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Hernia
DEFINITION、CLINICALTYPES、ETIOLOGY、ANDANATOMY
SectionⅠ.GeneralIntroductionDefinitionsHerniawasderivedfromtheLatinword“Rupture"HerniaisdefinedasanabnormalprotrusionofanorganortissuethroughadefectinitssurroundingwallsAbdominalExternalHerniaisdefinedasanabnormalprotrusionofintra-abdominaltissueorviscerathroughadefectintheabdominalwall.ItmostlyoccurinthegroinTypesofHerniaDirectinguinalherniaIndirectinguinalherniaFemoralherniaIncisionalherniaUmbilicalhernia(脐疝)Para-umbilicalherniaDiaphragmatichernia(膈疝)Spigelianhernia(半月线疝)Lineaalbahernia(白线疝)Obturatorhernia(闭孔疝)Sciatichernia(坐骨疝)Perinealhernia(会阴疝)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
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