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Abdominalwallhernias

generalconsideration

inguinalherniasfemoralherniaincisionalherniaumbilialherniaherniaoflineaalbaAbdominalwallherniasgene1

generalconsiderationDefinitionHerniameansasprout,andprotrusion.Externalabdominalwallherniaisanabnormalprotrusionofintra-abdominaltissueorthewholeorpartofaviscerathroughanopeningorfascialdefectintheabdominalwall.mostoccurinthegriongeneralconsideration2Etiology

1.intensityofabdominalwalldecreased

commonfactors:1)sitethatsometissuespassthroughtheabdominalwall,eg.Spermaticcord,roundligamentofuterus2)baddevelopmentofabdominalwhiteline3)incision,trauma,infectionetal.defectincollagensynthesisorturnover2.anyconditionwhichincreasesintra-abdominalpressurechroniccough,chronicconstipation,dysuria,ascites,pregnancy,cryEtiology3

Pathologicalanatomycomposedof:

coveringtissue:skin,subcutanoustissue

hernialsac:protrusionofperitonum,neckofthesac:isnarrowwherethesacemergesfromtheabdomenbodyofthesac

hernialcontents:smallintestine,majoromentum

Pathologicalanatomy4Clinicaltypes

1.reducibleherniaisoneinwhichthecontentsofthesacreturntotheabdomenspontaneouslyorwithmanualpressurewhenthepatientisrecumbent.

2.irreducibleherniaisonewhosecontentsorpartofcontentscannotbereturnedtotheabdomen,withoutserioussymptoms.herniasaretrappedbythenarrowneckSlidingherniaisoneinwhichthewallofaviscusformsaportionofthewalloftheherniasac.Itismaybecolon(ontheleft),caccum(ontheright)orbladder(oneitherside).Belongstoirreduciblehernia

Clinicaltypes53.incarceratedhernia:isonewhosecontentscannotbereturnedtotheabdomen,withseveresymptoms.4.strangulatedhernia:denotescompromisetothebloodsupplyofthecontentsofthesac.incarceratedherniaandstrangulatedherniaarethetwostagesofapathologiccourseRichter’shernia(intestinalwallhernia)aherniathathasstrangulatedorincarceratedapartoftheintestinalwallwithoutcompromisingthelumen.Littrehernia:aherniathathasincarceratedtheintestinaldiverticulum(usuallyMeckeldiverticulum).Reductiveincarceratedhernia:reductionofthehernialcontents(intestine)intoabdominalcavity.3.incarceratedhernia:ison6Inguinalherniasinguinalhernia:aprotrusionofpartofthecontentsoftheabdomenthroughtheinguinalregionoftheabdominalwall.indirectinguinalhernia:theinternalinguinalringtheinguinalcanalexternalinguinalringscrotumdirectinguinalhernia:Hesselbach’striangleAnatomy1.Anatomiclayers1)skin,subcutaneoustissue2)externalobliquemuscle,aponeurosisSubcutaneous(external)inguinalring:Triangularopening,intheaponeurosisoftheexternalobliquejustsuperiorandlateraltothepubictubercle.Inguinalhernias7Inguinalligament:itisformedasthelateraledgeoftheaponeurosisofexternalobliquerollsuponitselfandthickensintoacord,extendingfromtheanteriorsuperioriliacspinetothepubictubercle.LacunarligamentCooper’sligament(pectinealligament)Sensorynerves:iliohypogastricnerve,ilioinguinalnerve3)internalobliquemuscleandtranverseabdominalmuscleConjoinedtendon(flaxinguinalis):thelowerfibersoftheinternalobliquemusclefusewiththelowermostarchingfibersofthetransversemuscleoftheabdomenandinsertwiththemintothepubictubercle,formingtheconjoinedtendon.Inguinalligament:itisforme84)TransversalisfasciaInternalinguinalring:isthepointatwhichthespermaticcordorroundligamentpassesthroughthetransversalisfasciatoentertheinguinalcanal.surfacemarking:2cmsuperiortothepointmidwaybetweentheanteriorsuperioriliacspineandthepubictubercle.Iliopubictract:itisthethickestportionofthetransversalisfasciaintheinguinalregion.Itparallelsandliesjustmedialtotheinguinalligament.5)extraperitonealfatandperitoneum4)Transversalisfascia92.AnatomyofinguinalcanalContents:spermaticcord,roundligament,ilioinguinalnerveWalls:anterior:skin,superficialfascia,andexternalabliqueaponeurosisposterior:transversalisfasciasuperior:conjoinedtendeninferior:inguinalligament3Hesselbach’striangleBoundedbytheinguinalligament,theinferiorepigastricvessels,andthelateraledgeofrectusmuscle.2.Anatomyofinguinalcanal10腹壁疝的診斷和治療(英文版)課件11

Causesofindirectinguinalhernia1.congenitalabnormalityofanatomyduetofailureoffusionoftheprocessusvaginalisperitoneiafterthetestishasdescendedintothescrotum.2.acquiredweaknessordefectofabdominalwallClinicalmanifestationanddiagnosisSymptoms:pain,discomfort,draggingsensationSign:reducibleorirreduciblelump,expansilecoughimpulse

Reducingtheherniafully,compresstheinternalring:becontrolled–indirectnotcontrolled--direct

Causesofindirectinguinalh12腹壁疝的診斷和治療(英文版)課件13Differencesbetweenindirectanddirectherniafeatureindirectdirectagechildren,youngpeopleagedpeoplepathwayofprotrusioncomingdowntheinguinalcanal,mayenterthescrotumpassthroughHesselbach’striangle,rarelyenterthescrotumcontoursofsacelliptic,pear-shapedsemispheric,widebasecompresstheinternalringafterreducedcontrolledcontrolledRelationshipofspermaticcordwithsacPosteriortothesacAnteriorandlateraltothesacRelationshipofsacneckwithinferiorepigastricarterySacneckislateraltoitSacneckismedialtoitIncarceratedincidencehighlowDifferencesbetweenindirecta14Differentialdiagnosis1dydroceleoftestistranslucenttest(+)2communicatedhydrocele3hydroceleofcord:notreducible4undescendedtestis5acuteintestinalobstructionTreatment

1.nonoperativetherapyIndications:<1yearoldelderlypatientsorwithseveresystemicdisease--trussDifferentialdiagnosis152.operationsforinguinalhernia

conventionalrepairsPrinciples:excisionorreductionofthehernialsac,highligationofthesac,andrepairthewallsoftheinguinalcanalA:highligationofherniasacUsedininfants,andpatientswithseverelocalinfectionB:repairofwallsoftheinguinalcancalIrepairoftheanteriorwalloftheinguinalcanalFergusonrepairIIRepairoftheposteriorwall

Bassinirepair

Halstedrepair:placingthelatterinasubcutanousposition2.operationsforinguinalher16McVayrepair:loweredgeofinternalobliquemuscleandtheconjoinedtendonareapproximatedtoCooper’sligamentontheiliopectineallineofthepubis.

Shouldicerepair:theposteriorwalloftheinguinalcanalisrepairedbydividingthetransversalisfasciafromthepubistoadjacenttotheinferiorepigastricvessel,thenimbricatesutures.Internalring:passafingertip2)tension-freehernioplastyinsertionofaprostheticmesh3)laparoscopicrepairofinguinalherniaMcVayrepair:loweredgeof17腹壁疝的診斷和治療(英文版)課件18腹壁疝的診斷和治療(英文版)課件19腹壁疝的診斷和治療(英文版)課件20腹壁疝的診斷和治療(英文版)課件21腹壁疝的診斷和治療(英文版)課件223.managementruleofincarceratedandstrangulatedherniaIndicationsformanualreduction:1)duration<3-4hours,nolocaltenderness,noabdominaltenderness,norigidityofabdominalmuscle2)elderlypatientsorwithotherseverediseases,andtheintestinalloopisstillaliveUsuallyrequiresemergencyoperation4.Managementruleofrecurrentinguinalhernia1)truerecurrenthernia2)concomitanthernia3)newoccurringhernia3.managementruleofincarcer23FemoralherniaintroductionFemoralherniaisaprotrusionofperitoneumthroughthefemoralcanal.Usuallyinwomen>40yearsCauses:laxityofgrointissueelevatedintra-abdominalcanalAnatomyoffemoralcanalFemoralring–fossaovalisAnterior:inguinalligamentPosterior:pectinealligamentMedial:lacunarligamentLateral:femoralveinFemoralhernia24

Pathologicanatomyfemoralringfemoralcanalfossaovalis

subcutaneoustessueofthethigh

Highincidenceofstrangulation腹壁疝的診斷和治療(英文版)課件25ClinicalfindingsanddiagnosisReduciblefemoralhernia:asymptomaticlump,localizedintermittentdiscomfortIrreduciblefemoralhernia:constantlumpandlocalizeddiscomfortStrangulatedfemoralherniaDifferentialdiagnosis1.indirectinguinalhernia2.lipoma3.groinlymphnodes4.longsaphenousvarix5.iliolumbartuberculousabscessClinicalfindingsanddiagnosi26TreatmentNotbetreatedconservativelyRuleoperation:excisionorreductionofthehernialsac,andnarrowingofthestretchedfemoralopeningmethods:McVayrepairtension-freehernioplastylaparoscopicrepairofinguinalhernia

Treatment27OtherabdominalexternalherniaIncisionalherniaIncisionalhernia:anabnormalprotrusionofaviscusthroughthemusculoaponeuroticlayersofasurgicalscar.WounddehiscenceEtiologyPreoperativefactorsOperativefactors:typesofincision:verticalincision,transrectusincision,midlineincision,standardparmedianincisiontechniqueofclosuresuturemateriaPostoperativefactors:increasedintra-abdominalpressure,etal.Otherabdominalexternalherni28ClinicalfeaturesanddiagnosisSwellingandmassintheincisionHernialringRarelyincarcerateTreatmentOperativerepair:thesamewayasalaparotomywoundisrepaired,orusemesh

Umbilicalhernia

1infantileumbilicalhernia1)failureoffusionofumbilicalring,orweakenedumbilicaltissue2)symptomless,reduciblelump3)usuallydisappearbytheageof2years4)rarelyincarcerate5)surgicalrepair>2yearsClinicalfeaturesanddiagnosi292Adultumbilicalhernia1)acquiredhernia2)morecommoninfemales3)incarcerationiscommon4)surgicalrepair:excisionofthesac,suturetheherniaringHerniaoflineaalbaEpigastricherniaItisaprotrusionofpreperitonealfatand/orperitonealsacthroughagapinthedecussatingfibersofthelineaalba,usuallythesupraumbilicalportionofthelineaalba.Mostareasymptomatic,orvagueupperabdominalpainandnauseamaybepresent.Surgicalrepair2Adultumbilicalhernia30Abdominalwallhernias

generalconsideration

inguinalherniasfemoralherniaincisionalherniaumbilialherniaherniaoflineaalbaAbdominalwallherniasgene31

generalconsiderationDefinitionHerniameansasprout,andprotrusion.Externalabdominalwallherniaisanabnormalprotrusionofintra-abdominaltissueorthewholeorpartofaviscerathroughanopeningorfascialdefectintheabdominalwall.mostoccurinthegriongeneralconsideration32Etiology

1.intensityofabdominalwalldecreased

commonfactors:1)sitethatsometissuespassthroughtheabdominalwall,eg.Spermaticcord,roundligamentofuterus2)baddevelopmentofabdominalwhiteline3)incision,trauma,infectionetal.defectincollagensynthesisorturnover2.anyconditionwhichincreasesintra-abdominalpressurechroniccough,chronicconstipation,dysuria,ascites,pregnancy,cryEtiology33

Pathologicalanatomycomposedof:

coveringtissue:skin,subcutanoustissue

hernialsac:protrusionofperitonum,neckofthesac:isnarrowwherethesacemergesfromtheabdomenbodyofthesac

hernialcontents:smallintestine,majoromentum

Pathologicalanatomy34Clinicaltypes

1.reducibleherniaisoneinwhichthecontentsofthesacreturntotheabdomenspontaneouslyorwithmanualpressurewhenthepatientisrecumbent.

2.irreducibleherniaisonewhosecontentsorpartofcontentscannotbereturnedtotheabdomen,withoutserioussymptoms.herniasaretrappedbythenarrowneckSlidingherniaisoneinwhichthewallofaviscusformsaportionofthewalloftheherniasac.Itismaybecolon(ontheleft),caccum(ontheright)orbladder(oneitherside).Belongstoirreduciblehernia

Clinicaltypes353.incarceratedhernia:isonewhosecontentscannotbereturnedtotheabdomen,withseveresymptoms.4.strangulatedhernia:denotescompromisetothebloodsupplyofthecontentsofthesac.incarceratedherniaandstrangulatedherniaarethetwostagesofapathologiccourseRichter’shernia(intestinalwallhernia)aherniathathasstrangulatedorincarceratedapartoftheintestinalwallwithoutcompromisingthelumen.Littrehernia:aherniathathasincarceratedtheintestinaldiverticulum(usuallyMeckeldiverticulum).Reductiveincarceratedhernia:reductionofthehernialcontents(intestine)intoabdominalcavity.3.incarceratedhernia:ison36Inguinalherniasinguinalhernia:aprotrusionofpartofthecontentsoftheabdomenthroughtheinguinalregionoftheabdominalwall.indirectinguinalhernia:theinternalinguinalringtheinguinalcanalexternalinguinalringscrotumdirectinguinalhernia:Hesselbach’striangleAnatomy1.Anatomiclayers1)skin,subcutaneoustissue2)externalobliquemuscle,aponeurosisSubcutaneous(external)inguinalring:Triangularopening,intheaponeurosisoftheexternalobliquejustsuperiorandlateraltothepubictubercle.Inguinalhernias37Inguinalligament:itisformedasthelateraledgeoftheaponeurosisofexternalobliquerollsuponitselfandthickensintoacord,extendingfromtheanteriorsuperioriliacspinetothepubictubercle.LacunarligamentCooper’sligament(pectinealligament)Sensorynerves:iliohypogastricnerve,ilioinguinalnerve3)internalobliquemuscleandtranverseabdominalmuscleConjoinedtendon(flaxinguinalis):thelowerfibersoftheinternalobliquemusclefusewiththelowermostarchingfibersofthetransversemuscleoftheabdomenandinsertwiththemintothepubictubercle,formingtheconjoinedtendon.Inguinalligament:itisforme384)TransversalisfasciaInternalinguinalring:isthepointatwhichthespermaticcordorroundligamentpassesthroughthetransversalisfasciatoentertheinguinalcanal.surfacemarking:2cmsuperiortothepointmidwaybetweentheanteriorsuperioriliacspineandthepubictubercle.Iliopubictract:itisthethickestportionofthetransversalisfasciaintheinguinalregion.Itparallelsandliesjustmedialtotheinguinalligament.5)extraperitonealfatandperitoneum4)Transversalisfascia392.AnatomyofinguinalcanalContents:spermaticcord,roundligament,ilioinguinalnerveWalls:anterior:skin,superficialfascia,andexternalabliqueaponeurosisposterior:transversalisfasciasuperior:conjoinedtendeninferior:inguinalligament3Hesselbach’striangleBoundedbytheinguinalligament,theinferiorepigastricvessels,andthelateraledgeofrectusmuscle.2.Anatomyofinguinalcanal40腹壁疝的診斷和治療(英文版)課件41

Causesofindirectinguinalhernia1.congenitalabnormalityofanatomyduetofailureoffusionoftheprocessusvaginalisperitoneiafterthetestishasdescendedintothescrotum.2.acquiredweaknessordefectofabdominalwallClinicalmanifestationanddiagnosisSymptoms:pain,discomfort,draggingsensationSign:reducibleorirreduciblelump,expansilecoughimpulse

Reducingtheherniafully,compresstheinternalring:becontrolled–indirectnotcontrolled--direct

Causesofindirectinguinalh42腹壁疝的診斷和治療(英文版)課件43Differencesbetweenindirectanddirectherniafeatureindirectdirectagechildren,youngpeopleagedpeoplepathwayofprotrusioncomingdowntheinguinalcanal,mayenterthescrotumpassthroughHesselbach’striangle,rarelyenterthescrotumcontoursofsacelliptic,pear-shapedsemispheric,widebasecompresstheinternalringafterreducedcontrolledcontrolledRelationshipofspermaticcordwithsacPosteriortothesacAnteriorandlateraltothesacRelationshipofsacneckwithinferiorepigastricarterySacneckislateraltoitSacneckismedialtoitIncarceratedincidencehighlowDifferencesbetweenindirecta44Differentialdiagnosis1dydroceleoftestistranslucenttest(+)2communicatedhydrocele3hydroceleofcord:notreducible4undescendedtestis5acuteintestinalobstructionTreatment

1.nonoperativetherapyIndications:<1yearoldelderlypatientsorwithseveresystemicdisease--trussDifferentialdiagnosis452.operationsforinguinalhernia

conventionalrepairsPrinciples:excisionorreductionofthehernialsac,highligationofthesac,andrepairthewallsoftheinguinalcanalA:highligationofherniasacUsedininfants,andpatientswithseverelocalinfectionB:repairofwallsoftheinguinalcancalIrepairoftheanteriorwalloftheinguinalcanalFergusonrepairIIRepairoftheposteriorwall

Bassinirepair

Halstedrepair:placingthelatterinasubcutanousposition2.operationsforinguinalher46McVayrepair:loweredgeofinternalobliquemuscleandtheconjoinedtendonareapproximatedtoCooper’sligamentontheiliopectineallineofthepubis.

Shouldicerepair:theposteriorwalloftheinguinalcanalisrepairedbydividingthetransversalisfasciafromthepubistoadjacenttotheinferiorepigastricvessel,thenimbricatesutures.Internalring:passafingertip2)tension-freehernioplastyinsertionofaprostheticmesh3)laparoscopicrepairofinguinalherniaMcVayrepair:loweredgeof47腹壁疝的診斷和治療(英文版)課件48腹壁疝的診斷和治療(英文版)課件49腹壁疝的診斷和治療(英文版)課件50腹壁疝的診斷和治療(英文版)課件51腹壁疝的診斷和治療(英文版)課件523.managementruleofincarceratedandstrangulatedherniaIndicationsformanualreduction:1)duration<3-4hours,nolocaltenderness,noabdominaltenderness,norigidityofabdominalmuscle2)elderlypatientsorwithotherseverediseases,andtheintestinalloopisstillaliveUsuallyrequiresemergencyoperation4.Managementruleofrecurrentinguinalhernia1)truerecurrenthernia2)concomitanthernia3)newoccurringhernia3.managementruleofincarcer53FemoralherniaintroductionFemoralherniaisaprotrusionofperitoneumthroughthefemoralcanal.Usuallyinwomen>40yearsCauses:laxityofgrointissueelevatedintra-abdominalcanalAnatomyoffemoralcanalFemoralring–fossaovalisAnterior:inguinalligamentPosterior:pectinealligamentMedial:lacunarligamentLateral:femoralveinFemoralhernia54

Pathologicanatomyfemoralringfemoralcanalfossaovalis

subcutaneoustessueofthethigh

Highincidenceofstrangulation腹壁疝的診斷和治療(英文版)

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