Академический Документы
Профессиональный Документы
Культура Документы
What’s these???
Affiliated Hospital of Jining Medical Colleg
External Hernia
Objectives of Course
Definition of hernia
Grasp anatomy of inguinal
canal
Categories of common
inguinal hernias
Principle of treatment for
inguinal hernias
Affiliated Hospital of Jining Medical Colleg
1.GENERAL
CONSIDERATIONS
Affiliated Hospital of Jining Medical Colleg
DEFINITION:
A sprout and
protrusion of tissue or
viscus through a
weakness or abnormal
opening in an
enclosing layer
an external abdominal
wall hernia is an
abnormal protrusion
of intra-abdominal
tissue or viscus, whole
or part, through an
opening or defect of
Affiliated Hospital of Jining Medical Colleg
Affiliated Hospital of Jining Medical Colleg
Inguinal hernias
Weakness of
abdominal wall
increased intra- A balloon with a
abdominal pressure protrusion
Affiliated Hospital of Jining Medical Colleg
Etiology
Hernia:
Affiliated Hospital of Jining Medical Colleg
Clinical types
1. reducible hernia
2. irreducible hernia
3. incarcerated hernia
4. strangulated hernia
Affiliated Hospital of Jining Medical Colleg
Clinical classification
Reducible hernia: Contained viscus can be
returned from the hernia to its normal
domain spontaneously or with manual
pressure when the patient is recumbent
Irreducible hernia: Contained viscus
cannot be returned from the hernia to its
normal domain, usually it is due to the
adhesions between the contents of hernia
sac and the wall of hernia sac
Affiliated Hospital of Jining Medical Colleg
Sliding
hernia
Huge hernia
irreducible hernia
Affiliated Hospital of Jining Medical Colleg
Sliding hernia:
A portion of the wall of the
hernia sac is composed of an
organ such as the cecum on
the right side and the sigmoid
colon on the left side.
Occasionally, bladder is
involved. The development of
a sliding hernia is related to
the variable degree of
posterior fixation of the large
Affiliated Hospital of Jining Medical Colleg
Incarcerated hernia:
If the neck of hernia is very
narrow, protruded part of
intra-abdominal viscus in
the hernia sac may be
trapped by the narrow
neck, and the lumen of a
segment of bowel within
the hernia sac, if it exists,
may become obstructed.
In which there is no
interference with blood
supply.
Affiliated Hospital of Jining Medical Colleg
Strangulated hernia:
If, in addition to incarceration, there is a
compromise of the blood supply of the
contained organ
Gangren
e of
incarcer
ated
intestine
strangulated hernia
Affiliated Hospital of Jining Medical Colleg
Richter’s hernia
Affiliated Hospital of Jining Medical Colleg
Pathological anatomy:
Pathological anatomy
Inguinal Hernia
Affiliated Hospital of Jining Medical Colleg
Anatomical layers of inguinal
region
Skin and subcutaneous fat
External oblique abdominal
muscle
Internal oblique abdominal
muscle and transverse
abdominal muscle
Transverse abdominal fascia
Fat out of peritoneum
Peritoneum
Affiliated Hospital of Jining Medical Coll
Affiliated Hospital of Jining Medical Colleg
Transvers abdominal
fascia:
Inguinal canal:
Inguinal canal passes through the lower
anterior abdominal wall from the external
inguinal ring to the internal inguinal ring,
which is about 4-5 cm long in the adults.
In the male, the testis and the spermatic
cord pass through the inguinal canal from
the abdomen to the scrotum.
In the female, the round ligament of the
uterus passes it to the major labia.
Affiliated Hospital of Jining Medical Colleg
Spermatic cord:
When the testicle descents into the
scrotum, it passes through the abdominal
wall in the inguinal region.
Inguinal triangle:
The inguinal triangle lies in the
inferomedial inguinal region,
which is an area of potential
weakness and thus often the site
of a direct inguinal hernia.
Affiliated Hospital of Jining Medical Colleg
Pathological mechanism:
Clinical manifestations:
Methods of examination:
When examining, patient should
be standing in a relaxed
position.
The finger should be introduced
through the external ring into
the inguinal canal.
The presence of a dilated
external inguinal canal would be
Affiliated Hospital of Jining Medical Colleg
Incarcerated or strangulated
hernia:
They can often be seen in
emergency conditions, which are
common in the indirect inguinal
hernia, but seldom in the direct
hernia.
Affiliated Hospital of Jining Medical Colleg
Differential diagnosis:
1. Indirect, direct, femoral
hernia: They have different
characters.
2. Hydrocele of the spermatic
cord.
3. An undescended testis: The
testis cannot be felt in the
scrotum.
4. Lymphadenopathy or
Affiliated Hospital of Jining Medical Colleg
Principles of treatment:
All inguinal hernias should be
managed by operative treatment
in the adult patient except that
the strong contraindications
exist.
Emergency operation should be
done when the complications of
incarceration, obstruction, and
strangulation in the indirect
hernia happen
Affiliated Hospital of Jining Medical Colleg
Principles of treatment:
Adult: operative
treatment
Child under 1: the
congenital inguinal
hernia may
spontaneously cure
Patient with strong
contraindications:
non-operative
Affiliated Hospital of Jining Medical Colleg
Non-operative
management:
Using some
external support
device or truss
to maintain
hernia reduction
Only in the
patients with
strong
contraindications
of surgical
operation
Affiliated Hospital of Jining Medical Colleg
Operative
treatment
Affiliated Hospital of Jining Medical Colleg
Before operation:
Any problems which could
increase intra-abdominal
pressure, should be solved to
prevent a recurrent hernia.
Chronic cough
Constipation
Prostatic hyperplasia
Affiliated Hospital of Jining Medical Colleg
Aim of Operation
Affiliated Hospital of Jining Medical Colleg
Review: Anatomy of inguinal
canal
inguinal canal
the external oblique aponeurosis the transverse fascia
Operative techniques
A. Simple high ligation of the
sac
used for child
B. Repair of hernia
C. Tension free Mesh repair
D. Laparoscopic Repair
Affiliated Hospital of Jining Medical Colleg
Operative techniques:
A. Simple high ligation of the
sac:
anatomically isolate hernia
sac, ligate at the neck of
hernia sac, and removal of the
sac.
If simple high ligation of the
sac is combined with a
tightening of the internal ring,
Affiliated Hospital of Jining Medical Colleg
A. Simple high ligation of the
sac:
Approximates
and sutures the
arcing edge of
the conjointed
tendon to the
inguinal ligament
beneath the
spermatic cord
Leaves the
spermatic cord
between the
internal oblique
Affiliated Hospital of Jining Medical Colleg
B. Repair of hernia:
herniorrhaphy
High ligation of the sac
Repair and reinforcement the
inguinal canal wall
reinforce the posterior wall of the
inguinal canal :
Bassini Shouldice
Halsted Mcvay
reinforce the anterior wall of the
inguinal canal:
Ferguson
Roof : Conjoint tendon
Before Bassini
repair, cut
transvers
abdominal
fascia and
suture it
overlaply
Decrease
recurrent
hernia
Halsted
Roof : Conjoint tendon
repair:
The posterior wall:
The anterior wall: the transverse fascia
the external oblique aponeurosis
Place the
external oblique
aponeurosis
beneath the cord
, but otherwise
resembles the
Bassini repair.
Leaves the
spermatic cord
under the skin
and
Roof : Conjoint tendon
edge of the
conjointed
tendon
posteriorly and
inferiorly to
Cooper’s
ligament and
suture them
For big hernia,
recurrent hernia,
femoral hernia
Ferguson
Roof : Conjoint tendon
repair:
The anterior wall: The posterior wall:
the external oblique aponeurosis the transverse fascia
Approximate and
suture the arcing
edge of the
conjointed tendon
to the inguinal
ligament above the
spermatic cord
Leave the
spermatic cord
beneath the
internal oblique
muscle and the
Affiliated Hospital of Jining Medical Colleg
D. Laparoscopic Repair
Conclusion
Affiliated Hospital of Jining Medical Colleg
Operative techniques
A. Simple high ligation of the sac
B. Repair of hernia
reinforce the posterior wall of the
inguinal canal :
Bassini Shouldice
Halsted Mcvay
reinforce the anterior wall of the
inguinal canal:
Ferguson
C. Tension free Mesh repair
D. Laparoscopic Repair
Affiliated Hospital of Jining Medical Colleg
Management of incarcerated or
strangulated hernias:
The most incarcerated hernias
need emergency operation.
During the operation, it is vital
to inspect whether strangulation
has occurred or not before
reduction.
Affiliated Hospital of Jining Medical Colleg
Management of sliding
hernia:
Management of the sac is
complicated when a sliding hernia
is present.
The failure to recognize a sliding
hernia may lead to injury involved
organs or their blood supply.
During operation, the hernia sac is
identified and opened anteriorly
away from the involved organ
which makes up its posterior wall.
Affiliated Hospital of Jining Medical Colleg
“Hernia today,
gone
tomorrow”
Affiliated Hospital of Jining Medical Colleg
FEMORAL HERNIA
Affiliated Hospital of Jining Medical Colleg
Anatomy:
The lateral border of the
femoral ring is the femoral
vein
The anterior border is the
inguinal ligament
The medial border is the
lacunar ligament
The posterior border is the
perineal ligament(Cooper's
ligament)
Affiliated Hospital of Jining Medical Colleg
Pathological mechanism:
Mainly due to the defect in the
transverse fascia in the direct
triangle.
A peritoneal sac passes under
the inguinal ligament(the
femoral ring) into the femoral
canal.
The inguinal ligament is a tight
band and beneath it the femoral
Affiliated Hospital of Jining Medical Colleg
Clinical manifestations:
Symptoms: Normally
asymptomatic until
incarceration or strangulation
occurs. Even with obstruction
or strangulation, the patient
may feel discomfort more in
the abdomen than in the
femoral area.
Signs: A small bulge in the
Affiliated Hospital of Jining Medical Colleg
Differential diagnosis:
Inguinal hernia:
A saphenous varix: without
comfortable
Lipoma:
Abscess:
Affiliated Hospital of Jining Medical Colleg
Affiliated Hospital of Jining Medical Colleg
Treatment:
Because of the high incidence of
incarceration and strangulation,
all femoral hernias should be
managed by operative
treatment.
If incarceration of femoral hernia
has occurred, manual reduction
is forbidden and emergency
operation is indicated.
Affiliated Hospital of Jining Medical Colleg
Incisional hernia
Develop in an old operative
incision.
The incisional wound infection
is the most important factor.
Age, obesity, other diseases,
poor surgical technique are
other causes.
The principle of management
is early operative repair.
Affiliated Hospital of Jining Medical Colleg
Umbilical hernia:
Umbilicus is a weakened area in
the abdominal wall due to the
exist of the umbilical cord of
embryo.
Congenital umbilical hernia is
common in infants. But most of
these infants spontaneous close
the fascial defect within the first
two years of life.
Affiliated Hospital of Jining Medical Colleg
Epigastric hernia:
Also called the hernia linea
alba, usually occur above the
level of the umbilicus.
An area of congenital
weakness in the linea alba with
increased intra-abdominal
pressure is the cause of this
type of hernia.
More common in men than in
women.
A small epigastric hernia
谢谢