腹外疝课件ENGLISH.ppt

AbdominalExternalHernia ZHANGMaoThefirstaffiliatedhospital chongqingmedicaluniversity 1 generalintroduction definition etiology anatomyandclinicaltypesinguinalhernia definition anatomy Clinicalmanifestation diagnosis Differentialdiagnosisandtreatmentfemoralherniaincisionalhernia 2 AbdominalExternalHernia Hernia isderivedfromtheLatinwordfor rupture 3 generalconsideration Definition herniaisdefinedasanabnormalprotrusionofanorganortissuethroughadefectinitssurroundingwallsabdominalExternalherniaisdefinedasanabnormalprotrusionofintra abdominaltissueorviscerathroughadefectintheabdominalwall mostlyoccurinthegroin 1 intensityofabdominalwalldecreasescommonfactors 1 thesitethatsometissuespassthroughtheabdominalwall eg Spermaticcord roundligamentofuterus 2 baddevelopmentofabdominalwhiteline3 incisionalinfection trauma 2 intra abdominalpressureincreaseschroniccough chronicconstipation dysuria ascites pregnancy cry 4 generalconsideration Etiology 5 Spermaticcordpassthroughtheabdominalwall 6 incisionalweaknesscauseincisionalhernia compositionofabdominalexternalhernia 1 coveringtissues skin subcutanoustissue2 hernialsac protrusionofperitoneum neckofthesac isnarrowwherethesacemergesfromtheabdomenbodyofthesac3 hernialcontents smallintestine majoromentum 7 generalconsideration anatomy 8 1 reducibleherniaisoneinwhichthecontentsofthesaccanreturntotheabdomenspontaneouslyorwithmanualpressurewhenthepatientissupine generalconsideration Clinicaltypes 2 irreducibleherniaisonewhosecontentsorpartofcontentscannotbereturnedtotheabdomen withoutserioussymptoms herniasaretrappedbythenarrowneckSlidingherniaisoneinwhichthewallofaviscusformsaportionofthewalloftheherniasac Itismaybecolon ontheleft cecum ontheright orbladder oneitherside Belongstoirreduciblehernia 9 generalconsideration Clinicaltypes 10 Slidingherniasac 3 incarceratedherniaisonewhosecontentscannotbereturnedtotheabdomen withSeveresymptoms 11 generalconsideration Clinicaltypes SpecialtypesofincarceratedherniaRichter shernia intestinalwallhernia aherniainvolvingonlyonesidewallofthebowel whichcanresultinbowelstrangulationwithoutcausingbowelobstructionoranyofitswarningsigns 12 generalconsideration Clinicaltypes 13 generalconsideration Clinicaltypes SpecialtypesofincarceratedherniaLittreherniaanincarceratedherniainvolvingasmallinternationaldiverticulum usuallyMeckeldiverticulum 14 neck Intra abdominalgangreneintestine sac generalconsideration Clinicaltypes Retrogradeincarceratedhernia maydl twoadjacentloopsofsmallintestinearewithinahernialsacwithatightneck TheinterveningportionofbowelWITHINtheabdomenisdeprivedofitsbloodsupplyandeventuallybecomesnecrotic 4 strangulatedherniapressureonthehernialcontentsmaycompromisebloodsupplyandcauseischemia andlaternecrosisandgangrene whichmaybecomefatal 15 generalconsideration Clinicaltypes howtounderstandincarceratedherniaandstrangulatedherniaThecontentofthesacinbothtypesareincarceratedincarceratedherniaisn twithischemiaoftissuestrangulatedherniaiswithischemiaoftissueincarceratedherniaandstrangulatedherniaarethetwostagesofapathologiccourse generalconsideration Clinicaltypes 16 GeneralconsiderationClinicalmanifestationanddiagnosisDifferentialdiagnosisTreatment 17 Inguinalhernias Definition aprotrusionoftissueorvisceraoftheabdomenthroughtheinguinalregionoftheabdominalwall 18 Inguinalhernias generalconsideration Inguinalherniasareclassifiedaseitherdirectorindirect Anatomyofinguinalarea Thesurgeonmusthaveacomprehensiveunderstandingoftheanatomyofthegroininordertoproperlyselectandutilizevariousoptionsforherniarepair 1 Anatomiclayersofabdominalwallinthegroin Theabdominalwalliscomposedof7layers Theyare fromanteriortoposterior asfollows 19 Inguinalhernias generalconsideration skin Superficiefascia externalobliquemuscleandaponeurosis internalobliquemuscle Transversusmuscle Transversalisfascia peritoneum thereareseveralspecialstructionthatasurgeonshouldknow Subcutaneous external inguinalringInguinalligamentLacunarligamentCooper sligament pectinealligament ConjoinedtendonInternalinguinalringIliopubictract 27 specialstructioningroin 28 external superficial inguinalring Anovoidopeningoftheexternalobliqueaponeurosisthatispositionedsuperiorandslightlylateraltothepubictubercle 29 InguinalligamentandLacunarligament Inguinalligamentistheinferioredgeoftheexternalobliqueaponeurosisandextendsfromtheanteriorsuperioriliacspinetothepubictubercle turningposteriorlytoformashelvingedge lacunarligamentisformedbytheinsertionoftheinguinalligamenttothepubis 30 Cooper sligament pectinealligament Inguinalligament Cooper sligament Cooper sligamentisformedbytheperiosteumandfasciaalongthesuperiorramusofthepubis itisastructureformedfromthelowerpartoftransversusabdominalmuscleasitinsertsintothecrestofthepubisandpectineallineimmediatelybehindthesubcutaneousinguinalring Itisusuallyconjointwiththetendonoftheabdominalinternalobliquemuscle 31 Conjoinedtendon conjoinedtendon ilioinguinalnerve Internalinguinalringisthepointatwhichthespermaticcordorroundligamentpassesthroughthetransversalisfasciatoentertheinguinalcanal surfacemarkingofInternalinguinalring 2cmsuperiortothepointmidwayofinguinalligament Iliopubictractisthethickestportionofthetransversalisfasciaintheinguinalregion Itparallelsandliesjustmedialtotheinguinalligament 32 InternalinguinalringandIliopubictract 2 Anatomyofinguinalcanal definition inguinalcanalisashortpassagethatruns obliquelyandinferomedially throughtheinferiorpartoftheanteriorabdominalwall Itrunsparallelandslightlysuperiortotheinguinalligament 34 Inguinalhernias generalconsideration boundry anteriorwall externalabliqueaponeurosis internalobliquemuscleposteriorwall transversalisfascia conjointtendonroof archingfibersoftheinternalobliqueandtransversusabdominismusclesfloor superiorsurfacesofboththeinguinalandlacunarligaments 35 Inguinalhernias generalconsideration openings superficial external inguinalringdeep internal inguinalringContents spermaticcordsinmalesorroundligamentsinfemalesilioinguinalnerve 36 Inguinalhernias generalconsideration 3 Hesselbach striangleisboundedby TheinferiorepigastricvesselsThelateralborderoftherectusmuscleTheinguinalligamentDirectHernialeavetheabdomenandprotrudethroughthisTriangle 37 Inguinalhernias generalconsideration Symptoms AbulgeintheinguinalregionremainsthemaindiagnosticfindinginmostgroinherniasTheremaybeassociatedpainorvaguediscomfortintheregionSign reducibleorirreduciblelumpPhysicalexamination TheinguinalregionshouldbeexaminedwiththepatientinbothsupineandstandingpositionsTheexaminershouldvisuallyinspectandpalpatetheinguinalregion observingforasymmetry bulges oramass 38 Inguinalhernias Clinicalmanifestationanddiagnosis Differencesbetweenindirectanddirecthernia 1 39 Differencesbetweenindirectanddirecthernia 2 40 41 indirect direct Differencesbetweenindirectanddirecthernia 3 41 Differencesbetweenindirectanddirecthernia 4 42 43 direct Differencesbetweenindirectanddirecthernia 5 indirect 44 medial lateral Righthernia Differencesbetweenindirectanddirecthernia 6 Mainidentificationpoint 45 indirect direct Differencesbetweenindirectanddirecthernia 7 1 hydroceletestis translucenttest 46 Inguinalhernias Differentialdiagnosis itiscommonininfants swellingorprotusion withoutdiscomfort betransilluminable municatedhydrocele translucenttest 3 hydroceleofcord notreducible helumpmovewhilepullingsamelateraltestis4 undescendedtestis specialsenseofpainwhilepressingthelump thesamelateraltestiisvacant 5 acuteintestinalobstruction someintestinalobstructionarecausedbyincarceratedhernia Soweshouldinspectgroincarefully 47 Inguinalhernias Differentialdiagnosis herniasarenotamenabletomedicaltherapy palliationcanbemaintainedwiththeuseofatruss earlydiagnosisandsurgicalrepairofherniasisthemainstayoftreatment 48 Inguinalhernias Treatment thegoalofsurgicaltreatmentistoreturntheherniatedcontentsandrestorethecontinuityoftheabdominalwall 49 Inguinalhernias surgicalTreatment 49 makingasmallincisionoverthehernia pushingthebulgingtissuebackintoplaceremovingtheherniasac highligation Closeandfirmhernialorifice repairofwallsoftheinguinalcancal 50 Inguinalhernias herniorrhaphy 50 51 Bassinirepair loweredgeofinternalobliquemuscleandtheconjoinedtendonaresuturedtoinguinalligament Itiswidelyused 51 52 McVayrepair loweredgeofinternalobliquemuscleandtheconjoinedtendonaresuturedtoCooper sligamentdirect itispopularfordirecthernias largeindirecthernias recurrenthernias andfemoralhernias 52 53 HalstedRepair liketheBassinirepair buttheSpermaticcordissuperficialtoexternalobliqueaponeurosis externalobliqueaponeurosis Spermaticcord 53 54 Shouldicerepair theposteriorwalloftheinguinalcanalisrepairedbydividingthetransversalisfasciafromthepubistoadjacenttotheinferiorepigastricvessel thenimbricatesutures 54 55 tension freerepair Greattensioninaconventionalrepairistheprincipalcauseofrecurrence 10 Lichtensteinfirstlyemployasyntheticmeshprosthesistobridgethedefectandreleasetissuetensiontension freerepairhasbecomethedominantmethodofinguinalherniarepairrecurrencedecrease 1 56 Thecommompatchormesh 56 57 Inguinalhernias Treatment2 operativetherapy3 laparoscopicrepairofinguinalhernia theminimallyinvasivetechniqueoflaparoscopicsurgerycanbeusedtorepairthemostcommontypesofhernias 57 1 Indicationsformanualreduction 1 duration 3 4hours nolocaltenderness noabdominaltenderness norigidityofabdominalmuscle 2 elderlypatientsorwithotherseverediseases andtheintestinalloopisstillalive 2 Usuallyrequiresemergencyoperationifmanualreductionisfail 3 bowelsresectionisnecessarywhentheincarceratedbowelsisgangrene inthiscase onlyhighligationofthesaccanbedone andhernioplastyisnotsuitable 58 3 managementruleofincarceratedandstrangulatedhernia 59 procedure 60 introductionFemoralherniaisaprotrusionofperitoneumthroughthefemoralcanal Usuallyinwomen 40yearsCauses laxityofgrointissueandelevatedintra abdominalpressureAnatomyoffemoralcanalFemoralring fossaovalisAnterior inguinalligamentPosterior pectinealligamentMedial lacunarligamentLateral femoralvein 61 Femoralhernia femoralcanal ClinicalfindingsanddiagnosisReduciblefemoralhernia asymptomaticlump localizedintermittentdiscomfortIrreduciblefemoralhernia constantlumpandlocalizeddiscomfortStrangulatedfemoralhernia 62 Femoralhernia Differentialdiagnosisinguinalherniagroinlymphnodeslongsaphenousvarixiliolumbartuberculousabscess 63 Femoralhernia TreatmentNotbetreatedconservativelyRuleoperation excisionorreductionofthehernialsac andnarrowingofthestretchedfemoralopeningmethods McVayrepairtension freehernioplastylaparoscopicrepairofinguinalhernia 64 Femoralhernia Anincisionalherniaisonewhichdevelopsatthesiteofapreviousoperation Itistheextensionofabdominalcontentsthroughadefectacquiredfromthein