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HERNIA INGHINALA
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Hammurabi of Babylon (1700
BC)
Described hernia reduction and application of bandages to
prevent protrusion
Hippocrates (400 BC) Described hernia as "a tear in the abdomen."Galen (200 BC) Described the anatomy of the abdominal wall
Heliodorus (200 BC) Described his original method for hernia repair.
Celsus (100 AD) Introduced translumination; described clinical signs that
differentiate a hernia from a hydrocele
Paulus Aegina Divided hernia into enterocele (abdominal viscera descend intoscrotum), and bubonocele (swelling remains in the groin and
does not descend into the scrotum)
Maupassius (1559) First operation to relieve a strangulated hernia
Caspar Stromayr (16th
century)
Wrote Practaica Coposa; defined direct and indirect hernias;
stressed importance of high dissection of the indirect sac;sanctioned removal of testicle and spermatic cord for indirect
hernia
Littre Reported a Meckel's diverticulum in a hernia sac
DeGarengeot Described the appendix in a hernia sac
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Vesalius (Flemish) and allopius
(Italy) Poupart (France)Described the inguinal ligament.
Heister First to describe direct hernias. (1724)
Pott (England) Anatomy of congenital hernias; methods of incarceration
Camper (Holland) Described the superficial subcutaneous fascia
Scarpa (Italy) Described deep subcutaneous fascia; anatomic and surgical
importance of sliding hernias (en glissade) (1814)
Sir Ashley Cooper (England) Described anatomy and surgical treatment of crural and
umbilical hernias; anatomy of the groin including the
superior pubic (Cooper) ligament; cremasteric fascia and the
transversalis fascia
Hunter Emphasized the role of the processus vaginalis
Morton Described the conjoined tendon.
Cloquet Noted postnatal closure of the processus vaginalis; made
observations of the iliopubic tract
Hesselbach (Germany) Defined iliopubic tract; described importance of the medialtriangle of the groin (included the femoral canal). [1]; described the"corona mortis" (arterial circle formed by the deep epigastric and obturator arteries).
De Gimbernat Described medial ligament of the femoral canal (lacunar
ligament), and division of that ligament in the treatment of
strangulated femoral hernias.
Richter (Germany) Described partial obstruction and incarceration of a wall of the
bowel in a hernia defect.[2,3]
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Remember anatomic
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vase iliace externe acoperite de peritoneu
vase testiculare i ram genital al N. genitofemural
vase cremasterice
canal (duct) deferent
peritoneu
fascia extraperitoneal (esut conjunctiv lax)
fascia transversalis
N. ilioinghinal
originea fasciei spermatice interne din fas-ciatransversalis la orificiul inghinal profund
spin iliac anterosuperioar
m. transvers abdominal
m. oblic intern
m. oblic extern
vase testiculare acoperite de peritoneu
vase epigastrice inferioare
canal deferent acoperit de peritoneu
lig. ombilical median (urac)
m. drept abdominal
vase femurale
funicul spermatic
fascia spermatic externnvelind funiculul spermatic
simfiz pubian (acoperit de fibre
amestecate ale apone-vrozeioblicului extern)
falx inguinalis (tendonul conjunct)
tubercul pubic m. cremaster i fasciacremaste-ric nvelindfuniculul spermatic
lig. inghinal (Poupart)
fibre intercrurale
canalul inghinal i funicululspermatic [spermatic cord]
m. piramidal
vezica urinar
fascia ombilical prevezical
lig. ombilical medial (a. ombilical)
inele inghinale super-ficiale drept i stng
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lig. inghinal reflectat (lig.
reflex Colles)
fascia spermatic extern pe ieireafuniculului spermatic
regiunea inghinal vedere anterioar
inel inghinal superficial
lig. fundiform al penisului
fibre intercrurale
tendon conjunct(falx inguinalis)
linia alb
teaca dreptului abdomi-nal(foia anterioar)
fascia transversalis n in-teriorultrigonului inghinal
stlp lateral
stlp medial
creast pubian
m. transvers abdominal
vase epigastrice inferioare (pro-fund fade fascia transversalis)
inel (orificiu) inghinal superficial
inel inghinal profund (n fasciatransversalis)
m. cremaster (origine lateral)
aponevroza m. oblic extern
spina iliac antero-superioar
lig. inghinal (Poupart)
lig. lacunar (Gimbernat)
m. cremaster (origine medial)
m. oblic intern (sec-ionati reflectat)
m. oblic extern
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teaca dreptului (foia posterioar)
fascia transversalis (secionat)
spina iliac antero-superioar
linia arcuat
simfiz pubian
m. drept abdominal
trigon inghinal (Hesselbach)
vase epigastrice inferioare
tract iliopubian
linia alb
canal deferent
anastomoz arterial pubo-obturatorie (corona mortis)
lig. pectineal (Cooper)
ram pubic superior
a. obturatorie
regiunea inghinal vedere intern
m. iliopsoas
vase iliace externe
tendon conjunct (falx inguinalis)
inel femural (dilatat)
lig. lacunar (Gimbernat)
vase testiculare i ram genital al N. genitofemural
fascia iliopsoasului (acoperind N. femural)
inel inghinal profund
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Clasificare ghernii inghinale
1. Punct herniar
2. H. inghinala interstitiala3. H. inghino-pubiana
4. H. inghino-funiculara
5. H. inghino-scrotala (labiala)
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Punct herniar
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h. Interstitiala
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H. Inghinopubiana = pubonocel
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H inghino-funiculara
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H. inghino-scrotala
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H inghino-pubiana
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H inghino-pubiana
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H inghino-scrotala
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teaca dreptului (foia posterioar)
fascia transversalis (secionat)
spina iliac antero-superioar
linia arcuat
simfiz pubian
m. drept abdominal
trigon inghinal (Hesselbach)
vase epigastrice inferioare
tract iliopubian
linia alb
canal deferent
anastomoz arterial pubo-obturatorie (corona mortis)
lig. pectineal (Cooper)
ram pubic superior
a. obturatorie
regiunea inghinal vedere intern
m. iliopsoas
vase iliace externe
tendon conjunct (falx inguinalis)
inel femural (dilatat)
lig. lacunar (Gimbernat)
vase testiculare i ram genital al N. genitofemural
fascia iliopsoasului (acoperind N. femural)
inel inghinal profund
pleur parietaldiafragm
vedere intern a peretelui abdominal anterior
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fascia transversalis peritoneu
peritoneu (marginisecionate)
lig. falciform
fascia diafragmatic
ombilic
lig. rotund al ficatuluii vv. paraombilicale
fascia transversalislinia arcuat
(arcada Douglas)
vase epigastriceinferioare
m. transvers abdominalm. drept abdominal
m. oblic extern
lig. interfoveolarHesselbach
trigon inghinalHesselbach
lig. ombilical medial stng (a.ombilical stng obliterat)
lig. ombilical median (urac o-
bliterat) + vv. paraombilicalen plica ombilical
fascia transversalis
plica ombilical medial dreapt
vase circumflexeiliace profunde
fascia ombilical prevezical
inel inghinal profund
fascia iliopsoas
canal obturator
N. femural
plica ombilical lateral (vaseepigastrice inferioare)
m. iliopsoas
ureter (secionat)
vase iliace externe
canal deferent
a. vezical superioar
reces anterior al fosei ischioanale
gland bulbouretral Cowper nvelit
n m. transvers perineal profundveziculseminal
prostat i m. sfincter al uretrei
plica vezical transversal
fosa supravezical
arc tendinos alm. levator ani
m. obturator intern
m. oblic intern
teaca femural
lig. lacunar (Gimbernat)
lig. pectineal (Cooper)
nerv i vase obturatorii
a. ombilical (parte distal obliterat)
tendon conjunct (falx inguinalis)
vase iliace externe
funiculul spermatic
inelul femural
ram cremasteric i
ram pubic alea. epigastrice inferioare
g
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Hernie inghinala
1. Oblica-externa
2. Directa
3. Oblica interna
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Caracteristici
Hernia oblica-externa Hernie de forta sau congenitala
Prin orificiul inghinal profund
Sac herniar cu colet lung
Hernia directa
Hernie de slabiciune Adeseori bilaterala
Prin triunghiul de slaba rezistenta Gillis sau Hesselbach
Sac herniar globulos
Hernia oblica-interna Rara
De slabiciune
Sacul contine adesea vezica uriunara
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1. Hernie inghinala Oblica-Externa dobandita
2. Hernie inghinala Oblica-Externa congenitala
Hernia congenitala Persistenta canalului peritoneovaginal la barbati iar la
femei a canalului Nuck
Sacul herniar se afla in interiorul funiculului
spermatic
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Hernie inghinala
congenitala1. INGHINO-
TESTICULARA
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2. HERNIE
CONGENITALA
FUNICULARA
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Hernie inghinala
congenitala3. FUNICULARA CU
CHIST DE
CORDONSPERMATIC
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4. HERNIEINGHINALACONGENITALA
ASOCIATA CUHIDROCEL
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HERNII CONGENITALE ASOCIATE CU
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HERNII CONGENITALE ASOCIATE CU
ECTOPIE TESTICULARA
1. Inghino-properitoneala2. Inghino-interstitiala
3. Inghino-superficiala
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hernie Berger: prezen concomitent
de hernie inghinal i hernie femural
( hernie cu saci multipli)
- hernie Pantaloon: hernie inghinaldubl (n bisac, direct + indirect).
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ALTE CLASIFICARI
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CLASIFICARE HERNII INGHINALE
Many hernia classifications have been proposed in the last 4 decades, whichmeet these criteria to varying degrees. The most popular classificationsare described below.
Castendivided hernias into 3 stages:
1. Stage 1: an indirect hernia with a normal internal ring
2. Stage 2: an indirect hernia with an enlarged or distorted internal ring3. Stage 3: all direct or femoral hernias
The Halverson and McVayclassification divided hernias into 4 classes:
1. Class 1: small indirect hernia2. Class 2: medium indirect hernia3. Class 3: large indirect hernia or direct hernia4. Class 4: femoral hernia
Cl ifi N h
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Clasificarea Nyhus, este urmtoarea:
tip I = hernie indirect, cu inel inghinal profund normal;
tip II = hernie indirect, cu inel inghinal profund dilatat;
tip IIIA = hernie inghinal direct;
tip IIIB = hernie inghinal indirect cu perete posterior
slab al canalului inghinal, sau hernie prin alunecare;
tip IIIC = hernie femural;
tip IV = hernie recidivat (A = direct, B = indirect, C= femural, D = altele).
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Ponka'ssystem defined 2 types of indirecthernia:
(1) uncomplicated indirect inguinal hernia and
(2) sliding indirect inguinal hernia
and three types of directhernias:
(1)
small defect in the medial aspect of Hesselbach'striangle near the pubic tubercle;
(2) diverticular hernia in the posterior wall with anotherwise intact inguinal floor; and
(3) a large diffuse direct inguinal hernia of the entirefloor of Hesselbach's triangle.
Gilbert d i d l ifi ti f i d t i i l
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Gilbertdesigned a classification for primary and recurrent inguinalhernias done through an anterior approach (Figure 28). It is based on
evaluating 3 factors:
1.presence or absence of a peritoneal sac
2.size of the internal ring
3.integrity of the posterior wall of the canal
In 1993, RutkowandRobbinsadded a type6 to the Gilbertclassification todesignate double
inguinal hernias and atype 7 to designate afemoral hernia.
Types 1 2 and 3 are indirect hernias; types 4 and 5 are direct
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Types 1, 2 and 3 are indirect hernias; types 4 and 5 are direct.
Type 1 hernias have a peritoneal sac passing through an intact internal ring that will notadmit 1 fingerbreadth (ie,
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Diagnostic diferential
Hernia femurala
Intre tipurile de hernii inghinale OE si D
Hidrocel
Chisturi de cordon Varicocel
Lipoame
Tu testiculare Adenopatii
Diagnosticul definitiv
completde hernie trebuie scuprind urmtoarele: tipul
anatomo-clinic, varietatea(direct, indirect), eventualulstadiu complicat.
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Tratament
Regula este chirurgical
Ortopedic este exceptia
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Tratament chirurgical
1. Procedee anatomice
2. Procedee neanatomice
Retrofuniculare
Prefuniculare
3. Procedee cu transpozitia cordonului spermatic
4. Procedee plastice5. Procedee laparoscopice
Anestezie orice
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Anestezie - orice
Local anesthesia.Local infiltration can be performed on virtually any
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inguinal hernia, but it is usually reserved for patients of average weightwith a primary unilateral hernia. The local anesthetic is usually acombination of a rapid-acting anesthetic, such as lidocaine or
chloroprocaine, and a longer-acting agent, such as bupivacaine, whichalso provides several hours of postoperative pain relief. Addition of sodium bicarbonate to buffer local instillation decreases
the pain at the injection site and accelerates the onset of the anestheticeffect. Addition of epinephrine may provide some hemostasis andprolong the effects of local anesthetics.
The local infiltration technique consists of specific, layered infiltration.The most sensitive areas are the skin, the external oblique aponeurosis,and the neck of a hernia sac or a lipoma. Once the external obliqueaponeurosis is reached, a small area of it should be exposed andinfiltration through it should be accomplished. When the external
oblique is opened, infiltration can be performed around the obviousnerves, over the symphysis, and where the cord structures are adherentto an indirect sac at the internal ring -- an area that is almost alwayssensitive during dissection.
Cai de abord
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Bassini
Babcok-Meingot
Lavarde
AnnandaleLawson Tait
Cai de abord
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Procedeele anatomice
Proc Bassini 1890 - Edoardo Bassini -- considered thefather of modern day hernia surgery
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Incizie LaRoque
Manevra
Reymonddedepistare a sacului
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Rezectia saculuiSOCIN
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Proc Bassini
ANDREWS HACKENBRUCHrefacerea canalului ingnhinal
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Procedee care mentin canalul inghinal dar folosesc
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gLig Cooper
Lotheisen
primul care propune utilizarea ligCooper
Hashimotto
McVay
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McVay - Hashimotto
Proc Souldice 1945
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Shouldice repair. Canadian surgeon E.E. Shouldice contributed
substantially to hernia surgery in the second half of the 20th century.He founded a clinic that has since become a hospital devotedexclusively to the treatment of abdominal wall hernias. The Shouldiceoperation for hernia repair revitalizes Bassini's original technique. It
applies the principle of an imbricated posterior wall closure withcontinuous monofilament suture. At the Shouldice hospital,continuous stainless-steel wire is used for all layers of the repair,including the ligatures used in the subcutaneous layerLocal anesthesia is routinely used and bilateral hernias are usually
repaired separately, 2 days apart. Patients walk to and from theoperating room, begin exercise therapy on the day of surgery, andresume their usual activities within a reasonable time after theoperation
Proc Souldice
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Milestones in Hernia Repair: The Listerian Era
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p
Marcy (1871) Publication of original paper on antiseptic herniorrhaphy
("A New Use of Carbolized Catgut Ligature")
Czerny (1876) Described ligating and excising the indirect peritoneal sac
through the external ring
Kocher Twisted and suture-transfixed the peritoneal sac in the
lateral muscles. through the external ring
MacEwen
(1886)
Reefed the peritoneal sac into a plug to block the internal
ring.
Lucas-
Championniere
Opened the external oblique aponeurosis to expose the
entire inguinal canal.
Procedee neanatomicecud fii l l i i hi l
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desfiintarea canalului inghinal
Procedee retrofuniculare
POSTEMPSKI WISSE
Procedeeprefuniculare FORGUE GIRARD
FERRARIS PASOKUKOTHI VILANDRE TH. IONESCU BINET WOFLER MUGNAI HALSTEDT MARTINOV KIMBAROVSKI
Totul in spatele funiculului -
aduc orificiul superficial indreptul celui profund
Totul in fata funiculului -aduc orificiul profund in
dreptul celui superficial
Principiul Martinov
ALB la ALBROSU la ROSU
retrofunoicular f i l
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retrofunoicular prefunicular
Procedee cu transpozitia cordomului spermatic
S h i d
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Schmieden
Marin Popescu-Urlueni
Procedee plastice
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Cu material autolog Piele - Loeve Rehn
Fascia transversalis - Ziemann Sac herniarLischied M cremasterBrenner AponevrozeAdler Teaca drept abdominalHalsted , Vreden Fascia lataWangensteen, Binet
Cu material homolog Cu material heterolog
Natural
Sintetic - PLASE cele mai folosite plase neresorbabile sunt,n USA, Goretex (plas de politetrafluoroetilen = teflon) i Marlex(plas polipropilenic), n Frana, Mersilene (plas poliesteric, dindacron), iar n Romnia, Tricotplastex (plas poliesteric);
Replaced rubber, metals and animal products. Initially
used for sutures later knitted or woven into patches for
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Nylon (1944)used for sutures, later knitted or woven into patches for
hernia repair; disintegrates in tissue and loses most of
its tensile strength within 6 months.
Polyethylene mesh(1958)
Polypropylene mesh
(1962)
High-density polyethylene mesh (Marlex, 1958) resistantto chemicals and sterilizable, but unraveled after being
cut. Modified to polypropylene mesh (1962). Available
under various trade names (Hertra-2, Marlex,
PROLENE, Surgipro, Tramex, Trelex). Available as a flat
mesh as well as 3-dimensional devices (Altex,
Hermesh3, PerFix Plug, PROLENE Hernia System).[23]
Polyester mesh
(MERSILENE) (1984)
Composed of polyester fiber with the characteristics of
filigree; can be inserted into narrow spaces without
distortion.[16]
Expanded
polytetrafluoroethylene
Teflon product; produces minimal adhesions when
placed intraperitoneally.[22,24]
Does not allow significant fibroblastic orangiogenic ingrowth; must be removed if infection occurs.
Polyglycolic acid mesh
(Dexon)
Polyglactin 910 mesh
(Vicryl)
Absorbable mesh; loses strength after 8 -12 weeks;
should not be used as a sole prosthesis for the repair of
abdominal or groin hernias
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TENSION FREE PROCEDURES
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Stoppa (1967) and colleagues used the posterior approach
to implant an impermeable barrier around the entireperitoneal bag, demonstrating that permanent repair ofgroin hernias does not require closure of the abdominal
wall defect per se. Without having stated it, their repair used
a tension-free technique In Stoppa's approach, the mesh isheld in place by intra-abdominal pressure, an application ofPascal's principle
Wantz furthered Stoppa's work by using it for unilateral
hernia repair.Essential to these and all subsequent tension-free repairs isthe application of a barrier prosthesis, usually a permanentmesh.
STOPPA WANTZ
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STOPPA WANTZ
1993 RUTKOWROBINS proc.
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PerfixPlug. Flower-shapedpolypropylene mesh plug with multiplepetals, and onlay graft with slit toaccommodate the spermatic cord.
1997 - PROLENE Hernia System (PHS) bilayer patch
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1997-PROLENE Hernia System(PHS) bilayer patchrepair. Bilayer polypropylene mesh. Three-in-one device
with round disc for properitoneal repair, plug effect ofconnector, and oblong shaped onlay component.
Tension free
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Tension free The most important advance in hernia surgery has been
the development of tension-free repairs. In 1958, Usherdescribed a hernia repair usingMarlex
mesh. The benefit of that repair he described as being"tension-eliminating" or what we now call "tension-
free". Usher opened the posterior wall and sutured a swatch of
Marlexmesh to the undersurface of the medial marginof the defect (which he described as the transversalisfascia and the conjoined tendon) and to the shelving
edge of the inguinal ligament. He created tails from themesh that encircled the spermatic cord and securedthem to the inguinal ligament.
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USHER
PROC. LICHTENSTEIN - 1984
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97/120
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98/120
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99/120
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100/120
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101/120
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102/120
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103/120
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104/120
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105/120
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106/120
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107/120
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108/120
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PROLENE Hernia System - 1997
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PROCEDEE
ENDOSCOPICE
PROPERITONEALE
- 1991 -
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PROCEDEE LAPAROSPOPICETRANPERITONEALE
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TRANPERITONEALE
GILBERT - 1985
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In light of the huge benefit gained by the laparoscopic approach tocholecystectomy -- and the rapid acceptance of that technique by most
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y y p p q ysurgeons -- much interest was given to the concept of laparoscopichernioplasty, which was introduced widely around 1990. However, many
surgeons who explored this approach to hernia repair found the learningprocess to be longer and more challenging than that seen forlaparoscopic cholecystectomy or open herniorrhaphy. For this and otherreasons, the optimal and most appropriate use of the laparoscopictechnique remains a subject of debate among general surgeons.
Laparoscopic herniorrhaphy requires general rather than localanesthesia, takes more time, costs more, and carries the potential formore significant surgical complications than those encountered withopen techniques. As a result, at least one large trial has concluded that
laparoscopy should remain the province of specialists, with openprocedures the approach of choice for most general surgeons
COMPLICATII POSTOPERATORI
H
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Hematoame.
Seroame
Hemoragii din plaga
Supuratii de plaga
Edem scrotal
Necroza testiculara Recidiva herniara
Nevralgia inghinala
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hernie palpabil
reductibil
reparare deschis cu plas
reparare laparoscopic
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EXAMEN FIZIC
reparare laparoscopic
durere persistent n
absena detectrii
vreunei hernii
hernie palpabil
bilateral
hernie recurent
hernie palpabil
unilateral
ISTORIC:
deformare parietal
durere
evitare a efortului fizic,
injecie de steroizi sau alcool
reexaminare la 1-3 luni
blocad a nervului
tehnic alloplastic
deschis bilateral
tehnic alloplastic
deschis n etape
ntindere muscular
iritaie nervoas
aplicare laparoscopic de plas
reparare deschis, po-sibil
prin laparotomie
reparare deschis cu plas properitoneal
reparare deschis cu plas
ncarcerat