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Hernias2 Hernias2 Presentation Transcript

  • Treatment of inguinal hernias
    • Principles
    • Review relative anatomy
    • Operative methods
      • Include new progress in hernia surgery
  • Principles of treatment:
    • Adult: operative treatment
    • Child under 1: the congenital inguinal hernia may spontaneously cure
    • Patient with strong contraindications: non-operative treatment
  • Non-operative management:
    • Using some external support device or truss to maintain hernia reduction
    • Only in the patients with strong contraindications of surgical operation
    View slide
  • Operative treatment View slide
  • Before operation:
    • Any problems which could increase intraabdominal pressure, should be solved to prevent a recurrent hernia.
      • Chronic cough
      • Constipation
      • Prostatic hyperplasia
  • Aim of Operation
  • Review: Anatomy of inguinal canal
    • From the internal inguinal ring to the external inguinal ring, 4-5 cm long
    • Inside the canal
      • Male: the spermatic cord
      • Female: the round ligament of the uterus
  • Review: Anatomy of inguinal canal
    • The superior wall(roof)
      • Conjoint tendon
      • (the arcing edge of the fusing of the internal oblique abdominal muscle and the transverse abdominal muscle)
    • The inferior wall(floor)
      • The inguinal ligament
    • The anterior wall
      • The external oblique aponeurosis
      • Skin and superficial fascia
    • The posterior wall
      • The transverse fascia
    Roof : The conjoint tendon
      • The anterior wall:
    • the external oblique aponeurosis
    The posterior wall: the transverse fascia Floor : The inguinal ligament The spermatic cord
  • Review: Anatomy of inguinal canal External oblique aponeurosis Conjoint tendon
  • Review: Anatomy of inguinal canal The transverse fascia Site for inguinal hernia
  • Operative techniques
    • A. Simple high ligation of the sac
    • used for child
    • B. Repair of hernia
    • C. Tension free Mesh repair
    • D. Laparoscopic Repair
  • A. Simple high ligation of the sac:
    • Ligate neck of hernia sac
    • Isolate hernia sac
    • Cut exteral oblique aponeurosis
    • Removal of the sac
  • 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
  • Bassini repair:
    • 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 muscle and the external oblique aponeurosis.
    Roof : Conjoint tendon
      • The anterior wall:
    • the external oblique aponeurosis
    The posterior wall: the transverse fascia Floor : The inguinal ligament The spermatic cord
  • Shouldice repair:
    • Before Bassini repair, cut transvers abdominal fascia and suture it overlaply
    • Decrease recurrent hernia effectively
    Roof : Conjoint tendon
      • The anterior wall:
    • the external oblique aponeurosis
    The posterior wall: the transverse fascia Floor : The inguinal ligament The spermatic cord
  • Halsted repair:
    • Place the external oblique aponeurosis beneath the cord , but otherwise resembles the Bassini repair.
    • Leaves the spermatic cord under the skin and subcutaneous tissue
    • Used in older men
    Roof : Conjoint tendon
      • The anterior wall:
    • the external oblique aponeurosis
    The posterior wall: the transverse fascia Floor : The inguinal ligament The spermatic cord
  • McVay repair:
    • Brings the arcing edge of the conjointed tendon posteriorly and inferiorly to Cooper’s ligament and suture them
    • For big hernia, recurrent hernia, femoral hernia
    Roof : Conjoint tendon
      • The anterior wall:
    • the external oblique aponeurosis
    The posterior wall: the transverse fascia Floor : The inguinal ligament The spermatic cord The cooper’s ligament
  • Ferguson repair:
    • 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 external oblique aponeurosis (the repaired anterior wall)
    Roof : Conjoint tendon
      • The anterior wall:
    • the external oblique aponeurosis
    The posterior wall: the transverse fascia Floor : The inguinal ligament The spermatic cord
  • C. Tension free Mesh repair
    • Use artificial materials
    • Tesion free
    • Low recurrent rate
  • Tension free Mesh repair:
  • D. Laparoscopic Repair
    • Shorter recovery time and less post-operative discomfort
    • Used for bilateral hernias, recurrent hernia
  • Conclusion
  • 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