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1、腹股沟区和腹壁的解剖和手术,Objectives 目的,Describe what causes hernias阐述疝气成因 Classify the types of hernias疝气分类 Explain the different hernia repair techniques 解释不同的疝修补技术,What is a Hernia? 什么是疝？,疝气是脏器或组织通过非正常腔隙生成的一个突起。大多数疝气是由于腹压增大时，腹腔内容物从腹壁缺损或薄弱处突出，形成肿块，并引起相应的临床症状。,What causes a Hernia? 疝产生的原因,Weakness or defect 薄弱
2、或缺损 Present since birth 先天表现 Weakening factors 造成薄弱因素 Risk factors 风险因素,REALITY CHECK! 事实证明！,Just as people do not get any younger or healthier with time, nor do hernias get smaller.正如人们不会随岁月流逝变得更为年轻和健康一样，疝也不会随之变小。A hernia will not go away untreated. 疝不会自愈。The presence of a hernia indicates that a r
3、epair will be required at some stage. 疝的存在意味着在一定阶段需要进行疝修补。,HERNIAS 疝气,Groin Hernias 腹股沟疝 Inguinal & Femoral 腹股沟区和股区 Umbilical Hernias 脐疝 Ventral/Incisional Hernias 腹壁疝/切口疝 Epigastric 剑突疝 Gastroschisis & Omphalocele 腹裂和脐膨出 Internal Hernias 腹内疝 Rare Hernias 罕见的疝气种类,Epigastric 上腹疝,Femoral 股疝,Incisional
4、/Ventral 切口疝/腹壁疝,Inguinal 腹股沟疝,Umbilical 脐疝,Diaphragmatic 横隔膜疝 (Hiatal Hernia) （食管裂孔疝）,Describing a Hernia 疝描述,腹 股 沟 疝,脐 疝,切 口 疝,造 瘘口 旁 疝,骨架,骨架,髂前上棘,髂嵴,耻骨结节,腹股沟解剖简图,内斜肌,提睾肌,腹直肌,腹壁下动静脉,精索,腹股沟韧带,Myopectineal Orifice 耻骨肌孔, inclined oblique slanting tilted,Myopectineal Orifice Triple Triangles of the Gr
5、oin 耻骨肌孔的三组三角,Lateral Triangle 外侧三角 Medial Triangle 内侧三角 Femoral Triangle 股三角,Indirect Inguinal Hernia,Frequently a congenital defect 通常是先天缺损 Sac protrudes through the internal ring 疝囊通过内环口突出 Sac is inside cremaster fibers 疝囊被提睾肌包裹 Graded by size of ring, not size of sac 以内环口的大小，而非疝囊大小分类,Indirect In
6、guinal Hernia 腹股沟斜疝,Indirect Inguinal Hernia 腹股沟斜疝,Inferior Epigastrics 腹壁下血管,Direct Inguinal Hernia,Weakness in floor of canal 腹股沟管后壁薄弱 Size of sac corresponds to size of defect 疝囊大小与缺损大小相对应 Sac consists of peritoneum and transversalis fascia 疝囊壁由腹膜和腹横筋膜组成,Direct Inguinal Hernia 腹股沟直疝,Direct Inguin
7、al Hernia 腹股沟直疝,Inferior Epigastrics 腹壁下动静脉,Hernia Statistics 疝气统计表,Estimated incidence in the general population is 3% 估计有3%的发病率 Male-to-female ratio: 12:12男女患者比率为：12：1 More than 5 million hernia repairs performed worldwide* 全球已实施五百万例疝修补术Tension vs. Tension-Free Repairs vary country to country 采用张力
8、修补或无张力修补在不同的国家有很大的差异,Lichtenstein. Hernia Repair Without Disability. 2nd ed. St. Louis, MO: Ishiyaku Euroamerica, Inc; 1986: chapt. 2 Abrahamson et al. Maingots Abdominal Operations. 9th ed. Appleton 1990: Chapt. 11,* Source WW hernia procedure data marketing research ETHICON data on file,Adult Ingu
9、inal Hernia 成人腹股沟疝,Some Statistics 一些统计数据 Male to female ratio is 12:1 男女患者比率为12:1 6-8% of all males have some degree of inguinal hernia 68%的男性有一定程度的腹股沟疝 3% of population 患者占总人口的3% Elective to emergency ratio is 12:1 择期手术与急诊手术比率为12:1 Mean age = 60 平均患病年龄60岁,Methods of Repair 修补方法,Tension & Tension F
10、ree 张力和无张力,Surgical Techniques 外科技术,Open 开放式手术 Anterior repair 前壁修补 Posterior repair 后壁修补 Combined repair 联合修补Laparoscopic 腹腔镜手术 Posterior repair 后壁修补,Goals of Hernia Repair 疝修补的目标,Minimal operative and post operative discomfort 减小手术和术后不适 Effective repair 有效修补疝气 Lowest possible recurrence rate 使复发几率
11、降为最低 Rapid return to normal activities 迅速恢复正常功能 Cost effective 经济实用,Current Hernia Repair Techniques 当代的疝修补技术,Tension repairs 张力修补 Bassini 巴西尼手术 Shouldice McVay (Coopers Ligament) McVay（库珀韧带） Marcy Tension-free mesh repairs 无张力补片修补 Lichtenstein 平片修补 Devices (hernia systems) 疝装置 Laparoscopic 腹腔镜修补 TA
12、PP 经腹腔腹膜前修补 TEP 完全腹膜外修补,Tension Repairs 张力修补,巴西尼修补 Shouldice修补,张力修补,Advantages of Tension Repair 张力修补的优点,Easy to perform 易于操作 Cost effective 经济实用,4. Abrahamson. Maingots Abdominal Operations. Vol 1. 9th ed. Appleton 1986.,Disadvantages of Tension Repairs 张力修补的缺点,High recurrence rates 高复发率 10% to 30%
13、 recurrence rate with primary inguinal hernia repair 4 首次疝修补后伴随10%到30%的复发率 Estimated 35% or higher recurrence rate with recurrent hernia repairs 5 在再次修补后预计有35%或以上的复发率 Patient discomfort 病人疼痛及不适 Other potential complications 其它潜在并发症,Tension-Free Repairs 无张力修补,Introduced in 1984 1984年引进 Improved resul
14、ts over prior methods of repair 在之前的修补方法基础上取得进展 Open anterior approach 前路开放手术 Steps 步骤 deal with the sac 处理疝囊 mesh sutured to floor and around spermatic cord (between transversalis fascia and external oblique) 补片缝扎以覆盖和包裹精索（在腹横筋膜和腹外斜肌之间） running or interrupted sutures 连续或间断缝合,Lichtenstein (Onlay) Rep
15、air Lichtenstein（平片）修补,Lichtenstein Repair,Lichtenstein (Onlay) Repair Lichtenstein（平片）修补,Lichtenstein Technique Lichtenstein技术,Advantages 优点 Tension-Free Anterior Mesh Repair 无张力前壁修补 Quick and Easy 简单快速 Easily Teachable 易于教授,Disadvantages 缺点 No Posterior Repair 没有后壁修补 No “Plugging” of the defect 缺损
16、处无填充 Extensive continuous or interrupted suturing 需要广泛的连续或间段缝扎,Bard Perfix Plug Repair,Established in 1993 于1993年确立 Open, anterior approach 开放的前路手术 Steps 步骤 Deal with the sac 处理疝囊 Preperitoneal dissection 腹膜前分离 Plug inserted into defect & sutured to transversalis fascia in corners 将网塞填充入缺损，边缘与腹横筋膜缝合固定 Keyhole mesh sutured as onlay tofloor of inguinal canal 上片修补腹股沟管前壁,Plug and Patch Repair 网塞修补,Bard Perfix Plug & Patch 网塞修补,
