Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_718_Библиотеки_им_академика_М_И_Перельмана
.pdf
Surgical anatomy of pelvic organs
A) Male pelvic organs:
1. The Rectum.
2. The urinary bladder.
3. The pelvic part of the urethra.
4. The prostate.
5. The pelvic part of ductus deference.
6. The seminal glands.
Fig.173: Male vs female pelvic organs. Source [173].
1) The rectum:
¾ Syntopy:
A) Peritoneal division; loops of small intestine and lower part of the urinary bladder
(anteriorly).
B) Subperitoneal division;
a. Anteriorly; posterior wall of the urinary bladder, prostate, ductus deference, seminal
vesicles and the terminal part of the ureters.
b. Sides; ampulla, internal, iliac vessels and inferior hypogastric plexus.
c. Posteriorly; Sacrum.
¾ Holotopy: Lesser pelvis.
¾ Skeletopy: S3.
¾ Peritoneal relation:
The upper third; covered by peritoneum anteriorly and laterally (intraperitoneal).
The middle third; covered by peritoneum only anteriorly (Mesoperitoneal).
Upper third; is not covered by peritoneum (retroperitoneal).
160
Fig.174: The rectum. Source [174].
2) The urinary bladder:
¾ Syntopy:
x Anteriorly; Vesical fascia adjoining Pubic bone and symphysis.
x Posteriorly; ampulla of ductus deference, seminal vesicles, terminal part of ureters and
fascia retroprostatica.
x Laterally; ductus deference and ureters.
x Superiorly; loops of small intestine, sigmoid colon, transverse colon, cecum and vermiform
appendix.
¾ Holotopy: Projected on the suprapubic region.
¾ Skeletopy: At the level of the pubic symphysis.
¾ Peritoneal relations: Retroperitoneal organ (Primary).
Fig.175: Male urinary bladder. Source [175].
161
3) The ureter.
¾ Syntopy;
Anteriorly; parietal peritoneum and vasa testicularis (ovaria).
Posteriorly; Genitofemoral nerve, psoas major muscle, external iliac artery (Right) and
common iliac artery
Medially; IVC (to the right) And Abdominal aorta (to the left).
Laterally; ascending colon and the cecum (to the right) and descending colon (to the left).
¾ Skeletopy;
x Initial part of L1-L2
¾ Holotopy;
x Projects along the margins of the rectus abdominis muscle.
¾ Peritoneal relations:
¾ Retroperitoneal organ (Primary).
4) The prostate:
¾ Syntopy;
x Superiorly;
floor of the urinary bladder, ductus deference and seminal glands.
x Inferiorly;
Urogenital diaphragm.
x Anteriorly;
Posterior surface of public symphysis.
x Posteriorly;
Denonvillier fascia and rectal ampulla.
¾ Holotopy:
x Projected on the suprapubic region.
¾ Skeletopy:
x At the level of the pubic symphysis.
Fig.176: Per-rectal examination of the prostate. Source [176].
162
5) The pelvic part of ductus deference
¾ Syntopy:
x Parietal part: At the lateral pelvic wall.
x Intermediate part; lying on the lateral cellular space.
x Vesical; joining the urinary bladder
¾ Holotopy:
x Projected on the suprapubic region.
¾ Skeletopy:
x At the level of the pubic symphysis.
¾ Peritoneal relations:
¾ Retroperitoneal organ (Primary).
6) The seminal vesicles
¾ Syntopy;
x Anteriorly; posterior wall of urinary bladder and terminal part of ureters.
x Medially; ductus deference and ampulla.
x Inferiorly, base of the prostate.
x Superolaterally; peritoneum separating it from loops of intestine.
¾ Holotopy:
x Projected on the suprapubic region.
¾ Skeletopy
x At the level of the pubic symphysis.
¾ Peritoneal relations:
¾ Retroperitoneal organ (Primary).
Fig.177: The male genitourinary tract. Source [177].
163
B) Female pelvic organs:
1. The rectum.
2. Urinary bladder.
3. Uterus.
4. Fallopian tubes.
5. Ovary.
6. Vagina
1)The Female rectum:
¾ Syntopy;
x Anteriorly; uterus and vagina.
x Posteriorly; sacrum and coccyx.
x Superiorly; sigmoid colon.
¾ Skeletopy;
¾ S3.
¾ Holotopy;
¾ Suprapubic region.
¾ Peritoneal relations:
x The upper third; covered by peritoneum anteriorly and laterally (intraperitoneal).
x The middle third; covered by peritoneum only anteriorly (Mesoperitoneal).
x Upper third; is not covered by peritoneum (retroperitoneal).
2)The female urinary bladder;
¾ Syntopy;
x Peritoneal division;
o Intestinal loops.
x Subperitoneal division;
o Anterior; symphsis pubis.
o Posteriorly; Cervix and vagina
o Floor; urogenital diaphragm
¾ Holotopy; Projected on the suprapubic region.
¾ Skeletopy; At the level of the pubic symphysis.
¾ Peritoneal relations: Retroperitoneal organ (Primary).
¾
Fig.178: Female urinary bladder. Source [178].
164
3)The uterus:
¾ Syntopy;
Anteriorly; urinary bladder.
Posteriorly; rectum.
¾ Skeletopy; Pubic symphysis.
¾ Holotopy; Suprapubic region.
¾ Peritoneal relations: Retroperitoneal organ (Primary).
4)The fallopian tubes
¾ Syntopy; Broad ligament of the uterus.
¾ Skeletopy; Pubic symphysis.
¾ Holotopy; Suprapubic region.
¾ Peritoneal relations: Retroperitoneal organ (Primary).
5) The ovaries
¾ Syntopy; Situated in the broad ligament of the uterus near the fimbriae of the uterine
tubes.
¾ Skeletopy; Pubic symphysis.
¾ Holotopy; Suprapubic region.
¾ Peritoneal relations: Retroperitoneal organ (Primary).
6)The vagina
¾ Skeletopy;
x Anterior; floor of the urinary bladder and urethra.
x Posterior; rectum.
x Flanks; uterus, uterine arteries, Uterovaginal plexus and ganglia, rami from Uterovaginal
nervous plexus and lymphatics, levator ani m., M. Pubovaginalis.
Fig.179: The female reproductive system. Source [179].
165
CHAPTER EIGHT: PELVIC HERNIAS.
A.V Protasov ,M.Sh F .Mekhaeel ,S.Sameh
Pelvic hernias are rare among all hernias. They are more commonly seen in older patients. They
present both diagnostic and therapeutic dilemma due to their relative infrequency as well as their
location deep in the pelvis. The three major hernias which come under this heading are obturator,
perineal, and sciatic hernia.
1) Obturator Hernia:
Incidence:
Constitutes only 0.05–1.4 % of all hernias.
The most frequently encountered pelvic hernias.
Predisposing factors:
Female predisposition (6-9:1) due to their larger and wider pelvis and horizontally oriented
triangular obturator openings.
Advanced age, weight loss causing loss of preperitoneal fat, multiparity, and increased intraabdominal pressure from conditions such as chronic constipation, COPD, ascites, and
kyphoscoliosis.
Laterality:
Obturator hernias characteristically occur on the right side as presence of sigmoid colon usually
prevents left sided hernias. However, they can still occur bilaterally or in association with
another hernia, most often a femoral hernia.
Fig.180: The Pelvis. Source [180].
166
Hernial gate:
This hernia passes through the obturator canal, an opening in the superior part of the obturator
foramen. The obturator foramen is formed by the union of the pubic bone and ischium and is
covered by the obturator membrane. The defect is usually located anterior and medial to the
obturator neurovascular bundle.
Sac:
The hernia sac is deep within the thigh between the pectineus and adductor longus muscles.
Consists of the peritoneal lining of the contained viscera.
Contents: Small intestine, bladder, uterus, or adnexa.
Types of obturator hernia:
Type 1 or anterior branch type hernia; the sac passes along the anterior division of the obturator
nerve.
Type 2 or posterior branch type; the sac passes along the posterior branch of the obturator nerve
(rare).
Type 3; the sac passes in the space between the internal and external obturator
membranes(rarest).
Clinical:
1. The classic symptom is groin pain radiating down the medial aspect of the thigh to the knee
in the distribution of the obturator nerve.
2. Howship–Romberg sign is present in 37–50 % of patients and is described ipsilateral pain
along the inner thigh exacerbated by extension, adduction, or medial rotation of the hip,
and relieved by flexion. It is considered to be pathognomonic of an obturator hernia but the
sensitivity of the test is low and specificity varies considerably.
3. The Hannington–Kiff sign is the absence of the adductor reflex of the thigh with an intact
patellar tendon reflex and is more specific than the Howship–Romberg. This sign is elicited
by percussing on the index finger placed on the adductor muscle above the knee. The
contraction of the muscle either seen or felt rules out an obturator hernia.
4. Palpation of a mass in the upper medial thigh is difficult as the hernia is covered by the
pectineus however, a tender mass may be palpable on vaginal or rectal exam.
Diagnosis:
90 % of cases present as intestinal obstruction and strangulation, usually involving the small
bowel.
CT scan has diagnostic accuracy up to 90% in suspected patients.
Other investigative modalities are ultrasound scan and MRI.
Differential diagnosis:
Patients with chronic pain after inguinal surgery.
Recurrent inguinal hernias, nerve entrapment, or meshoma.
Surgical Repair:
Surgical approaches:
1. Midline laparotomy and primary repair remains the most common approach, with up to 50
% of cases requiring bowel resection.
2. In the absence of acute and complete intestinal obstruction, laparoscopy serve as a method
of diagnosis and treatment of obturator hernias.
3. An extraperitoneal technique using an inguinal or thigh incision, only used in elective
situations where preoperative diagnosis has been made and bowel resection is not required.
167
Surgical technique:
A) Open surgical repair:
¾ Reduction of the hernia may require incision of the obturator membrane posteromedially
and parallel to the neurovascular bundle with care to avoid its injury.
¾ The preferred repair technique consists of placing a large flat synthetic mesh in the
preperitoneal space to cover the obturator orifice, femoral, and inguinal areas.
¾ Mesh repair using a biologic mesh could be also used, however, periosteal flap, bladder
wall, uterine fundus, or ligaments may be mobilized and used in cases of gross
contamination, where use of synthetic mesh may be precluded.
B) Laparoscopic repair:
¾ The totally extraperitoneal approach (TEP) to hernia repair has been employed for
obturator hernias and is not different from the direct, indirect, or femoral repair.
¾ The obturator space is exposed by sweeping away the preperitoneal fat overlying the
Cooper ligament, visualizing the obturator artery and vein leading to the obturator fossa
along with the nerve. The endopelvic fascia and obturator defect are exposed by retracting
the bladder medially.
Recurrence:
Is rare, possibly because most patients with obturator hernias are elderly and die of unrelated
causes before their hernias might otherwise have recurred.
2) Sciatic Hernia:
Incidence:
The most infrequent of hernias of the pelvic floor.
Female predominance.
Predisposing factors:
Neoplasms, coexisting hernias, congenital anomalies, disorders of the pelvic bones, metabolic
problems, multiparity or pregnancy, malnutrition and the attenuation or atrophy of the piriformis
muscle.
Fig.181:
The greater and lesser sciatic foramina, the sites for sciatic hernia. Source [181].
168
Hernia gate:
The greater or lesser sciatic foramen.
Sac:
Hernias involving retroperitoneal structures have no peritoneal sac.
Contents:
Ovary, ureter, small intestine, colon, neoplasm, omentum, or urinary bladder.
Types:
The piriformis muscle divides the greater sciatic foramen further into the suprapiriform and
infrapiriform spaces. The lesser sciatic foramen hernia lies between the sacrospinous and
sacrotuberous ligaments or the spinotuberous space.
Fig.182: The piriformis muscle that divides the greater sciatic foramen into supra and infra
piriform spaces. Source [182].
Clinical:
1. The common clinical signs of sciatic hernia pertain to intestinal obstruction.
2. A less frequent presentation is of sciatica type pain due to sciatic nerve compression.
3. Similar to other pelvic hernias the onset of symptoms is insidious with abdominal pain
being the presenting symptom in around 50 % of patients.
4. Others present with urinary infection, gluteal sepsis, or mass.
5. Chronic pelvic pain was the presenting symptom (rare).
169
Соседние файлы в папке Библиотека им академика М.И. Перельмана