hernia shanghai jiaotong university medical school renji hospital ni xingzhi
TRANSCRIPT
HerniaHernia
Shanghai Jiaotong University Medical SchoolRenji Hospital
Ni Xingzhi
HerniaHernia
DefinitionDefinition A hernia is a swelling caused by the protrusion of A hernia is a swelling caused by the protrusion of
an organ or other tissue through an aperture in an organ or other tissue through an aperture in the wall surrounding the space in which it is the wall surrounding the space in which it is situated.situated.
Such an aperture may be present normal or Such an aperture may be present normal or abnormal, in which case it can be congenital or abnormal, in which case it can be congenital or acquiredacquired
HerniaHernia
CausesCauses Lowered abdominal strengthLowered abdominal strength
Abdominal wall where an orifice for an organ or soAbdominal wall where an orifice for an organ or some tissue go thorough such as inguinal and femoral canal,etme tissue go thorough such as inguinal and femoral canal,etcc
Or trauma, surgery, infection, obesity, senility etc. Or trauma, surgery, infection, obesity, senility etc.
Increased abdominal pressureIncreased abdominal pressureCough, constipation, dysuria, acites, pregnancy, Cough, constipation, dysuria, acites, pregnancy,
heavy-liftingheavy-lifting
HerniaHernia
Pathological anatomyPathological anatomy Hernia sacHernia sac
– Neck of sac Neck of sac corresponds where the orifice iscorresponds where the orifice is
– Mouth and bodyMouth and body Contents of sacContents of sac
– Intra-peritoneal structure: small intestine or omentumIntra-peritoneal structure: small intestine or omentum Covering of sacCovering of sac
– Layers of abdominal wallLayers of abdominal wall
HerniaHernia
ClassificationClassification Reducible herniaReducible hernia Irreducible herniaIrreducible hernia
– Can not return or completely Can not return or completely – With no severe symptomsWith no severe symptoms
Incarcerated herniaIncarcerated hernia Impaired blood supplyImpaired blood supply Strangulated hernia Strangulated hernia Impaired blood supply till nonImpaired blood supply till non
Special hernias:Special hernias:Richter’s, Littre”s (Meckel’s diverticulumRichter’s, Littre”s (Meckel’s diverticulum) )
HerniaHernia
Richter HerniaRichter Hernia
Hernia Hernia Inguinal herniaInguinal hernia
Anatomy Anatomy Inguinal herniaInguinal hernia 75% of hernia75% of hernia
– Inferior Inguinal ligamentInferior Inguinal ligament– Medial RectusMedial Rectus– superior Ant,sup.iliac spinesuperior Ant,sup.iliac spine
Indirect inguinal herniaIndirect inguinal hernia 60%60%
– Lateral to inferior epigastric vessel through inguinal canal to Lateral to inferior epigastric vessel through inguinal canal to scrotum or notscrotum or not
Direct inguinal herniaDirect inguinal hernia 25%25%
– Through Hesselbach triangle medial to inferior epigastric vessel Through Hesselbach triangle medial to inferior epigastric vessel
Hernia Hernia Inguinal herniaInguinal hernia
Inguinal Inguinal herniahernia– Inferior Inferior
Inguinal Inguinal ligamentligament
– Medial RectusMedial Rectus– superior superior
Ant,sup.iliac Ant,sup.iliac spinespine
Hernia Hernia Inguinal herniaInguinal hernia
Anatomy of Anatomy of the inguinal the inguinal region from region from the internal the internal aspect, as aspect, as seen with the seen with the laparoscopic laparoscopic approachapproach
Hernia Hernia Inguinal herniaInguinal hernia
AnatomyAnatomy Skin, fat and fascia(scarpa’s)Skin, fat and fascia(scarpa’s) External oblique muscleExternal oblique muscle
– External oblique muscle aponeurosisExternal oblique muscle aponeurosis– Inguinal ,lacunar and pectineal ligamentInguinal ,lacunar and pectineal ligament– External ring External ring Medial and superior to pubic tubercleMedial and superior to pubic tubercle
– Iliogastric and ilioinguinal nerveIliogastric and ilioinguinal nerve External oblique and transversus muscle External oblique and transversus muscle
– Conjoined tendonConjoined tendonfusion of the aponeuroses of the internal oblique and transversus musclefusion of the aponeuroses of the internal oblique and transversus muscles where they insert on the pubic tubercle and superior pubic ramus. s where they insert on the pubic tubercle and superior pubic ramus.
Hernia Hernia Inguinal herniaInguinal hernia
Skin, fat and fasciSkin, fat and fascia(scarpa’s)a(scarpa’s)
External oblique External oblique
musclemuscle– External obliqExternal obliq
ue muscle apoue muscle aponeurosisneurosis
Hernia Hernia Inguinal herniaInguinal hernia
• Inguinal ligaInguinal ligamentment
180-twist of the 180-twist of the external obliquexternal oblique muscle aponee muscle aponeurosis forms a urosis forms a shelving edge ishelving edge in the lower porn the lower portion of the ligation of the ligamentment
Hernia Hernia Inguinal herniaInguinal hernia
AnatomyAnatomy Transversalis fascia Transversalis fascia
– Internal ringInternal ring 1-2cm above mid-inguinal point1-2cm above mid-inguinal point Laterally to inferior epigastric arteryLaterally to inferior epigastric artery Spermatic cord (vas deferens, testicular vessels), round ligameSpermatic cord (vas deferens, testicular vessels), round ligame
ntnt
Extra-peritoneal fat Extra-peritoneal fat PeritoneumPeritoneum
Hernia Hernia Inguinal herniaInguinal hernia
Internal ringInternal ring– 1-2cm above mi1-2cm above mi
d-inguinal pointd-inguinal point– Laterally to inferiLaterally to inferi
or epigastric arteor epigastric arteryry
– Spermatic cord Spermatic cord (vas deferens, tes(vas deferens, testicular vessels), rticular vessels), round ligamentound ligament
Hernia Hernia Inguinal herniaInguinal hernia
inferior epinferior epigastric artigastric arteryery
Hernia Hernia Inguinal herniaInguinal hernia
Anatomy ofAnatomy of inguinal canalinguinal canal A canal for passage of spermatic cord in male and round liA canal for passage of spermatic cord in male and round li
gament in femalegament in female
Anterior----external oblique aponeurosis, Anterior----external oblique aponeurosis, internal oblique muscle(lateral 1/3)internal oblique muscle(lateral 1/3)
Posterior----transversalis fascia and peritoneumPosterior----transversalis fascia and peritoneum Superior---- internal oblique muscle and Superior---- internal oblique muscle and
conjoined tendonconjoined tendon Inferior----inguinal and lacunar ligamentInferior----inguinal and lacunar ligament
Hernia Hernia Inguinal herniaInguinal hernia
Anterior----externAnterior----external oblique aponeual oblique aponeurosis, internal oblirosis, internal oblique muscle(lateral que muscle(lateral 1/3)1/3)
Posterior----tranPosterior----transversalis fascia ansversalis fascia and peritoneum d peritoneum
Hernia Hernia Inguinal herniaInguinal hernia
Anterior----externAnterior----external oblique aponeual oblique aponeurosis, internal oblirosis, internal oblique muscle(lateral que muscle(lateral 1/3)1/3)
Posterior----tranPosterior----transversalis fascia ansversalis fascia and peritoneum d peritoneum
Hernia Hernia Inguinal herniaInguinal hernia
Superior---- internSuperior---- internal oblique muscle al oblique muscle and conjoined tand conjoined tendonendon
Inferior----inguinInferior----inguinal and lacunar ligal and lacunar ligamentament
Hernia Hernia Inguinal herniaInguinal hernia
Inguinal hernia
Hernia Hernia Inguinal herniaInguinal hernia
Anatomy ofAnatomy of Hesselbach’s Hesselbach’s triangletriangle
It is It is bounded superiorly bounded superiorly by lateral side of by lateral side of rectus abdominis, rectus abdominis, inferiorly by inferiorly by inguinal ligament inguinal ligament and laterally by and laterally by inferior epigastric inferior epigastric vessels.vessels.
Hernia Hernia Inguinal herniaInguinal hernia
Symptoms and Diagnosis of IIHSymptoms and Diagnosis of IIH Reducible hernia
– Inguinal protrusionInguinal protrusion– Dragging discomfort in the groinDragging discomfort in the groin– Particularly in lifting or strain Particularly in lifting or strain – Returns after lying down or with help of handsReturns after lying down or with help of hands
Irreducible hernia Irreducible hernia – Un-retractable inguinal protrusionUn-retractable inguinal protrusion– More discomfortMore discomfort
Hernia Hernia Inguinal herniaInguinal hernia
Symptoms and Diagnosis of IIHSymptoms and Diagnosis of IIH Incarcerated herniaIncarcerated hernia
– Sudden increased intra-abdominal pressureSudden increased intra-abdominal pressure– Sudden enlarged herniation with tendernessSudden enlarged herniation with tenderness– Bowel obstruction manifestations if content is small intBowel obstruction manifestations if content is small int
estineestine Strangulated herniaStrangulated hernia
– Relieved pain but herniation persistsRelieved pain but herniation persists– Infarction and perforation of strangulated bowelInfarction and perforation of strangulated bowel– Local and general infectionLocal and general infection
HerniaHernia
IncarcerationIncarceration
Hernia Hernia Inguinal herniaInguinal hernia
Symptoms and Symptoms and Diagnosis Diagnosis of DIHof DIH
Mostly seen in eldersMostly seen in elders Semi-spheres lateral to Semi-spheres lateral to
pubic tuberclepubic tubercle Seldom irreducible Seldom irreducible
and rarely and rarely strangulatesstrangulates
Never goes into Never goes into scrotumscrotum
Hernia Hernia Inguinal herniaInguinal hernia
DifferentiationDifferentiation IIH and DIHIIH and DIH see table 45-1(textbook)see table 45-1(textbook)
Other diseasesOther diseases– HydroceleHydrocele– Undescended testesUndescended testes– Acute bowel obstructionAcute bowel obstruction
Hernia Hernia Inguinal herniaInguinal hernia
AA NormalNormal
BB Proximal sacProximal sac
CC Hernia sac extended Hernia sac extended to the scrotumto the scrotum
DD Proximal and distal oProximal and distal obliteration with hydrbliteration with hydrocele of the cordocele of the cord
CC Hydrocele of the scroHydrocele of the scrotumtum
EE Patent processus witPatent processus with communicating hydh communicating hydrocelerocele
Hernia Hernia Inguinal herniaInguinal hernia
TreatmentTreatment Conservative Conservative
– Inguinal hernia trussInguinal hernia truss
SurgicalSurgical– Dissection of inguinal canalDissection of inguinal canal– Repair of myopectineal orificeRepair of myopectineal orifice– Closure of inguinal canalClosure of inguinal canal
Hernia Hernia Inguinal herniaInguinal hernia
TreatmentTreatment SurgicalSurgical
– HernioplastyHernioplasty FergusonFerguson BassiniBassini HalstedHalsted McVayMcVay ShouldiceShouldice
Hernia Hernia Inguinal hernia-Inguinal hernia-Bassini OperationBassini Operation
Incision of the External Oblique AponIncision of the External Oblique Apon
eurosiseurosis Isolating the spermatic cord Isolating the spermatic cord
Hernia Hernia Inguinal hernia-Inguinal hernia-Bassini OperationBassini Operation
Resection of the Cremaster MuscleResection of the Cremaster Muscle Management of an Indirect SacManagement of an Indirect Sac
Hernia Hernia Inguinal hernia-Inguinal hernia-Bassini OperationBassini Operation
Splitting the Transversalis FasciaSplitting the Transversalis Fascia
Hernia Hernia Inguinal hernia-Inguinal hernia-Bassini OperationBassini Operation
Suture of the Deep PlaneSuture of the Deep Plane
Hernia Hernia Inguinal hernia-Inguinal hernia-Bassini OperationBassini Operation
Suture of the Deep Plane Suture of the Deep Plane Reconstructing the Anterior Wall of theReconstructing the Anterior Wall of the Inguinal Canal and the Superficial PlanesInguinal Canal and the Superficial Planes
Hernia Hernia Inguinal hernia-Inguinal hernia-Shoudice RepairShoudice Repair
Hernia Hernia Inguinal herniaInguinal hernia
TreatmentTreatment SurgicalSurgical
– Tension-free hernioplasty
Hernia Hernia Inguinal herniaInguinal hernia
TreatmentTreatment SurgicalSurgical
– Tension-free
hernioplasty
Hernia Hernia Inguinal herniaInguinal hernia
TreatmentTreatment SurgicalSurgical
– Laparascopic hernioplstyLaparascopic hernioplsty
Hernia Hernia Inguinal herniaInguinal hernia
Laparascopic hernioplstyLaparascopic hernioplsty– Placement of mesh internally in inguinal region Placement of mesh internally in inguinal region
Hernia Hernia Inguinal herniaInguinal hernia
TreatmentTreatment Irreducible and strangulated herniaIrreducible and strangulated hernia
– ManeuverManeuver Within3-4hrs, no tenderness and abdominal irritationWithin3-4hrs, no tenderness and abdominal irritation Patient not fit for surgery and without bowel infarctionPatient not fit for surgery and without bowel infarction
– SurgerySurgery No hernioplasty after bowel resectionNo hernioplasty after bowel resection
Hernia Hernia femoral herniafemoral hernia A femoral hernia projects through femoral canalA femoral hernia projects through femoral canal
– 3-5% of groin hernia3-5% of groin hernia– Mostly seen in women over 40 or pregnantMostly seen in women over 40 or pregnant
Stretching of pelvic ligament Stretching of pelvic ligament Widening of femoral ring during pregnancyWidening of femoral ring during pregnancy
Femoral canalFemoral canal– Medial to femoral veinMedial to femoral vein– Opens into abdomen through femoral ringOpens into abdomen through femoral ring
Femoral canalFemoral canal– In front by inguinal ligamentIn front by inguinal ligament– Laterally by femoral veinLaterally by femoral vein– Internally by lacunar ligmentInternally by lacunar ligment– Posteriorly by pectineal ligamentPosteriorly by pectineal ligament
Hernia Hernia femoral herniafemoral hernia
Femoral Femoral canalcanal
Hernia Hernia femoral herniafemoral hernia Femoral canaFemoral cana
ll– In front by inIn front by in
guinal ligamguinal ligamentent
– Laterally by Laterally by femoral veinfemoral vein
– Internally by Internally by lacunar ligmlacunar ligmentent
– Posteriorly bPosteriorly by pectineal liy pectineal ligamentgament
Hernia Hernia femoral herniafemoral hernia
Clinical featureClinical feature– A bulge in upper aspect of thigh, beneath inguinal ligamentA bulge in upper aspect of thigh, beneath inguinal ligament– Below and lateral the pubic tubercleBelow and lateral the pubic tubercle– Absence of a cough impulse over inguinal ringAbsence of a cough impulse over inguinal ring– Liable to strangulate and can not be readily reducedLiable to strangulate and can not be readily reduced
DifferentiationDifferentiation SurgerySurgery
– McVay’s procedure McVay’s procedure – Cut inguinal ligament to enlarge the ring to reduce heriationCut inguinal ligament to enlarge the ring to reduce heriation
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