Hernia腹外疝教学课件修改稿

1、HerniaGeneral Surgery Department ,The First Affiliated Hospital of Chongqing Medical University Cheng Jun第1页，共87页。 definition、clinical types、 etiology、anatomy Section. General Introduction第2页，共87页。DefinitionsHernia is derived from the Latin word “RuptureHernia is the exit of anorgan, such as thebowe

2、l, through the wall of the cavity in which it normally resides.Abdominal External Hernia is defined as an abnormal protrusion of intra-abdominal tissue or viscera through a defect in the abdominal wall. It mostly occur in the groin第3页，共87页。Types of HerniaDirect inguinal herniaIndirect inguinal herni

3、aFemoral herniaIncisional herniaUmbilical hernia（脐疝）Para-umbilical herniaDiaphragmatic hernia(膈疝)Spigelian hernia（半月线疝）Linea alba hernia(白线疝)Obturator hernia(闭孔疝)Sciatic hernia（坐骨疝）Perineal hernia（会阴疝）第4页，共87页。Etiology 1 Intra-abdominal pressure increased crying / chronic cough / benign prostatic hy

4、perplasia(BPH) / constipation /ascites第5页，共87页。Etiology 2 Intensity of abdominal wall decreasesCommon factorthe site that some tissues pass through the abdominal wall, eg. Spermatic cord, round ligament of uterus.bad development of abdominal white lineincisional infection, trauma. 第6页，共87页。Spermatic

5、 cord via the abdominal wall 第7页，共87页。Incisional weakness cause incisional hernia(after SO)第8页，共87页。composition of abdominal external hernia 1. covering tissues: skin, subcutanous tissue2. hernial sac: protrusion of peritoneum, neck of the sac: the most narrow part of the sac hernial ring (portal):

6、a protrusion to the surface of the portal of hernia, where is the weak points or defects. (hernia named)3. hernial contents: small intestine, major omentum9General consideration-anatomy第9页，共87页。Hernia sacHernia ring spermatic cord第10页，共87页。Hernia sacHernia ringSpermatic cord 第11页，共87页。Types of Herni

7、asReducible hernia is one in which the contents of the sac can return to abdomenal cavity easily or give some manual pressure when the patient is in supine position. “ the Early hernia!第12页，共87页。 Irreducible hernia Hernial contents can not be easily or not fully return back into the abdominal cavity

8、 but does not cause severe symptoms. Repeatedly highlight the hernia contents, caused by hernial sac adhesion. Most of the contents are greater omentum or mesentery.第13页，共87页。 Sliding Hernia sac occurs when an organ drags along part of the peritoneum, or in other words, the organ is part of the hern

9、ia sac. Thecolonand theurinary bladderare often involved. The term also frequently refers tosliding hernias of the stomach.(Belongs to irreducible hernia)第14页，共87页。incarcerated hernia contents or part of hernial contents cannot be returned to the abdomen, without serious symptoms. hernias are trappe

10、d by the narrow neckstrangulated hernia pressure on the hernial contents may endanger blood supply and cause ischemia, at last the intestine appeared necrosis and gangrene.第15页，共87页。 Incarcerated hernianarrow hernia neck small bowel obstruction第16页，共87页。Strangulated herniaMesenteric artery pulse dis

11、appeared, wall gradually lose their luster, elasticity and creep and finally necrosis第17页，共87页。 How to distinguish incarcerated hernia and strangulated hernia? The content of the sac in both types are incarceratedincarcerated hernia -no ischemia of intestine strangulated hernia - ischemia of intesti

12、neincarcerated hernia and strangulated hernia are the two stages of a pathologic course.general considerationClinical types18第18页，共87页。Several special types of hernia sacIntestinal wallRichter Hernia: a hernia involving only one sidewall of the bowel, which can result in bowel strangulation without

13、causing bowel obstruction or any of its warning signs It is named after German surgeonAugust Gottlieb Richter(17421812).第19页，共87页。Littre hernia: a hernia involving aMeckels diverticulum. It is named after the French anatomist Alexis Littr(16581726).第20页，共87页。special types of hernia Retrograde incarc

14、eration Maydls hernia: two adjacent loops of small intestine are within a hernial sac with a tight neck. The intervening portion of bowel within the abdomen is deprived of its blood supply and eventually becomes necrotic.Hernia ringIncarcerated small bowel becomes necrotic in the abdominal cavitysac

15、WHernia ring第21页，共87页。definition、anatomy、Clinical manifestation、diagnosis 、Differential diagnosis and treatmentSection II. Inguinal Hernia第22页，共87页。Definitions Indirect inguinal hernia the most common hernia in males; it is the major type in infants and boys and it still makes up more than 55% of al

16、l the hernias in adults. Direct inguinal hernia Protruding(bulging) from the triangle directly , without inner ring, do not enter the scrotum.第23页，共87页。Anatomy of inguinal area(The surgeon must have a comprehensive of the anatomy of the groin in order to properly select and utilize various options f

17、or hernia repair )1.Anatomic layers of abdominal wall in the groin. The abdominal wall is composed of 7 layers. They are (from anterior to posterior) as follows.24Inguinal hernias-Introduction第24页，共87页。 skin第25页，共87页。 Superficial fascia第26页，共87页。 external oblique muscle and aponeurosis第27页，共87页。 int

18、ernal oblique muscle 第28页，共87页。 Transversus muscle第29页，共87页。 Transversalis fascia第30页，共87页。 peritoneum第31页，共87页。several special structure that a surgeon must to know：Subcutaneous (external) inguinal ringInguinal ligamentLacunar ligamentCoopers ligament (pectineal ligament) Conjoined tendonInternal i

19、nguinal ringIliopubic tract32Some special structure in groin第32页，共87页。33 external (superficial) inguinal ringAn ovoid opening of the external oblique aponeurosis that is positioned superior and slightly lateral to the pubic tubercle 第33页，共87页。34 Inguinal ligament and Lacunar ligamentInguinal ligamen

20、t is the inferior edge of the external oblique aponeurosis and extends from the anterior superior iliac spine to the pubic tubercle, turning posteriorly to form a shelving edge.lacunar ligament is formed by the insertion of the inguinal ligament to the pubis第34页，共87页。35Coopers ligament (pectineal li

21、gament)Inguinal ligament Coopers ligament Coopers ligament is formed by the periosteum and fascia along the superior ramus of the pubis 第35页，共87页。 It is a structure formed from the lower part of transversus abdominal muscle as it inserts into the crest of the pubis and pectineal line behind the subc

22、utaneous inguinal ring. It is usually conjoint with the tendon of the abdominal internal oblique muscle. 36Conjoined tendonconjoined tendonilioinguinal nerve第36页，共87页。Internal inguinal ring is the point at which the spermatic cord or round ligament passes through the transversalis fascia to enter th

23、e inguinal canal. surface marking of Internal inguinal ring : 2cm superior to the point midway of inguinal ligament.Iliopubic tract is the thickest portion of the transversalis fascia in the inguinal region. It parallels and lies just medial to the inguinal ligament. 37Internal inguinal ring and Ili

24、o-pubic tract 第37页，共87页。2.Anatomy of inguinal canal Definition：inguinal canal is a short access which runs (obliquely and inferomedially) through the inferior part of the anterior abdominal wall. 38第38页，共87页。 Boundry of inguinal canal ：Anterior wall :external ablique aponeurosis; internal oblique mu

25、scle Posterior wall: transversalis fascia; conjoint tendon Roof : arching fibers of the internal oblique and transversus abdominis muscles Floor :superior surfaces of both the inguinal and lacunar ligaments 39第39页，共87页。3. Hesselbachs triangle:The inferior epigastric vesselsThe lateral border of the

26、rectus muscleThe inguinal ligamentDirect Hernia leave the abdomen and protrude through this Triangle40Front view第40页，共87页。Back viewOutside（ Inferior epigastric artery)） Bottom（ Inguinal ligament ）insideDirect herniaIndirecthernia第41页，共87页。 Symptoms A bulge in the inguinal region remains the main dia

27、gnostic finding in most groin herniasThere may be associated pain or vague discomfort in the region Sign reducible or irreducible lump Physical examinationThe inguinal region should be examined with the patient in both supine and standing positions The examiner should visually inspect and palpate th

28、e inguinal region, observing for asymmetry, bulges, or a mass.42Inguinal hernias- Clinical manifestation and diagnosis第42页，共87页。Symptoms and Diagnosis Common features: a prominent inguinal mass increases; some patients with only mild early heavy feeling; hernia contents, such as the bowel loops, and

29、 bowel sounds can be heard.第43页，共87页。 Differential DiagnosisAgeDirect herniaindirect hernia第44页，共87页。Contours of Lump indirect inguinaldirect inguinalOval or pear-shapedDome or hemispherical第45页，共87页。pathway of protrusionindirect inguinal direct inguinalpass through Hesselbachs triangle, rarely ente

30、r the scrotum Pass through the inguinal canal, may enter the scrotum第46页，共87页。The relationship between the hernia sac and spermatic cordindirect inguinaldirect inguinalPosterior to the sacAnterior and lateral to the sac第47页，共87页。 Relationship of sac neck with inferior epigastric arteryindirect ingui

31、naldirect inguinal第48页，共87页。incarceration chanceeasyseldemIndirect herniaDirect hernia第49页，共87页。 compress the internal ringIndirect herniaDirect hernia第50页，共87页。Differential Diagnosis Hydrocele Presented by the mass hydrocele completely confined to the scrotumtest of transillumination（+） or opaque第5

32、1页，共87页。Differential Diagnosis communicating hydrocele Hydrocele mass similar in appearance, standing or after getting up each day when the lump appeared and increased slowly. Gradually reduced after the supine or sleep. Extrusion mass, the volume is gradually reduced. Test of transillumination （+）第

33、52页，共87页。Differential Diagnosis Spermatic cord hydrocele Small lumps in the inguinal canal, the stretch can be seen ipsilateral testicular mass movement.第53页，共87页。Section III The treatment of inguinal hernia1、 Non-surgical treatment Adapted: for infants under one year old, accompanied by other serio

34、us diseases in patients with contraindications surgery commonly used methods: hernia with compression 。Truss第54页，共87页。The treatment of inguinal hernia2、 Surgery Traditional hernia repair Tension-free hernia repair Laparoscopic hernia repair第55页，共87页。 Traditional Herniorrhaphy principles : High ligat

35、ion of hernia sac, strengthen or repair inguinal wall High ligation :exposed neck of hernia sac , high ligation and resect the hernia sac. To strengthen or repair the inguinal canal wall: Adults with varying degrees of inguinal hernia( anterior or posterior wall of the weak or defect)第56页，共87页。High

36、ligation第57页，共87页。High ligationmake a small incision over the herniaput the bulging tissue back into Ab cavity remove the hernia sac(high ligation)Close and enhance defect (repair of walls of the inguinal canal)第58页，共87页。 Classic Herniorrhaphystrengthening or repair inguinal canal wall Two typesTo s

37、trengthen the anterior wall To strengthen the posterior wall 第59页，共87页。To strengthen or repair the anterior wall of the inguinal canalFerguson Ferguson : Spermatic cord in the lower edge of the front of the abdominal oblique muscle and joint tendon to the inguinal ligament on the seam, so as to elim

38、inate abdominal oblique muscle and the arcuate lower edge of the gap between the inguinal ligament. For children and young people were no significant transverse fascia defect, the posterior wall of inguinal canal inguinal hernia is still normal and sound.第60页，共87页。Ferguson 第61页，共87页。Ferguson 精索第62页，

39、共87页。To strengthen or repair the posterior wall of the inguinal canal Bassini :是把精索提起，在其后方把腹内斜肌下缘和联合健缝至腹股沟韧带上，置精索于腹内斜肌与腹外斜肌腱膜之间。第63页，共87页。Bassini Bassini repair : lower edge of internal oblique muscle and the conjoined tendon are sutured to inguinal ligament. It is widely used.第64页，共87页。Bassini 第65页

40、，共87页。Halstedexternal oblique fasciae spermatic cordHalsted Repair : like the Bassini repair, but the spermatic cord is superficial to external oblique aponeurosis 第66页，共87页。McVayCoopers ligementInguinal ligamentMcVay repair : lower edge of internal oblique muscle and the conjoined tendon are suture

41、d to Coopers ligament direct. it is popular for direct hernias, large indirect hernias, recurrent hernias, and femoral hernias. 第67页，共87页。ShouldiceShouldice repair : the posterior wall of the inguinal canal is repaired by dividing the transversalis fascia from the pubis to adjacent to the inferior e

42、pigastric vessel, then imbricate sutures第68页，共87页。The development of inguinal hernia repair Since 1884, Bassini had completed of the first cases of hernia repair. Strengthen the posterior wall of the inguinal canal to cure inguinal hernia. Although there are many surgical methods to repair the poste

43、rior wall of the inguinal canal, however, hernia recurrence is a serious problem.第69页，共87页。Domestic statistics (Huang) Recurrence rate of indirect hernia HUANGTINGYAN（1984） 1722% Recurrence rate of direct hernia WANGHAINIAN（1988） 2040%第70页，共87页。 Major problems1. Higher recurrence rate 10%2. Large he

44、rnia, treatment of multiple recurrent hernia3. Severe local pain after hernia repair, restore normal activities and work need a long time.第71页，共87页。Tension-Free Herniorrhaphy Lichtenstein 1987 has proposed, tension-free hernia repair (Tension-Free Herniorrhaphy) theory, namely the use of permanent a

45、rtificial materials do not absorb the polymer repair defects, the hernia repair without disruption of normal anatomical structures and to achieve a tension-free state第72页，共87页。 Tension-Free Herniorrhaphy Plain film tension-free hernia repair surgery (Lichtenstein )-Use a considerable size of the pat

46、ch material is placed in the posterior wall of the inguinal canal.RutKow method-(plug+mesh)GPRVS (Giant prosthetic reinforce of the visceral sac) ，other name is Stoppa method。第73页，共87页。74The commom patch or mesh74第74页，共87页。Plug-Mesh Hernia RepairAdvantages:1. Very low relapse rate 1%2. Simple operat

47、ion, short time3. Minor trauma, postoperative pain lighter4. Return to normal activity and shorter time to work.第75页，共87页。Plug-Mesh Hernia RepairIndications: Apart from children with inguinal hernia, but applicable to all of the inguinal hernia, especially for older hernia, bilateral hernia, a huge hernia and recurrent hernia. Conical polypropylene mesh plug, mesh is difficult to deal with all the ideal material for inguinal hernia.第76页，共87页。Plug-Mesh Hernia RepairPlugMesh第77页，共87页。 Plug-Mes