Hernia Femurala Si Restul

8/10/2019 Hernia Femurala Si Restul

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HERNIA FEMURALA


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Moskovitz

Miolacunara

Hesselbach


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Diagnostic diferential

Forma necomplicata

abces rece osifluent

Anevrism artera femurala

Actazie de crosa safena

magna

Lipoame

Adenopatii nghinale

Forma incarcerata

Limfadenita ganglionului

Cloquet

Flebita crosei safenemagna


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TratamentCai de abord

1. Femurala2. Femurala largita

3. Inghinala

4. Transabdominala clasica Lawson Tait

5. Laparoscopica


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Procedee

Pe cale femurala Coborare fortata a arcadei femurale

BERGERarcada la fascia pectieneala

TRICOMINIface o bursa

ZATEPINpune o ligatura pe sub ramura pubiana RANYbate cuie in pubis coborasnd arcada

Coborare relaxata a arcadei femurale FABRICIUSsectioneaza lig Gimbernard

DELAGENIERfoloseste lig Cooper

Pe cale femurala largita Proc dublei perdele CADENAT

Pe cale inghinala RUGGI

PARLAVECHIO

CODIVILA

ROBINEAU

Procedee plastice

STRECHI lig rotund POLYA m. croitor

WATSON - . Prectineu

HOFFNER vena safena

GOROSLOVSKI aponevroza pectineala

TURNER - aponevroza pectineala si fasciapsoasului

KEYNE teaca dreptilor abdominali

Procedee plastice cu material

sintetic - PLASE


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Proc FABRICIUS BERGER pe cale femurala


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Procedeul dublei perdele CADENAT


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Procedeu RUGGI - PARLAVECHIO


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HERNIA OMBILICALA


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Ombilicul (buricul): este o cicatrice care se formeazconsecutiv secionrii la natere a cordonului ombilical,cu obliterare ifibrozare consecutiva vaselor ombilicale(ombilicul poate fi imaginat ca un trident ntors, undemnerul este format de v. ombilical obliterat ceformeaz lig. rotund al ficatului, iar braele, cu orientareinferioar, sunt reprezentate de cele dou artere

ombilicale, parial obliterate, i urac); majoritar laanimale, hernia ombilical ocup la om o poziiesecundarca frecven(datorittrecerii la poziiabiped);la nivelul ombilicului, peritoneul prezint adesea un pliucunoscut sub denumirea de fascia ombilicalRichet

se descriu hernii ombilicale directe (n caz de absen afasciei Richet) i hernii ombilicale indirecte (obliceinferioare sau superioare).


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Umbilical hernia is a frequently encountered clinicalproblem that is infrequently discussed critically in the

medical literature. Umbilical hernias were described asearly as the first century, but it was not until 1740 thatWilliam Cheselden reported the first repair. In theUnited States, Stoser performed the first operation foran umbilical hernia. It was, however, William Mayo whopopularized the vest-over-trousersoverlapping repairin 1901 in his classic description of 19 patients treated

with this revolutionary procedure. There were fewadvances in therapy during the next 100 years. A recent

contribution to the treatment of umbilical hernias hasbeen the introduction of mesh and the use oflaparoscopic techniques.


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ETIOLOGY AND PRESENTATION

The typical patient with an umbilical hernia is an overweightmultiparous female between the ages of 35 and 50. Women areaffected with umbilical hernias 3 to 5 times more frequently than

men. Ascites may be a contributing factor and makes the hernia more

difficult to treat.

The etiology of herniation at the umbilicus is multifactorial, butchronically increased intra-abdominal pressure and weakened

fascial tissue at the umbilicus are of utmost importance. The hernias can be quite large, with fascial defects of 10 to 15 cm,

but most are smaller than 5 cm in diameter. Omentum, colon, andsmall bowel can all be encountered within the umbilical hernia sac.Baccari described the presence of omentum alone or in

combination with small or large bowel in 60% of patients. 1 Smallbowel alone and large bowel were found in 4% and 7%,respectively. Adhesions from the omentum and bowel to the sacand the relatively small size of the fascial defect compared with thelarge amount of sac contents make these hernias prone toincarceration.


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CLASIFICARE

Congenitala Embrionaramembrana lui Ratke, gelatina lui Warton

Fetalasacul herniar este format

Dobandita A copilului mic

A adultului

(+Simptomatica)

Oblica

Directa


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Hernie ombilicala simptomatica


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Apare la 20% din bolnavii cu aascita. In 10% din cazuri se produce exulcerarea

tegumentului cu deschiderea sacului sifistula ombilicala.

Mortalitate 2% daca se repara hernia faraa se controla ascita


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Tratament H ombilicala

Omfalectomie in formele avansate Procedee

Ed. Quenu

Sapiejko-Picoli

Mayo-Menge Procedee plastice cu

Piele

PLASA

ClasiceLaparoscopice

Rata recidivelor 10-30%mai mare dupa

procedeele fara plasa


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HERNIA EPIGASTRICA

Lipom preherniar

Forma nedureroasa

Forma dureroasa

Se asociaza cu alte afectiuni ale etajului abdominal

superior

A S G L


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HERNIA SPIEGEL


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HERNII OBTURATORII

canalul obturator (ntre membrana obturatorie imarginea inferioar a coxalului de la nivelul guriiobturatorii, adpostind mnunchiul vasculo-nervosobturator = hernii obturatorii (este orificiu greu

distensibil frecvent hernie strangulat; trebuiediagnostic diferenial cu herniile femurale): pentru ase exterioriza la piele, trebuie sspargfascia cribri-formis (parte a fasciei lata) dificil (diagnostic cel

mai adesea intraoperator). Semnul Romberg

simfiz pubian

lig. pubic arcuat inferior


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canal sacral hiatus anorectal

lig. sacrococcigian anterior

orificii sacrale anterioare

m. piriform

m. ischicoccigian

spinischiatic

diafragma

pelvin brbat

- aspectsuperior -

articulaiesacroiliac

sacru

pecten pubis (parte a liniei iliopectinee)

spiniliacanterosuperioar

aripiliac

linie arcuat (parte iliac a

liniei iliopectinee)

spinischiatic

emineniliopubic

margine acetabular

puborectal

m. obturator intern

pubococcigian

iliococcigian

arc tendinos al m. levator ani

fibre musculare din levator ani spre stratul

muscular longitudinal al canalului anal

simfizpubian

ram pubic superior

tubercul pubic

canal obturator

creastpubic

fascie obturatorie

hiatus uretral

hiatus pentru vena dorsalprofunda penisului

lig. perineal transvers

membrana perineal

m. levator ani


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orficii ischiatice: orificiu suprapiriform (pasaj pentrumnunchiulvasculonervos fesier superior) iinfrapiriform(pasaj pentru N. ischiadic, N. femurocutanat posterior,

mnunchiulvasculonervos fesier inferior iruinosintern),determinate de trecerea m. piriform prin marea incizurischiatic apariie de hernii fesiere; (trebuie avute nvedere la diagnosticul diferenial al flegmoanelor fesiere,etc.); muchii fesieri acoper mult vreme hernia; suntdescrise i hernii sciatice, produse prin micul orificiu

sciatic.

HERNII ISCHIADICE

simfizbi v dorsal profund a penisului


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extensii fibromusculare ale levator ani spre prostat

tubercul pubic

pubianv. dorsalprofunda penisului

grsimen spaiulprevezical

iliococcigian

m. rectouretral superior

fibre musculare prerectale (Luschka) din m. levator ani

fibre musculare din levator ani spre m.

longitudinal al canalului anal

m. fesier mare

lig. pubic inferior

m. obturator intern

arc tendinos al m. levator ani

uretr

membranperineal(ndeprtat)

pubococcigian

fascia rectoprostaticDenonvilliers

margine mediala m. levator ani

ram ischiopubic

m. sfincter extern al uretrei

m. obturator intern

lig. sacrospinos (secionat)

lig. sacrotuberos (secionat)

tuberozitate ischiatic

tendon obturator intern

m. ischiococcigian

lig. sacrospinos (secionat)

lig. sacrotuberos (secionat) puborectal

strat muscular longitudinal

strat muscular circularvrful coccisuluijonciuneanorectal

m. levator ani

diafragma pelvin brbat

- aspect inferior -


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Hernie ischiadica Hernie perineala


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HERNII DIAFRAGMATICE

Z l b l di f l i


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Zone slabe ale diafragmului:

n afara orificiilor diafragmatice prin care se

realizeaz pasajul formaiunilor anatomice ntrecavitatea abdominal i cea toracic (hiatusaortic, hiatus esofagian, deschidere pentru VCI,orificii prin care trec canalul toracic, Nn.

splanhnici, vv. azygos, etc.), exist puncte slabediafragmatice ce pot justifica apariiaurmtoarelorhernii diafragmatice:

hernieanterioar

(prin orificiul costosternal Larrey), hernie posterioar (prin orificiul costovertebral

Bochdalek).


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Fig. 4Esofag abdominal

trigon sternocostal

parte sternal a diafragmului ram anterior al N. frenic stng


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MUCHIUL

DIAFRAGM

- suprafa

abdominal -

trigon lombocostal

N. splanhnic mare

N. splanhnic mic

v. lombar ascendent

(v. azygos)

ram lateral al a. frenice inferioare stngi

a. suprarenalstngsuperioar

N. frenic stngN. splanhnic minim

a. frenicinferioarstng- ram recurent spre esofag

parte sternala diafragmului

ram anterior al a. frenice inferioare stngi

parte costala diafragmului

v. lombarascendent(v. hemiazygos)

stlp stng al diafragmului

m. ptratlombar

lig. arcuat median

aort

abdominal

hiatus

aortictrunchi celiactrunchi simpatic

m. psoas mareproces transvers al vertebrei L1

lig. arcuat medial

m. transversabdominal

parte lombara diafragmului

lig. arcuat lateral

coasta 12

ram anterior al N. frenic stng

ram anterior al N. frenic drept

a. frenicinferioardreapt

deschiderea VCI

stlp diafragmatic drept fibre din stlpul drept trec la stnga hiatusului esofagian

hiatus esofagian

centru tendinos al diafragmului

parte costala diafragmului


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Background:A hiatal hernia occurs when a portion of

the stomach prolapses through the diaphragmatic

esophageal hiatus. Although the existence of hiatalhernia has been described in earlier medical literature, it

has come under scrutiny only in the last century or so

because of its association with gastroesophageal

reflux disease (GERD) and its complications. By far,most hiatal hernias are asymptomatic and are

discovered incidentally. On rare occasion, a life-

threatening complication, such as gastric volvulus or

strangulation, may present acutely.


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Mortality/Morbidity: Paraesophageal hernias

generally tend to enlarge with time, and sometimes theentire stomach is found within the chest. The risk of

these hernias becoming incarcerated, leading to

strangulation or perforation, is approximately 5%.This

complication is potentially lethal, and surgicalintervention is necessary. Because of the high mortality

associated with this condition, elective repair often is

advised wherever a paraesophageal hernia is found.


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Sex: Hiatal hernias are more common in women than

in men. This might relate to the intra-abdominal forces

exerted in pregnancy. Age: Muscle weakening and loss of elasticity as people

age is thought to predispose to hiatus hernia, based on

the increasing prevalence in older people. With

decreasing tissue elasticity, the gastric cardia may not

return to its normal position below the diaphragmatic

hiatus following a normal swallow. Loss of muscle tone

around the diaphragmatic opening also may make itmore patulous.

History: Hiatal hernias are relatively common and, in themselves, do


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not cause symptoms. For this reason, most people with hiatal herniasare asymptomatic. Hiatal hernias may predispose to reflux or

worsen existing reflux in a minority of individuals. Physicians should

resist the temptation to label hiatal hernia as a disease. Patients can have refluxwithout a demonstrable hiatal hernia. When

a hernia is present in a patient with symptomatic GERD, the herniamay worsen symptoms for several reasons, including the hiatalhernia acting as a fluid trap for gastric reflux and increasing the acidcontact time in the esophagus. In addition, with a hiatal hernia,episodes of transient relaxation of the LES are more frequent andthe length of the high-pressure zone is reduced. The main symptomsof a sliding hiatal hernia are those associated with reflux and itscomplications.

No clear correlation exists between the size of a hiatal hernia and theseverity of the symptoms. A very large hiatal hernia may be present

with no symptoms at all. Some complications are specific for a hiatalhernia.

Esophageal complications


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Esophageal complications

By far, the majority of hiatal hernias areasymptomatic.

Often, patients are left with the impression that theyhave a disease when a hiatal hernia is diagnosed.

In rare cases, however, a hiatal hernia may beresponsible for intermittent bleeding from associatedesophagitis, erosions (Cameron ulcers), or a discreteesophageal ulcer, leading to iron-deficiency anemia.

This particular complication is more likely in patientswho are bed-bound or those who take nonsteroidalanti-inflammatory drugs. Massive bleeding is rare.


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Nonesophageal complications

Incarceration of a hiatal hernia is rare and is

observed only with paraesophageal hernia.

When this occurs, it can present abruptly, with asudden onset of vomiting and pain, sometimes

requiring immediate operative intervention.

Causes:


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Predisposing factors include the following:

Muscle weakening and loss of elasticity as people ageis thought to

predispose to hiatus hernia, based on the increasing prevalence inolder people. With decreasing tissue elasticity, the gastric cardia may

not return to its normal position below the diaphragmatic hiatus

following a normal swallow. Loss of muscle tone around the

diaphragmatic opening also may make it more patulous. Hiatal hernias are more common inwomen. This may relate to the

intra-abdominal forces exerted in pregnancy.

Burkitt et al suggest that the Western, fiber-depleted dietleads to a

state of chronic constipation and straining during bowel movement,which might explain the higher incidence of this condition in

Western countries.


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Obesitypredisposes to hiatus hernia because ofincreased abdominal pressure.

Conditions such as chronic esophagitismay causeshortening of the esophagus by causing fibrosis of thelongitudinal muscles and, therefore, predispose to hiatalhernia. However, which comes first, the hiatal hernia

worsening the reflux or the reflux-induced shorteningof the esophagus, remains unknown.

The presence of abdominal ascitesalso is associatedwith hiatal hernias.

Di h ti h i b it l


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Diaphragmatic hernias may be congenitalor

acquired.

Acquired hiatal hernias are divided further intonontraumatic and traumatic hernias. The most

common types of hernias are those acquired in a

nontraumatic fashion. Hernias acquired in a

nontraumatic fashion are divided into 2 types, (1)sliding hiatal hernia and (2) paraesophageal hiatal

hernia. A mixed variety with coexisting sliding and

paraesophageal components is possible.

Sliding hiatal herniaby far is the most common type of hiatal


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g y yp

hernia. It occurs when the gastroesophageal junction, along with a

portion of the stomach, migrates into the mediastinum through the

esophageal hiatus The majority of patients with demonstrated hiatalhernias are asymptomatic. This type of hernia interferes with the

reflux barrier mechanism in several ways. As the LES moves into

the chest, it no longer is exposed to positive intra-abdominal

pressure and, therefore, is less effective as a sphincter. In fact, the

sphincter moves into an area of low pressure, which interferes withthe sphincter activity. In addition, the widening hiatus affects the

competence of the diaphragmatic crura. The angle of His is lost,

making regurgitation of gastric contents more likely. These changes

not only predispose to reflux of gastric contents into the esophagus,but also prolong the acid contact time with the epithelium of the

esophagus.

In paraesophageal hernia, also called rolling-type hiatal


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p p g g yphernia, the widened hiatus permits the fundus of thestomach to protrude into the chest, anterior and lateral to

the body of the esophagus; however, the gastroesophagealjunction remains below the diaphragm. This causes thestomach to rotate in a counter-clockwise direction. As thehiatus widens, increasing amounts of the greater curvature

of the stomach and, sometimes, the gastric-colicomentum, follow. The fundus eventually comes to lieabove the gastroesophageal junction, with the pylorusbeing pulled towards the diaphragmatic hiatus. In this typeof hernia, the anatomic relation of the stomach to thelower end of the esophagus (angle of His) tends to remainunchanged, so gross acid reflux does not occur.


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Medical Care:When hiatal hernias are symptomatic,


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y p ,

acid reflux usually produces the symptoms. If the hernia

itself is causing chest discomfort or other symptoms,

surgery may be necessary.

When symptoms are due to GERD, the goals of treatment

include prevention of reflux of gastric contents,

improved esophageal clearance, and reduction in acidproduction. This is achieved in the majority of patients

by a combination of the following:

Modifying lifestyle factors

Neutralizing acid or inhibiting acid production Enhancing esophageal and gastric motility

Surgical Care:A patient with a large hiatal hernia may experience vagueintermittent chest discomfort or pain The paraesophageal hernia ma strang late


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intermittent chest discomfort or pain. The paraesophageal hernia may strangulateand frequently is operated on prophylactically to prevent this complication.

Surgery is necessary only in the minority of patients with complications of

GERD despite aggressive treatment with proton pump inhibitors (PPIs).Because only a minority of patients with hiatal hernia have any problems, thisrepresents a very small proportion of patients with sliding hiatal hernia; mostpatients with problems are managed medically.

By far, the majority of patients who would have undergone surgery in the pastare managed successfully today with PPIs. However, young patients with severe

or recurrent complications of GERD, such as strictures, ulcers, and bleeding,who cannot afford lifelong PPI treatment or would prefer to avoid takingmedications long term, may be surgical candidates.

Another group of patients who are surgical candidates are those with pulmonarycomplications, in particular, asthma, recurrent aspiration pneumonia, chroniccough, or hoarseness linked to reflux disease.

Three major types of surgical procedures correct gastroesophageal reflux andrepair the hernia in the process. They can be performed by open laparotomy orwith laparoscopic approaches, which currently are being employed morefrequently.

Nissen fundoplication


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The Nissen fundoplication performed laparoscopically has gained

popularity because of its lower morbidity and shorter hospital stay

compared to the open procedure performed previously. Although arelatively high incidence of postoperative complications, such as

dysphagia and gas bloating, are reported, DeMeester and Peters

have shown that placing a larger bougie in the esophagus during this

procedure, along with a shorter wrap and more complete

mobilization of the stomach, have markedly reduced postoperativecomplications.

This procedure involves a 360 fundic wrap around the

gastroesophageal junction. The diaphragmatic hiatus also is repaired.

A transthoracic approach may be used in patients who have had aprevious Nissen wrap or those who have an irreducible hernia.

TheToupetprocedure is a variant of the Nissen wrapd i l 180 i l h


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and involves a 180wrap in an attempt to lessen thelikelihood of postoperative dysphagia

Belsey(mark IV) fundoplication: This operation involvesa 270wrap in an attempt to reduce the incidence of gasbloating and postoperative dysphagia. It also is preferred

when minimal esophageal dysmotility is suspected. To

complete this operation, the left and right crura of thediaphragm are approximated.

Hill repair: In this procedure, the cardia of the stomachis anchored to the posterior abdominal areas, such as the

medial arcuate ligament. This also has the effect ofaugmenting the angle of His and thus strengthening theantireflux mechanism.


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Fundoplicatura TOUPET


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Hernia Femurala Si Restul

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