1、q general considerationq inguinal herniasq femoral herniaq incisional herniaq umbilial herniaq hernia of linea alba general considerationl 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 visce
2、ra 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 line 3)incisi
3、on,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:covering tissue:skin,subcutanous tissue hernial sac:protrusion of peritonum,n
4、eck of the sac:is narrow where the sac emerges from the abdomen body of the sac 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 the patient is recumbent.2.irredu
5、cible 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),caccum(on the rig
6、ht)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.incarcerated hernia and strangulated hernia are the t
7、wo 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 diverticulum(usually Meckel diverticulum).Reductive incarcer
8、ated 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 hernia:the internal inguinal ring the inguinal canal external inguinal
9、 ring scrotumdirect inguinal hernia:Hesselbachs trianglelAnatomy1.Anatomic layers1)skin,subcutaneous tissue2)external oblique muscle,aponeurosislSubcutaneous(external)inguinal ring:Triangular opening,in the aponeurosis of the external oblique just superior and lateral to the pubic tubercle.Inguinal
10、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 ligament(pectineal ligament)Sensory nerves:iliohypogastric nerve,ilioinguinal ner
11、ve3)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 abdomen and insert with them into the pubic tubercle,forming the conjoined tendon.4)Tran
12、sversalis 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 midway between the anterior superior iliac spine and the pubic tubercle.Iliopubic tract:it i
13、s 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:spermatic cord,round ligament,ilioinguinal nerveWalls:anterior:skin,superficial fascia,and ext
14、ernal ablique aponeurosis posterior:transversalis fascia superior:conjoined tenden inferior:inguinal ligament3 Hesselbachs triangle Bounded by the inguinal ligament,the inferior epigastric vessels,and the lateral edge of rectus muscle.v Causes of indirect inguinal hernia 1.congenital abnormality of
15、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 and diagnosis Symptoms:pain,discomfort,dragging sensation Sign:reducible or irreducible lump,expansile cough im
16、pulse Reducing the hernia fully,compress the internal ring:be controlled indirect not controlled-direct featureindirectdirectagechildren,young peopleaged peoplepathway of protrusioncoming down the inguinal canal,may enter the scrotumpass through Hesselbachs triangle,rarely enter the scrotum contours
17、 of sacelliptic,pear-shapedsemispheric,wide basecompress the internal ring after reducedcontrolledcontrolledRelationship of spermatic cord with sacPosterior to the sacAnterior and lateral to the sacRelationship of sac neck with inferior epigastric arterySac neck is lateral to it Sac neck is medial t
18、o itIncarcerated incidencehighlow1.Differential diagnosis2.1 dydrocele of testis translucent test(+)3.2 communicated hydrocele4.3 hydrocele of cord:not reducible5.4 undescended testis6.5 acute intestinal obstruction7.Treatment 1.nonoperative therapy Indications:1 year old elderly patients or with se
19、vere systemic disease-truss2.operations for inguinal hernia conventional repairsPrinciples:excision or reduction of the hernial sac,high ligation of the sac,and repair the walls of the inguinal canalA:high ligation of hernia sac Used in infants,and patients with severe local infectionB:repair of wal
20、ls 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 latter in a subcutanous position McVay repair:lower edge of internal oblique muscle and the conjoined tendon are approximated to Coo
21、pers 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 pubis to adjacent to the inferior epigastric vessel,then imbricate sutures.Internal ring:pass a fingertip2)tension-free hernioplast
22、y insertion of a prosthetic mesh3)laparoscopic repair of inguinal hernia3.management rule of incarcerated and strangulated herniaIndications for manual reduction:1)duration 40 years Causes:laxity of groin tissue elevated intra-abdominal canallAnatomy of femoral canal Femoral ring fossa ovalis Anteri
23、or:inguinal ligament Posterior:pectineal ligament Medial:lacunar ligament Lateral:femoral veinv Pathologic anatomyfemoral ring femoral canal fossa ovalis subcutaneous tessue of the thigh High incidence of strangulationvClinical findings and diagnosis Reducible femoral hernia:asymptomatic lump,locali
24、zed intermittent discomfort Irreducible femoral hernia:constant lump and localized discomfort Strangulated femoral herniavDifferential diagnosis 1.indirect inguinal hernia 2.lipoma 3.groin lymph nodes 4.long saphenous varix 5.iliolumbar tuberculous abscessvTreatmentNot be treated conservativelyRule
25、operation:excision or reduction of the hernial sac,and narrowing of the stretched femoral openingmethods:McVay repairtension-free hernioplastylaparoscopic repair of inguinal hernia Other abdominal external herniaIncisional herniaIncisional hernia:an abnormal protrusion of a viscus through the muscul
26、oaponeurotic layers of a surgical scar.Wound dehiscencelEtiologyEtiologyPreoperative factorsOperative factors:types of incision:vertical incision,transrectus incision,midline incision,standard parmedian incision technique of closure suture materiaPostoperative factors:increased intra-abdominal press
27、ure,et al.vClinical features and diagnosisClinical features and diagnosisSwelling and mass in the incisionHernial ringRarely incarceratevTreatment 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
28、 umbilical ring,or weakened umbilical tissue2)symptomless,reducible lump3)usually disappear by the age of 2 years4)rarely incarcerate5)surgical repair 2 years2 Adult umbilical hernia1)acquired hernia2)more common in females3)incarceration is common4)surgical repair:excision of the sac,suture the her
29、nia 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
