002 hernia inghinala

8/10/2019 002 Hernia Inghinala

1/120

HERNIA INGHINALA


2/120

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


3/120

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]


4/120


5/120

Remember anatomic


6/120


7/120


8/120

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


9/120

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


10/120


11/120


12/120


13/120


14/120


15/120


16/120

teaca dreptului (foia posterioar)

fascia transversalis (secionat)


linia arcuat

simfiz pubian

m. drept abdominal

trigon inghinal (Hesselbach)


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)



fascia iliopsoasului (acoperind N. femural)

inel inghinal profund


17/120


18/120


19/120


20/120


21/120


22/120


23/120


24/120


25/120


26/120

Clasificare ghernii inghinale

1. Punct herniar

2. H. inghinala interstitiala3. H. inghino-pubiana

4. H. inghino-funiculara

5. H. inghino-scrotala (labiala)


27/120

Punct herniar


28/120

h. Interstitiala


29/120

H. Inghinopubiana = pubonocel


30/120

H inghino-funiculara


31/120

H. inghino-scrotala


32/120


33/120


34/120


35/120


36/120


37/120

H inghino-pubiana


38/120

H inghino-pubiana


39/120

H inghino-scrotala


40/120

teaca dreptului (foia posterioar)

fascia transversalis (secionat)


linia arcuat

simfiz pubian

m. drept abdominal

trigon inghinal (Hesselbach)


tract iliopubian

linia alb

canal deferent

anastomoz arterial pubo-obturatorie (corona mortis)


ram pubic superior

a. obturatorie

regiunea inghinal vedere intern

m. iliopsoas

vase iliace externe


inel femural (dilatat)



fascia iliopsoasului (acoperind N. femural)


pleur parietaldiafragm

vedere intern a peretelui abdominal anterior


41/120

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


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



nerv i vase obturatorii

a. ombilical (parte distal obliterat)


vase iliace externe

funiculul spermatic

inelul femural

ram cremasteric i

ram pubic alea. epigastrice inferioare

g


42/120

Hernie inghinala

1. Oblica-externa

2. Directa

3. Oblica interna


43/120


44/120

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


45/120

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


46/120

Hernie inghinala

congenitala1. INGHINO-

TESTICULARA


47/120

2. HERNIE

CONGENITALA

FUNICULARA


48/120

Hernie inghinala

congenitala3. FUNICULARA CU

CHIST DE

CORDONSPERMATIC


49/120

4. HERNIEINGHINALACONGENITALA

ASOCIATA CUHIDROCEL


50/120


51/120

HERNII CONGENITALE ASOCIATE CU


52/120

HERNII CONGENITALE ASOCIATE CU

ECTOPIE TESTICULARA

1. Inghino-properitoneala2. Inghino-interstitiala

3. Inghino-superficiala


53/120

hernie Berger: prezen concomitent

de hernie inghinal i hernie femural

( hernie cu saci multipli)

- hernie Pantaloon: hernie inghinaldubl (n bisac, direct + indirect).


54/120

ALTE CLASIFICARI


55/120

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


56/120

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).


57/120

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


58/120

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


59/120

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,


60/120

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.


61/120


62/120


63/120


64/120


65/120


66/120

Tratament

Regula este chirurgical

Ortopedic este exceptia


67/120

Tratament chirurgical

1. Procedee anatomice

2. Procedee neanatomice

Retrofuniculare

Prefuniculare

3. Procedee cu transpozitia cordonului spermatic

4. Procedee plastice5. Procedee laparoscopice

Anestezie orice


68/120

Anestezie - orice

Local anesthesia.Local infiltration can be performed on virtually any


69/120

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


70/120

Bassini

Babcok-Meingot

Lavarde

AnnandaleLawson Tait

Cai de abord


71/120

Procedeele anatomice

Proc Bassini 1890 - Edoardo Bassini -- considered thefather of modern day hernia surgery


72/120


73/120


74/120

Incizie LaRoque

Manevra

Reymonddedepistare a sacului


75/120

Rezectia saculuiSOCIN


76/120


77/120

Proc Bassini

ANDREWS HACKENBRUCHrefacerea canalului ingnhinal


78/120

Procedee care mentin canalul inghinal dar folosesc


79/120

gLig Cooper

Lotheisen

primul care propune utilizarea ligCooper

Hashimotto

McVay


80/120

McVay - Hashimotto

Proc Souldice 1945


81/120

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


82/120

Milestones in Hernia Repair: The Listerian Era


83/120

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


84/120

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


85/120

retrofunoicular prefunicular

Procedee cu transpozitia cordomului spermatic

S h i d


86/120

Schmieden

Marin Popescu-Urlueni

Procedee plastice


87/120

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


88/120

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


89/120


90/120

TENSION FREE PROCEDURES


91/120

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


92/120

STOPPA WANTZ

1993 RUTKOWROBINS proc.


93/120

PerfixPlug. Flower-shapedpolypropylene mesh plug with multiplepetals, and onlay graft with slit toaccommodate the spermatic cord.

1997 - PROLENE Hernia System (PHS) bilayer patch


94/120

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


95/120

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.


96/120

USHER

PROC. LICHTENSTEIN - 1984


97/120


98/120


99/120


100/120


101/120


102/120


103/120


104/120


105/120


106/120


107/120


108/120


109/120


110/120


111/120

PROLENE Hernia System - 1997


112/120

PROCEDEE

ENDOSCOPICE

PROPERITONEALE

- 1991 -


113/120

PROCEDEE LAPAROSPOPICETRANPERITONEALE


114/120

TRANPERITONEALE

GILBERT - 1985


115/120


116/120

In light of the huge benefit gained by the laparoscopic approach tocholecystectomy -- and the rapid acceptance of that technique by most


117/120

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


118/120

Hematoame.

Seroame

Hemoragii din plaga

Supuratii de plaga

Edem scrotal

Necroza testiculara Recidiva herniara

Nevralgia inghinala


119/120

hernie palpabil

reductibil

reparare deschis cu plas

reparare laparoscopic


120/120

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

002 hernia inghinala

Documents