Professional Documents
Culture Documents
Dr. Nachmany
Lecture Subjects
Anatomy Inguinal & Femoral canals Clinical aspects of hernia Repair of Inguinofemoral Hernia:
Open Rrhaphy; Tension free. Laparoscopic
Anatomy
Extends from the deep (fascia transversalis) to the superficial inguinal ring (ext. oblique) Parallel and above the inguinal ligament Walls of the Inguinal Canal:
Anterior Posterior Superior Inferior
Physiology
Inguinal canal - a passage through the lower abdominal wall
Males - to and from the testis Females - round ligament of the uterus to the labium major Both sexes Ilio-inguinal nerve
Embryology
Processus Vaginalis Spermatic Fasciae Gubernaculum
Spermatic Cord
Forms at the level of the Deep ring It is covered with three concentric layers of fascia derived from the layers of the anterior abdominal wall
Embryology - Gubernaculum
Extends from the lower pole of the developing gonad to the labioscrotal swelling In the male the testis descends during the 7th and 8th months of fetal life
Embryology - Gubernaculum
The stimulus for the descent is testosterone, secreted by the fetal testes The testis follows the gubernaculum and descends behind the processus vaginalis Pulls down its duct, blood vessels, nerves and lymphatics In the female - extends from the uterus into the developing labium major Persists as the round ligament
A hernia - protrusion of part of the abdominal contents beyond the normal confines of the abdominal wall Consists of:
Sac Contents of the sac Coverings of the sac
Complications:
Incarceration Strangulation Bowel obstruction
Femoral Umbilical:
Congenital Acquired
Incisional (POVH)
Femoral Hernia
The femoral sheath - a protrusion of the fascial envelope lining the abdominal walls Surrounds the femoral vessels & lymphatics for 1 inch below the inguinal ligament
The femoral septum, which is a condensation of extraperitoneal tissue, plugs the opening The femoral vein is separated from it by a fibrous septum
Femoral Hernia
Much more common in women The sac passes down the canal, pushing the septum On the lower end, it forms a swelling in the upper thigh With further expansion the sac may turn upward to cross the inguinal ligament The neck always lies below and lateral to the pubic tubercle
Classification
Those that close all or part of the myopectineal orifice Anterior Vs. Posterior Repair by suturing the tissues at boundaries:
Bassini Shouldice Cooper (McVay)
Anterior Repairs
Dissection and hernia reduction is the same: incision 2 to 3 cm above and parallel to the inguinal ligament Dissection through the subcutaneous tissues and Scarpas fascia The external oblique fascia and external ring is identified The external oblique fascia is incised to expose the inguinal canal The ilioinguinal and iliohypogastric nerves should be preserved
Herniorrhaphy
Bassini Shouldice McVay (Coopers ligament repair) Ileopubic tract
2nd posterior suture Int. oblique and transversus abdominis to inguinal ligament
Relaxing incision
Lateral to the medial aspect of the femoral canal , the transversus abdominis aponeurosis is secured to the iliopubic tract
Lichtenstein Repair
Tension is the principal cause of recurrence Synthetic mesh prosthesis to bridge the defect
Inferior suture line - Shelving edge of the inguinal (Pouparts) ligament Superior line Conjoint muscle & tendon
Posterior Repairs
Open Repair:
Stoppa
Laparoscopic
Trans Abdominal Pre-Peritoneal (TAPP) Total Extra Peritoneal (TEP)
Preperitoneal Anatomy
Whats that?
and that?
Danger areas
TEP
TAPP
Direct Hernia
Indirect Hernia
TAPP