腹股溝區(qū)和腹壁的解剖和手術(shù)課件

腹股溝區(qū)和腹壁的解剖和手術(shù)

Objectives

目的Describewhatcauseshernias

闡述疝氣成因Classifythetypesofhernias

疝氣分類Explainthedifferentherniarepairtechniques

解釋不同的疝修補(bǔ)技術(shù)WhatisaHernia?

什么是疝？疝氣是臟器或組織通過非正常腔隙生成的一個(gè)突起。大多數(shù)疝氣是由于腹壓增大時(shí)，腹腔內(nèi)容物從腹壁缺損或薄弱處突出，形成腫塊，并引起相應(yīng)的臨床癥狀。WhatcausesaHernia?

疝產(chǎn)生的原因Weaknessordefect

薄弱或缺損Presentsincebirth

先天表現(xiàn)Weakeningfactors

造成薄弱因素Riskfactors

風(fēng)險(xiǎn)因素REALITYCHECK!

事實(shí)證明！Justaspeopledonotgetanyyoungerorhealthierwithtime,nordoherniasgetsmaller.

正如人們不會(huì)隨歲月流逝變得更為年輕和健康一樣，疝也不會(huì)隨之變小。

Aherniawillnotgoawayuntreated.

疝不會(huì)自愈。Thepresenceofaherniaindicatesthatarepairwillberequiredatsomestage.

疝的存在意味著在一定階段需要進(jìn)行疝修補(bǔ)。HERNIAS

疝氣GroinHernias

腹股溝疝Inguinal&Femoral

腹股溝區(qū)和股區(qū)UmbilicalHernias

臍疝Ventral/IncisionalHernias

腹壁疝/切口疝Epigastric

劍突疝Gastroschisis&Omphalocele

腹裂和臍膨出InternalHernias

腹內(nèi)疝RareHernias

罕見的疝氣種類Epigastric

上腹疝Femoral

股疝Incisional/Ventral

切口疝/腹壁疝Inguinal

腹股溝疝Umbilical

臍疝D(zhuǎn)iaphragmatic

橫隔膜疝(HiatalHernia)

（食管裂孔疝）

DescribingaHernia

疝描述腹股溝疝臍疝切口疝造瘺口旁疝骨架骨架髂前上棘髂嵴

恥骨結(jié)節(jié)

腹股溝解剖簡圖內(nèi)斜肌提睪肌腹直肌腹壁下動(dòng)靜脈精索腹股溝韌帶MyopectinealOrifice

恥骨肌孔D±inclinedobliqueslantingtiltedMyopectinealOrifice

TripleTrianglesoftheGroin

恥骨肌孔的三組三角LateralTriangle

外側(cè)三角MedialTriangle

內(nèi)側(cè)三角FemoralTriangle

股三角IndirectInguinalHerniaFrequentlyacongenitaldefect

通常是先天缺損Sacprotrudesthroughtheinternalring

疝囊通過內(nèi)環(huán)口突出Sacisinsidecremasterfibers

疝囊被提睪肌包裹Gradedbysizeofring,notsizeofsac

以內(nèi)環(huán)口的大小，而非疝囊大小分類IndirectInguinalHernia

腹股溝斜疝IndirectInguinalHernia

腹股溝斜疝InferiorEpigastrics

腹壁下血管DirectInguinalHerniaWeaknessinfloorofcanal

腹股溝管后壁薄弱Sizeofsaccorrespondstosizeofdefect

疝囊大小與缺損大小相對(duì)應(yīng)Sacconsistsofperitoneumandtransversalisfascia

疝囊壁由腹膜和腹橫筋膜組成DirectInguinalHernia腹股溝直疝D(zhuǎn)irectInguinalHernia

腹股溝直疝InferiorEpigastrics

腹壁下動(dòng)靜脈HerniaStatistics

疝氣統(tǒng)計(jì)表Estimatedincidenceinthegeneralpopulationis3%

估計(jì)有3%的發(fā)病率Male-to-femaleratio:12:12男女患者比率為：12：1Morethan5millionherniarepairs

performedworldwide*

全球已實(shí)施五百萬例疝修補(bǔ)術(shù)

Tensionvs.Tension-FreeRepairsvarycountrytocountry

采用張力修補(bǔ)或無張力修補(bǔ)在不同的國家有很大的差異Lichtenstein.HerniaRepairWithoutDisability.2nded.St.Louis,MO:IshiyakuEuroamerica,Inc;1986:chapt.2Abrahamsonetal.Maingot’sAbdominalOperations.9thed.Appleton&Lange:EastNorwalk,CT;1990:Chapt.11*SourceWWherniaproceduredatamarketingresearchETHICONdataonfileAdultInguinalHernia

成人腹股溝疝SomeStatistics一些統(tǒng)計(jì)數(shù)據(jù)Maletofemaleratiois12:1

男女患者比率為12:16-8%ofallmaleshavesomedegreeofinguinalhernia

6——8%的男性有一定程度的腹股溝疝3%ofpopulation

患者占總?cè)丝诘?%Electivetoemergencyratiois12:1

擇期手術(shù)與急診手術(shù)比率為12:1Meanage=60

平均患病年齡60歲MethodsofRepair

修補(bǔ)方法Tension&TensionFree

張力和無張力SurgicalTechniques

外科技術(shù)Open開放式手術(shù)Anteriorrepair

前壁修補(bǔ)Posteriorrepair

后壁修補(bǔ)Combinedrepair

聯(lián)合修補(bǔ)Laparoscopic腹腔鏡手術(shù)Posteriorrepair

后壁修補(bǔ)GoalsofHerniaRepair

疝修補(bǔ)的目標(biāo)Minimaloperativeandpostoperativediscomfort

減小手術(shù)和術(shù)后不適Effectiverepair

有效修補(bǔ)疝氣Lowestpossiblerecurrencerate

使復(fù)發(fā)幾率降為最低Rapidreturntonormalactivities

迅速恢復(fù)正常功能Costeffective

經(jīng)濟(jì)實(shí)用CurrentHerniaRepairTechniques

當(dāng)代的疝修補(bǔ)技術(shù)Tensionrepairs張力修補(bǔ)Bassini巴西尼手術(shù)ShouldiceMcVay(Cooper’sLigament)

McVay（庫珀韌帶）MarcyTension-freemeshrepairs無張力補(bǔ)片修補(bǔ)Lichtenstein平片修補(bǔ)Devices(herniasystems)

疝裝置Laparoscopic腹腔鏡修補(bǔ)TAPP經(jīng)腹腔腹膜前修補(bǔ)TEP完全腹膜外修補(bǔ)TensionRepairs

張力修補(bǔ)巴西尼修補(bǔ)Shouldice修補(bǔ)張力修補(bǔ)AdvantagesofTensionRepair

張力修補(bǔ)的優(yōu)點(diǎn)Easytoperform

易于操作Costeffective

經(jīng)濟(jì)實(shí)用4.Abrahamson.Maingot’sAbdominalOperations.Vol1.9thed.Appleton&Lange:EastNorwalk,Conn;1990:chap11.5.Lichtenstein.HerniaRepairWithoutDisability.2nded.St.Louis,Mo:IshiyakuEuroamerica,Inc;1986.DisadvantagesofTensionRepairs

張力修補(bǔ)的缺點(diǎn)Highrecurrencerates

高復(fù)發(fā)率10%to30%recurrenceratewithprimaryinguinalherniarepair4

首次疝修補(bǔ)后伴隨10%到30%的復(fù)發(fā)率Estimated35%orhigherrecurrenceratewithrecurrentherniarepairs5

在再次修補(bǔ)后預(yù)計(jì)有35%或以上的復(fù)發(fā)率Patientdiscomfort

病人疼痛及不適Otherpotentialcomplications其它潛在并發(fā)癥Tension-FreeRepairs

無張力修補(bǔ)Introducedin19841984年引進(jìn)Improvedresultsoverpriormethodsofrepair在之前的修補(bǔ)方法基礎(chǔ)上取得進(jìn)展

Openanteriorapproach前路開放手術(shù)Steps步驟dealwiththesac處理疝囊meshsuturedtofloorandaroundspermaticcord(betweentransversalisfasciaandexternaloblique)

補(bǔ)片縫扎以覆蓋和包裹精索（在腹橫筋膜和腹外斜肌之間）runningorinterruptedsutures

連續(xù)或間斷縫合Lichtenstein(Onlay)RepairLichtenstein（平片）修補(bǔ)LichtensteinRepairLichtenstein(Onlay)Repair

Lichtenstein（平片）修補(bǔ)LichtensteinTechnique

Lichtenstein技術(shù)Advantages優(yōu)點(diǎn)Tension-FreeAnteriorMeshRepair

無張力前壁修補(bǔ)QuickandEasy

簡單快速EasilyTeachable

易于教授Disadvantages缺點(diǎn)NoPosteriorRepair

沒有后壁修補(bǔ)No“Plugging”ofthedefect

缺損處無填充Extensivecontinuousorinterruptedsuturing

需要廣泛的連續(xù)或間段縫扎

BardPerfixPlugRepairEstablishedin1993

于1993年確立

Open,anteriorapproach

開放的前路手術(shù)Steps步驟

Dealwiththesac處理疝囊Preperitonealdissection腹膜前分離Pluginsertedintodefect&suturedtotransversalisfasciaincorners

將網(wǎng)塞填充入缺損，邊緣與腹橫筋膜縫合固定Keyholemeshsuturedasonlaytofloorofinguinalcanal

上片修補(bǔ)腹股溝管前壁PlugandPatchRepair

網(wǎng)塞修補(bǔ)BardPerfixPlug&Patch

網(wǎng)塞修補(bǔ)Advantages優(yōu)點(diǎn)Quick&Easy簡單迅速“Plugging”ofdefectwithoptionalanteriormeshoverlay

可任選網(wǎng)片來填塞缺損

Disadvantages缺點(diǎn)Meshshrinkage網(wǎng)片收縮Migration移位Patientdiscomfort患者不適ErosionofashrunkensoftMarlex?plugintothebladderwall.

膀胱壁內(nèi)縮小的軟Marlex?塞的腐蝕情況

ImagecourtesyofParvizK.Amid,MD.3plugsinonepatientwitharecurrence.

一位病人的一次復(fù)發(fā)使用三個(gè)網(wǎng)塞

ImagecourtesyofKarlLeBlanc,MD.Plug&PatchRepairPerfixPlug&Patch

網(wǎng)塞修補(bǔ)Introducedin1998

1998年確立Asecureposteriorrepairfromasimpleanteriorapproach

由簡單的前入路方法發(fā)展成為安全后壁修補(bǔ)方法Lowestreportedrecurrencerates

低復(fù)發(fā)率Lowcost

低成本3pointsofprotection

三點(diǎn)保護(hù)8.CombinedAnteriorandPosteriorInguinalHerniaRepair:IntermediaterecurrencerateswiththreegroupsofsurgeonsGilbert,AIetal.Hernia,2004:8:203-207ThePROLENEHerniaSystem(PHS)

普里靈三合一疝裝置(PHS)LaparoscopicHerniorrhaphy

Laparoscopic腔鏡手術(shù)TAPP=TransAbdominalPrePeritoneal經(jīng)腹腔腹膜前修補(bǔ)

LaparoscopicApproachLaparoscopic方法PosteriorRepair后壁修補(bǔ)TAPPTransversalisfascia

腹橫筋膜Mesh補(bǔ)片Incision

切口PreperitonealSpace

腹膜前間隙Trocar

穿刺器Peritoneum

腹膜TAPPwithUltraPro

使用UltraPro的經(jīng)腹腔腹膜前修補(bǔ)TEPTEP=TotallyExtraPeritoneal完全腹膜外修補(bǔ)LaparoscopicApproach腹腔鏡入路PosteriorRepair后壁修補(bǔ)StepsofRepair修補(bǔ)步驟PeritoneumTransversalisfascia

腹橫筋膜Mesh

補(bǔ)片PreperitonealSpace

腹膜前間隙Trocar

穿刺器Peritoneum

腹膜TEPwithUltraPro

用UltraPro的完全腹膜外修補(bǔ)Ventral/IncisionalHernia

腹壁疝/切口疝Agenda

日程VentralHerniaTechniques

腹壁疝修補(bǔ)技術(shù)IssueswithVentralHernias

腹壁疝熱點(diǎn)問題WhatmakesaMesh?

網(wǎng)片由什么制造？IdealMeshAttributes

理想的網(wǎng)片特征Facts

事實(shí)Mostherniasoccurinthemidline

大多數(shù)疝在腹中線發(fā)生Transverseincisiontendstoherniatewheretheycrossthemidline

腹部橫切口在穿過腹中線容易誘發(fā)疝的發(fā)生Initialclosureisveryimportant

手術(shù)切口的縫合非常重要Faultytechniqueuniversallyleadstodevelopmentofherniation

通常手術(shù)縫合或其他操作失誤導(dǎo)致疝發(fā)生YOUNEEDTOKNOWTHEANATOMY!!!VENTRALHERNIA:anatomy

腹壁解剖圖Abdominalwallregion(腹壁區(qū)):EXTERNALOBLIQUE腹外斜肌INTERNALOBLIQUE腹內(nèi)斜肌RECTUS腹直肌TRANSVERSEABDOMINUS

腹橫肌VentralHerniaRepair

腹壁疝修補(bǔ)ProceduralOptions

術(shù)式的選擇History:RepairTechniques

修補(bǔ)技術(shù)發(fā)展史Primaryrepair(Herniorrhaphy)基本修補(bǔ)（疝縫合手術(shù)）Runningsuture連續(xù)縫合Interruptedsuture間斷縫合Vestoverpants重疊縫合MeshRepair–OPEN(Hernioplasty)

網(wǎng)片修補(bǔ)—開放式（疝成形術(shù)）anteriortofascia(onlay)筋膜淺層（層上）Posteriortorectus(Rives-Stoppa-Wantz)腹直肌深面Pre-peritonealorretromuscular腹膜前或腹直肌層深面Inlay(edgesofthedefect)層間（缺損邊緣）Intraperitoneal腹腔內(nèi)MeshRepair–Laparoscopic(Hernioplasty)

網(wǎng)片修補(bǔ)—腔鏡手術(shù)（疝成形術(shù)）Intraperitoneal腹腔內(nèi)VentralHerniaTechniques*

腹壁疝技術(shù)Tension-Free:無張力OpenApproach:67%

開放手術(shù)約67%LaparoscopicApproach:18%

腔鏡手術(shù)約18%Tension:張力Suture:15%

縫合：15%*U.S.figures-thissplitwillvarycountrytocountry在不同國家數(shù)據(jù)有很大差別Issues!

實(shí)例RecurrenceRateofIncisionalHerniaRepair

切口疝修補(bǔ)復(fù)發(fā)率Luijendijketal.NEJM2000

Prospective,Randomized,Multicentertrial

前瞻性的，隨機(jī)的，多中心試驗(yàn)200pts200病例Meshrepairfoundtoresultinlowerrateofrecurrencethesuturerepair(notaffectedbythesizeof