1、(外科学课件）11-腹外疝(英)-陈以宽2022-7-182腹外疝腹外疝Abdominal External Hernia Abdominal Wall Hernia Ventral Hernia Department of Abdominal Wall and Peripheral Vascular Disease陈以宽 Abdominal external hernia:protrudes through all layers of the abdominal wall.由腹腔内的脏器或组织连同壁腹膜,经腹壁薄弱点或孔隙，向体表突出而致.Abdominal internal hernia:
2、a protrusion of intestine or tissue through a defect within the peritoneal cavity.2022-7-184 Groin：Inguinal：Indirect，Direct，Combined Femoral Pre/peri-Vessel hernia Anterior Umbilical，Spigelian，Linea alba Artificial fistula-induced,Incisional Pelvic：Obturator，Sciatic，Perineal Posterior：Lumbar：Superio
3、r triangle Inferior triangle Diaphramatic2022-7-1852022-7-186 Superior lumbar trigone(Grynfeltts):more common.is bounded by the 12th rib,paraspinal muscles,and internal oblique muscle.Inferior lumbar trigone(Petits)：Less common.bounded by the iliac crest髂嵴,latissimus dorsi muscle背阔肌,and external obl
4、ique muscle.Repair is best done by placement of prosthetic mesh2022-7-18 Sciatic hernia：extremely unusual and difficult to diagnose and frequently are asymptomatic until intestinal obstruction occurs.an uncomfortable or slowly enlarging mass in the gluteal臀肌or intragluteal area.Prosthetic mesh repai
5、r is usually preferred Spigelian hernia：occurs through the spigelian fascia(semilunar line).Most spigelian hernias are small.often present with localized pain in the area without a bulge.simple suture repair of the transversus abdominis and internal oblique musclesWeakness or defect of abdominal wal
6、l:Site of tissue pass through abdominal wall:spermatic cord,round ligament,femoral vessels,umbilical vessels.Linea alba dysplasia poor wound healing,wound infection,nerve injury of abdominal wall,eldly,obesityChronically increased intra-abdominal pressure:abdominal strain from heavy exercise or lift
7、ing,chronic cough,constipation with straining at stool,prostatism with straining on micturition.cirrhosis with ascitise,pregancy,chronic ambulatory peritoneal dalysis,chronic enlarged pelvic organ or tumors.EtiologyHernia sac:Neck or orifice of a hernia,hernia ring(疝囊颈、疝环、疝门)，named according to the
8、site of hernia ring.Hernia body Content:mainly are intestine，omentum,cecum,colon,sigmoid colon,appendix,bladder.Hernia coveringClinical classificationreducible hernia:contents can be pushed back into the abdomen by applying manual pressure.irreducible hernia:contents cannot or not completely be redu
9、ced.sliding hernia:internal organ comprises a portion of the wall of the hernia sac.usually the bladder or colon(cecum or sigmoid colon).a special challenge in handling the sac.incarcerated hernia:occurs more often when contents protrude through a small orifices.herniated part of intestine is obstru
10、cted but the blood supply to the hernial sac is intact.strangulated hernia：small neck of the hernia obstructs arterial blood flow,venous drainage,or both to the contents of the hernia sac.has compromised blood supply to its contents.a serious and potentially fatal complicationincarcerated hernia and
11、 strangulated hernia are the two stages in one pathologic process.Ritchers hernia:a small portion of the antimesenteric wall of the intestine is trapped within the hernia.Littre heria：intestinal diverticulum(Meckel diverticulum).Both are result in incomplete intestinal obstruction.Sliding hernia：May
12、dl hernia：Hernia-in-W.hernial sac contains two loops of bowel with another loop of bowel being intra-abdominal.The centre portion of the W loop may become strangulated and lies within the abdominal cavity.may result in non-viable bowel being missed.Amyand hernia:appendix is included in the hernial s
13、ac and becomes incarcerated.Symptoms mimicking appendicitis may occur.Treatment consists of a combination of appendectomy and hernia repair2022-7-1812 Inguinal ligament Lateral edge of rectus abdominis Anterior superior iliac spineIndirect inguinal hernia：protrusion of a peritoneal sac through the i
14、nternal inguinal ring.arising lateral to the triangle.Direct inguinal hernia：sac protrudes directly forwards within Hesselbachs triangle.（1）skin、subcutaneous tissues（2）External Oblique Muscle and Aponeurosis;Inguinal ligament(Pouparts ligament)is the inferior edge of the external oblique aponeurosis
15、 and extends from the anterior superior iliac spine to the pubic tubercle,turning posteriorly to form the lacunar(Gimbernats,reflex)ligament;The external(superficial)inguinal ring is an ovoid opening of the external oblique aponeurosis;The spermatic cord exits the inguinal canal through the external
16、 inguinal ring.（3）The internal oblique aponeurosis fuses with fibers from the transversus abdominis aponeurosis to form a conjoined tendon;（4）Transversus Abdominis Muscle and Aponeurosis and Transversalis Fascia;The iliopubic tract(Thomson ligament),is a continuation of the transverse abdominis apon
17、eurosis and fascia;interfoveolar ligament(凹间韧带)（5）Coopers Ligament.In about 75%of patients,there will be a vessel that crosses the lateral border of Coopers ligament and is a direct communication from the obturator and iliac vessels.This is also known as the corona mortis（6）preperitoneal space;，Retz
18、ius space(耻骨膀胱间隙),Bogros spaceImportant nerves iliohypogastric and ilioinguinal nerves provide sensation to the skin of the groin,the base of the penis,and the ipsilateral upper medial thigh.iliohypogastric and ilioinguinal nerves lie beneath the internal oblique muscle to a point just medially and
19、superior to the anterior superior iliac spine.where they penetrate the internal oblique muscle and lie beneath the external oblique aponeurosis.The main trunk of the iliohypogastric nerve runs on the anterior surface of the internal oblique muscle and aponeurosis medial and superior to the internal
20、ring about 4 cm in length.extends between the internal(deep)inguinal and external(superficial)inguinal rings.contains the spermatic cord or round ligament of the uterus.bounded superficially by the external oblique aponeurosis,internal oblique muscle.cephalad wall:internal oblique and transversus ab
21、dominis musculoaponeurosis.inferior wall of the inguinal canal:the inguinal ligament and lacunar ligament.posterior wall or floor of the inguinal canal:the transversalis fascia,falx inguinalis,and the aponeurosis of the transversus abdominis muscle.:rectus sheath inguinal ligament Pathogenesis Conge
22、nital abnormal anatomy:persistent processus vaginalis.Nearly all infants,children and young adult are indirect hernia.Most often present during the first year of life,but first clinical evidence may not appear until middle or old age.An untreated indirect hernia will inevitably dilate the internal i
23、nguinal ring and displace or attenuate the inguinal floor.Acquired weakness or defect of abdominal wall：the result of a developed weakness of the transversalis fascia in Hesslebachs area.Be related to hereditary or acquired defects in collagen synthesis or turnover.Indirect inguinal hernia：A bulge i
24、n the inguinal region,a sense of discomfort or arching pain,may or may not reducible,may descend into the scrotum,reducible,a bulge moving lateral to medial in the inguinal canal,palpable mass with fingertip insert into inguinal canal.irreducible：indigestion,constipationincarcerated：severe pain,inte
25、stinal obstructionStrangulated：pain relieve after perforation direct hernia：symmetric,circular swelling Dont descend into the scrotumSeldom incarcerationSliding(bladder)Distinction of indirect and direct hernia indirect hernia direct herniaOnset age infant,children,adult,elderly adult,elderlyProtrud
26、e through deep inguinal ring Hesselbachs triangleDescend into the scrotum yes noswelling：elliptical symmetric,circularcontrolled by pressure over the internal ring yes no Covered by internal spermatic fascia yes noRelationship to inferioriepigastric vessels lateral to medial to Incarcerated common s
27、eldomAlthough it sometimes can be difficult to distinguish between an indirect and a direct hernia,the distinction is of little importance because the operative repair of these types of hernias is similar.2022-7-1823:diameter of hernia ring1.5cm，posterior inguinal wall intact.:diameter of hernia rin
28、g 1.5-3.0cm，posterior inguinal wall incomplete:diameter of hernia ring 3.0cm，Posterior wall defect,destroying the transversalis fascia of Hesselbachs triangle.:recurrent hernia（Academy of Chinese Hernia 2012).Numerous classification systems for groin hernias exist nowadays,such as CHARTS,Nyhus,Benda
29、vid,Stoppa,EHS and Academy of Chinese Hernia(2003),but none has been accepted widely.Academy of Chinese Hernia 2012 failed to reach a consensus.2022-7-1824 Inguinal hernia Hydrocele testis睾丸鞘膜积液 communicating hydrocele，funicular hydrocele Inguinal adenitis淋巴结炎 Varicocele精索静脉曲张 Ectopic testis异位睾丸 Lip
30、oma脂肪瘤 Hematoma血肿 Sebaceous cyst皮脂囊肿 Psoas abscess腰肌脓肿 Lymphoma淋巴瘤 Metastatic neoplasm Epididymitis附睾炎 Testicular torsion Femoral hernia Femoral artery aneurysm or pseudoaneurysm 子宫内膜异位症Should always be repaired unless there are specific contraindications.Sabiston：a strategy of watchful waiting is s
31、afe for elderly patients with asymptomatic or minimally symptomatic inguinal hernias,and that even though almost 25%of patients eventually undergo repair,when they do,the operative risks and complication rates are no different than those of patients undergoing prophylactic repair.Children of less th
32、an one year old.the use of a truss。patients with Contraindication of hernia repair:severe disease of vital organ.Hernia repair is the most effective therapy for hernia.The increased pressure of abdominal cavity should be treated prior to hernia repair.Chronic cough,constipation,micturition,ascitisTi
33、ssue Repairs Tension-free repairPreperitoneal RepairTissue Repairs传统的疝修补术vAlthough tissue repairs have largely been abandoned because of unacceptably high recurrence rates,they remain useful in certain situations.In strangulated hernias where bowel resection is necessary,mesh prostheses are contrain
34、dicated,and a tissue repair is necessary.Available options for tissue repair include,Ferguson,Halsted,Shouldice,Bassini,and McVay repairs Tissue Repairs Principal of surgery：ligation of hernia ring，hernia repair.ligate the neck of hernia,然后去除疝囊(the sac is divided with cautery near the internal ingui
35、nal ring,leaving the distal sac in situ).Child hernia、strangulated hernia.Reinforce or repair of inguinal canal wall.The weak or defect of inguinal canal wall exists in all adult hernia.Ligation of hernia ring alone cant prevent recurence.Ferguson repair In front of spermatic cord,suturing the trans
36、versus abdominis and internal oblique musculoaponeurotic arches or conjoined tendon to the inguinal ligament.Mainly for young adult.Bassini:Under spermatic cord,suturing the transversus abdominis and internal oblique musculoaponeurotic arches or conjoined tendon to the inguinal ligament.Halsted：afte
37、r Bassini repair,the external oblique aponeuroses was sutured under spermatic cord.Mc Vay：has traditionally been popular for the correction of direct inguinal hernias,large indirect hernias,recurrent hernias,and femoral hernias.Interrupted,nonabsorbable sutures are used to approximate the edge of th
38、e transversus abdominis aponeurosis to Coopers ligament.particularly suited for strangulated femoral hernias.Shouldice:the posterior wall of the inguinal canal was dissected.The initial suture of the transversus abdominis aponeurotic arch to the iliopubic tract.Next,the internal oblique and transver
39、sus abdominis muscles and aponeuroses are sutured to the inguinal ligament.a low recurrence rate and a high degree of patient satisfaction in highly selected patients.The tension-free repair has become the dominant method of inguinal hernia repair.Recognizing that tension in a repair is the principa
40、l cause of recurrence,current practices in hernia management employ a synthetic mesh prosthesis to bridge the defect,a concept first popularized by Lichtenstein.The site of Mesh:Intraperitoneal Onlay Preperitoneal space AponeurosisMaterial：膨化聚四氟乙烯（：膨化聚四氟乙烯（e-PTFE,Expanded-Polytetrafluoroethylene）,聚丙
41、烯聚丙烯（prolene），聚酯（），聚酯（polyester）2022-7-1836There are several options for placement of mesh during anterior inguinal herniorrhaphy:Lichtenstein approachPlug-and-patch technique,the sandwich technique with both an anterior and preperitoneal piece of mesh,(Gilbert)(Prolene Hernia System or Ultraprolene
42、 Hernia System)2022-7-1838轻量型2022-7-1841underlay circular patch onlay patch connectorv The open preperitoneal approach is useful for the repair of recurrent inguinal hernias,sliding hernias,strangulated hernias,and femoral hernias.The posterior approach avoids mobilization of the spermatic cord and
43、injury to the sensory nerves of the inguinal canal,which is particularly important for hernias previously repaired through an anterior approach.Preperitoneal RepairsThe transversalis fascia and transversus abdominis aponeurosis are identified and sutured to the iliopubic tract.A mesh prosthesis is f
44、requently used to reinforce the closure of the femoral canal,particularly with large hernias.giant prosthetic reinforcement of the visceral sac,巨大补片加强内脏囊,),Laparoscopic Management TEP(totally extraperitoneal),TAPP(transabdominal preperitoneal)2022-7-1844 another method of tension-free mesh repair a
45、preperitoneal approach a large mesh covering the myopectineal orifice ongoing debate about the best inguinal hernia repair Proponents tout quicker recovery,less pain,better visualization of anatomy,utility in fixing all inguinal hernia defects,and decreased surgical site infections.Critics emphasize
46、 longer operative times,technical challenges,and increased cost.most agree that this approach has advantages for patients with bilateral or recurrent herniasLaparoscopic ManagementSurgical indication:Type I、II、III and IV(Academy of Chinese Hernia 2003.8)Bilateral and recurrent hernia.Finding occult
47、herniaSurgical contraindication:no absolute contraindications to laparoscopic inguinal hernia repair other than the inability to tolerate general.Strangulated hernia,giant and/or sliding hernia.extensive prior lower abdominal surgery,preperitoneal space previously dissected,Transabdominal Preperiton
48、eal，TAPP：preperitoneal space is accessed after initially entering the peritoneal cavity.working space of the peritoneal cavity make early experience with the laparoscopic approach safer and easier.Mesh covers the direct,indirect,and femoral spaces and rests over the cord structures.imperative that t
49、he peritoneum is closed.Totally Extraperitoneal,TEP：dissection begins in the preperitoneal space.working space is more limited.Intraperitoneal Onlay Mesh,IPOM:mesh in an intraperitoneal position.This approach has largely been abandoned secondary to high recurrence rates and the drawbacks of intraper
50、itoneal mesh(anti-adhesive patch).Incisional herniaSuturing the neck of hernia：Child hernia 1.-4 hours，no peritonitis.2.Severe vital organ disease.Methord：injection of pain-killer.Supine,push back gently.Attentions:gently Close observation of abdominal signs To prevent necrosis of hernia conten,acut
