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1、HERNIAS,Dr David SwarGeneral SurgeryQilu HospitalShandong University,Definition,A hernia is the protrusion of an organ through its containing wall.,Composition of a hernia,The sacThe covering of the sacThe content of the sac,Composition of a hernia,The sac:It is a diverticulum of peritoneum and is m
2、ade up of three parts:The mouth,The neck and The body of the sac.,Composition of a hernia,The covering:Coverings are derived from the layers of abdominal wall through which the sac passContents:can beOmentum=omentocleIntestine=enterocelePortion of circumference of intestine=Richters herniaPortion of
3、 the bladderOvary(with or without oviduct)Meckels diverteculum=Littres hernia,Etiology,Hernias occur at sites of weakness in the wallThis weakness may be:Normal(physiological)weakness,related to the anatomical causes.Congenital abnormality.Acquired:TraumaticDiseases,Varieties,A hernia at any site ma
4、y be:Reducible This is the one which the contents of the sac reduced spontaneously or can be pushed back manually.A reducible hernia imparts an expansile impulse on coughing.Irreducible This one whose contents cannot be returned to the peritoneal cavity either because there are:adhesions between the
5、 sac and contents,or because of the narrow neck of the sac.,Varieties,Irreducible hernia can be:Incarcerated:there are adhesions between the sac and the contents,but there is no obstruction or interference with blood supply.the hernia simply will not reduce Obstructed:a hollow viscus is trapped with
6、in the sac and obstruction occurs.The blood supply remains intact.This is a common cause of small bowel obstruction.Strangulated:the arterial blood supply to the contents of the sac is compromised,in such a hernia unless surgical relief is undertaken the contents of the sac will become gangrenous.,C
7、lassification,External herniaInternal hernia,Classification continue,External herniaCommon hernia inguinal Femoral Umbilical incisional,Classification continue,External herniaRare herniaSpigelianGlutealObturatorlumbar,Classification continue,Internal herniaDiaphragmatic herniaEsophogial herniaParaes
8、ophogial hernia,Signs and Symptoms,-A lump disappears,reappears,and enlarges on straining and discomfort.Physical Signs:Reduced.+ve cough impulse.Investigation:Hernia is diagnosed clinically.Investigations are rarely indicated or valuable.,Management,Treatment:hernias should be operatively repaired
9、both to relieve symptoms and to eliminate the complications.Surgical techniques:Herniotomy:removal of sac and closure of its neck.Herniorrhaphy:involves some sort of reconstruction to:Restore the anatomy if this is disturbed.Increase the strength of the abdomenal wall.Construct a barrier to recurren
10、ce.,Inguinal hernia,Epidemiology:Male:Female by 9 to 1 ratioyoung adults mostly have indirect inguinal hernia.As age of patient increases,the incidence of direct hernias increases.,Inguinal hernia,Risk factors:(increases intra-abdominal pressure)Chronic cough.Constipation.Pregnancy.Straining at mict
11、uration.Severe muscular effort(lifting heavy objects).Ascites-fluid may increase the size of an existing sac.,Inguinal hernia,Inguinal Canal AnatomyAnterior wall:aponeurosis of external oblique(along entire length),internal oblique on lateral one thirdPosterior:fascia transversalisconjoint tendonon
12、in medial one thirdRoof:arching fibers of internal oblique,andtransversus abdominisFloor(inferior):inguinal ligament,and lacunar ligamen at the medial end,Inguinal hernia,Inguinal Canal Contents:Male:Spermatic cord structures:vas deferens,testicular artery testicular veins(pampiniform plexus),genita
13、l branch of genitofemoral nerve,artery of the vas deference,lymphatics,autonomic nerves,processus vaginalis.Ilio inguinal nerveFemale:Round ligament of the uterus,genital branch of genitofemoral nerve,lymphatics,sympathetic plexus.,Inguinal hernia,Signs&symptoms:Bulge that enlarges when stand or str
14、ain,but often asymptomatic.In general direct hernias produce fewer symptoms than indirect hernias and are less likely to complicate.On examination:Palpable defect or swelling may be present.Indirect Hernia usually bulge at Internal Inguinal Ring.Direct Hernia usually bulge at External Inguinal Ring.
15、,Inguinal hernia,There are two typesof inguinal hernia:Direct inguinal herniaIndirect inguinal hernia,Differences between direct and indirect hernias,Origin and coarse:Direct:Develops in the area of Hasselbachs triangle.The origin is medially to the inferior epigastric vessels.Indirect:Develops at t
16、he internal ring.The origin is lateral to the inferior epigastric artery.Content:Direct:Retroperitoneal fat.less commonly,peritoneal sac containing bowel.Indirect:Sac of peritoneum coming through internal ring,through which omentum or bowel can enter.Etiology:Direct:weakness of the posterior floor o
17、f the inguinal canal(acquired).Indirect:patent processus vaginalis(Congenital).,Differences between direct and indirect hernias,Boundaries of Hasselbachs triangle:Medially:lateral border of rectus abdominis.Laterally:inferior epigastric vessels.Inferiorly:inguinal ligament.,Inguinal hernia,Different
18、ial diagnosis:TendonitisMuscle tearLymphadenopathy LipomaVaricose veinHydroceleEpididymitisSpermatocele,Inguinal hernia,Complications:Irreducibility,but without signs of obstruction or strangulation Small Bowel Obstruction,Usually urgent surgical repair Strangulation,Surgical emergency 50%indirect,3
19、-10%direct.,Inguinal hernia,Management:Inguinal hernias should always be repaired(herniotomy,herniorrhaphy)unless there are specific contraindications.Types of operations:a permanent sutures,as in Shouldice repair(layered suture).a permanent mesh-greater frequency to decrease tension.,Inguinal herni
20、a management,Treatment of aggravating factors(chronic cough,prostatic obstruction,etc).Use of truss(appliance to prevent hernia from protruding)when a patient refuses operative repair or when there are absolute contraindications to operation,Inguinal hernia,Both types(direct and indirect inguinal he
21、rnia)may occur at the same time and straddle the inferior epigastric artery.This is called:Pantaloon hernia,Femoral hernia,The defect is in the transversalis fascia overlying the femoral ring at the entry to the femoral canal.The hernia passes through the femoral canal and presents in the groin,belo
22、w and lateral to the pubic tubercle.It is more common in females and carries a higher risk of strangulation.Femoral canal-ant.by inguinal ligament,post by fascia over pectineus muscle,lat.by femoral vein n medial by lacunar ligament,Femoral hernia,Signs&symptoms:A lump occurs below and lateral to th
23、e pubic tubercle.It may be reducible.It may not be noticed until it becomes tender and painful.This type of hernia should be carefully sought in the obese patient who presents with signs of intestinal obstruction without an obvious cause.DDs-saphena varix,enlarged inguinal LN,femoral artery aneurysm
24、,rare femoral abscess.,Femoral hernia,Surgical repair:An incision is made directly over the swelling.The sac is opened and the contents reduced and the sac removed.Femoral canal obliterated with 3 interrupted non absorbable suture.Treatment of strangulation or obstruction,if present.There is no plac
25、e for a truss in the treatment of femoral hernia.,Femoral hernia,Umbilical hernia,This occurs in children because of incomplete closure of the umbilical orifice.The majority close spontaneously during the first year of life.Surgical repair should only be carried out if the hernia has not disappeared
26、 by the age of 3 and the fascial defect is greater than 1.5cm in diameter.,Para-Umbilical hernia,It occurs just above or just below the umbilicus,and is more common in obese females.Predisposing factors multiple pregnancies andobesity.,Para-Umbilical hernia,The neck of the sac is usually narrow and
27、therefore there is a high risk of strangulation.The most common content is omentum,then transverse colon and small intestine.Treatment:is by Contents of sac freed from its wall,excision of the sac,and fascial defect repaired byUpper flap overlapping the lower,a two layer overlapping repair thereby d
28、oubling the strength of repair(Mayo repair)4 cm,recurrent-polypropylene mesh,Epigastric hernia,This is usually a small protrusion through the linea Alba in the upper part of the abdomen.It consists of:extraperitoneal fat only,but May contain omentum or small bowel.,Epigastric hernia,It may be extrem
29、ely painful,probably because of trapping and ischaemia of extraperitoneal fat.Treatment is by enlaging the defect,excising the fat,simple suture of the defect with non-absorbable sutures.4 cm propylene mesh placed retromuscular plane,Incisional hernia,This occurs through a defect in the scar of a pr
30、evious abdominal incision.,Incisional hernia,Etiology:Age:Wound healing is poor in the older patient.Obesity.Postoperative wound infection.Postoperative wound haematoma.Raised intra-abdominal pressure postoperatively,e.g.coughing,straining,constipation,ileus.Steroid therapy.Type of incision:Midline
31、vertical wounds have a higher incidence than transverse incisions.Poor suturing technique:Rarely does a suture break,Incisional hernia,Sign&symptoms:A swelling protrudes through the wound.It May occur up to 5 years postoperatively.Many are large and involve the whole incision and consequently the ne
32、ck of the sac is wide and the risk of strangulation rare.If the defect is small there is a greater risk of strangulation.Treatment-palliative-abd.belt-preoperative measures-reduce weight,treat cough,improve nutritional status.stop smoking.-surgery:excision of sac,identification n apposition,-large h
33、ernia-poly propylene mesh,Richters hernia,Part of the wall of the intestine becomes trapped in the defect.This is usually the antimesenteric border of the small bowel.The lumen is intact(no obstruction),Diaphragmatic hernia,Traumatic:rare and followed by injuries to chest and abdomen.The Lt diaphrag
34、m is affected more than Rt and is accompanied by herniation of stomach and spleen.Hiatus:Sliding.Para-esophegial.,Diaphragmatic hernia,Sliding:in which the gastroesophogeal junction itself slides through the defect into the chest.,Diaphragmatic hernia,Para-esophagealin which the junction remains fix
35、ed while another portion of the stomach moves up through the defect.This can be dangerous as they may allow the stomach to rotate and obstruct.,Hiatus hernia,Some other hernias,Spigelian hernia:This is a hernia through the linea semilunaris at the lateral border of the rectus sheath.Littres hernia:A hernia that contains a Meckels diverticulum in the sac.Obturator hernia:This hernia occurs through the obturator foramen.It is commoner in elderly females.Lumbar herniae:These occur in the lumbar region(below the 12th rib&above the iliac crest).,THANK YOU,谢谢你的阅读,知识就是财富丰富你的人生,xiexie!,谢谢！,
