1、HERNIASDr David SwarGeneral SurgeryQilu HospitalShandong UniversityDefinitionA hernia is the protrusion of an organ through its containing wall.Composition of a herniaThe sacThe covering of the sacThe content of the sacComposition of a herniaThe sac :nIt is a diverticulum of peritoneum and is made u
2、p of three parts :nThe mouth,nThe neck and1. The body of the sac.Composition of a herniaThe covering:nCoverings are derived from the layers of abdominal wall through which the sac passContents:n can benOmentum = omentoclenIntestine = enterocelenPortion of circumference of intestine = Richters hernia
3、nPortion of the bladdernOvary(with or without oviduct)nMeckels diverteculum =Littres herniaEtiologyHernias occur at sites of weakness in the wallThis weakness may be :lNormal (physiological) weakness, related to the anatomical causes.lCongenital abnormality.lAcquired : Traumatic DiseasesVarietiesA h
4、ernia at any site may be:Reducible This is the one which the contents of the sac reduced spontaneously or can be pushed back manually. A reducible hernia imparts an expansile impulse on coughing.Irreducible This one whose contents cannot be returned to the peritoneal cavity either because there are:
5、ladhesions between the sac and contents, or lbecause of the narrow neck of the sac.VarietiesIrreducible hernia can be :Incarcerated: there are adhesions between the sac and the contents, but there is no obstruction or interference with blood supply. the hernia simply will not reduce Obstructed: a ho
6、llow viscus is trapped within the sac and obstruction occurs. The blood supply remains intact. This is a common cause of small bowel obstruction.Strangulated: the arterial blood supply to the contents of the sac is compromised, in such a hernia unless surgical relief is undertaken the contents of th
7、e sac will become gangrenous. ClassificationExternal herniaInternal herniaClassification continueExternal herniaCommon hernia l inguinall Femorall Umbilical l incisionalClassification continueExternal herniaRare hernialSpigelianlGluteallObturatorllumbarClassification continueInternal herniaDiaphragm
8、atic hernialEsophogial hernialParaesophogial herniaSigns and Symptoms- A lump disappears, reappears, and enlarges on straining and discomfort.Physical Signs:lReduced.l+ ve cough impulse.Investigation: Hernia is diagnosed clinically. Investigations are rarely indicated or valuable.ManagementTreatment
9、: hernias should be operatively repaired both to relieve symptoms and to eliminate the complications.lSurgical techniques: Herniotomy: removal of sac and closure of its neck. Herniorrhaphy: involves some sort of reconstruction to: Restore the anatomy if this is disturbed. Increase the strength of th
10、e abdomenal wall. Construct a barrier to recurrence.Inguinal herniaEpidemiology:lMale : Female by 9 to 1 ratiolyoung adults mostly have indirect inguinal hernia. lAs age of patient increases, the incidence of direct hernias increases . Inguinal herniaRisk factors:( increases intra-abdominal pressure
11、 )lChronic cough.lConstipation.lPregnancy.lStraining at micturation.lSevere muscular effort (lifting heavy objects).lAscites - fluid may increase the size of an existing sac.Inguinal herniaInguinal Canal AnatomyAnterior wall: laponeurosis of external oblique (along entire length),linternal oblique o
12、n lateral one thirdPosterior:lfascia transversalislconjoint tendonon in medial one thirdRoof:larching fibers of internal oblique ,andltransversus abdominisFloor (inferior):linguinal ligament, and llacunar ligamen at the medial endInguinal herniaInguinal Canal Contents: Male:lSpermatic cord structure
13、s:vas deferens, testicular artery testicular veins (pampiniform plexus), genital branch of genitofemoral nerve,artery of the vas deference, lymphatics, autonomic nerves,processus vaginalis.Ilio inguinal nerveFemale:lRound ligament of the uterus,lgenital branch of genitofemoral nerve, llymphatics,lsy
14、mpathetic plexus.Inguinal herniaSigns & symptoms:Bulge that enlarges when stand or strain, but often asymptomatic.In general direct hernias produce fewer symptoms than indirect hernias and are less likely to complicate.On examination:lPalpable defect or swelling may be present .lIndirect Hernia usua
15、lly bulge at lDirect Hernia usually bulge at Inguinal herniaThere are two typesof inguinal hernia:lDirect inguinal hernialIndirect inguinal herniaDifferences between direct and indirect herniaslOrigin and coarse:Direct: Develops in the area of Hasselbachs triangle. The origin is medially to the infe
16、rior epigastric vessels.Indirect: Develops at the internal ring. The origin is lateral to the inferior epigastric artery. lContent:Direct: Retroperitoneal fat. less commonly, peritoneal sac containing bowel .Indirect: Sac of peritoneum coming through internal ring, through which omentum or bowel can
17、 enter. lEtiology:Direct: weakness of the posterior floor of the inguinal canal (acquired).Indirect: patent processus vaginalis (Congenital) .Differences between direct and indirect herniasBoundaries of Hasselbachs triangle:lMedially: lateral border of rectus abdominis.lLaterally: inferior epigastri
18、c vessels.lInferiorly: inguinal ligament.Inguinal herniaDifferential diagnosis:lTendonitislMuscle tearlLymphadenopathy lLipomalVaricose veinlHydrocelelEpididymitis1.SpermatoceleInguinal herniaComplications:lIrreducibility, but without signs of obstruction or strangulation lSmall Bowel Obstruction, U
19、sually urgent surgical repair lStrangulation, Surgical emergency 50% indirect, 3-10% direct.Inguinal herniaManagement:Inguinal hernias should always be repaired ( herniotomy, herniorrhaphy ) unless there are specific contraindications.Types of operations:la permanent sutures, as in Shouldice repair
20、(layered suture).1.a permanent mesh -greater frequency to decrease tension.Inguinal hernia managementTreatment of aggravating factors (chronic cough, prostatic obstruction, etc).Use of truss (appliance to prevent hernia from protruding) when a patient refuses operative repair or when there are absol
21、ute contraindications to operationInguinal herniaBoth types (direct and indirect inguinal hernia) may occur at the same time and straddle the inferior epigastric artery.This is called:Pantaloon herniaFemoral herniaThe defect is in the transversalis fascia overlying the femoral ring at the entry to t
22、he femoral canal.The hernia passes through the femoral canal and presents in the groin, below and lateral to the pubic tubercle.It is more common in females and carries a higher risk of strangulation.Femoral canal-ant.by inguinal ligament,post by fascia over pectineus muscle,lat. by femoral vein n m
23、edial by lacunar ligamentFemoral herniaSigns & symptoms:A lump occurs below and lateral to the pubic tubercle. It may be reducible.It may not be noticed until it becomes tender and painful.This type of hernia should be carefully sought in the obese patient who presents with signs of intestinal obstr
24、uction without an obvious cause.DDs-saphena varix,enlarged inguinal LN,femoral artery aneurysm,rare femoral abscess.Femoral herniaSurgical repair:An incision is made directly over the swelling.The sac is opened and the contents reduced and the sac removed.Femoral canal obliterated with 3 interrupted
25、 non absorbable suture.Treatment of strangulation or obstruction, if present.There is no place for a truss in the treatment of femoral hernia.Femoral herniaUmbilical herniaThis occurs in children because of incomplete closure of the umbilical orifice.The majority close spontaneously during the first
26、 year of life.Surgical repair should only be carried out if the hernia has not disappeared by the age of 3 and the fascial defect is greater than 1.5cm in diameter.Para-Umbilical herniaIt occurs just above or just below the umbilicus, and is more common in obese females.Predisposing factors lmultipl
27、e pregnancies andlobesity.Para-Umbilical herniaThe neck of the sac is usually narrow and therefore there is a high risk of strangulation.The most common content isl omentum ,thenl transverse colon and small intestine.Treatment: is by lContents of sac freed from its wall,excision of the sac, and fasc
28、ial defect repaired bylUpper flap overlapping the lower,a two layer overlapping repair thereby doubling the strength of repair (Mayo repair) l4 cm,recurrent-polypropylene meshEpigastric herniaThis is usually a small protrusion through the linea Alba in the upper part of the abdomen.It consists of :l
29、extraperitoneal fat only, butl May contain omentum or small bowel.Epigastric herniaIt may be extremely painful, probably because of trapping and ischaemia of extraperitoneal fat.Treatmentl is by enlaging the defect,excising the fat, simple suture of the defect with non-absorbable sutures .l4 cm prop
30、ylene mesh placed retromuscular planeIncisional herniaThis occurs through a defect in the scar of a previous abdominal incision.Incisional herniaEtiology :lAge: Wound healing is poor in the older patient.lObesity.lPostoperative wound infection.lPostoperative wound haematoma.lRaised intra-abdominal p
31、ressure postoperatively, e.g. coughing, straining, constipation, ileus.lSteroid therapy.lType of incision: Midline vertical wounds have a higher incidence than transverse incisions. lPoor suturing technique: Rarely does a suture breakIncisional herniaSign & symptoms :lA swelling protrudes through th
32、e wound.lIt May occur up to 5 years postoperatively.lMany are large and involve the whole incision and consequently the neck of the sac is wide and the risk of strangulation rare. lIf the defect is small there is a greater risk of strangulation .lTreatment-palliative-abd.beltl - preoperative measure
33、s-reduce weight,treat cough,improve nutritional status.stop smoking.l-surgery:excision of sac,identification n apposition,l-large hernia-poly propylene mesh,Richters herniaPart of the wall of the intestine becomes trapped in the defect.This is usually the antimesenteric border of the small bowel.The
34、 lumen is intact ( no obstruction )Diaphragmatic herniaTraumatic:rare and followed by injuries to chest and abdomen. The Lt diaphragm is affected more than Rt and is accompanied by herniation of stomach and spleen.Hiatus: Sliding. Para-esophegial.Diaphragmatic herniaSliding:l in which the gastroesop
35、hogeal junction itself slides through the defect into the chest.Diaphragmatic herniaPara-esophageallin which the junction remains fixed while another portion of the stomach moves up through the defect.lThis can be dangerous as they may allow the stomach to rotate and obstruct. Hiatus herniaSome othe
36、r herniasSpigelian hernia: lThis is a hernia through the linea semilunaris at the lateral border of the rectus sheath.Littres hernia: lA hernia that contains a Meckels diverticulum in the sac. Obturator hernia:lThis hernia occurs through the obturator foramen. It is commoner in elderly females.Lumbar herniae: lThese occur in the lumbar region (below the 12th rib & above the iliac crest).THANK YOU谢谢你的阅读v知识就是财富v丰富你的人生
