1、General Surgery Department ,The First Affiliated Hospital of Chongqing Medical University DEFINITION、CLINICAL TYPES、 ETIOLOGY、ANATOMY Section. General IntroductionDefinitionsHernia is an one of the earliest diseases, which derived from the Latin word “Rupture“, in Ancient Greek“Hernios”，branch or em
2、bryo.p Hernia is the exit of an organ, such as the bowel, through the wall of the cavity in which it normally resides.p Abdominal External Hernia is defined as an abnormal protrusion of intra-abdominal tissue or viscera through a defect in the abdominal wall. It mostly occur in the groinTypes of Her
3、nialDirect inguinal hernialIndirect inguinal hernialFemoral hernialIncisional hernianUmbilical hernia（脐疝）（脐疝）nPara-umbilical hernianDiaphragmatic hernia(膈疝膈疝)nSpigelian hernia（半月线疝）（半月线疝）nLinea alba hernia(白线疝白线疝)nObturator hernia(闭孔疝闭孔疝)nSciatic hernia（坐骨疝）（坐骨疝）nPerineal hernia（会阴疝）（会阴疝）Etiology 1
4、Intra-abdominal pressure increased ncrying / chronic cough / benign prostatic hyperplasia(BPH) / constipation /ascitesEtiology 2 Intensity of abdominal wall decreasesCommon factorpthe site that some tissues pass through the abdominal wall, eg. Spermatic cord, round ligament of uterus.pbad developmen
5、t of abdominal white linepincisional infection, trauma. Spermatic cord via the abdominal wall Incisional weakness cause incisional hernia(after SO)composition of abdominal external hernia 1. covering tissues: skin, subcutanous tissue2. hernial sac: protrusion of peritoneum, neck of the sac: the most
6、 narrow part of the sac hernial ring (portal): : a protrusion to the surface of the portal of hernia, where is the weak points or defects. (hernia named)3. hernial contents: small intestine, major omentum9General consideration-anatomyHernia sacHernia ring Hernia ringSpermatic cord Types of HerniasRe
7、ducible hernia is one in which the contents of the sac can return to abdomenal cavity easily or give some manual pressure when the patient is in supine position. “ the Early hernia! Irreducible hernia Hernial contents can not be easily or not fully return back into the abdominal cavity but does not
8、cause severe symptoms. Repeatedly highlight the hernia contents, caused by hernial sac adhesion. Most of the contents are greater omentum or mesentery. Sliding Hernia sac occurs when an organ drags along part of the peritoneum, or in other words, the organ is part of the hernia sac. The colon and th
9、e urinary bladder are often involved. The term also frequently refers to sliding hernias of the stomach.(Belongs to irreducible hernia)incarcerated hernia contents or part of hernial contents cannot be returned to the abdomen, without serious symptoms. hernias are trapped by the narrow neckstrangula
10、ted herniapressure on the hernial contents may endanger blood supply and cause ischemia, at last the intestine appeared necrosis and gangrene. Incarcerated herniaIncarcerated hernianarrow hernia neck small bowel obstructionStrangulated herniaMesenteric artery pulse disappeared, wall gradually lose t
11、heir luster, elasticity and creep and finally necrosis How to distinguish incarcerated hernia and strangulated hernia? p The content of the sac in both types are incarceratedp incarcerated hernia -no ischemia of intestine strangulated hernia - ischemia of intestinep incarcerated hernia and strangula
12、ted hernia are the two stages of a pathologic course.general considerationClinical types18 Several special types of hernia sac sacIntestinal Intestinal wallwallRichter Hernia: a hernia involving only one sidewall of the bowel, which can result in bowel strangulation without causing bowel obstruction
13、 or any of its warning signs It is named after German surgeon August Gottlieb Richter (17421812).nLittre hernia: a hernia involving a Meckels diverticulum. It is named after the French anatomist Alexis Littr (16581726). special types of hernian Retrograde incarceration Maydls hernia: two adjacent lo
14、ops 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.Hernia Hernia ringringIncarcerated small bowel becomes necrotic in the abdominal cavitysacsacWHernia Hernia ringringD
15、EFINITION、ANATOMY、CLINICAL MANIFESTATION、DIAGNOSIS 、DIFFERENTIAL DIAGNOSIS AND TREATMENTSection II. Inguinal HerniaDefinitions Indirect inguinal herniaIndirect inguinal hernia the most common hernia in males; it is the major type in infants and boys and it still makes up more than 55% of all the her
16、nias in adults. Direct inguinal hernia Direct inguinal hernia Protruding(bulging) from the triangle directly , without inner ring, not enter the scrotum.Anatomy of inguinal area(The surgeon must have a comprehensive of the anatomy of the groin in order to properly select and utilize various options
17、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.24Inguinal hernias-Introduction skin Superficial fascia external oblique muscle and aponeurosis internal oblique muscle Transversus muscle
18、 Transversalis fascia peritoneumseveral special structure that a surgeon must to know：nSubcutaneous (external) inguinal ringnInguinal ligamentnLacunar ligamentnCoopers ligament (pectineal ligament) nConjoined tendonnInternal inguinal ringnIliopubic tract32Some special structure in groin33 external (
19、superficial) inguinal ringAn ovoid opening of the external oblique aponeurosis that is positioned superior and slightly lateral to the pubic tubercle 34 Inguinal ligament and Lacunar ligamentInguinal ligament is the inferior edge of the external oblique aponeurosis and extends from the anterior supe
20、rior 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 pubis35Coopers ligament (pectineal ligament)Inguinal ligament Coopers ligament Coopers ligament is formed by the periosteum and fascia along
21、 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 behind the subcutaneous inguinal ring. It is usually conjoint with the tendon of the abdominal internal oblique muscle. 36Conjoin
22、ed tendonconjoined tendonilioinguinal nerveInternal 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.Iliopubi
23、c tract is the thickest portion of the transversalis fascia in the inguinal region. It parallels and lies just medial to the inguinal ligament. 37Internal inguinal ring and Ilio-pubic tract 2.Anatomy of inguinal canal Definition：inguinal canal is a short access which runs (obliquely and inferomedial
24、ly) through the inferior part of the anterior abdominal wall. 38 Boundry of inguinal canal ：uAnterior wall :external ablique aponeurosis; internal oblique muscle u Posterior wall: transversalis fascia; conjoint tendon u Roof : arching fibers of the internal oblique and transversus abdominis muscles
25、u Floor :superior surfaces of both the inguinal and lacunar ligaments 393. Hesselbachs triangle:uThe inferior epigastric vesselsuThe lateral border of the rectus muscleuThe inguinal ligamentDirect Hernia leave the abdomen Direct Hernia leave the abdomen and protrude through this Triangleand protrude
26、 through this Triangle40Front viewBack viewOutside（ Inferior epigastric artery)） Bottom（ Inguinal ligament Inguinal ligament ）insideDirect herniaIndirecthernia Symptoms nA bulge in the inguinal region remains the main diagnostic finding in most groin herniasnThere may be associated pain or vague dis
27、comfort in the region Sign n reducible or irreducible lump Physical examinationnThe inguinal region should be examined with the patient in both supine and standing positions n The examiner should visually inspect and palpate the inguinal region, observing for asymmetry, bulges, or a mass.42Inguinal
28、hernias- Clinical manifestation and diagnosisSymptoms and DiagnosisCommon features: a prominent inguinal mass increases; some patients with only mild early heavy feeling; hernia contents, such as the bowel loops, and bowel sounds can be heard. Differential DiagnosisAgeDirect herniaindirect hernia on
29、tours of Lumpindirect inguinaldirect inguinalOval or pear-shapedDome or hemispherical pathway of protrusionindirect inguinal direct inguinalpass through Hesselbachs triangle, rarely enter the scrotum Pass through the inguinal canal, may enter the scrotum The relationship between the hernia sac and s
30、permatic cordindirect inguinaldirect inguinalPosterior to the sacAnterior and lateral to the sac Relationship of sac neck with inferior epigastric arteryindirect inguinaldirect inguinal easyseldemDirect hernia compress the internal ring Differential Diagnosis Hydrocele Presented by the mass hydrocel
31、e completely confined to the scrotumtest of transillumination（+） or opaque Differential Diagnosis communicating hydrocele Hydrocele mass similar in appearance, standing or after getting up each day when the lump appeared and increased slowly. Gradually reduced after the supine or sleep. Extrusion ma
32、ss, the volume is gradually reduced. Test of transillumination （+ +）Differential Diagnosis Spermatic cord hydrocele Small lumps in the inguinal canal, the stretch can be seen ipsilateral testicular mass movement.Section III The treatment of inguinal hernia1、 Non-surgical treatment Adapted: for infan
33、ts under one year old, accompanied by other serious diseases in patients with contraindications surgery commonly used methods: hernia with compression 。TrussThe treatment of inguinal hernia2、 Surgery Traditional hernia repair Tension-free hernia repair Laparoscopic hernia repair Traditional Herniorr
34、haphy principles : High ligation of hernia sac, strengthen or repair inguinal wall High ligation :exposed neck of hernia sac , high ligation and resect the hernia sac. To strengthen or repair the inguinal canal wall: Adults with varying degrees of inguinal hernia( anterior or posterior wall of the w
35、eak or defect)High ligationHigh ligationpmake a small incision over the herniapput the bulging tissue back into Ab cavity premove the hernia sac(high ligation)pClose and enhance defect (repair of walls of the inguinal canal) Classic Herniorrhaphystrengthening or repair inguinal canal wall Two typesT
36、o strengthen the anterior wall To strengthen the posterior wall To strengthen or repair the anterior wall of the inguinal canalFerguson Ferguson : Spermatic cord in the lower edge of the front of the abdominal oblique muscle and joint tendon to the inguinal ligament on the seam, so as to eliminate a
37、bdominal oblique muscle and the arcuate lower edge of the gap between the inguinal ligament.For children and young people were no significant transverse fascia defect, the posterior wall of inguinal canal inguinal hernia is still normal and sound.Ferguson Ferguson 精精索索To strengthen or repair the pos
38、terior wall of the inguinal canal Bassini :Bassini Bassini repair : lower edge of internal oblique muscle and the conjoined tendon are sutured to inguinal ligament. It is widely used.Bassini Halstedexternal oblique fasciae spermatic cordHalsted Repair : like the Bassini repair, but the spermatic cor
39、d is superficial to external oblique aponeurosis McVayCoopers ligementInguinal ligamentMcVay 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 hernia
40、s. ShouldiceShouldice 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 suturesThe development of inguinal hernia repair Since 1884, Bassini had completed of the first cases
41、of hernia repair. Strengthen the posterior wall of the inguinal canal to cure inguinal hernia. Although there are many surgical methods to repair the posterior wall of the inguinal canal, however, hernia recurrence is a serious problem.Domestic statistics (Huang) Recurrence rate of indirect hernia（1
42、9841722% Recurrence rate of direct hernia2040% Major problems1. Higher recurrence rate 10%2. Large hernia, treatment of multiple recurrent hernia3. Severe local pain after hernia repair, restore normal activities and work need a long time. Lichtenstein 1987 has proposed, tension-free hernia repair (
43、Tension-Free Herniorrhaphy) theory, namely the use of permanent artificial materials do not absorb the polymer repair defects, the hernia repair without disruption of normal anatomical structures and to achieve a tension-free stateTension-Free Herniorrhaphy pPlain film tension-free hernia repair sur
44、gery ()-Use a considerable size of the patch material is placed in the posterior wall of the inguinal canal.pRutKow method-(plug+mesh)pGPRVS (Giant prosthetic reinforce of the visceral sac) ，other name is Stoppa method。74The commom patch or mesh74nAdvantages:1. Very low relapse rate2. Simple operati
45、on, short time3. Minor trauma, postoperative pain lighter4. Return to normal activity and shorter time to work.nIndications: Apart from children with inguinal hernia, but applicable to all of the inguinal hernia, especially for older hernia, bilateral hernia, a huge hernia and recurrent hernia. Coni
46、cal polypropylene mesh plug, mesh is difficult to deal with all the ideal material for inguinal hernia.81 Laparoscopic repair of inguinal herniathe minimally invasive technique of laparoscopic surgery can be used to repair the most common types of hernias81 Incarcerated hernia strangulated hernia an
47、d treatment principles Emergency surgeryThe key is to correctly judge the hernia surgery contents of vitality How to determine the intestinal necrosis Bowel was dark purple and dull and flexibility No intestinal motility after stimulation Not palpable mesenteric artery pulseIncarcerated hernia stran
48、gulated hernia and treatment principles Not sure if necrosis, the following procedures:a)procaine injection of 60 80ml.b)Warm saline gauze and then cover the section of intestinec)returned to the abdominal intestine, 10 to 20 minutes after the re-observation.Incarcerated hernia strangulated hernia a
49、nd treatment principlesTreatment principles for bowel necrosis: A bowel resection and anastomosis: the condition of patients permitted (systemic, local).b. an intestinal External: patients are not allowed; stoma, remove the obstruction, 7 to 14 days after the two anastomosis.SummarynFocus Cause of h
50、ernia, type and composition indirect hernia, direct hernia and femoral hernia clinical manifestations, differential diagnosis and surgical treatment of the basic principles, a variety of surgical indications. concept of tension-free hernia repair Incarcerated and strangulated hernia diagnosis and su
