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
Iliohypogastric and ilioinguinal nerves (level L1), both reaches the inguinal region just inside the
anterior superior iliac spine, piercing the internal oblique muscle and runs parallel to the superficial
fibers of the conjoint tendon. The former nerve supplies sensation to the skin over the lateral gluteal
and hypogastric regions and motor to the internal oblique and transversus abdominis muscles while
the latter one supplies somatic sensation to the skin of the upper and medial thigh and innervates
the base of the penis and labium majus in females.
The genitofemoral nerve (L1ဨL2) runs over the sheath of the psoas muscle, and divides into two
branches: The femoral branch courses along the femoral sheath, descends to the thigh, supplying
the skin of the upper anterior thigh, the genital branch reaches the spermatic cord, cremaster muscle
and finally gives branches to genital teguments. The lateral femoral cutaneous nerve (L2ဨL3)
emerges lateral to the psoas muscle toward the anterior superior iliac spine. It then passes inferior
to the inguinal ligament.
Abdominal plains:
There are two horizonal lines which divided the abdomen into 3 regions.
Horizontal lines:
1.The superior horizontal line, linea bicostoarum; connects the inferior points of the X pair of ribs
and corresponds to the superior border of L3.
2.The inferior horizontal line, linea bispinarum; connects the ASISs and corresponds to the
superior border of S2.
Regions:
1.Epigastrium; located above the superior horizontal line.
2.Mesogastuim; located between the both lines.
3.Hypogastrium; located between the inferior horizontal line.
Fig 30: Abdominal plains and regions. Source [30].
30
Abdominal Quadrants:
There are 2 abdominal planes which divide the abdomen into 4 quadrants:
Planes:
Median Plane: vertical plane which follows the linea alba and extends from the xiphoid process
to the symphysis pubis.
Transumblical Plane; Horizontal plane at the level of the umbilicus.
Quadrants:
1. Right upper quadrant (RUQ).
2. Right lower quadrant (RLQ).
3. Left upper quadrant (LUQ).
4. Left lower quadrant (LLQ).
Fig. 31: Abdominal viscera in each quadrant. Source [31].
The abdomen could also be divided into 9 regions by 4 planes.
Transpyloric plane; horizontal plane located halfway between the suprasternal notch of the
manubrium and the upper border of the symphysis pubis at the level of L1.
Transumblical Plane; Horizontal plane at the level of the umbilicus.
Midclavicular lines; 2 vertical lines extending from the mid-point of the clavicle (costal arches)
to the mid-point of the inguinal ligament (Pubic tubercle). Runs along the external borders of the
rectus abdominis muscles.
31
Fig. 32: Abdominal planes. Source [32].
¾ Nine abdominal regions; divided into…
3 Paired abdominal regions: Hypochondrium, Lumbar and iliac.
3 unpaired abdominal regions: proper epigastric, Umbilical and hypogastric.
Fig. 33: Abdominal regions and the projections of the abdominal organs. Source [33].
32
Projections of the abdominal organs:
y
y
y
(I) In the Epigastrium:
Table 7: Projections of the abdominal organs in the Epigastrium.
1. Right hypochondrium 1. Rt. Lope of the liver.
2. Rt. Colic (hepatic) flexure.
2.Proper epigastric Region
3. Rt. Kidne
1. Lt. lobe of the liver.
2. The gall bladder.
(superior pole).
3. Pancreas.
4. Duodenum.
5. Partially the stomach
3.Left hypochondrium
1. Fundus of the stomach.
2. Spleen.
3. Tail of the pancreas.
4. Lt. colonic (splenic) flexure.
5. Lt. Kidne
(superior pole).
(II) In the Mesogastruim:
Table 8: Projections of the abdominal organs in the Mesogastruim.
4.Right lateral region 1. Ascending colon.
2. Small intestinal loops.
5.Umbilical region
3. Rt. Kidne
1. Transverse colon.
2. Small intestinal loops.
rd
3. 3
(inferior pole).
and 4th parts of the duodenum.
4. Greater curvature of the stomach.
5. Pota hepatis.
6. Superior part of the uterus.
6.Left lateral region
1. Descending colon.
2. Small intestinal loops.
3. Left kidney (inferior pole).
(III) In the Hypogastrium:
Table 9: Projections of the abdominal organs in the Hypogastrium.
7.Right iliac region
1. Terminal ileum.
2. Vermiform process.
3. Cecum
8.Pubic region
1. Urinary bladder.
2.Inferior part of the uterus.
3. Small intestinal loops.
9.Left iliac region
1. Sigmoid colon
2. Small intestinal loops
33
CHAPTER TWO: ANTEROLATERAL ABDOMONAL WALL HERNIAS.
A.V Protasov , M.Y.Persov, M.Sh F .Mekhaeel ,S.Sameh
A) Definition:
Anterolateral abdominal wall hernia is the protrusion of the contents of the abdominal cavity
(abdominal Vesicare and/or omentum) through an opening; either natural or induced in the
abdominal wall beneath the skin.
B) Etiology:
1.Predisposing factors: Hereditary predisposition to hernia formation, as well as typical, sexual
and age differences in body structure.
2.Constitutional factors: Changes in the abdominal wall associated with pregnancy, unfavorable
working and living conditions, as well as various pathological conditions, for example, obesity or
exhaustion.
3.Producing factors: Hard physical labor, frequent crying and screaming in infancy, difficult
childbirth, cough in chronic diseases, prolonged constipation, difficulty urinating with prostate
adenoma or urethral stricture.
C)Pathogenesis:
The most important moment in the occurrence of hernias is a violation of the dynamic balance
between intra-abdominal pressure and the ability of the abdominal walls to counteract the pressure.
In a healthy individual, despite the presence of “weak spots”, the tone of the muscles of the
diaphragm and abdominal press keep the abdominal organs in their natural receptacles even with
significant fluctuations in intra-abdominal pressure, for example, when lifting weights, coughing,
defecation, difficulty urinating, delivery, etc.
D)Classification:
Anatomically: Inguinal, femoral, umbilical hernias, hernias of the white line of the abdomen (linea
alba hernia), Spigelian line hernia.
According to etiology: Congenital and acquired.
Clinically: Uncomplicated and complicated.
Weak points of the anterolateral abdominal wall:
A) Ventral:
A) The white line (Linea alba).
B) Epigastric.
C) Paraumbilical.
B) Umbilicus (Annulus umblicalis).
E) Spigelian line (Linea semilunaris
spigli).
B) Groin:
C) Inguinal canal (Canalis inguinalis).
D) Femoral canal (Canalis femoralis).
Fig.34: Weak points of the anterolateral
abdominal wall Source [34].
34
E) Parts of the hernia:
1. Hernial opening (Gate):
It is the weak point of the abdominal wall through which the visceral organs of the peritoneal
cavity protrude into the hernial sac. A weak point of the abdominal wall is the point lacking
sufficient muscular coverings.
Fig.35: Hernial gate. Source [35].
2. Hernia sac:
Is the parietal lamina of the peritoneum which is pushed out by the organs protruding from the
abdominal cavity.
The hernial sac is further subdivided into body, neck and fundus.
Fig.36: The hernial sac. Source [36].
3. Hernial contents:
A) Usual contents:
1.Intestine (Enterocele).
2. Omentum (Omentocele).
35
B) Unusual contents:
1.Richter’s hernia: Protrusion of the Antimesenteric border of the intestine through the
hernial gate.
Fig.37: Richter’s hernia. Source [37].
2.Littre’s hernia: Protrusion of Meckel’s diverticulum.
Fig.38: Littre’s hernia. Source [38].
36
3.Maydl’s hernia:2 loops of the intestine protrude through the hernial gate compressing a middle
third loop (W or M shaped).
Fig.39: Maydl’s hernia. Source [39].
4.Pantaloon Hernia: Also called (Double hernia, or Saddle hernia, or Romberg hernia).
Contains both direct and indirect inguinal sacs.
Fig.40: Pantaloon hernia. Source [40].
37
5.Amyand’s hernia: The content is vermiform appendix; either healthy (incidence 0.6%-1%) or
inflamed (incidence 0.1%).
Commonly associated with large indirect inguinoscrotal hernias, more than direct hernias.
Males are affected than females. The pathophysiology of inflammation is unclear, as when the
appendix enters the sac, the contraction of the abdominal wall muscles and/or external forces
comprise and traumatize the appendix leading to its inflammation. Another predisposing factor is
the presence of mobile cecum. It is most commonly presented by irreducible painful hernia (83 %)
and the most common differential diagnoses are strangulated hernia and incarcerated omentum.
In both cases appendectomy is mandatory, but…
1. In case of normal appendix repair is done by hernioplasty.
2. Appendicitis; primary repair (risk of hernia mesh infection).
3. Complicated appendicitis i.e., perforation (laparotomy and herniorrhaphy).
Fig.41: Amyand’s hernia. Source [41].
38
6.Sliding hernia: The wall of a retroperitoneal viscus forms a part of the hernial sac wall (RARE).
Fig.42: sliding hernia. Source [42].
7.Urinary bladder: The urinary bladder could be encountered in the hernia.
The incidence of bladder herniation in inguinal hernia, which is commonly associated with direct
hernia and rarely with indirect ones, common in right more than left side, with male predominance
especially in old and obsesses has been estimated at (1- 3 %), however, some authors estimated
the range as high as (10 %).
As the size of hernia increase, urinary symptoms like dysuria, polyuria, hematuria, nocturia, and
reduction of hernia size after micturition were reported or rarely presented by abdominal pain.
Fig.43: Pelviabdominal X-ray demonstrating the urinary bladder as a content of huge direct
inguinal hernia. Source [43].
39
Соседние файлы в папке Библиотека им академика М.И. Перельмана