腹外疝课件ENGLISH.ppt

单击此处编辑母版标题样式,*,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,Abdominal External Hernia,ZHANG Mao,The,first,affiliated hospital,，,chongqing medical university,1,general introduction,*,definition,、,etiology,、,anatomy and clinical types,inguinal hernia,*,definition,、,anatomy,、,Clinical manifestation,、,diagnosis,、,Differential diagnosis and treatment,femoral hernia,incisional hernia,2,Abdominal External Hernia,“Hernia”is derived from the Latin word for“rupture”.,3,general consideration-,Definition,hernia,is defined as an abnormal protrusion of an organ or tissue through a defect in its surrounding walls,abdominal External hernia,is defined as an abnormal protrusion of intra-abdominal tissue or viscera through a defect in the abdominal wall.,mostly occur in the groin,1.intensity of abdominal wall decreases,common factors:,1)the site that some tissues pass through the abdominal wall,eg.Spermatic cord,round ligament of uterus.,2)bad development of abdominal white line,3)incisional infection,trauma.,2.intra-abdominal pressure increases,chronic cough,chronic constipation,dysuria,ascites,pregnancy,cry,4,general consideration-,Etiology,5,Spermatic cord pass through the abdominal wall,6,incisional weakness cause incisional hernia,composition of,abdominal external hernia:,1.,covering tissues,:skin,subcutanous tissue,2.,hernial sac,:protrusion of peritoneum,neck of the sac,:is narrow where the sac emerges from the abdomen,body of the sac,3.,hernial contents,:small intestine,major omentum,7,general consideration-,anatomy,8,1.,reducible hernia,is one in which the contents of,the sac can return to the,abdomen spontaneously,or with manual pressure,when the patient,is supine.,general consideration,-,Clinical types,2.,irreducible hernia,is one whose contents or part of contents cannot be returned to the abdomen,without serious symptoms.hernias are trapped by the narrow neck,Sliding hernia,is one in which the wall of a viscus forms a portion of the wall of the hernia sac.It is may be colon(on the left),cecum(on the right)or bladder(on either side).,Belongs to irreducible hernia,9,general consideration-,Clinical types,10,Sliding hernia sac,3.,incarcerated hernia,is one whose contents,cannot be returned to the abdomen,with Severe symptoms.,11,general consideration-,Clinical types,Special types of incarcerated hernia,Richters hernia,(intestinal wall hernia),a hernia involving only one sidewall of the bowel,which can result in bowel strangulation without causing bowel obstruction or any of its warning signs,12,general consideration-,Clinical types,13,general consideration-,Clinical types,Special types of incarcerated hernia,Littre hernia,an incarcerated hernia involving a small international diverticulum,(usually Meckel diverticulum).,14,neck,Intra-abdominal gangrene intestine,sac,general consideration-,Clinical types,Retrograde incarcerated hernia,(maydl),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.,4.,strangulated hernia,pressure on the hernial contents may compromise blood supply and cause ischemia,and later necrosis and gangrene,which may become fatal.,15,general consideration-,Clinical types,how to understand incarcerated hernia and strangulated hernia,The content of the sac in both types are incarcerated,incarcerated hernia isnt with ischemia of tissue strangulated hernia is with ischemia of tissue,incarcerated hernia and strangulated hernia are the two stages of a pathologic course,general consideration-,Clinical types,16,General consideration,Clinical manifestation and diagnosis,Differential diagnosis,Treatment,17,Inguinal,hernias,Definition:,a protrusion of,tissue or viscera,of the abdomen through the inguinal region of the abdominal wall.,18,Inguinal hernias-,general consideration,Inguinal hernias are classified as either direct or indirect,Anatomy of inguinal area,(The surgeon must have a comprehensive understanding of the anatomy of the groin in order to properly select and utilize various options for 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:,19,Inguinal hernias-,general consideration,skin,Superficie fascia,external oblique muscle and aponeurosis,internal oblique muscle,Transversus muscle,Transversalis,fascia,peritoneum,there are several special struction that a surgeon should know,：Subcutaneous(external)inguinal ring,Inguinal ligament,Lacunar ligament,Coopers ligament(pectineal ligament),Conjoined tendon,Internal inguinal ring,Iliopubic tract,27,special struction in groin,28,external(superficial)inguinal ring,An ovoid opening of the external oblique aponeurosis that is positioned superior and slightly lateral to the pubic tubercle,29,Inguinal ligament and Lacunar ligament,Inguinal ligament,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,30,Coopers ligament,(pectineal ligament),Inguinal ligament,Coopers ligament,Coopers ligament,is formed by the periosteum and fascia along the superior ramus of,the pubis,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 immediately,behind the subcutaneous,inguinal ring.It is usually,conjoint with the tendon,of the abdominal internal,oblique muscle.,31,Conjoined tendon,conjoined,tendon,ilioinguinal nerve,Internal inguinal ring,is the point at which the spermatic cord or round ligament passes through the transversalis fascia to enter the 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.,32,Internal inguinal ring and Iliopubic tract,2.Anatomy of inguinal canal,definition,：,inguinal canal is a short passage that runs(obliquely and inferomedially)through the inferior part of the anterior abdominal wall.It runs parallel and slightly superior to the inguinal ligament.,34,Inguinal hernias-,general consideration,boundry,：,anterior wall,:external ablique aponeurosis;,internal oblique muscle,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,35,Inguinal hernias-,general consideration,openings:,superficial(external)inguinal ring,deep(internal)inguinal ring,Contents:,spermatic cords in males or round ligaments in females,ilioinguinal nerve.,36,Inguinal hernias-,general consideration,3.Hesselbachs triangle,is,bounded by:,The inferior epigastric vessels,The lateral border of the rectus muscle,The inguinal ligament,Direct Hernia leave the abdomen,and protrude through this Triangle.,37,Inguinal hernias-,general consideration,Symptoms,:,A bulge in the inguinal region remains the main diagnostic finding in most groin hernias,There may be associated pain or vague discomfort in the region,Sign,:,reducible or irreducible lump,Physical examination:,The inguinal region should be examined with the patient in both supine and standing positions,The examiner should visually inspect and palpate the inguinal region,observing for asymmetry,bulges,or a mass.,38,Inguinal hernias-,Clinical manifestation and diagnosis,Differences between indirect and direct hernia,（,1,）,feature,indirect,direct,age,children,younger,aged people,39,Differences between indirect and direct hernia,（,2,）,feature,indirect,direct,pathway of protrusion,Pass through the inguinal canal,may enter the scrotum,pass through Hesselbachs triangle,rarely enter the scrotum,40,41,indirect,direct,feature,indirect,direct,contours of lump,elliptic,pear-shaped,semispheric,wide base,Differences between indirect and direct hernia,（,3,）,41,feature,indirect,direct,compress the internal ring after reducing hernia,controlled,uncontrolled,Differences between indirect and direct hernia,（,4,）,42,43,direct,Differences between indirect and direct hernia,（,5,）,feature,indirect,direct,Relationship of spermatic cord with sac,Posterior to the sac,Anterior and lateral to the sac,indirect,44,medial,lateral,Right hernia,feature,indirect,direct,Relationship of sac neck with inferior epigastric artery,Sac neck is lateral,to it,Sac neck is medial to it,Differences between indirect and direct hernia,（,6,）,(Main identification point),45,indirect,direct,Differences between indirect and direct hernia,（,7,）,feature,indirect,direct,Incarcerated incidence,high,low,1,.,hydrocele testis,：,translucent test(+),46,Inguinal hernias-,Differential diagnosis,it is common in infants,swelling or protusion,without discomfortbe transilluminable.,municated hydrocele:,translucent test(+),3.hydrocele of cord:not reducible,he lump move while pulling same lateral testis,4.undescended testis:special sense of pain while pressing the lump,，,the same lateral testi is,vacant.,5.acute intestinal obstruction,：,some intestinal obstruction are caused by incarcerated hernia.So we should,inspect groin carefully.,47,Inguinal hernias-,Differential diagnosis,hernias are not amenable to medical therapy.,palliation can be maintained with the use of a truss.,early diagnosis and surgical repair of hernias is the mainstay of treatment,48,Inguinal hernias,-,Treatment,the goal of surgical treatment is to return the herniated contents and restore the continuity of the abdominal wall.,49,Inguinal hernias-,surgical,Treatment,49,making a small incision over the hernia,pushing the bulging tissue back into place,removing the hernia sac(high ligation).,Close and firm hernial orifice(repair of walls of the inguinal cancal).,50,Inguinal hernias-,herniorrhaphy,50,51,Bassini repair:,lower edge of internal oblique muscle and the conjoined tendon are sutured to inguinal ligament.,It is widely used.,Spermatic cord,51,52,McVay repair:,lower edge of internal oblique muscle and the conjoined tendon are sutured to Coopers ligament direct.it is popular for direct hernias,large indirect hernias,recurrent hernias,and femoral hernias.,Spermatic cord,52,53,Halsted Repair,:,like the Bassini repair,but the Spermatic cord is superficial to external oblique aponeurosis,external oblique aponeurosis,Spermatic cord,53,54,Shouldice repair:,the posterior wall of the inguinal canal is repaired by dividing the transversalis fascia from the pubis to adjacent to the inferior epigastric vessel,then imbricate sutures,54,55,tension-free,repair,Great tension in a conventional repair is the principal cause of recurrence(10%).,Lichtenstein firstly employ a synthetic mesh prosthesis to bridge the defect,and release tissue tension,tension-free repair has become,the dominant method of,inguinal hernia repair,recurrence decrease(1%).,56,The commom,patch or mesh,56,57,Inguinal hernias-Treatment 2.operative therapy,3)laparoscopic repair of inguinal hernia,the minimally invasive technique of laparoscopic surgery can be used to repair the most common types of hernias,57,1.Indications for manual reduction:,1)duration 40 years,Causes:laxity of groin tissue and elevated intra-,abdominal pressure,Anatomy of femoral canal,Femoral ring fossa ovalis,Anterior:inguinal ligament,Posterior:pectineal ligament,Medial:lacunar ligament,Lateral:femoral vein,61,Femoral hernia,femoral canal,Clinical findings and diagnosis,Reducible femoral hernia:asymptomatic lump,localized intermittent discomfort,Irreducible femoral hernia:constant lump and localized discomfort,Strangulated femoral hernia,62,Femoral hernia,Differential diagnosis,inguinal hernia,groin lymph nodes,long saphenous varix,iliolumbar tuberculous abscess,63,Femoral hernia,Treatment,Not be treated conservatively,Rule operation:excision or reduction of the hernial sac,and narrowing of the stretched femoral opening,methods:,McVay repair,tension-free hernioplasty,laparoscopic repair of inguinal hernia,64,Femoral hernia,An incisional hernia is one which develops at the site of a previous operation.It is the extension of abdominal contents through a defect acquired from the incomplete closure of a previous incision,The most common Risk factors is Wound infection,Treatment:,Laparoscopic vs.open repair,tension-free repair,65,Incisional Hernia,66,Before operation,67,Before operation,68,Post-operation,Pectineal ligament,Lateral border of the rectus sheath,Cooper,s ligament,Inguinal ligament,Inferior epigastric vessels,69,Components of Hesselbach,s triangle include which of the following anatomic landmarks?,Spigelian hernia,Grynfelt,s hernia,Petit,s hernia,Richter,s hernia,Littre,s hernia,70,Which of the following hernias represent an incarceration of a limited portion of small bowel?,Jejunum composing the posterior wall of the sac,Ovary and fallopian tube in a female infant,Omentum,Sigmoid colon composing the posterior wall of the sac,Cecum composing the anteromedial wall of the sac,71A sliding inguinal hernia on the left side is likely to involve which of the following?,The most likely cause is destruction of connective tissue resulting form physical stress.,Direct hernias should be repaired promptly because of the risk of incarceration.,A direct hernia may be a sliding hernia involving a portion of the bladder wall.,A direct hernia may pass through the external inguinal ring.,Colon carcinoma is a known cause of direct inguinal hernias.,72,Which of the following statements is/are true regarding direct inguinal hernias?,