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1、Abdominal wall hernias,general consideration inguinal hernias femoral hernia incisional hernia umbilial hernia hernia of linea alba,general consideration DefinitionHernia means a sprout,and protrusion.External abdominal wall hernia is an abnormal protrusion of intra-abdominal tissue or the whole or
2、part of a viscera through an opening or fascial defect in the abdominal wall.most occur in the grion,Etiology 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 of abdominal whit
3、e 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,cry,Pathological anatomy composed of:covering tissue:skin,subcutanous tissue hernial sac:protrusion
4、of peritonum,neck of the sac:is narrow where the sac emerges from the abdomen body of the sac hernial contents:small intestine,major omentum,Clinical types 1.reducible hernia is one in which the contents of the sac return to the abdomen spontaneously or with manual pressure when the patient is recum
5、bent.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 hernia sac.It is may be colon(on the left),cacc
6、um(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 contents of the sac.incarcerated hernia and strangulated her
7、nia 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 incarcerated the intestinal diverticulum(usually Meckel diverticulum).Reduc
8、tive 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.indirect inguinal hernia:the internal inguinal ring the inguinal canal ext
9、ernal inguinal ring scrotumdirect inguinal hernia:Hesselbachs triangleAnatomy1.Anatomic layers1)skin,subcutaneous tissue2)external oblique muscle,aponeurosisSubcutaneous(external)inguinal ring:Triangular opening,in the aponeurosis of the external oblique just superior and lateral to the pubic tuberc
10、le.,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.Lacunar ligamentCoopers ligament(pectineal ligament)Sensory nerves:iliohypogastric nerve,ili
11、oinguinal 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 transverse muscle of the abdomen and insert with them into the pubic tubercle,forming the conjoined
12、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 superior to the point midway between the anterior superior iliac spine and the pubic tubercle.Iliopu
13、bic 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 peritoneum,2.Anatomy of inguinal canal Contents:spermatic cord,round ligament,ilioinguinal nerveWalls:anterior:skin,superficial
14、 fascia,and external ablique aponeurosis posterior:transversalis fascia superior:conjoined tenden inferior:inguinal ligament3 Hesselbachs triangle Bounded by the inguinal ligament,the inferior epigastric vessels,and the lateral edge of rectus muscle.,Causes of indirect inguinal hernia 1.congenital a
15、bnormality 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 wallClinical manifestation and diagnosis Symptoms:pain,discomfort,dragging sensation Sign:reducible or irreducible lump,expan
16、sile cough impulse Reducing the hernia fully,compress the internal ring:be controlled indirect not controlled-direct,Differences between indirect and direct hernia,Differential diagnosis1 dydrocele of testis translucent test(+)2 communicated hydrocele3 hydrocele of cord:not reducible4 undescended te
17、stis5 acute intestinal obstructionTreatment 1.nonoperative therapy Indications:1 year old elderly patients or with severe systemic disease-truss,2.operations for inguinal hernia conventional repairsPrinciples:excision or reduction of the hernial sac,high ligation of the sac,and repair the walls of t
18、he 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 of the inguinal canal Ferguson repair II Repair of the posterior wall Bassini repair Halsted repair:placing the latter in a su
19、bcutanous 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.Shouldice repair:the posterior wall of the inguinal canal is repaired by dividing the transversalis fascia from the pubis to adja
20、cent to the inferior epigastric vessel,then imbricate sutures.Internal ring:pass a fingertip2)tension-free hernioplasty insertion of a prosthetic mesh3)laparoscopic repair of inguinal hernia,3.management rule of incarcerated and strangulated herniaIndications for manual reduction:1)duration 3-4 hour
21、s,no local tenderness,no abdominal tenderness,no rigidity of abdominal muscle 2)elderly patients or with other severe diseases,and the intestinal loop is still aliveUsually requires emergency operation 4.Management rule of recurrent inguinal hernia 1)true recurrent hernia 2)concomitant hernia 3)new
22、occurring hernia,Femoral herniaintroduction Femoral hernia is a protrusion of peritoneum through the femoral canal.Usually in women 40 years Causes:laxity of groin tissue elevated intra-abdominal canalAnatomy of femoral canal Femoral ring fossa ovalis Anterior:inguinal ligament Posterior:pectineal l
23、igament Medial:lacunar ligament Lateral:femoral vein,Pathologic anatomyfemoral ring femoral canal fossa ovalis subcutaneous tessue of the thigh High incidence of strangulation,Clinical findings and diagnosis Reducible femoral hernia:asymptomatic lump,localized intermittent discomfort Irreducible fem
24、oral hernia:constant lump and localized discomfort Strangulated femoral herniaDifferential diagnosis 1.indirect inguinal hernia 2.lipoma 3.groin lymph nodes 4.long saphenous varix 5.iliolumbar tuberculous abscess,TreatmentNot be treated conservativelyRule operation:excision or reduction of the herni
25、al sac,and narrowing of the stretched femoral openingmethods:McVay repairtension-free hernioplastylaparoscopic repair of inguinal hernia,Other abdominal external herniaIncisional herniaIncisional hernia:an abnormal protrusion of a viscus through the musculoaponeurotic layers of a surgical scar.Wound
26、 dehiscenceEtiologyPreoperative 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.,Clinical features and diagnosisSwelling an
27、d mass in the incisionHernial ringRarely incarcerateTreatment 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,reducible lump3)usually disappear by
28、the age of 2 years4)rarely incarcerate5)surgical repair 2 years,2 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,
