腹 外 疝 Abdominal hernia 长江大学临床医学院 外科教研室

什么是疝？（hernia）shan? Shuai? 概念？

体内某个脏器或组织离开其正常解剖部位，通过先天或后天形成的薄弱点、缺损或孔隙进入另一部位。

从病患图片了解疝

Hernia History 腹股沟疝是人类最早认识的疾病之一，是人类及直立动物所特有的疾病。回顾腹股沟疝外科的历史，清晰可见的是它的历程就如同外科发展史的缩影。外科历程中的每一重大进步，如解剖学的认识、麻醉学的发展、无菌术、抗生素、合成生物学材料及腹腔镜技术的应用等等，无不和疝外科的发展息息相关。

3、历史回顾 关于腹股沟疝最早的记载要追溯到公元前1500年四大文明古国的埃及。公元40年，Celsus采用腹股沟管切开术、阴囊切开睾丸切除术、疝囊分离后切除和缝合内环，术后切口敞开，让伤口发生炎症而形成瘢痕愈合，甚至用烙铁烫烧伤口以形成更多瘢痕来治疗腹股沟疝，被公认为是疝治疗的开始。 公元200年，Galen继承了Celsus的思想，最早采用疝囊结扎术治疗斜疝，但他仅在皮下环局部结扎疝囊，Lanfrance进一步使用金属线在外环口结扎疝囊。 直到16世纪，Pare采用通过腹股沟管切除疝囊，用金属线缝合疝囊颈的手术方法，这是疝外科技术的重大进步，但当时未广泛接受。 17~19世纪及文艺复兴以后，实体解剖学遍及整个欧洲，人们对疝的清醒认识要归功于疝外科解剖学的进展，此时疝外科也趋向成熟。

Historical Hernia

Historical Hernias: Trusses & Techniques

病因 腹壁强度降低； 腹内压力增高。

临床类型 难复性疝 易复性疝 嵌顿性疝 绞窄性疝

胚胎早期睾丸位 于腹膜后L 2-3旁 睾丸下降 鞘突下段成为 睾丸固有鞘膜 鞘突未闭即成疝

几种特殊疝 ◆滑疝 ◆Richter疝 ◆Littre疝 ◆逆行性嵌顿

滑动性疝:属于难复性疝。疝内容物是疝囊壁的一部分。 疝内容物常见为：阑尾、乙状结肠、膀胱

Richter——嵌顿的疝内容物为肠管壁的一部分 也称为肠管壁疝 Littre ——嵌顿的内容物为Meakel憩室

逆 行 性 嵌 顿

概述 腹内疝 斜疝90% 腹股沟疝 直疝5% 疝 腹外疝 股疝3-5% 切口疝、脐疝、白线疝 其它疝——膈疝、脑疝

了解疝的治疗的前提：解剖概要 疝的解剖 疝囊=疝囊颈+疝囊体 疝内容物 疝外被盖 疝门——命名依据

疝的周围解剖

疝的周围解剖

重点掌握点：腹股沟疝

临床表现 腹股沟肿块 肠梗阻症状 肠绞窄症状 其它症状

鉴别诊断 1：直疝与斜疝 2：交通性鞘膜积液 3：精索鞘膜积液 4：睾丸鞘膜积液

腹股沟直疝

腹股沟斜疝

斜疝 直疝 发病年龄 多见与儿童与青壮年 多见于老年 突出途径 经腹股沟管突出 由直疝三角突出 进入阴囊 可进入 决不 斜疝 直疝 发病年龄 多见与儿童与青壮年 多见于老年 突出途径 经腹股沟管突出 由直疝三角突出 进入阴囊 可进入 决不 疝块外形 椭圆形或梨形，有蒂 半球形，基底较宽 压住内环 疝块不再突出 仍可突出 关 系 精索在疝囊后方 精索在疝囊前外方 疝囊颈在腹壁下A外侧 囊颈在腹壁下A内 嵌顿机会 较多 极少

疝的治疗 非手术治疗 1岁以内的婴糼儿 年老体弱或合并重要脏器疾病无法耐受手术者 手术治疗

非手术治疗

手术治疗的标准术式创建人 Edoardo Bassini (April 14, 1844 – July 19, 1924)

Edoardo Bassini (April 14, 1844 – July 19, 1924) was an Italian surgeon who was born in Pavia. In 1866 he received his medical degree from the University of Pavia, and afterwards joined the Italian Unification movement as an infantry soldier under Giuseppe Garibaldi (1807-1882). In 1867 he was seriously wounded and taken prisoner. After his release and recovery, he traveled throughout Europe, furthering his medical studies. He learned surgical procedures in Vienna under Theodor Billroth (1829-1894), in Berlin under Bernhard von Langenbeck (1810-1887), and in Munich with Johann Nepomuk von Nussbaum (1829-1890). He also visited London, where he met with Thomas Spencer Wells (1818-1897) and Joseph Lister (1827-1912).

Afterwards, he was in charge of the surgical department at the hospital La Spezia, and in 1878 became a lecturer in surgery at Parma. In 1882 he became head of surgical pathology at the University of Padua, and later succeeded Tito Vanzetti (1809-1888) as the chair of clinical surgery. Bassini is remembered for his operative techniques regarding inguinal hernia repair. In 1884 Bassini introduced a surgical procedure that allowed for reconstruction of the inguinal canal and restoration of the patient's anatomy following the removal of the hernial sac. It was a landmark operation because the posterior wall of the inguinal canal could be rebuilt and reinforced with only sutures, and no additional reinforcement or prosthesis was required. Despite the importance of this new surgical method, it didn't become known outside of Italy until 1890.

手术治疗模式分析：水坝拦截 A B C

2 手术治疗 ①疝囊高位结扎 ②传统疝修补的方法 加强前壁——Ferguson Bassini Halsted 加强后壁 2 手术治疗 ①疝囊高位结扎 ②传统疝修补的方法 加强前壁——Ferguson Bassini Halsted 加强后壁 Mc Vay (Cooper’s Ligament) Shouldice (Canadian)

各种术式的适用范围 Ferguson——适用于腹横筋膜无显著缺损、腹股沟管后壁尚健全的斜疝；一般的直疝 Bassini、Halsted、Shouldice——适用于腹横筋膜松弛，腹股沟管薄弱者 Mc Vay——适用于大斜疝、复发疝、直疝、股疝、老年病人

Bassini Repair Is frequently used for indirect inguinal hernias and small direct hernias The conjoined tendon of the transversus abdominis and the internal oblique muscles is sutured to the inguinal ligament

Bassini Repair

McVay Repair Cooper’s ligament Repair Is for the repair of large inguinal hernias, direct inguinal hernias, recurrent hernias and femoral hernias The conjoined tendon is sutured to Cooper’s ligament from the pubic cubicle laterally

McVay Repair This repair reconstructs the inguinal canal without using a mesh prosthesis.

Shouldice Repair AKA: Canadian Repair A primary repair of the hernia defect with 4 overlapping layers of tissue. Two continuous back-and-forth sutures of permanent suture material are employed. The closure can be under tension, leading to swelling and patient discomfort.

Shouldice Repair

无张力疝修补术 Tension-Free Repair Same initial approach as anterior repair Instead of sewing fascial layers together to repair defect, a prosthetic mesh onlay used Simple to learn, easy to perform, suited for local anesthesia, excellent results with recurrence less than 4%.

Lichtenstein Repair AKA: Tension-Free Repair 1:One of the most commonly performed procedures 2:A mesh patch is sutured over the defect with a slit to allow passage of the spermatic cord 3:reconstruct the inguinal canal. Minimal tension is used to bring tissue together.

Gilbert repair

Techniques Coined by Liechtenstein in 1989 Central feature is polypropylene mesh over unrepaired floor. Gilbert repair uses a cone shaped plug placed thru deep ring. Slit placed in mesh for cord structures

Kugel Patch

Bard Perfix Plug and Patch

Prolene Hernia System

腹腔镜疝修补术 Laparoscopic Hernia Repair Current techniques include Transabdominal preperitoneal repair (TAPP) Totally extraperitoneal approach (TEP)

TAPP

TEP---完全腹膜外途径

TEP

股疝-femoral hernia 股疝——经股环、股管、卵圆窝突出 股管的解剖——上下两口、前后内外4缘 股疝易嵌顿60%

Femoral hernia 上——股环 下——卵圆窝 前——腹股沟Lig 后——耻骨梳Lig 内——腔隙Lig 外——股V

治疗——最常用Mc Vay

切口疝-incisional hernia 最常发生切口疝的是经腹直肌切口疝,最主要的原因是切口感染。（50%）