腹外疝课件英文课件

HerniaGeneral Surgery Department,The First Affiliated Hospital of Chongqing Medical University HerniaGeneralSurgeryDepartmeDEFINITION、CLINICAL TYPES、ETIOLOGY、ANATOMY Section.General Introductiondefinition、clinicaltyDefinitionsHerniaisanoneoftheearliestdiseases,whichderivedfromtheLatinword“Rupture“,inAncientGreek“Hernios”，branchorembryo.nHerniaistheexitofanorgan,suchasthebowel,throughthewallofthecavityinwhichitnormallyresides.nAbdominal External Hernia isdefinedasanabnormalprotrusionofintra-abdominaltissueorviscerathroughadefectintheabdominalwall.ItmostlyoccurinthegroinDefinitionsHerniaisanoneofTypesofHernianDirectinguinalhernianIndirectinguinalhernianFemoralhernianIncisionalhernianUmbilical 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）TypesofHerniaDirectinguinalEtiology1Intra-abdominalpressureincreasedncrying/chroniccough/benignprostatichyperplasia(BPH)/constipation/ascitesEtiology1Intra-abdominalpreEtiology2 IntensityofabdominalwalldecreasesCommonfactornthesitethatsometissuespassthroughtheabdominalwall,eg.Spermaticcord,roundligamentofuterus.nbaddevelopmentofabdominalwhitelinenincisionalinfection,trauma.Etiology2IntensityofabdomiSpermaticcordviatheabdominalwallSpermaticcordviatheabdominIncisionalweaknesscauseincisionalhernia(afterSO)Incisionalweaknesscauseincicompositionofabdominalexternalhernia1.coveringtissues:skin,subcutanoustissue2.hernialsac:protrusionofperitoneum,neckofthesac:themostnarrowpartofthesachernialring(portal):aprotrusiontothesurfaceoftheportalofhernia,whereistheweakpointsordefects.(hernianamed)3.hernialcontents:smallintestine,majoromentum9Generalconsideration-anatomycompositionofabdominalexterHernia sacHernia ring spermatic cordspermatic cordHerniasacHerniaringspermatiHerniasacHerniasacHerniaringSpermatic cord HerniasacHerniaringSpermaticTypesofHerniasReducibleherniaisoneinwhichthecontentsofthesaccanreturntoabdomenalcavityeasilyorgivesomemanualpressurewhenthepatientisinsupineposition.“theEarlyhernia!TypesofHerniasReducibleher Irreduciblehernia Hernialcontentscannotbeeasilyornotfullyreturnbackintotheabdominalcavitybutdoesnotcauseseveresymptoms.Repeatedlyhighlighttheherniacontents,causedbyhernialsacadhesion.Mostofthecontentsaregreateromentumormesentery.SlidingHerniasacoccurswhenanorgandragsalongpartoftheperitoneum,orinotherwords,theorganispartoftheherniasac.Thecolonandtheurinarybladderareofteninvolved.Thetermalsofrequentlyreferstoslidingherniasofthestomach.(Belongstoirreduciblehernia)SlidingHerniasacoccurswhincarceratedherniacontentsorpartofhernialcontentscannotbereturnedtotheabdomen,withoutserioussymptoms.herniasaretrappedbythenarrowneckstrangulatedherniapressureonthehernialcontentsmayendangerbloodsupplyandcauseischemia,atlasttheintestineappearednecrosisandgangrene.incarceratedhernia Incarcerated herniaIncarcerated hernianarrowhernianecksmallbowelobstructionIncarceratedherniaStrangulatedherniaMesentericarterypulsedisappeared,wallgraduallylosetheirluster,elasticityandcreepandfinallynecrosisStrangulatedherniaMesenteric How to distinguish incarcerated hernia and strangulated hernia?pThecontentofthesacinbothtypesareincarceratedpincarceratedhernia-noischemiaofintestinestrangulatedhernia-ischemiaofintestinepincarceratedherniaandstrangulatedherniaarethetwostagesofapathologiccourse.general considerationClinicaltypes18HowtodistinguishincarSeveralspecialtypesofhernia sacsacIntestiIntestinal nal wallwallRichter Hernia:aherniainvolvingonlyonesidewallofthebowel,whichcanresultinbowelstrangulationwithoutcausingbowelobstructionoranyofitswarningsignsItisnamedafterGermansurgeonAugustGottliebRichter(17421812).SeveralspecialtypesofherninLittrehernia:aherniainvolvingaMeckelsdiverticulum.ItisnamedaftertheFrenchanatomistAlexisLittr(16581726).Littrehernia:specialtypesofhernian Retrogradeincarceration Maydlshernia:twoadjacentloopsofsmallintestinearewithinahernialsacwithatightneck.Theinterveningportionofbowelwithintheabdomenisdeprivedofitsbloodsupplyandeventuallybecomesnecrotic.Hernia Hernia ringringIncarcerated small bowel becomes necrotic in the abdominal cavitysacsacWHernia Hernia ringringspecialtypesofherniaDEFINITION、ANATOMY、CLINICAL MANIFESTATION、DIAGNOSIS、DIFFERENTIAL DIAGNOSIS AND TREATMENTSection II.InguinalHerniadefinition、anatomy、ClinicalmaDefinitionsIndirect inguinal herniaIndirect inguinal hernia themostcommonherniainmales;itisthemajortypeininfantsandboysanditstillmakesupmorethan55%ofalltheherniasinadults.Direct inguinal hernia Direct inguinal hernia Protruding(bulging)fromthetriangledirectly,withoutinnerring,notenterthescrotum.DefinitionsIndirectinguinaAnatomy of inguinal area(Thesurgeonmusthaveacomprehensiveoftheanatomyofthegroininordertoproperlyselectandutilizevariousoptionsforherniarepair)1.Anatomic layers of abdominal wall in the groin.Theabdominalwalliscomposedof7layers.Theyare(fromanteriortoposterior)asfollows.24Inguinalhernias-IntroductionAnatomyofinguinalarea24InguskinskinSuperficialfasciaSuperficialfasciaexternalobliquemuscleandaponeurosisexternalobliquemuscleandinternalobliquemuscleinternalobliquemuscleTransversusmuscleTransversusmuscleTransversalisfasciaTransversalisfasciaperitoneumperitoneumseveralspecialstructurethatasurgeonmusttoknow：nSubcutaneous(external)inguinalringnInguinalligamentnLacunarligamentnCoopersligament(pectinealligament)nConjoinedtendonnInternalinguinalringnIliopubictract32Somespecialstructureingroin32Somespecialstructureingr33external(superficial)inguinalringAnovoidopeningoftheexternalobliqueaponeurosisthatispositionedsuperiorandslightlylateraltothepubictubercle33external(superficial)ing34InguinalligamentandLacunarligamentInguinal ligament is the inferior edge of the external oblique aponeurosis and extends from the anterior superior 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 pubis34InguinalligamentandLacun35Coopersligament(pectinealligament)Inguinal ligamentCoopers ligamentCoopers ligamentisformedbytheperiosteumandfasciaalongthesuperiorramusofthepubis35Coopersligament(pectineal Itisastructureformedfromthelowerpartoftransversusabdominalmuscleasitinsertsintothecrestofthepubisandpectineallinebehindthesubcutaneousinguinalring.Itisusuallyconjointwiththetendonoftheabdominalinternalobliquemuscle.36Conjoinedtendonconjoined tendonilioinguinal nerveItisastructureformeInternalinguinalringisthepointatwhichthespermaticcordorroundligamentpassesthroughthetransversalisfasciatoentertheinguinalcanal.surface marking of Internal inguinal ring:2cmsuperiortothepointmidwayofinguinalligament.Iliopubictractisthethickestportionofthetransversalisfasciaintheinguinalregion.Itparallelsandliesjustmedialtotheinguinalligament.37InternalinguinalringandIlio-pubictractInternalinguinalringisthe2.AnatomyofinguinalcanalDefinition：inguinalcanalisashortaccesswhichruns(obliquelyandinferomedially)throughtheinferiorpartoftheanteriorabdominalwall.382.Anatomyofinguinalcanal38Boundryofinguinalcanal：nAnterior wall:externalabliqueaponeurosis;internalobliquemusclenPosterior wall:transversalisfascia;conjointtendonnRoof:archingfibersoftheinternalobliqueandtransversusabdominismusclesnFloor:superiorsurfacesofboththeinguinalandlacunarligaments39Boundryofinguinalcanal：33.Hesselbachstriangle:nTheinferiorepigastricvesselsnThelateralborderoftherectusmusclenTheinguinalligamentDirectHernialeavetheabdomenandprotrudethroughthisTriangle40Front view3.Hesselbachstriangle:40FroBack viewBack viewOutside（Inferiorepigastricartery)）Bottom（Inguinal ligament Inguinal ligament）insideDirectherniaIndirectherniaBackviewOutsideBottSymptoms nAbulgeintheinguinalregionremainsthemaindiagnosticfindinginmostgroinherniasnTheremaybeassociatedpainorvaguediscomfortintheregion Sign nreducibleorirreduciblelumpPhysical examinationnTheinguinalregionshouldbeexaminedwiththepatientinbothsupineandstandingpositionsnTheexaminershouldvisuallyinspectandpalpatetheinguinalregion,observingforasymmetry,bulges,oramass.42Inguinalhernias-ClinicalmanifestationanddiagnosisSymptoms42InguSymptomsandDiagnosisCommonfeatures:aprominentinguinalmassincreases;somepatientswithonlymildearlyheavyfeeling;herniacontents,suchasthebowelloops,andbowelsoundscanbeheard.SymptomsandDiagnosisCommoDifferentialDiagnosisAgeDirectherniaindirectherniaDifferentialDiagnosContours of Lump indirectinguinaldirectinguinalOvalorpear-shapedDomeorhemisphericalContoursofLumpindirectingpathwayofprotrusionindirectinguinaldirectinguinalpassthroughHesselbachstriangle,rarelyenterthescrotumPassthroughtheinguinalcanal,mayenterthescrotumpathwayofprotrusionindireTherelationshipbetweentheherniasacandspermaticcordindirectinguinaldirectinguinalPosterior to the sacAnterior and lateral to the sacTherelationshipbetweentheRelationshipofsacneckwithinferiorepigastricarteryindirectinguinaldirectinguinalRelationshipofsacneckwiincarcerationchanceeasyseldemIndirectherniaIndirectherniaDirectherniaincarcerationchanceeasyselde compress the internal ringIndirect herniaIndirect herniaIndirect herniaIndirect herniaDirect herniaDirect herniaDirect herniaDirect herniacompresstheinternalringInDifferentialDiagnosisHydrocelePresentedbythemasshydrocelecompletelyconfinedtothescrotumtestoftransillumination（+）oropaqueDifferentialDiagnosisHydrDifferentialDiagnosiscommunicatinghydrocele Hydrocelemasssimilarinappearance,standingoraftergettingupeachdaywhenthelumpappearedandincreasedslowly.Graduallyreducedafterthesupineorsleep.Extrusionmass,thevolumeisgraduallyreduced.Testoftransillumination（+）DifferentialDiagnosiscommDifferentialDiagnosisSpermaticcordhydroceleSmalllumpsintheinguinalcanal,thestretchcanbeseenipsilateraltesticularmassmovement.DifferentialDiagnosisSperSectionIIIThetreatmentofinguinalhernia1、Non-surgicaltreatmentAdapted:forinfantsunderoneyearold,accompaniedbyotherseriousdiseasesinpatientswithcontraindicationssurgerycommonlyusedmethods:herniawithcompression。TrussSectionIIIThetreatmentofThetreatmentofinguinalhernia2、SurgeryTraditionalherniarepairTension-freeherniarepairLaparoscopicherniarepairThetreatmentofinguinalherTraditionalHerniorrhaphyprinciples:Highligationofherniasac,strengthenorrepairinguinalwall High ligation:exposedneckofherniasac,highligationandresecttheherniasac.To strengthen or repair the inguinal canal wall:Adultswithvaryingdegreesofinguinalhernia(anteriororposteriorwalloftheweakordefect)TraditionalHerniorrhaphyprHighligationHighligationHighligationpmakeasmallincisionovertheherniapputthebulgingtissuebackintoAbcavitypremovetheherniasac(highligation)pCloseandenhancedefect(repairofwallsoftheinguinalcanal)Highligationmakeasmallinci ClassicHerniorrhaphystrengtheningorrepairinguinalcanalwallTwotypesTostrengthentheanteriorwallTostrengthentheposteriorwallClassicHerniorrhaphystrengTostrengthenorrepairtheanteriorwalloftheinguinalcanalFerguson Ferguson:Spermaticcordintheloweredgeofthefrontoftheabdominalobliquemuscleandjointtendontotheinguinalligamentontheseam,soastoeliminateabdominalobliquemuscleandthearcuateloweredgeofthegapbetweentheinguinalligament.Forchildrenandyoungpeoplewerenosignificanttransversefasciadefect,theposteriorwallofinguinalcanalinguinalherniaisstillnormalandsound.TostrengthenorrepairtheanFerguson FergusonFerguson 精精索索Ferguson精TostrengthenorrepairtheposteriorwalloftheinguinalcanalBassini:是把精索提起，在其后方把腹内斜肌下缘和联合健缝至腹股沟韧带上，置精索于腹内斜肌与腹外斜肌腱膜之间。TostrengthenorrepairthepoBassini Bassini repair:lower edge of internal oblique muscle and the conjoined tendon are sutured to inguinal ligament.It is widely used.BassiniBassinirepair:lowerBassini BassiniHalstedexternal oblique fasciae spermatic cordHalstedRepair:liketheBassinirepair,butthespermaticcordissuperficialtoexternalobliqueaponeurosisHalstedexternalobliquefasciaMcVayCoopersligementInguinal ligamentMcVayrepair:loweredgeofinternalobliquemuscleandtheconjoinedtendonaresuturedtoCoopersligamentdirect.itispopularfordirecthernias,largeindirecthernias,recurrenthernias,andfemoralhernias.McVayCoopersInguinalMcVayreShouldiceShouldicerepair:theposteriorwalloftheinguinalcanalisrepairedbydividingthetransversalisfasciafromthepubistoadjacenttotheinferiorepigastricvessel,thenimbricatesuturesShouldiceShouldicerepair:thThedevelopmentofinguinalherniarepair Since1884,Bassinihadcompletedofthefirstcases of hernia repair.Strengthen the posteriorwalloftheinguinalcanaltocureinguinalhernia.Although there are many surgical methods torepair the posterior wall of the inguinal canal,however,herniarecurrenceisaseriousproblem.ThedevelopmentofinguinalhDomesticstatistics(Huang)Recurrencerateofindirecthernia HUANGTINGYANHUANGTINGYAN（1984）1722%Recurrencerateofdirecthernia WANGHAINIANWANGHAINIAN（19881988）2040%Domesticstatistics(Huang)RMajorproblems1.Higherrecurrencerate10%2.Largehernia,treatmentofmultiplerecurrenthernia3.Severelocalpainafterherniarepair,restorenormalactivitiesandworkneedalongtime.Majorproblems1.HigherrecurTension-FreeHerniorrhaphyLichtenstein1987hasproposed,tension-freeherniarepair(Tension-FreeHerniorrhaphy)theory,namelytheuseofpermanentartificialmaterialsdonotabsorbthepolymerrepairdefects,theherniarepairwithoutdisruptionofnormalanatomicalstructuresandtoachieveatension-freestateTension-FreeHerniorrhaphy Tension-FreeHerniorrhaphynPlainfilmtension-freeherniarepairsurgery(LichtensteinLichtenstein)-Useaconsiderablesizeofthepatchmaterialisplacedintheposteriorwalloftheinguinalcanal.nRutKowmethod-(plug+mesh)nGPRVS(Giantprostheticreinforceofthevisceralsac)，othernameisStoppa method。Tension-FreeHerniorrhaphy74Thecommompatchormesh7474Thecommompatchormesh74Plug-Mesh Hernia RepairnAdvantages:1.Verylowrelapserate 1%1%2.Simpleoperation,shorttime3.Minortrauma,postoperativepainlighter4.Returntonormalactivityandshortertimetowork.Plug-MeshHerniaRepairAdvantPlug-Mesh Hernia RepairnIndications:Apartfromchildrenwithinguinalhernia,butapplicabletoalloftheinguinalhernia,especiallyforolderhernia,bilateralhernia,ahugeherniaandrecurrenthernia.Conicalpolypropylenemeshplug,meshisdifficulttodealwithalltheidealmaterialforinguinalhernia.Plug-MeshHerniaRepairIndicaPlug-Mesh Hernia RepairPlugMeshPlug-MeshHerniaRepairPlugMes Plug-Mesh Hernia RepairPlug-MLichtenstein Hernia RepairLichtensteinHerniaRepairPHS Hernia RepairPHSHerniaRepair81Laparoscopicrepairofinguinalherniatheminimallyinvasivetechniqueoflaparoscopicsurgerycanbeusedtorepairthemostcommontypesofhernias8181LaparoscopicrepairofingIncarceratedherniastrangulatedherniaandtreatmentprinciplesEmergencysurgery ThekeyistocorrectlyjudgetheherniasurgerycontentsofvitalityHowtodeterminetheintestinalnecrosis a.a.Bowelwasdarkpurpleanddullandflexibility b.b.Nointestinalmotilityafterstimulation c c.NotpalpablemesentericarterypulseIncarceratedherniastrangulIncarceratedherniastrangulatedherniaandtreatmentprinciplesNotsureifnecrosis,thefollowingprocedures:a)procaineinjectionof6080ml.b)Warmsalinegauzeandthencoverthesectionofintestinec)returnedtotheabdominalintestine,10to20minutesafterthere-observation.IncarceratedherniastrangulatIncarceratedherniastrangulatedherniaandtreatmentprinciplesn nTreatmentprinciplesforbowelnecrosis:a.a.Abowelresectionandanastomosis:theconditionofpatientspermitted(systemic,local).b.anintestinalExternal:patientsarenotallowed;stoma,removetheobstruction,7to14daysafterthetwoanastomosis.Incarceratedherniastrangulat腹外疝课件英文课件SummarynFocusCauseofhernia,typeandcompositionindirecthernia,directherniaandfemoralherniaclinicalmanifestations,differentialdiagnosisandsurgicaltreatmentofthebasicprinciples,avarietyofsurgicalindications.conceptoftension-freeherniarepairIncarceratedandstrangulatedherniadiagnosisandsurgicalprinciples.SummaryFocusThank you!Thankyou!