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1、Abdominal wall hernias q general considerationq inguinal herniasq femoral herniaq incisional herniaq umbilial herniaq hernia of linea alba general considerationv DefinitionHernia means a sprout, and protrusion. External abdominal wall hernia is an abnormal protrusion of intra-abdominal tissue or the
2、 whole or part of a viscera 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
3、 of abdominal white line 3) incision, 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:l covering tissue: skin, subcutano
4、us tissuel hernial sac: protrusion of peritonum, neck of the sac: is narrow where the sac emerges from the abdomen body of the sac l 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 wit
5、h manual pressure when the patient is recumbent. 2. 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
6、hernia sac. It is may be colon ( on the left), caccum (on the right) 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
7、 contents of the sac. incarcerated hernia and strangulated hernia are the two 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 incarcer
8、ated the intestinal diverticulum (usually Meckel diverticulum). Reductive incarcerated 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.
9、indirect inguinal hernia: the internal inguinal ring the inguinal canal external inguinal ring scrotumdirect inguinal hernia: Hesselbachs trianglevAnatomy1. Anatomic layers1) skin, subcutaneous tissue2) external oblique muscle, aponeurosislSubcutaneous (external) inguinal ring: Triangular opening, i
10、n the aponeurosis of the external oblique just superior and lateral to the pubic tubercle.Inguinal 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.Lacu
11、nar ligamentCoopers ligament (pectineal ligament)Sensory nerves: iliohypogastric nerve, ilioinguinal nerve3) 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 trans
12、verse muscle of the abdomen and insert with them into the pubic tubercle, forming the conjoined tendon. 4) Transversalis 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
13、superior to the point midway between the anterior superior iliac spine and the pubic tubercle.Iliopubic tract: it is 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
14、inguinal canal Contents: spermatic cord, round ligament, ilioinguinal nerveWalls: anterior: skin, superficial fascia, and external ablique aponeurosis posterior: transversalis fascia superior: conjoined tenden inferior: inguinal ligament3 Hesselbachs triangle Bounded by the inguinal ligament, the in
15、ferior epigastric vessels, and the lateral edge of rectus muscle.v Causes of indirect inguinal hernia 1. congenital abnormality of 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 wallvC
16、linical manifestation and diagnosis Symptoms: pain, discomfort, dragging sensation Sign: reducible or irreducible lump, expansile cough impulse Reducing the hernia fully, compress the internal ring: be controlled indirect not controlled - direct Differences between indirect and direct herniaDifferen
17、ces between indirect and direct herniafeatureindirectdirectagechildren, young peopleaged peoplepathway of protrusioncoming down the inguinal canal, may enter the scrotumpass through Hesselbachs triangle, rarely enter the scrotum contours of sacelliptic, pear-shapedsemispheric, wide basecompress the
18、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 to itIncarcerated incidencehighlow1.Differential diagnosisl1 d
19、ydrocele of testis translucent test (+)l2 communicated hydrocelel3 hydrocele of cord: not reduciblel4 undescended testisl5 acute intestinal obstruction1.Treatment 1. nonoperative therapy Indications: 1 year old elderly patients or with severe systemic disease-truss2. operations for inguinal hernia c
20、onventional 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 walls of the inguinal cancal I repair of the anterior wall
21、 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 Coopers ligament on the iliopectineal line of the pubis.
22、 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 hernioplasty insertion of a prosthetic mesh3) laparoscopic
23、 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 canalvAnatomy of femoral canal Femoral ring fossa ovalis Anterior: inguinal ligament Posterior: pectineal
24、 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, localized intermittent discomfort Irreduci
25、ble 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 operation: excision or reducti
26、on of the hernial sac, and narrowing of the stretched femoral openingmethods: lMcVay repairltension-free hernioplastyllaparoscopic repair of inguinal hernia Other abdominal external herniaIncisional herniaIncisional hernia: an abnormal protrusion of a viscus through the musculoaponeurotic layers of
27、a surgical scar.Wound dehiscencevEtiologyPreoperative factorsOperative factors: types of incision: vertical incision, transrectus incision, midline incision, standard parmedian incision technique of closure suture materiaPostoperative factors: increased intra-abdominal pressure, et al.vClinical feat
28、ures and diagnosisSwelling and mass in the incisionHernial ringRarely incarceratevTreatment Operative repair: the same way as a laparotomy wound is repaired, or use mesh Umbilical hernia 1 infantile umbilical hernia1) failure of fusion of umbilical ring, or weakened umbilical tissue2) symptomless, r
29、educible 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 hernia 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
