腹外疝-課件(同名179)

AbdominalExternalHerniaAbdominalExternalHernia1generalintroduction*

definition、etiology、anatomyandclinicaltypesinguinalhernia*

definition、anatomy、Clinicalmanifestation、diagnosis、Differentialdiagnosisandtreatmentfemoralherniaincisionalhernia2AbdominalExternalHerniageneralintroduction*2Abdomin2

“Hernia”isderivedfromtheLatinwordfor“rupture”.

3generalconsideration

--Definitionherniaisdefinedasanabnormalprotrusionofanorganortissuethroughadefectinitssurroundingwalls

abdominalExternalherniaisdefinedasanabnormalprotrusionofintra-abdominaltissueorviscerathroughadefectintheabdominalwall.mostlyoccurinthegroin“Hernia”isderivedfromth31.intensityofabdominalwalldecreases

commonfactors:1)thesitethatsometissuespassthroughtheabdominalwall,eg.Spermaticcord,roundligamentofuterus.2)baddevelopmentofabdominalwhiteline3)incisionalinfection,trauma.2.intra-abdominalpressureincreaseschroniccough,chronicconstipation,dysuria,ascites,pregnancy,cry4generalconsideration

--Etiology1.intensityofabdominalwall45Spermaticcordpassthroughtheabdominalwall5Spermaticcordpassthrought56incisionalweaknesscauseincisionalhernia6incisionalweaknesscauseinc6compositionofabdominalexternalhernia:1.coveringtissues:skin,subcutanoustissue2.hernialsac:protrusionofperitoneum,

neckofthesac:isnarrowwherethesacemergesfromtheabdomenbodyofthesac3.hernialcontents:smallintestine,majoromentum7generalconsideration

--anatomycompositionofabdominalexter781.reducibleherniaisoneinwhichthecontentsofthesaccanreturntotheabdomenspontaneouslyorwithmanualpressurewhenthepatientissupine.

generalconsideration

--Clinicaltypes81.reducibleherniaisonein82.irreducibleherniaisonewhosecontentsorpartofcontentscannotbereturnedtotheabdomen,withoutserioussymptoms.herniasaretrappedbythenarrowneck

Slidingherniaisoneinwhichthewallofaviscusformsaportionofthewalloftheherniasac.Itismaybecolon(ontheleft),cecum(ontheright)orbladder(oneitherside).Belongstoirreduciblehernia9generalconsideration

--Clinicaltypes2.irreducibleherniaisonew910Slidingherniasac10Slidingherniasac103.incarceratedherniaisonewhosecontentscannotbereturnedtotheabdomen,withSeveresymptoms.

11generalconsideration

--Clinicaltypes3.incarceratedherniaisone11SpecialtypesofincarceratedherniaRichter’shernia

(intestinalwallhernia)aherniainvolvingonlyonesidewallofthebowel,whichcanresultinbowelstrangulationwithoutcausingbowelobstructionoranyofitswarningsigns

12generalconsideration

--

Clinicaltypes

Specialtypesofincarcerated1213generalconsideration

--

Clinicaltypes

SpecialtypesofincarceratedherniaLittrehernia

anincarceratedherniainvolvingasmallinternationaldiverticulum(usuallyMeckeldiverticulum).13generalconsideration

--Cli1314neckIntra-abdominalgangreneintestinesacgeneralconsideration

--

ClinicaltypesRetrogradeincarceratedhernia(maydl)

twoadjacentloopsofsmallintestinearewithinahernialsacwithatightneck.TheinterveningportionofbowelWITHINtheabdomenisdeprivedofitsbloodsupplyandeventuallybecomesnecrotic.

14neckIntra-abdominalgangrene144.strangulatedherniapressureonthehernialcontentsmaycompromisebloodsupplyandcauseischemia,andlaternecrosisandgangrene,whichmaybecomefatal.

15generalconsideration

--

Clinicaltypes4.strangulatedhernia15genera15

howtounderstandincarceratedherniaandstrangulatedhernia

Thecontentofthesacinbothtypesareincarceratedincarceratedherniaisn’twithischemiaoftissuestrangulatedherniaiswithischemiaoftissueincarceratedherniaandstrangulatedherniaarethetwostagesofapathologiccoursegeneralconsideration

--

Clinicaltypes16howtounderstandincarc16GeneralconsiderationClinicalmanifestationanddiagnosisDifferentialdiagnosisTreatment17Inguinal

herniasGeneralconsideration17Inguin17Definition:

aprotrusionoftissueorvisceraoftheabdomenthroughtheinguinalregionoftheabdominalwall.18Inguinalhernias

--generalconsideration

Inguinalherniasareclassifiedaseitherdirectorindirect

Definition:aprotrusionofti18Anatomyofinguinalarea(Thesurgeonmusthaveacomprehensiveunderstandingoftheanatomyofthegroininordertoproperlyselectandutilizevariousoptionsforherniarepair)1.Anatomiclayersofabdominalwallinthegroin.

Theabdominalwalliscomposedof7layers.

Theyare(fromanteriortoposterior)asfollows:19Inguinalhernias

--generalconsiderationAnatomyofinguinalarea19Ingu19⑴skin⑴skin20⑵Superficiefascia⑵Superficiefascia21⑶externalobliquemuscleandaponeurosis⑶externalobliquemuscleand22⑷internalobliquemuscle⑷internalobliquemuscle23⑸Transversusmuscle⑸Transversusmuscle24⑹Transversalisfascia⑹Transversalisfascia25⑺peritoneum⑺peritoneum26thereareseveralspecialstructionthatasurgeonshouldknow：Subcutaneous(external)inguinalringInguinalligamentLacunarligamentCooper’sligament(pectinealligament)ConjoinedtendonInternalinguinalringIliopubictract27specialstructioningroin27specialstructioningroin2728external(superficial)inguinalringAnovoidopeningoftheexternalobliqueaponeurosisthatispositionedsuperiorandslightlylateraltothepubictubercle

28external(superficial)ingui2829InguinalligamentandLacunarligamentInguinalligamentistheinferioredgeoftheexternalobliqueaponeurosisandextendsfromtheanteriorsuperioriliacspinetothepubictubercle,turningposteriorlytoformashelvingedge.lacunarligamentisformedbytheinsertionoftheinguinalligamenttothepubis29InguinalligamentandLacuna2930Cooper’sligament(pectinealligament)Inguinalligament

Cooper’sligament

Cooper’sligamentisformedbytheperiosteumandfasciaalongthesuperiorramusofthepubis

30Cooper’sligament(pectineal30itisastructureformedfromthelowerpartoftransversusabdominalmuscleasitinsertsintothecrestofthepubisandpectineallineimmediatelybehindthesubcutaneousinguinalring.Itisusuallyconjointwiththetendonoftheabdominalinternalobliquemuscle.

31Conjoinedtendonconjoinedtendonilioinguinalnerveitisastructureformedfr31Internalinguinalringisthepointatwhichthespermaticcordorroundligamentpassesthroughthetransversalisfasciatoentertheinguinalcanal.

surfacemarkingofInternalinguinalring:2cmsuperiortothepointmidwayofinguinalligament.Iliopubictractisthethickestportionofthetransversalisfasciaintheinguinalregion.Itparallelsandliesjustmedialtotheinguinalligament.32Internalinguinalring

andIliopubictractInternalinguinalringisthe32腹外疝--課件(同名179)332.Anatomyofinguinalcanal

⑴definition：inguinalcanalisashortpassagethatruns(obliquelyandinferomedially)throughtheinferiorpartoftheanteriorabdominalwall.Itrunsparallelandslightlysuperiortotheinguinalligament.34Inguinalhernias

--generalconsideration2.Anatomyofinguinalcanal34I34⑵boundry：

anteriorwall:externalobliqueaponeurosis;

internalobliquemuscle

posteriorwall:transversalisfascia;conjointtendon

roof

:archingfibersoftheinternalobliqueandtransversusabdominismuscles

floor

:superiorsurfacesofboththeinguinalandlacunarligaments35Inguinalhernias

--generalconsideration⑵boundry：35Inguinalhernias

-35openings:

superficial(external)inguinalringdeep(internal)inguinalringContents:spermaticcordsinmalesorroundligamentsinfemalesilioinguinalnerve.36Inguinalhernias

--generalconsiderationopenings:

36Inguinalhernias

-363.Hesselbach’striangleisboundedby:TheinferiorepigastricvesselsThelateralborderoftherectusmuscleTheinguinalligament

DirectHernialeavetheabdomenandprotrudethroughthisTriangle.37Inguinalhernias

--generalconsideration3.Hesselbach’striangleisbo37

Symptoms:AbulgeintheinguinalregionremainsthemaindiagnosticfindinginmostgroinherniasTheremaybeassociatedpainorvaguediscomfortintheregionSign:reducibleorirreduciblelump

Physicalexamination:TheinguinalregionshouldbeexaminedwiththepatientinbothsupineandstandingpositionsTheexaminershouldvisuallyinspectandpalpatetheinguinalregion,observingforasymmetry,bulges,oramass.38Inguinalhernias

--ClinicalmanifestationanddiagnosisSymptoms:38Inguinalhernias38Differencesbetweenindirectanddirecthernia（1）39Differencesbetweenindirecta39Differencesbetweenindirectanddirecthernia（2）40Differencesbetweenindirecta4041indirectdirectDifferencesbetweenindirectanddirecthernia（3）4141indirectdirectDifferencesbe41Differencesbetweenindirectanddirecthernia（4）42Differencesbetweenindirecta4243directDifferencesbetweenindirectanddirecthernia（5）indirect43directDifferencesbetweenin4344mediallateralRighthernia

Differencesbetweenindirectanddirecthernia（6）(Mainidentificationpoint)44mediallateralRightherniaDi4445indirectdirectDifferencesbetweenindirectanddirecthernia（7）45indirectdirectDifferencesbe451.

hydroceletestis：translucenttest(+)46Inguinalhernias

--Differentialdiagnosisitiscommonininfants,swellingorprotusion,withoutdiscomfort,betransilluminable.1.hydroceletestis：translucen462.communicatedhydrocele:translucenttest(+)3.hydroceleofcord:notreducible,helumpmovewhilepullingsamelateraltestis4.undescendedtestis:specialsenseofpainwhilepressingthelump，thesamelateraltestiisvacant.5.acuteintestinalobstruction：someintestinalobstructionarecausedbyincarceratedhernia.Soweshouldinspectgroincarefully.47Inguinalhernias

--Differentialdiagnosis2.communicatedhydrocele:tran47herniasarenotamenabletomedicaltherapy.palliationcanbemaintainedwiththeuseofatruss.earlydiagnosisandsurgicalrepairofherniasisthemainstayoftreatment

48Inguinalhernias

--Treatment

herniasarenotamenabletome48

thegoalofsurgicaltreatmentistoreturntheherniatedcontentsandrestorethecontinuityoftheabdominalwall.49Inguinalhernias--surgicalTreatment49thegoalofsurgicaltreatm49makingasmallincisionoverthehernia,pushingthebulgingtissuebackintoplaceremovingtheherniasac(highligation).Closeandfirmhernialorifice(repairofwallsoftheinguinalcancal).

50Inguinalhernias--herniorrhaphy50makingasmallincisionovert5051Bassinirepair:

loweredgeofinternalobliquemuscleandtheconjoinedtendonaresuturedtoinguinalligament.Itiswidelyused.Spermaticcord

5151Bassinirepair:loweredge5152McVayrepair:

loweredgeofinternalobliquemuscleandtheconjoinedtendonaresuturedtoCooper’sligamentdirect.itispopularfordirecthernias,largeindirecthernias,recurrenthernias,andfemoralhernias.Spermaticcord

5252McVayrepair:loweredgeof5253HalstedRepair:liketheBassinirepair,buttheSpermaticcordissuperficialtoexternalobliqueaponeurosisexternalobliqueaponeurosisSpermaticcord5353HalstedRepair:liketheBa5354Shouldicerepair:

theposteriorwalloftheinguinalcanalisrepairedbydividingthetransversalisfasciafromthepubistoadjacenttotheinferiorepigastricvessel,thenimbricatesutures5454Shouldicerepair:theposte5455tension-free

repair

Greattensioninaconventionalrepairistheprincipalcauseofrecurrence(10%).Lichtensteinfirstlyemployasyntheticmeshprosthesistobridgethedefectandreleasetissuetension

tension-freerepairhasbecomethedominantmethodofinguinalherniarepairrecurrencedecrease(1%).

55tension-freerepairGreatte5556Thecommompatchormesh5656Thecommompatchormesh565657Inguinalhernias--Treatment

2.operativetherapy

3)laparoscopicrepairofinguinalherniatheminimallyinvasivetechniqueoflaparoscopicsurgerycanbeusedtorepairthemostcommontypesofhernias5757Inguinalhernias--Treatment571.Indicationsformanualreduction:1)duration<3-4hours,nolocaltenderness,noabdominaltenderness,norigidityofabdominalmuscle.2)elderlypatientsorwithotherseverediseases,andtheintestinalloopisstillalive.2.Usuallyrequiresemergencyoperationifmanualreductionisfail.3.bowelsresectionisnecessarywhentheincarceratedbowelsisgangrene,inthiscase,onlyhighligationofthesaccanbedone,andhernioplastyisnotsuitable.583.managementruleofincarceratedandstrangulatedhernia1.Indicationsformanualreduc5859procedure59procedure59606060introductionFemoralherniaisaprotrusionofperitoneumthroughthefemoralcanal.Usuallyinwomen>40yearsCauses:laxityofgrointissueandelevatedintra-abdominalpressureAnatomyoffemoralcanalFemoralring–fossaovalisAnterior:inguinalligamentPosterior:pectinealligamentMedial:lacunarligamentLateral:femoralvein61Femoralherniafemoralcanalintroduction61Femoralherniafe61

Clinicalfindingsanddiagnosis

Reduciblefemoralhernia:asymptomaticlump,localizedintermittentdiscomfortIrreduciblefemoralhernia:constantlumpandlocalizeddiscomfortStrangulatedfemoralhernia62FemoralherniaClinicalfindingsanddiagnos62Differentialdiagnosisinguinalherniagroinlymphnodeslongsaphenousvarixiliolumbartuberculousabscess63FemoralherniaDifferentialdiagnosis63Femora63TreatmentNotbetreatedconservativelyRuleoperation:excisionorreductionofthehernialsac,andnarrowingofthestretchedfemoralopeningmethods:McVayrepairtension-freehernioplastylaparoscopicrepairofinguinalhernia

64FemoralherniaTreatment64Femoralhernia64Anincisionalherniaisonewhichdevelopsatthesiteofapreviousoperation.

Itistheextensionofabdominalcontentsthrougha