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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_718_Библиотеки_им_академика_М_И_Перельмана
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Diagnosis:
1. A palpable mass in the gluteal region with associated symptoms such as pain or obstruction
is diagnostic of a sciatic hernia.
2. Digital rectal or vaginal examination may reveal a mass in the sciatic region.
3. A CT scan diagnose the hernia emerging through the sciatic foramen, with the sac beneath
the gluteus maximus muscle.
4. MRI and MR neurography; evaluate the location of the nerve to prevent iatrogenic injury.
Differential diagnosis:
Gluteal lipoma, gluteal artery aneurysm and abscess.
Surgical Repair:
A) Open surgical approaches:
1.Trans-peritoneal approach;
The hernia defect is identified posterolateral to the rectum in men and in the ovarian fossa in
women. After reduction of the contents the defect may be repaired by positioning the mesh in the
extraperitoneal space, anchoring to the periosteum of the inner side of the pubis and posteriorly
to the periosteum of the sacrum.
Large or recurrent hernias need extensive reconstruction of the pelvic floor using mesh while
allowing for the rectum, iliac vessels, and ureters to descend alongside the prosthesis to the
pelvis.
2.The transgluteal approach:
Can be used in elective cases where preoperative diagnosis is made and there is no bowel
compromise in the hernia.
The gluteal approach involves splitting the gluteus maximus muscle along a line that connects
the greater trochanter and the middle portion of the sacrum, corresponding to the course of the
piriformis muscle.
3. A combined abdomino-gluteal approach:
In a large hernia where there is an increased risk of neurovascular injury
B) Laparoscopic approach:
laparoscopic plug and patch extraperitoneal repair which aimed at reducing the risk of injury to
neurovascular structures, with the same techniques required for laparoscopic extraperitoneal
inguinal hernia repair.
Various methods of repair have been reported to include a variety of endogenous tissue and
prosthetic meshes.
More recently, robot assisted laparoscopic repair of sciatic hernia has been reported.
Recurrence rate: Is of 4 %.
Clinical note:
Ureterosciatic hernia is an unusual variant of the sciatic hernia.
The urinary bladder or the ureter is involved in the hernia causing symptoms of obstructive
uropathy.
Patient could present with intermittent crampy abdominal pain, chronic renal insufficiency,
hydronephrosis, hydroureter, or rarely pyonephrosis.
Diagnosis of this variant can be made by the retrograde pyelogram, classically showing the
pathognomonic “curlicue ureter” or with contrast-enhanced CT.
A preperitoneal approach may be used if the diagnosis of ureteric sciatic hernia is established
preoperatively.
More recent studies have shown successful treatment of uretero-sciatic hernia by stent placement
or percutaneous reduction.
170
CHAPTER NINE: THE PERINEUM.TOPOGRAPHO-ANATOMICAL EXPLANATION.
M.Sh F .Mekhaeel ,S.Sameh
Bounders:
Front; by the angle formed by the pubic bones,
Behind; by the top of the coccyx,
Outside; by the sciatic bones and makes up the bottom of the pelvis.
Shape: The perineum has the shape of a rhombus.
Partitions of the perineum:
The perineum is divided by a line connecting the sciatic tubercles is divided into two triangles:
Anterior; urogenital area.
Posterior; anal area.
Fig.183: Female and male perineum. Source [183].
171
The anal region:
Boundaries:
The anal region is bounded in front by a line connecting the sciatic tubercles, behind by the coccyx,
and laterally by the Sacro — tubercular ligaments.
Contents:
The anus and the ischiorectal fossa.
Fig.184: Boundaries and contents of the anal triangle. Source [184].
Layered topography (is the same for male and female):
1. the skin of the anal area has a greater thickness on the periphery and a smaller one in the center,
contains sweat and sebaceous glands, and is covered with hair.
2. Fat deposits are well developed on the periphery of the area, in them there are superficial vessels
and nerves to the skin of the anal area:
¾ Perineal nerves (nn. perineales).
¾ Perineal branches of the posterior cutaneous nerve of the femur (rr. perineales n.
cutaneus femori posterior).
¾ Cutaneous branches of the lower gluteal (a. et V. glutea inferior) and rectal (a. et
V. rectalis inferior) arteries and veins; subcutaneous veins forming a plexus around
the anal opening.
¾ Under the skin of the Central part of the area is the external sphincter of the anus,
which is attached to the tendon center of the perineum in front, and to the anal —
coccygeal ligament in the back.
3. The superficial fascia of the perineum within the anal triangle is very thin.
4. The fat body of the sciatico-rectal fossa fills the fossa of the same name.
5. The lower fascia of the pelvic diaphragm from below lines the muscle that raises the anus,
restricts the sciatico-rectal fossa from above.
6. The muscle that raises the anus (m. levator ani), represented in this area by the iliococcygeal
muscle (m. iliococcygeus), begins from the tendon arch of the pelvic fascia, located on the inner
surface of the internal obturator muscle. The muscle interweaves its medial bundles into the
external sphincter of the anus, the upper and lower fascia of the urogenital diaphragm are attached
172
to the latter in front, forming the tendon center of the perineum. Behind the anal canal, the muscle
that raises the anus is attached to the anal-coccygeal ligament.
7. the upper fascia of the pelvic diaphragm is part of the parietal fascia of the pelvis, which lines
the muscle that raises the anus from above.
8. The peritoneal cavity of the pelvis, contains the extraperitoneal part of the rectal ampoule, the
peritoneal, post-peritoneal and lateral cellular space of the pelvis.
9. The parietal peritoneum.
10. The abdominal cavity of the pelvis.
Fig.185: Perineal muscles in female. Source [185].
173
Sciatico-rectal fossa (fossa ischiorectalis):
o It is bounded in front by the superficial transverse perineal muscle, behind by the lower
edge of the gluteus Maximus, the lateral obturator fascia; located on the internal obturator
muscle, above and medial — lower fascia of the pelvic diaphragm, lining the lower surface
of the muscle that raises the anus.
o The sciatico-rectal fossa in front forms a frontal pocket (recessus pubicus), located
between the deep transverse muscle of the perineum and the muscle that raises the anus,
back — buttock pocket (recessus glutealis), located under the edge of the gluteus
Maximus.
o At the lateral wall of the sciatico-rectal fossa between the leaves of the obturator fascia is
located sexual canal (canalis pudendalis); it passes sexual nerve and internal sexual artery
and vein, entering the sciatic-rectal fossa through the small sciatic opening and the lower
ones that give off the rectal vessels and nerves suitable for the anal canal.
Fig.186: The ischiorectal fossa. Source [186].
174
CLINICAL NOTE:
The ischiorectal fossa is the site of drainage of perianal suppurations; perianal accesses
and fistula.
Urogenital area:
Fig.187: Perianal suppurations. Source [187].
Front by the pubic arch.
Posterior; a line connecting the ischial tuberosity.
Laterally; lower branches of the pubic and ischial bones branches.
Fig.188: The boundaries of the urogenital triangle. Source [188].
175
Layered topography of the urogenital region: Is same in males and females expect for the
prostate.
1.Skin
2. Subcutaneous fatty layer.
3. Superficial perineal fascia
4. The surface space of the perineum containing:
• Superficial perineal muscles:
superficial transverse perineal muscle (m. transversus perinei superficialis), sciatico-cavernous
muscle (m. Ischiocavernosus) bulbous-spongy muscle (m. bulbospongiosus)
• The end and bulb of the penis (in males).
• The end of the clitoris and bulb of the vestibule (in females).
5. Lower fascia of the urogenital diaphragm (perineal membrane).
6. The deep perineal space containing the deep transverse perineal muscle and the sphincter of
the urethra (m. transversus perinei profundus et m. sphincter urethrae).
7. The upper fascia of the urogenital diaphragm.
8. The lower fascia of the pelvic floor.
9. The muscle that raises the anus (m. Levator ani), represented in the genitourinary region by
the pubic-coccygeal muscle (m. pubococcygeus).
10. The upper fascia of the pelvic floor.
11. The capsule of the prostate.
12. Prostate gland.
13. The bottom of the bladder.
Male genitourinary area:
The scrotum and penis are located within the genitourinary region in men.
The scotum:
Scrotum is a bag of skin and fleshy shell.
The skin is thin, more pigmented than the surrounding areas, and has sebaceous glands. The fleshy
shell lines the skin of the scrotum from the inside, is a continuation of the subcutaneous connective
tissue, devoid of fat, and contains a large number of smooth muscle cells and elastic fibers.
The fleshy shell forms the scrotum septum (septum scroti), which divides it into two parts, each
of them in the process of lowering the testicles fall surrounded by shells testis with an appendage
of the testicle (epididymis) and the spermatic cord (funiculus spermaticus).
Layered structure of the scrotum:
1. Skin.
2. Fleshy shell that gathers the skin in folds.
3. The outer seed fascia down into the scrotum superficial fascia.
4. the fascia of the testicle — raising muscle is the own fascia of the external oblique abdominal
muscle that has descended into the scrotum.
5. The muscle that lifts the testicle (m. cremaster), a derivative of the internal oblique and
transverse abdominal muscles.
6. The internal seminal fascia is a derivative of the transverse fascia.
7. the aponeurotic membrane of the testicle, derived from the peritoneum, has parietal and visceral
plates, between which there is a serous testicular cavity.
8. Exposed shell of the egg.
176
Mnemonics: Some Dangerous Englishmen Called It The Testis.
S-Skin.
D- Datros muscle and fascia.
E- External spermatic fascia.
C-Cremasteric fascia.
I- Internal spermatic fascia.
T-Tunica vaginalis.
T-Tunica albuginea.
Fig.189: Layered structure of the scrotum. Source [189].
The testis:
¾ Testis, located in the scrotum, is covered with a dense protein shell, has an oval shape. The
average size of the testicle is 4x3x2 cm. In the testicle, the lateral and medial surfaces, the
anterior and posterior edges, and the upper and lower end are distinguished.
¾ The lateral and medial surfaces, the upper end and anterior edge of the testicle are covered
with a visceral leaf of the vaginal membrane. On the posterior edge is the mediastinum
testis, which extends out of the testicular tubules (ductuli efferentes testis), extending to
the appendage of the testis.
Epididymis:
¾ The appendage of the testicle (epididymis) has a head, body, and tail and lies on the
posterior edge of the testicle.
¾ The head and body of the testicular appendage are covered by a visceral leaf of the
aponeurotic membrane. The tail of the testicular appendage passes into the testicular part
of the VAS deferens, which is located in the scrotum at the level of the testicle and has a
convoluted course. On the head of the appendage there is an appendage of the testicular
appendage (appendix epididymidis) — a vestige of the mesonephral duct.
177
Fig.190: The testis and the epididymis. Source [190].
Spermatic cord (funiculus spermaticus):
Extends from the upper end of the testicle to the deep inguinal ring.
The location of the elements of the spermatic cord is as follows:
In its posterior part lies the VAS deferens (ductus deferens).
Anterior to it is the testicular artery (a. testicularis).
Behind it is the artery of the VAS deferentialis (a. deferentialis); the veins of the same name
accompany the arterial trunks.
Lymphatic vessels in large numbers pass with the anterior group of veins.
Fig.191: The spermatic cord. Source [191].
178
Blood supply:
The following arteries are involved in the blood supply to the testicle, appendage, spermatic
cord, and scrotum:
¾ Testicular artery (a. testicularis) extending from the abdominal aorta. The testicular artery
through the deep inguinal ring enters the inguinal canal and the spermatic cord, where it
lies throughout on the anterior surface of the VAS deferens.
¾ Artery of the VAS deferentis (a. ductus deferentis), extending from the umbilical artery (a.
umbilicalis) — a branch of the internal iliac artery (a. iliaca interna). The artery of the VAS
deferens accompanies the VAS deferens, usually located on its posterior surface.
¾ Artery of the muscle that raises the testicle (a. cremasterica), extending from the lower
epigastric artery (a. epigastrica inferior). The artery in the area of the deep inguinal ring
approaches the spermatic cord and accompanies it, branching widely in its shell.
¾ The external genital arteries (aa. pudendae externae), which extend from the femoral artery
(a. femoralis), give off the anterior scrotal branches (aa. scrotales anteriores), which
supply blood to the anterior part of the scrotum.
¾ Posterior scrotal branches (aa. scrotales posteriores) extending from the perineal artery (a.
perinealis), branches of the internal genital artery (a. pudenda interna).
The veins of the testicle and appendage form a cluster-like plexus (plexus pampiniformis),
consisting of many intertwining and anastomosing venous vessels.
¾ The veins of this plexus rise up, gradually merging, venous trunks form testicular vein (V.
testicularis).
¾ The right testicular vein (V. testicularis dextra) flows into the inferior Vena cava (V. cava
inferior) directly, and the left testicular vein (V. testicularis sinistra) flows into the left
renal vein (V. renalis).
¾ At the confluence of the right testicular vein forms a valve, and the left valve does not
form, so varicose veins of the spermatic cord occur on the left much more often than on
the right.
¾ Collateral outflow from the testicle and spermatic cord is possible by external sexual veins
(vv. pudendae externae) to the femoral vein (V. femoralis), along the posterior scrotum
veins (vv. scrotales posteriores) to the internal sexual vein (V. pudenda interna), along the
vein of the muscle that raises the testicle (V. cremasterica), and the vein of the VAS
deferentis (V. Ductus deferentis) to the lower epigastric vein (V. epigastrica inferior).
Fig.192: Blood supply of the testis. Source [192].
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