1、1Abdominal External Hernia2pgeneral introduction*definition、etiology、anatomy and clinical types pinguinal hernia*definition、anatomy、Clinical manifestation、diagnosis、Differential diagnosis and treatment pfemoral herniapincisional herniaAbdominal External Hernia3 “Hernia”is derived from the Latin word
2、 for“rupture”.general consideration-Definitionhernia is defined as an abnormal protrusion of an organ or tissue through a defect in its surrounding walls abdominal External hernia is defined as an abnormal protrusion of intra-abdominal tissue or viscera through a defect in the abdominal wall.mostly
3、occur in the groin41.intensity of abdominal wall decreases common factors:1)the site that some tissues pass through the abdominal wall,eg.Spermatic cord,round ligament of uterus.2)bad development of abdominal white line 3)incisional infection,trauma.2.intra-abdominal pressure increases chronic cough
4、,chronic constipation,dysuria,ascites,pregnancy,crygeneral consideration-Etiology5Spermatic cord pass through the abdominal wall 6incisional weakness cause incisional hernia7composition of abdominal external hernia:1.covering tissues:skin,subcutanous tissue2.hernial sac:protrusion of peritoneum,neck
5、 of the sac:is narrow where the sac emerges from the abdomen body of the sac 3.hernial contents:small intestine,major omentumgeneral consideration-anatomy81.reducible hernia is one in which the contents of the sac can return to the abdomen spontaneously or with manual pressure when the patient is su
6、pine.general considerationClinical types92.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.
7、It is may be colon(on the left),cecum(on the right)or bladder(on either side).Belongs to irreducible herniageneral consideration-Clinical types10Sliding hernia sac113.incarcerated hernia is one whose contents cannot be returned to the abdomen,with Severe symptoms.general consideration-Clinical types
8、12Special types of incarcerated herniaRichters hernia (intestinal wall hernia)a hernia involving only one sidewall of the bowel,which can result in bowel strangulation without causing bowel obstruction or any of its warning signs general consideration-Clinical types 13general consideration-Clinical
9、typesSpecial types of incarcerated herniaLittre hernia an incarcerated hernia involving a small international diverticulum (usually Meckel diverticulum).14neckIntra-abdominal gangrene intestinesacgeneral consideration-Clinical typesRetrograde incarcerated hernia(maydl)two adjacent loops of small int
10、estine 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.154.strangulated hernia pressure on the hernial contents may compromise blood supply and cause ischemia,and later necrosis and gangren
11、e,which may become fatal.general consideration-Clinical types how to understand incarcerated hernia and strangulated hernia p The content of the sac in both types are incarceratedp incarcerated hernia isnt with ischemia of tissue strangulated hernia is with ischemia of tissue p incarcerated hernia a
12、nd strangulated hernia are the two stages of a pathologic coursegeneral consideration-Clinical types1617 General consideration Clinical manifestation and diagnosis Differential diagnosis TreatmentInguinal hernias18Definition:a protrusion of tissue or viscera of the abdomen through the inguinal regio
13、n of the abdominal wall.Inguinal hernias-general considerationInguinal hernias are classified as either direct or indirect 19Anatomy of inguinal area(The surgeon must have a comprehensive understanding of the anatomy of the groin in order to properly select and utilize various options for hernia rep
14、air)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:Inguinal hernias-general consideration skin Superficie fascia external oblique muscle and aponeurosis internal oblique muscle Transversus muscle Transversali
15、s fascia peritoneum27there are several special struction that a surgeon should know：Subcutaneous(external)inguinal ring Inguinal ligament Lacunar ligament Coopers ligament(pectineal ligament)Conjoined tendon Internal inguinal ring Iliopubic tractspecial struction in groin28external(superficial)ingui
16、nal ringAn ovoid opening of the external oblique aponeurosis that is positioned superior and slightly lateral to the pubic tubercle 29Inguinal ligament and Lacunar ligamentInguinal ligament is the inferior edge of the external oblique aponeurosis and extends from the anterior superior iliac spine to
17、 the pubic tubercle,turning posteriorly to form a shelving edge.lacunar ligament is formed by the insertion of the inguinal ligament to the pubis30Coopers ligament(pectineal ligament)Inguinal ligament Coopers ligament Coopers ligament is formed by the periosteum and fascia along the superior ramus o
18、f the pubis 31 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 immediately behind the subcutaneous inguinal ring.It is usually conjoint with the tendon of the abdominal internal oblique muscle.Conjoined tendonc
19、onjoined tendonilioinguinal nerve32Internal 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.Iliopubic tract is
20、the thickest portion of the transversalis fascia in the inguinal region.It parallels and lies just medial to the inguinal ligament.Internal inguinal ring and Iliopubic tract 342.Anatomy of inguinal canal definition：inguinal canal is a short passage that runs(obliquely and inferomedially)through the
21、inferior part of the anterior abdominal wall.It runs parallel and slightly superior to the inguinal ligament.Inguinal hernias-general consideration35 boundry：anterior wall:external oblique aponeurosis;internal oblique muscle posterior wall:transversalis fascia;conjoint tendon roof:arching fibers of
22、the internal oblique and transversus abdominis muscles floor:superior surfaces of both the inguinal and lacunar ligaments Inguinal hernias-general considerationopenings:psuperficial(external)inguinal ring pdeep(internal)inguinal ring Contents:pspermatic cords in males or round ligaments in females p
23、ilioinguinal nerve.36Inguinal hernias-general consideration373.Hesselbachs triangle is bounded by:The inferior epigastric vessels The lateral border of the rectus muscle The inguinal ligament Direct Hernia leave the abdomen and protrude through this Triangle.Inguinal hernias-general consideration38
24、Symptoms:A bulge in the inguinal region remains the main diagnostic finding in most groin hernias There may be associated pain or vague discomfort in the region Sign:reducible or irreducible lump Physical examination:The inguinal region should be examined with the patient in both supine and standing
25、 positions The examiner should visually inspect and palpate the inguinal region,observing for asymmetry,bulges,or a mass.Inguinal hernias-Clinical manifestation and diagnosis39Differences between indirect and direct hernia（1）agechildren,youngeraged people40Differences between indirect and direct her
26、nia（2）featureindirectdirectpathway of protrusionPass through the inguinal canal,may enter the scrotumpass through Hesselbachs triangle,rarely enter the scrotum 41indirectdirectfeatureindirectdirectcontours of lumpelliptic,pear-shaped semispheric,wide baseDifferences between indirect and direct herni
27、a（3）41featureindirectdirectcompress the internal ring after reducing herniacontrolleduncontrolledDifferences between indirect and direct hernia（4）4243directDifferences between indirect and direct hernia（5）featureindirectdirectRelationship of spermatic cord with sacPosterior to the sacAnterior and la
28、teral to the sacindirect44Right hernia featureindirectdirectRelationship of sac neck with inferior epigastric arterySac neck is lateral to itSac neck is medial to itDifferences between indirect and direct hernia（6）(Main identification point)45Differences between indirect and direct hernia（7）featurei
29、ndirectdirectIncarcerated incidencehighlow461.hydrocele testis：translucent test(+)Inguinal hernias-Differential diagnosisit is common in infants,swelling or protusion,without discomfort,be municated hydrocele:translucent test(+)3.hydrocele of cord:not reducible,he lump move while pulling same latera
30、l testis4.undescended testis:special sense of pain while pressing the lump，the same lateral testi is vacant.5.acute intestinal obstruction：some intestinal obstruction are caused by incarcerated hernia.So we should inspect groin carefully.Inguinal hernias-Differential diagnosis48p hernias are not ame
31、nable to medical therapy.p palliation can be maintained with the use of a truss.p early diagnosis and surgical repair of hernias is the mainstay of treatment Inguinal hernias-Treatment 49 the goal of surgical treatment is to return the herniated contents and restore the continuity of the abdominal w
32、all.Inguinal hernias-surgical Treatment 4950pmaking a small incision over the hernia,ppushing the bulging tissue back into place premoving the hernia sac(high ligation).pClose and firm hernial orifice(repair of walls of the inguinal cancal).Inguinal hernias-herniorrhaphy 5051Bassini repair:lower edg
33、e of internal oblique muscle and the conjoined tendon are sutured to inguinal ligament.It is widely used.Spermatic cord 5152McVay 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,recur
34、rent hernias,and femoral hernias.Spermatic cord 5253Halsted Repair:like the Bassini repair,but the Spermatic cord is superficial to external oblique aponeurosis external oblique aponeurosis Spermatic cord 5354Shouldice repair:the posterior wall of the inguinal canal is repaired by dividing the trans
35、versalis fascia from the pubis to adjacent to the inferior epigastric vessel,then imbricate sutures5455tension-free repair Great tension in a conventional repair is the principal cause of recurrence(10%).Lichtenstein firstly employ a synthetic mesh prosthesis to bridge the defect and release tissue
36、tension tension-free repair has become the dominant method of inguinal hernia repair recurrence decrease(1%).56The commom patch or mesh5657Inguinal hernias-Treatment 2.operative therapy 3)laparoscopic repair of inguinal herniathe minimally invasive technique of laparoscopic surgery can be used to re
37、pair the most common types of hernias57581.Indications for manual reduction:1)duration 40 years Causes:laxity of groin tissue and elevated intra-abdominal pressureAnatomy of femoral canal Femoral ring fossa ovalis Anterior:inguinal ligament Posterior:pectineal ligament Medial:lacunar ligament Latera
38、l:femoral veinFemoral herniafemoral canal62 Clinical findings and diagnosis Reducible femoral hernia:asymptomatic lump,localized intermittent discomfortIrreducible femoral hernia:constant lump and localized discomfortStrangulated femoral hernia63Differential diagnosis inguinal hernia groin lymph nod
39、es long saphenous varix iliolumbar tuberculous abscessFemoral hernia64TreatmentNot be treated conservativelyRule operation:excision or reduction of the hernial sac,and narrowing of the stretched femoral openingmethods:McVay repairtension-free hernioplastylaparoscopic repair of inguinal hernia 65 An
40、incisional hernia is one which develops at the site of a previous operation.It is the extension of abdominal contents through a defect acquired from the incomplete closure of a previous incision,The most common Risk factors is Wound infection Treatment:Laparoscopic vs.open repair tension-free repair
41、Incisional Hernia66Before operation67Before operation68Post-operation69Pectineal ligamentLateral border of the rectus sheathCoopers ligamentInguinal ligamentInferior epigastric vesselsComponents of Hesselbachs triangle include which of the following anatomic landmarks?70Spigelian herniaGrynfelts her
42、niaPetits herniaRichters herniaLittres herniaWhich of the following hernias represent an incarceration of a limited portion of small bowel?71Jejunum composing the posterior wall of the sacOvary and fallopian tube in a female infantOmentumSigmoid colon composing the posterior wall of the sacCecum com
43、posing the anteromedial wall of the sacA sliding inguinal hernia on the left side is likely to involve which of the following?72The most likely cause is destruction of connective tissue resulting form physical stress.Direct hernias should be repaired promptly because of the risk of incarceration.A direct hernia may be a sliding hernia involving a portion of the bladder wall.A direct hernia may pass through the external inguinal ring.Colon carcinoma is a known cause of direct inguinal hernias.Which of the following statements is/are true regarding direct inguinal hernias?
