外科學課件：19腹外疝

Hernia

DEFINITION、CLINICALTYPES、ETIOLOGY、ANDANATOMY

SectionⅠ.GeneralIntroductionDefinitionsHerniawasderivedfromtheLatinword“Rupture"HerniaisdefinedasanabnormalprotrusionofanorganortissuethroughadefectinitssurroundingwallsAbdominalExternalHerniaisdefinedasanabnormalprotrusionofintra-abdominaltissueorviscerathroughadefectintheabdominalwall.ItmostlyoccurinthegroinTypesofHerniaDirectinguinalherniaIndirectinguinalherniaFemoralherniaIncisionalherniaUmbilicalhernia（臍疝）Para-umbilicalherniaDiaphragmatichernia(膈疝)Spigelianhernia（半月線疝）Lineaalbahernia(白線疝)Obturatorhernia(閉孔疝)Sciatichernia（坐骨疝）Perinealhernia（會陰疝）Etiology1.Intra-abdominalpressureincreasedcrying/chroniccough/benignprostatic/hyperplasia(BPH)/constipation/ascitesEtiology2IntensityofabdominalwalldecreasesCommonfactorthesitethatsometissuespassthroughtheabdominalwall,eg.spermaticcord,roundligamentofuterus.baddevelopmentofabdominalwhitelineincisionalinfection,trauma.SpermaticcordpassthroughtheabdominalwallIncisionalweaknesscauseincisionalherniacompositionof

abdominalexternalhernia1.coveringtissues:skin,subcutanoustissue2.hernialsac:protrusionofperitoneum,

neckofthesac:isthenarrowpartofthesachernialring(portal):aprotrusiontothesurfaceoftheportalofhernia,wherearetheweakpointsordefects.3.hernialcontents:smallintestine,majoromentum9Generalconsideration

--anatomyHernialsacHernialringspermaticcordHernialsacHernialringSpermaticcordTypesofHernias★Reducibleherniaisoneinwhichthecontentsofthesaccanreturntotheabdomenspontaneouslyorwithmanualpressurewhenthepatientissupine.“theearlyhernia!"

★Irreduciblehernia

Hernialcontentscannotbesatisfiedornotfullyreturnbackintotheabdominalcavitybutdoesnotcauseseveresymptoms.Repeatedlyhighlighttheherniacontents,causedbythefrictiongeneratedsacadhesionneck.Mostofthesecontentsareomentum.★

SlidingHerniasacisoneinwhichthewallofaviscusformsaportionofthewalloftheherniasac.Itismaybecolon(ontheleft),cecum(ontheright)orbladder(oneitherside)(Belongstoirreduciblehernia)★Strangulatedhernia

withthedevelopmentofillness,pressureonthehernialcontentsmaycompromisebloodsupplyandcauseischemia,andlaternecrosisandgangrene,whichmaybecomefatal.

IncarceratedhernianarrowhernialnecksmallbowelobstructionStrangulatedherniaMesentericarterypulsedisappeared,wallgraduallylosetheirluster,elasticityandcreep,andfinallynecrosisSeveralspecialtypesofherniasacIntestinalwall★Richter

Hernia:

aherniainvolvingonlyonesidewallofthebowel,whichcanresultinbowelstrangulationwithoutcausingbowelobstructionoranyofitswarningsigns★Littrehernia:

anincarceratedherniainvolvingasmalldiverticulum(usuallyMeckeldiverticulum)specialtypesofhernia★

Retrogradeincarceration

twoadjacentloopsofsmallintestinearewithinahernialsacwithatightneck.TheinterveningportionofbowelWITHINtheabdomenisdeprivedofitsbloodsupplyandeventuallybecomesnecrotic.

(maydl)

HernialringIncarceratedsmallbowelbecomesnecroticintheabdominalcavitysacWHerniaringDEFINITION、ANATOMY、CLINICALMANIFESTATION、DIAGNOSIS、DIFFERENTIALDIAGNOSISANDTREATMENTSectionII.InguinalHerniaDefinitions

★Indirectinguinalhernia

Thisisthemostcommonherniainmales;itistheoverwhelminglypredominanttypeininfantsandboysandstillmakesupmorethan55%ofalltheherniasseeninadults.★Directinguinalhernia

Directlyprotrudefromthe“directtriangleofhernia”,ratherthaninnerring,notfallintothescrotum.Anatomyofinguinalarea(Thesurgeonmusthaveacomprehensiveunderstandingoftheanatomyofthegroininordertoproperlyselectandutilizevariousoptionsforherniarepair)1.Anatomiclayersofabdominalwallinthegroin.

Theabdominalwalliscomposedof7layers.

Theyare(fromanteriortoposterior)asfollows.23Inguinalhernias

--generalconsideration⑴skin⑵Superficialfascia⑶Externalobliquemuscleandaponeurosis⑷Internalobliquemuscle⑸Transversusmuscle⑹Transversalisfascia⑺peritoneumseveralspecialstructurethatasurgeonshouldknow：Subcutaneous(external)inguinalringInguinalligamentLacunarligamentCooper’sligament(pectinealligament)ConjoinedtendonInternalinguinalringIliopubictract31specialstructureingroin32External(superficial)inguinalringAnovoidopeningoftheexternalobliqueaponeurosisthatispositionedsuperiorandslightlylateraltothepubictubercle

33InguinalligamentandLacunarligamentInguinalligamentistheinferioredgeoftheexternalobliqueaponeurosisandextendsfromtheanteriorsuperioriliacspinetothepubictubercle,turningposteriorlytoformashelvingedge.lacunarligamentisformedbytheinsertionoftheinguinalligamenttothepubis34Cooper’sligament(pectinealligament)Inguinalligament

Cooper’sligament

Cooper’sligamentisformedbytheperiosteumandfasciaalongthesuperiorramusofthepubis

Itisastructureformedfromthelowerpartoftransversusabdominalmuscleasitinsertsintothecrestofthepubisandpectineallineimmediatelybehindthesubcutaneousinguinalring.Itisusuallyconjointwiththetendonoftheabdominalinternalobliquemuscle.35ConjoinedtendonconjoinedtendonilioinguinalnerveInternalinguinalringisthepointatwhichthespermaticcordorroundligamentpassesthroughthetransversalisfasciatoentertheinguinalcanal.surfacemarkingofInternalinguinalring:2cmsuperiortothepointmidwayofinguinalligament.Iliopubictractisthethickestportionofthetransversalisfasciaintheinguinalregion.Itparallelsandliesjustmedialtotheinguinalligament.36InternalinguinalringandIliopubictract2.Anatomyofinguinalcanal

⑴

Definition：inguinalcanalisashortpassagewhichruns(obliquelyandinferomedially)throughtheinferiorpartoftheanteriorabdominalwall.Itrunsparallelandslightlysuperiortotheinguinalligament.37⑵Boundry：Anteriorwall:externalabliqueaponeurosis;internalobliquemuscle

Posteriorwall:transversalisfascia;conjointtendon

Roof

:archingfibersoftheinternalobliqueandtransversusabdominismuscles

Floor

:superiorsurfacesofboththeinguinalandlacunarligaments383.Hesselbach’striangleisboundedby:TheinferiorepigastricvesselsThelateralborderoftherectusmuscleTheinguinalligamentDirectHernialeavetheabdomenandprotrudethroughthisTriangle39FrontviewBackviewOutside（

Inferiorepigastricartery)）Bottom（

Inguinalligament）insideDirectherniaIndirecthernia

★Symptoms

AbulgeintheinguinalregionremainsthemaindiagnosticfindinginmostgroinherniasTheremaybeassociatedpainorvaguediscomfortintheregion

★Signreducibleorirreduciblelump

★PhysicalexaminationTheinguinalregionshouldbeexaminedwiththepatientinbothsupineandstandingpositions

Theexaminershouldvisuallyinspectandpalpatetheinguinalregion,observingforasymmetry,bulges,oramass.41Inguinalhernias

--ClinicalmanifestationanddiagnosisSymptomsandDiagnosis

Commonfeatures:aprominentinguinalmassincreases;somepatientswithonlymildearlyheavyfeeling;herniacontents,suchasthebowelloops,andbowelsoundscanbeheard.

DifferentialDiagnosis

①——AgeDirectherniaIndirecthernia②ContoursofLump

indirectinguinaldirectinguinalOvalorpear-shapedDomeorhemispherical③pathwayofprotrusion

indirectinguinal

directinguinalProtrudethroughHesselbach’striangle,rarelyfallintothescrotumProtrudethroughtheinguinalcanal,mayfallintothescrotum④Therelationshipbetween

thehernialsacandspermaticcord

indirectinguinaldirectinguinalPosteriortothesacAnteriorandlateraltothesac⑤Relationshipofsacneck

withinferiorepigastricarteryindirectinguinaldirectinguinal⑥incarcerationchanceeasyseldemIndirectherniaDirecthernia

⑦holdtheinternalring

IndirectherniaDirectherniaDifferentialDiagnosis-①★

Hydrocele＊

Presentedbythemasshydrocelecompletelyconfinedtothescrotumtestoftransillumination（+）

opaque＊

Whentesticularhydrocelethemiddleofthefluid,themasscannotreachthepartiestoappearbeforesubstantialcystictesticularDifferentialDiagnosis②★

communicatinghydrocele

＊

Hydrocelemasssimilarinappearance,standingoraftergettingupeachdaywhenthelumpappearedandincreasedslowly.Graduallyreducedafterthesupineorsleep.Extrusionmass,thevolumeisgraduallyreduced.

＊

Testoftransillumination（+）DifferentialDiagnosis③★

Spermaticcordhydrocele＊

Smalllumpsintheinguinalcanal,thestretchcanbeseenipsilateraltesticularmassmovement.SectionIII

Thetreatmentofinguinalhernia1、

Non-surgicaltreatment＊

Adaption:forinfantsunderoneyearold,accompaniedbyotherseriousdiseasesinpatientswithcontraindicationssurgery＊

commonlyusedmethods:herniawithcompression。Truss

Thetreatmentofinguinalhernia2、

Surgery⑴Traditionalherniarepair⑵Tension-freeherniarepair⑶Laparoscopicherniarepair

TraditionalHerniorrhaphy★

Thebasicprinciplesofoperation:

ligationofherniasacontheneck,strengthenorrepairinguinalwall＊

Highligation:exposedneck

ofherniasac,highligationandresectionoftheherniasac.＊

Tostrengthenorrepairtheinguinalcanalwall:Adultpatientswithvaryingdegreesofinguinalherniainthegroinafteranteriororposteriorwalloftheweakordefect.HighligationHighligationmakingasmallincisionovertheherniapushingthebulgingtissuebackintoplaceremovingtheherniasac(highligation)Closeandfirmhernialorifice(repairofwallsoftheinguinalcancal)

ClassicHerniorrhaphy

strengtheningorrepairinguinalcanalwallTwoMenthod{TostrengthentheanteriorwallTostrengthentheposteriorwallTostrengthenorrepairtheanteriorwalloftheinguinalcanal＊Ferguson:

Spermaticcordintheloweredgeofthefrontoftheabdominalobliquemuscleandjointtendontotheinguinalligamentontheseam,soastoeliminateabdominalobliquemuscleandthearcuateloweredgeofthegapbetweentheinguinalligament.

Forchildrenandyoungpeoplewerenosignificanttransversefasciadefect,theposteriorwallofinguinalcanalinguinalherniaisstillsound.Ferguson①②③④Ferguson精索Tostrengthenorrepairtheposteriorwalloftheinguinalcanal-BassiniBassinirepair:

loweredgeofinternalobliquemuscleandtheconjoinedtendonaresuturedtoinguinalligament.Itiswidelyused.Bassini①②③④HalstedexternalobliquefasciaespermaticcordHalstedRepair:liketheBassinirepair,buttheSpermaticcordissuperficialtoexternalobliqueaponeurosisMcVayCoopersligementInguinalligamentMcVayrepair:loweredgeofinternalobliquemuscleandtheconjoinedtendonaresuturedtoCooper’sligamentdirect.itispopularfordirecthernias,largeindirecthernias,recurrenthernias,andfemoralhernias.Shouldice法Shouldicerepair:theposteriorwalloftheinguinalcanalisrepairedbydividingthetransversalisfasciafromthepubistoadjacenttotheinferiorepigastricvessel,thenimbricatesuturesThedevelopmentofinguinal

herniarepair

Since1884,Bassinibegantodothefirstcasesofherniarepair.Strengthentheposteriorwalloftheinguinalcanaltocureinguinalherniasurgeryinguinalherniaisagreatprogress.Althoughthereweremanysurgicalmethodstorepairtheposteriorwalloftheinguinalcanal,however,recurrenceremainsaseriousproblem.Domesticstatistics(Mr.Huang)※

Recurrentrateofindirecthernia

HUANGTINGYAN（1984）

17～22%※Recurrentrateofdirecthernia

WANGHAINIAN（1988）

20～40%Majorproblems1.

Higherrecurrentrate>10%2.Largehernia,treatmentofmultiplerecurrenthernia3.Severelocalpainafterherniarepair,restorenormalactivitiesandworkrequiredforalongtime.

Tension-FreeHerniorrhaphyLichtensteinin1987hasproposed,"tension-freeherniarepair"(Tension-FreeHerniorrhaphy)theory,namelytheuseofpermanentartificialmaterialsdonotabsorbthepolymerrepairdefects,theherniarepairwithoutdisruptionofnormalanatomicalstructuresandtoachieveatension-freestate.

Tension-FreeHerniorrhaphyPlainfilmtension-freeherniarepairsurgery(Lichtenstein

)--Useaconsiderablesizeofthepatchmaterialisplacedintheposteriorwalloftheinguinalcanal.RutKowmethod--(plug+mesh)GPRVS(Giantprostheticreinforceofthevisceralsac)

，othernameisStoppamethod。72somecommomusedpatchormesh72Plug-MeshHerniaRepair

Advantages:1.Verylowrecurentrate<1%2.Simpleoperation,shorttime3.Minortrauma,postoperativepainlighter4.Returntonormalactivityandshortertimetowork。Plug-MeshHerniaRepair

Indications:Apartfromchildrenwithinguinalhernia,butapplicabletoalloftheinguinalhernia,especiallyforolderhernia,bilateralhernia,ahugeherniaandrecurrenthernia.Conicalpolypropylenemeshplug,meshisdifficulttodealwithalltheidealmaterialforinguinalhernia.Plug-MeshHerniaRepairPlugMeshPlug-MeshHerniaRepairLichtensteinHerniaRepairPHS