의학과 4학년외과학강의

Hernia

KIM MYOUNG SOO M.D.

Department of Surgery Yonsei University Wonju College of Medicine

ysms91@wonju.yonsei.ac.krhttp://gs.yonsei.ac.kr

학습목표

1.서혜부의해부학적구조를도시한다.(B) 2. 직접과간접서혜부탈장을비교설명한다.(B)3. 서혜부탈장의수술적치료원칙을설명한다.(A) 4. 서혜삼각(Hesselbach's striangle)을이루는해부학적구조를도시하고그의의를설명한다.(B)

5. 반흔탈장의원인, 발생예방법및치료에대하여기술한다.(A)6. 활주탈장(Sliding hernia)의정의와진단적특징을기술한다.(A)7. 희귀탈장을정의한다.(요부탈장(Lumbar hernia), 폐쇄막탈장(Obturator hernia), 좌골탈장(Sciatica hernia)).(B)

Anatomical Information

(1) inguinal Cannal

Anatomical Information

(2) Hesselbach’s Triangle

1:inguinal ligament2:Femoral a.3:inferior epigastric a.A: Indirect herniaB: Direct herniaC: Femoral hernia

Diagnosis and DDx of Hernia

Symptoms bulge in the inguinal region. minor pain or vague discomfort associated with the groin bulge.parethesias related to irritation or compression of inguinal nerves by the hernia Extreme pain is unusual related with incarceration and intestinal vascular compromise

Physical exam.

Visual inspection of the groin - a loss of symmetry in the inguinal area or a discrete bulge. Valsalva's maneuver or cough accentuate the bulge

Fingertips on the abdominal wall over the inguinal region + repeat Valsalva's maneuver

Bulging from lateral wall indirect inguinalBulging from deep portion direct inguinalBulging below the inguinal ligament femoral hernia

Incarcerated hernia Gentle pressure on the hernial mass under theTrendelenburg's position + analgesic agents

Gangrenous bowel Rarely be reduced by manual reductionPatients should be followed for the development of peritoneal signs

Reduction en masse Reduction of the entire hernia sac with the intestine remaining incarcerated within the sac

Failure of manual reduction of incarcerated hernia

Immediate operation

Incidence

Indirect inguinal hernia, 50%

Direct inguinal hernia, 24%

Ventral hernia, 10%

Femoral hernia, 3%Unusual hernia, 5-10%

Male >> Female=25% of males vs. only 2% of females will develop inguinal hernias

The most common hernia in males and females is the indirect inguinal hernia. Femoral hernias occur much more frequently in females than in males.. Right >> Left, why ? Time-internal of testicle descending

Inguinal Hernia : Etiology

(1) congenital origins = The lack of obliteration of the processus vaginalis= indirect herniaRisk factors: Prematurity and low birth weight, Congenital

abnormalities such as pelvic deformities or exstrophy of the urinary bladder

(2) acquired origins = wear-and-tear stresses = direct herniaRisk factors : Straining to urinate or defecate, coughing, and

heavy lifting, Smoking

Inguinal Hernia : Operation

“I know more than a hundred surgeons whom I would cheerfully allow to remove my gallbladder but only one to whom I should like to expose my inguinal canal.”(Sir Henage Ogilvie)

Natural course : Hernias do not resolve spontaneously or improve with time. Wearing a truss does not cure a hernia. Repair of a groin hernia can be planned electively unless incarceration

or strangulation is present.

Principles :

“High ligation of hernia sac + Posterior wall enforcement(reconstruction)”

Approach method : Anterior approach versus Preperitoneal approach (laparoscopic )

Inguinal Hernia : Operation ; Bassini operation

Conjoin tendon – inguinal ligament

Inguinal Hernia : Operation ; McVay operation

Conjoin tendon – Cooper’s ligament

Inguinal Hernia : Operation ; Shouldish operation

Inguinal Hernia : Operation ; Lichtenstein (tension-free)

Single layer mesh versus double layer meshOp.

Inguinal Hernia : Operation ; Laparoscopic Hernia Repair -transabdominal preperitoneal(TAPP) repair

Inguinal Hernia : Operation ; Laparoscopic Hernia Repair -totally extraperitoneal approach (TEPA)

Femoral Hernia

below the inguinal ligament. more common in femalesrepaired using a standard Cooper's ligament (McVay) repair. incarceration is common – viability of bowel ???

Umbilical Hernia

Congenital form - common in infantdelay operation until 5 years old

Acquired form - during adulthood, Pregnancy, ascites, acute

abdominal distention (e.g., intestinal obstruction)

Incarceration and strangulation are unusual but rupture can occur.

Treatment : Umbilical hernias can be repaired in a pants over vest manneror a simple transverse closure. Recurrence of umbilical hernias is extremely uncommon.

Ventral(Incisional) Hernia

Inadequate healingPostoperative wound infection Postoperative pulmonary complicationsPostoperative hematoma

Excessive strainObesity, Advanced age, Malnutrition, Ascites, Peritoneal dialysis, Pregnancy

Sliding Hernia

A sliding inguinal hernia is defined as one in which a viscus forms a portion of the wall of the hernia sac.

Common involved viscus : bowel(cecum; Rt side, sigmoid colon; Lt side )urinary bladder.

The primary danger associated with a sliding hernia is the failure to detect due to visceral component.

Unusual Hernia(1) Epigastric Hernia (2) Richter's Hernia(3) Littre's Hernia (4) Spigelian Hernia (5) Obturator Hernia (6) Lumbar (Dorsal) Hernia (7) Sciatic Hernia (8) Perineal Hernia

Unusual Hernia

(1) Epigastric Hernia (2) Richter's Hernia(3) Littre's Hernia (4) Spigelian Hernia (5) Obturator Hernia (6) Lumbar (Dorsal) Hernia (7) Sciatic Hernia (8) Perineal Hernia

Complication after Hernioplasty

In adult patients, complication rates from open inguinal herniorrhaphyvary from 1% to 26%, with most reports ranging from 7% to 12%.

Recurrence after Hernioplasty

Recurrence rates vary from less than 1% to 7% for indirect inguinal hernias, from 4% to 10% for direct inguinal hernias,from 1% to 7% for femoral hernias, and from 5% to 35% for recurrent hernia repair

Recurrence may result from technical failure,inadequate fascial strength, impaired wound healing, trauma, progressive weakening of surrounding tissues,

or tissue approximated under excessive tension.

Failure of high ligation and posterior wall reconstruction

Thank You

Kim Myoung Soo M.D.

Department of SurgeryYonsei University Wonju College of Medicine

ysms91@wonju.yonsei.ac.kr