1、q general considerationq inguinal herniasq femoral herniaq incisional herniaq umbilial herniaq hernia of linea alba general considerationv DefinitionHernia means a sprout, and protrusion. External abdominal wall hernia is an abnormal protrusion of intra-abdominal tissue or the whole or part of a vis
2、cera through an opening or fascial defect in the abdominal wall. most occur in the grionvEtiology 1. intensity of abdominal wall decreased common factors: 1) site that some tissues pass through the abdominal wall, eg. Spermatic cord, round ligament of uterus 2) bad development of abdominal white lin
3、e 3) incision, trauma, infection et al. defect in collagen synthesis or turnover 2. any condition which increases intra-abdominal pressure chronic cough, chronic constipation, dysuria, ascites, pregnancy, cryv Pathological anatomy composed of:l covering tissue: skin, subcutanous tissuel hernial sac:
4、 protrusion of peritonum, neck of the sac: is narrow where the sac emerges from the abdomen body of the sac l hernial contents: small intestine, major omentum vClinical types 1. reducible hernia is one in which the contents of the sac return to the abdomen spontaneously or with manual pressure when
5、the patient is recumbent. 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 b
6、e colon ( on the left), caccum (on the right) or bladder (on either side). Belongs to irreducible hernia 3. incarcerated hernia: is one whose contents cannot be returned to the abdomen, with severe symptoms. 4. strangulated hernia: denotes compromise to the blood supply of the contents of the sac. i
7、ncarcerated hernia and strangulated hernia are the two stages of a pathologic course Richters hernia (intestinal wall hernia ) a hernia that has strangulated or incarcerated a part of the intestinal wall without compromising the lumen. Littre hernia: a hernia that has incarcerated the intestinal div
8、erticulum (usually Meckel diverticulum). Reductive incarcerated hernia: reduction of the hernial contents ( intestine ) into abdominal cavity.Inguinal herniasinguinal hernia: a protrusion of part of the contents of the abdomen through the inguinal region of the abdominal wall.indirect inguinal herni
9、a: the internal inguinal ring the inguinal canal external inguinal ring scrotumdirect inguinal hernia: Hesselbachs trianglevAnatomy1. Anatomic layers1) skin, subcutaneous tissue2) external oblique muscle, aponeurosislSubcutaneous (external) inguinal ring: Triangular opening, in the aponeurosis of th
10、e external oblique just superior and lateral to the pubic tubercle.Inguinal ligament: it is formed as the lateral edge of the aponeurosis of external oblique rolls upon itself and thickens into a cord, extending from the anterior superior iliac spine to the pubic tubercle.Lacunar ligamentCoopers lig
11、ament (pectineal ligament)Sensory nerves: iliohypogastric nerve, ilioinguinal nerve3) internal oblique muscle and tranverse abdominal muscleConjoined tendon ( flax inguinalis): the lower fibers of the internal oblique muscle fuse with the lower most arching fibers of the transverse muscle of the abd
12、omen and insert with them into the pubic tubercle, forming the conjoined tendon. 4) Transversalis fasciaInternal 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: 2cm superior to the point m
13、idway between the anterior superior iliac spine and the pubic tubercle.Iliopubic tract: it is the thickest portion of the transversalis fascia in the inguinal region. It parallels and lies just medial to the inguinal ligament.5) extraperitoneal fat and peritoneum2. Anatomy of inguinal canal Contents
14、: spermatic cord, round ligament, ilioinguinal nerveWalls: anterior: skin, superficial fascia, and external ablique aponeurosis posterior: transversalis fascia superior: conjoined tenden inferior: inguinal ligament3 Hesselbachs triangle Bounded by the inguinal ligament, the inferior epigastric vesse
15、ls, and the lateral edge of rectus muscle.v Causes of indirect inguinal hernia 1. congenital abnormality of anatomy due to failure of fusion of the processus vaginalis peritonei after the testis has descended into the scrotum. 2. acquired weakness or defect of abdominal wallvClinical manifestation a
16、nd diagnosis Symptoms: pain, discomfort, dragging sensation Sign: reducible or irreducible lump, expansile cough impulse Reducing the hernia fully, compress the internal ring: be controlled indirect not controlled - direct featureindirectdirectagechildren, young peopleaged peoplepathway of protrusio
17、ncoming down the inguinal canal, may enter the scrotumpass through Hesselbachs triangle, rarely enter the scrotum contours of sacelliptic, pear-shapedsemispheric, wide basecompress the internal ring after reducedcontrolledcontrolledRelationship of spermatic cord with sacPosterior to the sacAnterior
18、and lateral to the sacRelationship of sac neck with inferior epigastric arterySac neck is lateral to it Sac neck is medial to itIncarcerated incidencehighlowvDifferential diagnosisl1 dydrocele of testis translucent test (+)l2 communicated hydrocelel3 hydrocele of cord: not reduciblel4 undescended te
19、stisl5 acute intestinal obstructionvTreatment 1. nonoperative therapy Indications: 1 year old elderly patients or with severe systemic disease-truss2. operations for inguinal hernia conventional repairsPrinciples: excision or reduction of the hernial sac, high ligation of the sac, and repair the wal
20、ls of the inguinal canalA: high ligation of hernia sac Used in infants, and patients with severe local infectionB: repair of walls of the inguinal cancal I repair of the anterior wall of the inguinal canal Ferguson repair II Repair of the posterior wall Bassini repair Halsted repair: placing the lat
21、ter in a subcutanous position McVay repair: lower edge of internal oblique muscle and the conjoined tendon are approximated to Coopers ligament on the iliopectineal line of the pubis. Shouldice repair: the posterior wall of the inguinal canal is repaired by dividing the transversalis fascia from the
22、 pubis to adjacent to the inferior epigastric vessel, then imbricate sutures. Internal ring: pass a fingertip2) tension-free hernioplasty insertion of a prosthetic mesh3) laparoscopic repair of inguinal hernia3. management rule of incarcerated and strangulated herniaIndications for manual reduction:
23、 1) duration 40 years Causes: laxity of groin tissue elevated intra-abdominal canalvAnatomy of femoral canal Femoral ring fossa ovalis Anterior: inguinal ligament Posterior: pectineal ligament Medial: lacunar ligament Lateral: femoral veinv Pathologic anatomyfemoral ring femoral canal fossa ovalis s
24、ubcutaneous tessue of the thigh High incidence of strangulationvClinical findings and diagnosis Reducible femoral hernia: asymptomatic lump, localized intermittent discomfort Irreducible femoral hernia: constant lump and localized discomfort Strangulated femoral herniavDifferential diagnosis 1. indi
25、rect inguinal hernia 2. lipoma 3. groin lymph nodes 4. long saphenous varix 5. iliolumbar tuberculous abscessvTreatmentNot be treated conservativelyRule operation: excision or reduction of the hernial sac, and narrowing of the stretched femoral openingmethods: lMcVay repairltension-free hernioplasty
26、llaparoscopic repair of inguinal hernia Other abdominal external herniaIncisional herniaIncisional hernia: an abnormal protrusion of a viscus through the musculoaponeurotic layers of a surgical scar.Wound dehiscencevEtiologyEtiologyPreoperative factorsOperative factors: types of incision: vertical i
27、ncision, transrectus incision, midline incision, standard parmedian incision technique of closure suture materiaPostoperative factors: increased intra-abdominal pressure, et al.vClinical features and diagnosisClinical features and diagnosisSwelling and mass in the incisionHernial ringRarely incarcer
28、atevTreatment Treatment Operative repair: the same way as a laparotomy wound is repaired, or use mesh Umbilical hernia 1 infantile umbilical hernia1) failure of fusion of umbilical ring, or weakened umbilical tissue2) symptomless, reducible lump3) usually disappear by the age of 2 years4) rarely inc
29、arcerate5) surgical repair 2 years2 Adult umbilical hernia1) acquired hernia2) more common in females3) incarceration is common4) surgical repair: excision of the sac, suture the hernia ringHernia of linea albaEpigastric herniaIt is a protrusion of preperitoneal fat and / or peritoneal sac through a gap in the decussating fibers of the linea alba, usually the supraumbilical portion of the linea alba.Most are asymptomatic, or vague upper abdominal pain and nausea may be present.Surgical repair
