ing duct. If intraperitoneally part obliteruyetsya and peripheral saved, formed incomplete umbilical fistu ¬ la, which opened in navel and ends blindly at different depth ¬ byni. With such a fistula stands colorless liquid or mucus, which in the case of infection is purulent. In this case it is necessary to differential diagnosis of omphalitis. Unlike omphalitis, conservative treatment fistula ineffective. Necessary to determine the depth of the fistula, in the case of incomplete intestinal fistula it ends blindly in the abdominal cavity. In the case when the intraperitoneal part vitelline duct obliteruyetsya, but does not resolve, the child may have the phenomenon of intestinal obstruction.
Diagnosis of fistulae vitelline duct is not difficult. After falling umbilical protrusion appears Neve ¬ lykyh sized bright red color, diameter
which depends on the thickness of the fistula, which secretes mucus or intestinal contents. Conducting sensing fistula and fistulography confirms the diagnosis.

Treatment of fistulas vitelline duct surgery alone.

Uncomplicated fistula vitelline duct must operated in age from 3 to 6 months.
Such complications as exsicosis, evahinatsiya and intestinal obstruction requiring surgery, regardless of the child's age, that is, in the neonatal period. In case uncovered vitelline duct and a great quantity of intestinal contents should not postpone the operation and close the fistula in the first days of life. Early surgery in evahinatsiyi is the prevention of bowel strangulation.
If neobliterovana part vitelline ducts adjacent to the bowel wall, formed Meckel diverticulum. Depending on the violation of the inverse of duct diverticulum forms may be different.
Incomplete Fistula vitelline duct may continue fibrous tyazhem switched into Meckel diverticulum.
Diagnosis of Meckel diverticulum heavy. Only in rare cases it is possible recognition by X-ray. Most diverticula show how random discovery during surgery on abdominal organs.
In some cases, Meckel diverticulum causes serious complications that require emergency surgery: gastrointestinal bleeding, intussusception, strangulative intestinal obstruction, peritonitis due to perforation of ulcers diverticula or inflammation (diverticulitis), volvulus or bowel diverticulum.
When you save the strand, which diverticulum combined with the navel or abdominal organs, it is possible strangulation intestinal loops, which occurs unexpectedly. Developed clinic strangulative intestinal obstruction. One should always remember that Meckel diverticulum may cause intussusception.

Materials for selfcontrol.

Situational task.
Task 1. The boy is 2 years. A week ago, have noticed that there is no right scrotal testis. Left testicle in scrotum. On examination, both scrotal developed normally. Right testicle in the scrotum missing.
1. Your diagnosis?
2. Explain the pathogenesis of this disease.
3. What method of examination will help in diagnosis?

Task 2. Boy 1,5 years. From the first year of life parents noticed that the child is absent left testicle. During the examination of the child and genital physical development of age. Right testicle in the scrotum, the left half of the scrotum underdeveloped, missing testicle, during inguinal canal palpable rounded education 1.2 x1, 0 cm

1. Your detailed diagnosis?
2. What method of treatment and period of performance?
3. What diseases should conduct a differential diagnosis?

Problem 3. The boy 3 years 6 months Parents find the right area not painful tistuvatoyi consistency vypyachuvannya that in the supine position decreases and disappears. Overall condition is violated. External genital organs developed normally.

1. What disease can there be?
2. What are the symptoms to determine at the time of diagnosis?
3. What tactics surgeon?

Problem 4. The boy 2 years swelling in the right inguinal region, which falls in the right half of the scrotum, palpation sharp pain. According to the mother of the child that was swelling day ago. It was repeatedly vomiting, gas and stool is missing.

1. Your diagnosis?
2. What should be the doctor's tactics?
3. What complication arose in a boy?
4. What diseases should conduct a differential diagnosis?

Problem 5. In separate newborn boy when viewed on the 20th day after birth pediatrician showed tumor formation in the suprapubic area. The mother of the child pointed to the child's anxiety before urinating and discharge through the navel some clear fluid.

1. Your preliminary diagnosis?
2. Specify the methods that will help establish the diagnosis?
3. What diseases should conduct a differential diagnosis?
4. Tactics treatment.

Problem 6. The boy of 2 years, to examine another surgeon about pinching inguinal hernia, strangulation within 30 hours. Another doctor during surgery hernial protrusion vpravylos. An plastic inguinal canal by Martynov.

1. What a mistake doctor?
2. What are the stages of the operation had to be conducted?
3. What complications can occur?
4. What is the postoperative management of the patient?

Problem 7. The boy of 2 years appeared painful swelling in the right groin. According to the mother, this tumor appeared 24 hours ago. Mother complains of vomiting, anxiety, baby, no discharge of gas and feces.

1. What is the diagnosis?
2. What should conduct a survey?
3. What preoperative preparation?
4. Tactics another doctor.

Task 8. The child is 6 months in somatic hospitals in connection with left-sided pneumonia. In history - left-sided inguinal - scrotal hernia, strangulated had before. Two hours ago zchynylos pinching.

1. What tactic regular doctor?
2. What is the provision of medical care?
3. Further treatment in hernia

Problem 9. The girl 2x-months in the area of ​​the navel - protrusion, up to 2 cm in diameter, soft-elastic consistency, vpravyme into the abdominal cavity.

1. What is the clinical diagnosis?
2. Tactics treatment?
3. Term and volume of surgical intervention in this pathology.

Problem 10. The boy 1 month of age with navel constant allocation of sero-purulent character. Conducted conservative treatment omphalitis.

1. What is your diagnosis?
2. What method will help in diagnosis?
3. What diseases to diagnose?
4. Clinical management of the patient.

Problem 11. Boy, 2 years old, operated the clinic about strangulated inguinal hernia 36 hours after pinching. During surgery, the hernial protrusion vpravylos independently released "hemorrhagic hernia" fluid. Child made hryzhoroztyn, plastic inguinal canal by Roux-Krasnobayeva. After 12 hours of surgery the child's condition worsened, increased body temperature to 390S, increased abdominal pain, muscle tension appears, vomiting, a symptom of peritoneal irritation.

1. What complication arose?
2. What is the main reason allowed the surgeon during the operation?
3. What additional research method conducted to clarify the object jamming?
4. What is the main indication for surgery strangulated inguinal hernia?
5. The main criteria of viability intestine?

Tests.
1. Parents of boy, 2 months turned to another doctor complaining of periodic increases in the groin formation. On examination, the child is determined by tumor-formation, expanding external inguinal ring. At what age is indicated surgical treatment of inguinal hernias, pinched if the formation is missing?

A. Up to 6 months.
B. After 6 months.
C. 1-3 years.
D. 3-6 years.
E. After 10 years.

2. Parents of the girl of 2 years turned to another doctor complaining of an increase in the groin. On examination, the child is determined tumor formation bowel symptom reduction positive. What is the front wall of inguinal canal in children?

A. recti.
V. aponeurosis of the rectus abdominis muscle.
C. The internal oblique muscle of abdomen.
D. Aponeurosis of the external oblique abdominal muscles.
E. Transverse fascia.

3. In clinics boy received 1 year of age. In the differential diagnosis of pathology inguinal area should be excluded lymphadenitis, dropsy shells eggs and inguinal hernia. Specify the main clinical symptom inguinal hernia:

A. Pain in the abdomen.
B. Vomiting.
C. The presence of tumor in the groin area.
D. Lack of testes in scrotum.
E. Fever.

4. Parents of the girl of 2 years turned to another doctor complaining of an increase in the groin. On examination, the child is determined tumor formation bowel symptom reduction positive. In circumstances in inguinal hernia shown urgent operation?

A. jammed.
B. Pneumonia.
S. Acute urinary retention.
D. Cryptorchidism.
E. Liquid stools.

5. Parents of boy 2 months turned to another doctor complaining of periodic increases in the groin formation. On examination, the child is determined by tumor formation, reduction education is not possible. Which condition must differentiate incarcerated inguinal hernia?

A. Acute inguinal lymphadenitis.
V. Acute appendicitis.
S. coprostasia.
D. Intussusception.
E. Dropsy shell eggs.

6. A boy of 4 months went to the hospital complaining of excitement, refusal of food, formation of large size in the groin. What complication occurred in a child?

A. Acute appendicitis.
B. Acute intussusception.
S Pinching inguinal hernia.
D. Acute inguinal lymphadenitis.
E. Acute hydrops occurred shell eggs.

7. Boy 12 years, came to the office complaining of colicky abdominal pain, repeated vomiting, the presence of a painful tumor formation in the right groin. The pain appeared after the rise of the burden, 12 hours ago. OBJECTIVE: pulse 112 per minute, dry tongue, belly vzdutyy, painful on palpation. Radiological findings: hiperpnevmatoz small intestine. What is the most likely diagnosis?

A. Acute intestinal obstruction.
V. Torsion right testicle.
S. Seminoma right testicle.
D. Acute hydrops right.
E. sided strangulated inguinal-scrotal hernia.

8. A child of 4 years, 12 days ago there was a pinched left-sided inguinal hernia. OBJECTIVE: child restless, crying during palpation determined by a sharp pain at the site of strangulation, which is not out of practice in the abdominal cavity. Inguinal ring palpated impossible. What is the most optimal treatment strategy?

A. Complex conservative measures designed to reposition self hernia.
V. Appointment of pain medication.
C. Manual reduction of hernia.
D. Reduction of hernia under general anesthesia.
E. Emergency operation.

9. The girl appeared 3y.o. pinched inguinal hernia. Age pinched -1. What method of treatment may be used?

A. Complex conservative measures to samovpravlennya hernia.
V. Enema of chloral hydrate.
C. Short-term anesthesia.
D. Immediate surgery.
E. Manual reduction of hernia.

10. The child, aged 1roku 10misyatsiv, diagnosis: right sided cryptorchidism. What tactics and timing of surgical treatment?

A. Surgical treatment of a 6-year-old.
B. Treatment of an endocrinologist.
S. Surgical treatment during puberty.
D. Surgical treatment routinely up to 3 years.
E. Observations in a planned manner.

11. By clinic turned parents boy 2 years old complaining of lack of child right scrotal testis. OBJECTIVE: hypoplasia of the right half of the scrotum, testicle missing. It is reduced in size, palpable along the inguinal canal into the scrotum but not nyzvodytsya. What is the most likely diagnosis?

A. Psevdokryptorhizm.
V. dextral cryptorchidism, inguinal form.
S. ectopic right testicle.
D. Right-sided cryptorchidism, abdominal shape.
E. nearside monorchism.

12. The 5-month boy in scrotal missing left testicle. Right testicle is in the scrotum are not changed. Palpation in the projection of the left inguinal canal is defined oval formation 2x1, 5 cm What is your diagnosis?

A. Cryptorchidism.
V. ectopic testis.
S. aplasia of testis.
D. Monorchism.
E. Funikotsele.

13. Newborn Umbilical residue after exclusion characterized pronounced inflammatory changes. In the center of the navel - granulation. Perifocal inflammatory changes there. What disease most likely?

AV fistulas navel.
V. omphalitis.
S. Phlegmon babies.
D. Enterocolitis.
E. Sepsis.

14. The girl 4 years marked by persistent inflammatory changes in the area of ​​the navel. Similar phenomena occur with period novonarozhdenosti. What research should be done to clarify the diagnosis?

A. Planting flora sensitivity.
B. Probing followed fistulography.
S. biopsy.
D. Cystography.
E. radiographic study of the gastrointestinal tract.

15. Violation obliteration vitelline duct may be formed Meckel diverticulum. Which of these complications may be due to Meckel diverticulum?

A. intussusception.
B. Bleeding.
S. perforation.
D. Volvulus.
E. intraperitoneal bleeding.

Checklist

1. What is different from the fetal umbilical hernia hernia umbilical cord?
2. Dates of conservative treatment umbilical hernia?
3. What is the surgical treatment of herniated abdominal white line?
4. What are the stages of surgical treatment of patients with embryonic hernia umbilical cord.
5. What types of plastic enlarged umbilical ring?
6. What is the operation Shpittsa with umbilical hernia?
7. What options pathology yolk duct?
8. How to prove the existence of incomplete umbilical fistula?
9. Perelikuyte types of plastic surgery in inguinal hernias.
10. How is plastic inguinal canal by Roux-Krasnobayeva of plastics by Martynov?
11. Indications for surgery for inguinal hernia Dyuomelem?

Practical skills.

1. To demonstrate the method of palpation of inguinal areas symptom "cough impulse."
2. Demonstrate methods of blending leykoplastyrnoyi bandages when umbilical hernia.