HERNIA FEMURALA

Miolacunara
Hesselbach

Moskovitz

Diagnostic diferential
Forma necomplicata
Forma incarcerata
abces rece osifluent
Limfadenita ganglionului
Cloquet
Anevrism artera femurala
Flebita crosei safene
Actazie de crosa safena
magna
magna
Lipoame
Adenopatii nghinale

Tratament

Cai de abord
1. Femurala
2. Femurala largita
3. Inghinala
4. Transabdominala clasica Lawson Tait
5. Laparoscopica

Procedee
Pe cale femurala

Coborare fortata a arcadei femurale

Coborare relaxata a arcadei femurale

Proc dublei perdele CADENAT

Pe cale inghinala

FABRICIUS sectioneaza lig Gimbernard

DELAGENIER foloseste lig Cooper

Pe cale femurala largita

BERGER arcada la fascia pectieneala

TRICOMINI face o bursa
ZATEPIN pune o ligatura pe sub ramura pubiana
RANY bate cuie in pubis coborasnd arcada

RUGGI
PARLAVECHIO
CODIVILA
ROBINEAU

Procedee plastice

STRECHI lig rotund

POLYA m. croitor
WATSON - . Prectineu
HOFFNER vena safena
GOROSLOVSKI aponevroza pectineala
TURNER - aponevroza pectineala si fascia
psoasului
KEYNE teaca dreptilor abdominali

Procedee plastice cu material

sintetic - PLASE

Proc FABRICIUS BERGER pe cale femurala

Procedeul dublei perdele CADENAT

Procedeu RUGGI - PARLAVECHIO

HERNIA OMBILICALA

Ombilicul (buricul): este o cicatrice care se formeaz

consecutiv secionrii la natere a cordonului ombilical,
cu obliterare i fibrozare consecutiv a vaselor ombilicale
(ombilicul poate fi imaginat ca un trident ntors, unde
mnerul este format de v. ombilical obliterat ce
formeaz lig. rotund al ficatului, iar braele, cu orientare
inferioar, sunt reprezentate de cele dou artere
ombilicale, parial obliterate, i urac); majoritar la
animale, hernia ombilical ocup la om o poziie
secundar ca frecven (datorit trecerii la poziia biped);
la nivelul ombilicului, peritoneul prezint adesea un pliu
cunoscut sub denumirea de fascia ombilical Richet
se descriu hernii ombilicale directe (n caz de absen a
fasciei Richet) i hernii ombilicale indirecte (oblice
inferioare sau superioare).

Umbilical hernia is a frequently encountered clinical

problem that is infrequently discussed critically in the
medical literature. Umbilical hernias were described as
early as the first century, but it was not until 1740 that
William Cheselden reported the first repair. In the
United States, Stoser performed the first operation for
an umbilical hernia. It was, however, William Mayo who
popularized the vest-over-trousers overlapping repair
in 1901 in his classic description of 19 patients treated
with this revolutionary procedure. There were few
advances in therapy during the next 100 years. A recent
contribution to the treatment of umbilical hernias has
been the introduction of mesh and the use of
laparoscopic techniques.

ETIOLOGY AND PRESENTATION

The typical patient with an umbilical hernia is an overweight

multiparous female between the ages of 35 and 50. Women are
affected 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, but
chronically 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, and
small 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 Small
bowel alone and large bowel were found in 4% and 7%,
respectively. Adhesions from the omentum and bowel to the sac
and the relatively small size of the fascial defect compared with the
large amount of sac contents make these hernias prone to
incarceration.

CLASIFICARE

Congenitala

Embrionara membrana lui Ratke, gelatina lui Warton

Fetala sacul herniar este format

Dobandita

A copilului mic
A adultului

(+Simptomatica)

Oblica
Directa

Hernie ombilicala simptomatica

Apare la 20% din bolnavii cu aascita.

In 10% din cazuri se produce exulcerarea
tegumentului cu deschiderea sacului si
fistula ombilicala.
Mortalitate 2% daca se repara hernia fara
a se controla ascita

Tratament H ombilicala

Omfalectomie in formele avansate

Procedee

Ed. Quenu
Sapiejko-Picoli
Mayo-Menge
Procedee plastice cu

Piele

PLASA
Clasice
Laparoscopice

Rata recidivelor 10-30%

mai mare dupa
procedeele fara plasa

HERNIA EPIGASTRICA
Lipom preherniar
Forma nedureroasa
Forma dureroasa
Se asociaza cu alte afectiuni ale etajului abdominal
superior

HERNIA SPIEGEL

HERNII OBTURATORII

canalul obturator (ntre membrana obturatorie i

marginea inferioar a coxalului de la nivelul gurii
obturatorii, adpostind mnunchiul vasculo-nervos
obturator = hernii obturatorii (este orificiu greu
distensibil frecvent hernie strangulat; trebuie
diagnostic diferenial cu herniile femurale): pentru a
se exterioriza la piele, trebuie s sparg fascia cribriformis (parte a fasciei lata) dificil (diagnostic cel
mai adesea intraoperator). Semnul Romberg

lig. pubic arcuat inferior

simfiz pubian
creast pubic
tubercul pubic

hiatus pentru vena dorsal profund a penisului

lig. perineal transvers
membrana perineal
hiatus uretral

pecten pubis (parte a liniei iliopectinee)

fibre musculare din levator ani spre stratul

muscular longitudinal al canalului anal

ram pubic superior

canal obturator

puborectal

fascie obturatorie

m. levator ani

pubococcigian

eminen iliopubic

iliococcigian

margine acetabular

arc tendinos al m. levator ani

spin iliac anterosuperioar

m. obturator intern

diafragma
pelvin brbat
- aspect
superior -

arip iliac
linie arcuat (parte iliac a
liniei iliopectinee)

spin ischiatic
m. ischicoccigian

spin ischiatic

m. piriform
articulaie sacroiliac
orificii sacrale anterioare
sacru

lig. sacrococcigian anterior

canal sacral

hiatus anorectal

HERNII ISCHIADICE

orficii ischiatice: orificiu suprapiriform (pasaj pentru

mnunchiul vasculonervos fesier superior) i infrapiriform
(pasaj pentru N. ischiadic, N. femurocutanat posterior,
mnunchiul vasculonervos fesier inferior i ruinos intern),
determinate de trecerea m. piriform prin marea incizur
ischiatic apariie de hernii fesiere; (trebuie avute n
vedere la diagnosticul diferenial al flegmoanelor fesiere,
etc.); muchii fesieri acoper mult vreme hernia; sunt
descrise i hernii sciatice, produse prin micul orificiu
sciatic.

v. dorsal profund a penisului

grsime n spaiul prevezical

m. sfincter extern al uretrei

uretr

simfiz
pubian
lig. pubic inferior
extensii fibromusculare ale levator ani spre prostat

tubercul pubic
m. rectouretral superior

fascia rectoprostatic Denonvilliers

fibre musculare prerectale (Luschka) din m. levator ani

margine medial a m. levator ani

fibre musculare din levator ani spre m.

longitudinal al canalului anal

membran perineal (ndeprtat)

ram ischiopubic

diafragma pelvin brbat

- aspect inferior -

tendon obturator intern

tuberozitate ischiatic
lig. sacrotuberos (secionat)
m. fesier mare

lig. sacrospinos (secionat)

m. obturator intern

m. obturator intern

arc tendinos al m. levator ani

m. ischiococcigian
lig. sacrospinos (secionat)
lig. sacrotuberos (secionat)
vrful coccisului

iliococcigian
pubococcigian

m. levator ani

puborectal
strat muscular circular
strat muscular longitudinal

jonciune anorectal

Hernie ischiadica

Hernie perineala

HERNII DIAFRAGMATICE

Zone slabe ale diafragmului:

n afara orificiilor diafragmatice prin care se
realizeaz pasajul formaiunilor anatomice ntre
cavitatea abdominal i cea toracic (hiatus
aortic, hiatus esofagian, deschidere pentru VCI,
orificii prin care trec canalul toracic, Nn.
splanhnici, vv. azygos, etc.), exist puncte slabe
diafragmatice ce pot justifica apariia
urmtoarelor hernii diafragmatice:
hernie anterioar (prin orificiul costosternal Larrey),
hernie posterioar (prin orificiul costovertebral
Bochdalek).

Fig. 4 Esofag abdominal

trigon sternocostal
parte sternal a diafragmului
ram anterior al N. frenic stng
ram anterior al N. frenic drept
parte costal a diafragmului
a. frenic inferioar dreapt
centru tendinos al diafragmului
deschiderea VCI
hiatus esofagian
stlp diafragmatic drept
fibre din stlpul drept trec la stnga hiatusului esofagian
N. splanhnic mare
a. frenic inferioar stng - ram recurent spre esofag
N. splanhnic mic
ram anterior al a. frenice inferioare stngi
v. lombar ascendent
(v. azygos)

ram lateral al a. frenice inferioare stngi

a. suprarenal stng superioar
N. frenic stng

N. splanhnic minim

v. lombar ascendent
(v. hemiazygos)
parte costal a diafragmului
stlp stng al diafragmului

MUCHIUL
DIAFRAGM
- suprafa
abdominal -

m. transvers
abdominal
trigon lombocostal
coasta 12
lig. arcuat lateral
parte lombar a diafragmului
lig. arcuat medial

m. ptrat lombar
m. psoas mare
trunchi simpatic

trunchi celiac

hiatus
aortic

proces transvers al vertebrei L1

lig. arcuat median
aort
abdominal

Background: A hiatal hernia occurs when a portion of

the stomach prolapses through the diaphragmatic
esophageal hiatus. Although the existence of hiatal
hernia 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 lifethreatening complication, such as gastric volvulus or
strangulation, may present acutely.

Mortality/Morbidity:
Paraesophageal
hernias
generally tend to enlarge with time, and sometimes the
entire 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 surgical
intervention is necessary. Because of the high mortality
associated with this condition, elective repair often is
advised wherever a paraesophageal hernia is found.

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 it
more patulous.

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

not cause symptoms. For this reason, most people with hiatal hernias
are 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 reflux without a demonstrable hiatal hernia. When
a hernia is present in a patient with symptomatic GERD, the hernia
may worsen symptoms for several reasons, including the hiatal
hernia acting as a fluid trap for gastric reflux and increasing the acid
contact time in the esophagus. In addition, with a hiatal hernia,
episodes of transient relaxation of the LES are more frequent and
the length of the high-pressure zone is reduced. The main symptoms
of a sliding hiatal hernia are those associated with reflux and its
complications.
No clear correlation exists between the size of a hiatal hernia and the
severity of the symptoms. A very large hiatal hernia may be present
with no symptoms at all. Some complications are specific for a hiatal
hernia.

Esophageal complications
By

far, the majority of hiatal hernias are

asymptomatic.
Often, patients are left with the impression that they
have a disease when a hiatal hernia is diagnosed.
In rare cases, however, a hiatal hernia may be
responsible for intermittent bleeding from associated
esophagitis, erosions (Cameron ulcers), or a discrete
esophageal ulcer, leading to iron-deficiency anemia.
This particular complication is more likely in patients
who are bed-bound or those who take nonsteroidal
anti-inflammatory drugs. Massive bleeding is rare.

Nonesophageal complications
Incarceration

of a hiatal hernia is rare and is

observed only with paraesophageal hernia.
When this occurs, it can present abruptly, with a
sudden onset of vomiting and pain, sometimes
requiring immediate operative intervention.

Causes:
Predisposing factors include the following:
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 it more patulous.
Hiatal hernias are more common in women. This may relate to the
intra-abdominal forces exerted in pregnancy.
Burkitt et al suggest that the Western, fiber-depleted diet leads to a
state of chronic constipation and straining during bowel movement,
which might explain the higher incidence of this condition in
Western countries.

Obesity predisposes to hiatus hernia because of

increased abdominal pressure.
Conditions such as chronic esophagitis may cause
shortening of the esophagus by causing fibrosis of the
longitudinal muscles and, therefore, predispose to hiatal
hernia. However, which comes first, the hiatal hernia
worsening the reflux or the reflux-induced shortening
of the esophagus, remains unknown.
The presence of abdominal ascites also is associated
with hiatal hernias.

Diaphragmatic hernias may be congenital or

acquired.
Acquired

hiatal hernias are divided further into

nontraumatic 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 hernia by far is the most common type of hiatal

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 hiatal
hernias 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 with
the 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

hernia, the widened hiatus permits the fundus of the
stomach to protrude into the chest, anterior and lateral to
the body of the esophagus; however, the gastroesophageal
junction remains below the diaphragm. This causes the
stomach to rotate in a counter-clockwise direction. As the
hiatus widens, increasing amounts of the greater curvature
of the stomach and, sometimes, the gastric-colic
omentum, follow. The fundus eventually comes to lie
above the gastroesophageal junction, with the pylorus
being pulled towards the diaphragmatic hiatus. In this type
of hernia, the anatomic relation of the stomach to the
lower end of the esophagus (angle of His) tends to remain
unchanged, so gross acid reflux does not occur.

Medical Care: When hiatal hernias are symptomatic,

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 acid
production. 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 vague
intermittent chest discomfort or pain. The paraesophageal hernia may strangulate
and 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, this
represents a very small proportion of patients with sliding hiatal hernia; most
patients with problems are managed medically.
By far, the majority of patients who would have undergone surgery in the past
are 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 taking
medications long term, may be surgical candidates.
Another group of patients who are surgical candidates are those with pulmonary
complications, in particular, asthma, recurrent aspiration pneumonia, chronic
cough, or hoarseness linked to reflux disease.
Three major types of surgical procedures correct gastroesophageal reflux and
repair the hernia in the process. They can be performed by open laparotomy or
with laparoscopic approaches, which currently are being employed more
frequently.

Nissen fundoplication
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 a
relatively 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 postoperative
complications.
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 a
previous Nissen wrap or those who have an irreducible hernia.

The Toupet procedure is a variant of the Nissen wrap

and involves a 180 wrap in an attempt to lessen the
likelihood of postoperative dysphagia
Belsey (mark IV) fundoplication: This operation involves
a 270 wrap in an attempt to reduce the incidence of gas
bloating and postoperative dysphagia. It also is preferred
when minimal esophageal dysmotility is suspected. To
complete this operation, the left and right crura of the
diaphragm are approximated.
Hill repair: In this procedure, the cardia of the stomach
is anchored to the posterior abdominal areas, such as the
medial arcuate ligament. This also has the effect of
augmenting the angle of His and thus strengthening the
antireflux mechanism.

Fundoplicatura TOUPET