Presentacion Hernias de Pared Abdominal
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HERNIAS DE PARED HERNIAS DE PARED ABDOMINALABDOMINAL
Dr. Dolores Sandoval CastroDr. Dolores Sandoval Castro
Cirujano GeneralCirujano General
Oct. 2010Oct. 2010
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HERNIASHERNIAS
Definición: Definición: • Hernia (latín): roturaHernia (latín): rotura
… … un área de debilidad completa de los tejidos un área de debilidad completa de los tejidos fibromusculares de la pared del cuerpo, con fibromusculares de la pared del cuerpo, con protrusiòn de contenido preperitoneal o protrusiòn de contenido preperitoneal o intraperitoneal. Y puede ser de origen congénito intraperitoneal. Y puede ser de origen congénito o adquirido.o adquirido.
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HERNIASHERNIAS
Componentes Componentes
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HERNIASHERNIAS
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HERNIAS HERNIAS
Anatomopatologìa:Anatomopatologìa:• Saco peritoneal o grasa preperitoneal Saco peritoneal o grasa preperitoneal • Cicatriz distendida en las eventracionesCicatriz distendida en las eventraciones
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CLASIFICACIONCLASIFICACION
ClínicaClínica AnatómicaAnatómica TopográficaTopográfica
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CLASIFICACION CLINICACLASIFICACION CLINICA
ReductiblesReductibles IrreductiblesIrreductibles IncarceradasIncarceradas ExtranguladasExtranguladas
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CLASIFICACION ANATOMICACLASIFICACION ANATOMICA
Hernias inguinales:Hernias inguinales:• DirectasDirectas• IndirectasIndirectas• FemoralesFemorales Hernias ventrales:Hernias ventrales:• PrimariasPrimarias• RecidivantesRecidivantes• IncisionalesIncisionales
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CLASIFICACION ANATOMICACLASIFICACION ANATOMICA
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CLASIFICACION TOPOGRAFICACLASIFICACION TOPOGRAFICA
Inguinal-FemoralInguinal-Femoral UmbilicalUmbilical SpiegelSpiegel ObturatrìzObturatrìz LumbarLumbar IncisionalIncisional EpigástricaEpigástrica
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EPIDEMIOLOGIA (USA)EPIDEMIOLOGIA (USA)
75% Se encuentra en la ingle75% Se encuentra en la ingle
95% En el conducto inguinal95% En el conducto inguinal
05% En el conducto femoral05% En el conducto femoral
20% Prevalencia20% Prevalencia
Maingot.Operaciones Abdominales. 2008: 103 -139.
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EPIDEMIOLOGIA (MEXICO)EPIDEMIOLOGIA (MEXICO)
En el SNIS (2000 al 2007)En el SNIS (2000 al 2007)• 282, 105, 000 egresos hospitalarios282, 105, 000 egresos hospitalarios• Inguinales: 58.5%Inguinales: 58.5%• Umbilicales: 24.3%Umbilicales: 24.3%• Incisionales: 10.2%Incisionales: 10.2%• Otras: 7% Otras: 7%
AMH, mayo 2009 AMH, mayo 2009
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EPIDEMILOGIA (MEXICO)EPIDEMILOGIA (MEXICO)
Incisionales: 10 al 13% de las celiotomìasIncisionales: 10 al 13% de las celiotomìas Puertos: 3-8%Puertos: 3-8%
AMH, mayo 2009AMH, mayo 2009
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EPIDEMIOLOGIA (MEXICO)EPIDEMIOLOGIA (MEXICO)
Género:Género:• Inguinal predomina en varones (2-3:1)Inguinal predomina en varones (2-3:1)• Femoral predomina en mujeres (3:1)Femoral predomina en mujeres (3:1)• Umbilical e incisional en mujeres (2:1)Umbilical e incisional en mujeres (2:1)
AMH, mayo 2009AMH, mayo 2009
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EPIDEMIOLOGIA: HERNIA INGUINAL (USA)EPIDEMIOLOGIA: HERNIA INGUINAL (USA)
Comùn en el lado derecho; 2:1 D/IComùn en el lado derecho; 2:1 D/I Relación 7:1 H/MRelación 7:1 H/M 750 000 hernio rafias anuales750 000 hernio rafias anuales III C (Nyhus) mayor tasa de complicacionesIII C (Nyhus) mayor tasa de complicaciones 10-15% hernias bilaterales10-15% hernias bilaterales
Schwartz. Principios de Cirugía. 2006:1353-1394.
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EPIDEMIOLOGIA (MEXICO)EPIDEMIOLOGIA (MEXICO)
Rangos de edad:Rangos de edad:• 30 a 59 años (40 al 51% de todas las 30 a 59 años (40 al 51% de todas las
hernias) hernias)
AMH, mayo 2009AMH, mayo 2009
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EPIDEMIOLOGIA (MEXICO)EPIDEMIOLOGIA (MEXICO)
Complicaciones:Complicaciones:
• Incarceraciòn (7 A 30%)Incarceraciòn (7 A 30%)• Estrangulación (10% de éstas)Estrangulación (10% de éstas)
AMH, mayo 2009AMH, mayo 2009
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EPIDEMIOLOGIA (MEXICO)EPIDEMIOLOGIA (MEXICO)
Recidiva de hernias inguinales:Recidiva de hernias inguinales:
• Técnicas con tensión: 11-20%Técnicas con tensión: 11-20%• Técnicas sin tensión: 0.5 - 5%Técnicas sin tensión: 0.5 - 5%
AMH, mayo 2009AMH, mayo 2009
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DIAGNOSTICODIAGNOSTICO
Clínico:Clínico:
• Interrogatorio: asintomáticos vs sintomáticosInterrogatorio: asintomáticos vs sintomáticos
• Síntomas: molestia vaga, dolor localizado, Síntomas: molestia vaga, dolor localizado, obstrucción intestinal por estrangulamientoobstrucción intestinal por estrangulamiento
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DIANOSTICODIANOSTICO
Inspección:Inspección:• borde lateral del músculo rectoborde lateral del músculo recto• región umbilicalregión umbilical• región inguinalregión inguinal• región lumbarregión lumbar• línea albalínea alba• piso pélvicopiso pélvico
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DIAGNOSTICODIAGNOSTICO
PalpaciónPalpación (escrotal, abdominal anterior y (escrotal, abdominal anterior y posterior posterior
• Diferenciar: tumor, hidrocele, varicocele, Diferenciar: tumor, hidrocele, varicocele, hematocele (inguinal), hipertrofia de ganglio hematocele (inguinal), hipertrofia de ganglio
de Cloquet (femoral) de Cloquet (femoral)
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EXPLORACION REGION INGUINALEXPLORACION REGION INGUINAL
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EXPLORACION REGION CRURALEXPLORACION REGION CRURAL
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DIAGNOSTICODIAGNOSTICO
Percusión:Percusión:• ruìdos timpànicoruìdos timpànico• matemate
Auscultación:Auscultación:• ruìdos peristálticosruìdos peristálticos• ausencia de ruìdos peristálticosausencia de ruìdos peristálticos
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AUXILIARES DIAGNOSTICOSAUXILIARES DIAGNOSTICOS
HerniografìaHerniografìa RadiografíasRadiografías USGUSG TACTAC IRMIRM
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TRATAMIENTO QUIRURGICOTRATAMIENTO QUIRURGICO
Técnica abierta con tensión:Técnica abierta con tensión:• BassiniBassini• Mc VayMc Vay• ShouldiceShouldice• NyhusNyhus• MayoMayo
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TRATAMIENTO QUIRURGICOTRATAMIENTO QUIRURGICO
Técnica abierta sin tensión:Técnica abierta sin tensión:• LichtensteinLichtenstein• GilbertGilbert• RutkowRutkow• RobbinnsRobbinns• StoppaStoppa• RivesRives
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MATERIAL PROTESICO PARA HERNIOPLASTIAMATERIAL PROTESICO PARA HERNIOPLASTIA
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TRATAMIENTO QUIRURGICOTRATAMIENTO QUIRURGICO
Por vía laparoscópicaPor vía laparoscópica
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HERNIA HERNIA INGUINALINGUINAL
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Club de los herniados: Sudáfrica 2010
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Table 1. The Anatomists: Historic Firsts
Vesalius (Flemish) and Fallopius (Italy) Poupart (France)
Described the inguinal ligament.
Heister First to describe direct hernias. (1724)
Pott (England) Anatomy of congenital hernias; methods of incarceration
Camper (Holland) Described the superficial subcutaneous fascia
Scarpa (Italy) Described deep subcutaneous fascia; anatomic and surgical importance of sliding hernias (en glissade) (1814)
Sir Ashley Cooper (England)
Described anatomy and surgical treatment of crural and umbilical hernias; anatomy of the groin including the superior pubic (Cooper) ligament; cremasteric fascia and the transversaiis fascia
Hunter Emphasized the role of the processus vaginalis
Morton Described the conjoined tendon.
Cloquet Noted postnatal closure of the processus vaginalis; made observations of the iliopubic tract
Hesselbach (Germany)
Defined iliopubic tract; described importance of the medial triangle of the groin (included the femoral canal).!1'; described the "corona mortis" (arterial circle formed by the deep epigastric and obturator arteries). (See original drawing and current interpretation)
De Gimbernat Described medial ligament of the femoral canal (lacunar ligament), and division of that ligament in the treatment of strangulated femoral hernias.
Richter (Germany)
Described partial obstruction and incarceration of a wall of the bowel in a hernia defect.t2-3'
INGUINAL HERNIA: ANATOMY AND MANAGEMENT. 04OCT.2000
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LIGAMENTO INGUINALLIGAMENTO INGUINAL
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MUSCULOS DEL ABDOMENMUSCULOS DEL ABDOMEN
Región anterolateralRegión anterolateral
Recto anterior del abdomenRecto anterior del abdomen
Oblicuo mayor y menorOblicuo mayor y menor
Transverso Transverso Región posteriorRegión posterior
Cuadrado lumbarCuadrado lumbar
PsoasilìacoPsoasilìaco
Psoas menorPsoas menor
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MUSCULO RECTO MAYORMUSCULO RECTO MAYOR
MUSCULO LARGO Y APLANADOMUSCULO LARGO Y APLANADO SE EXTIENDE DEL PUBIS A LA PARTE SE EXTIENDE DEL PUBIS A LA PARTE
ANTEROINFERIOR EL TORAXANTEROINFERIOR EL TORAX FORMA AL LIGAMENTO DE HENLEFORMA AL LIGAMENTO DE HENLE RELACION POSTERIOR CON LA RELACION POSTERIOR CON LA
FASCIA TRANSVERSALISFASCIA TRANSVERSALIS
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MUSCULO OBLICUO MAYORMUSCULO OBLICUO MAYOR
INSERCIONES: INSERCIONES: • 8 ULTIMAS COSTILLAS8 ULTIMAS COSTILLAS• CRESTA ILIACACRESTA ILIACA• PUBISPUBIS• LINEA ALBALINEA ALBA
REFLEXIONES:REFLEXIONES:• LIGAMENTO DE POUPARTLIGAMENTO DE POUPART• LIGAMENTO DE GIMBERNATLIGAMENTO DE GIMBERNAT
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MUSCULO OBLICUO MENORMUSCULO OBLICUO MENOR
INSERCIONES:INSERCIONES:• LA CRESTA ILIACALA CRESTA ILIACA• APOFISIS ESPINOSA DE L5APOFISIS ESPINOSA DE L5• 4 ULTIMOS CARTILAGOS COSTALES4 ULTIMOS CARTILAGOS COSTALES• LINEA ALBALINEA ALBA• PUBISPUBIS• 1/3 EXTERNO DEL ARCO CRURAL1/3 EXTERNO DEL ARCO CRURAL
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MUSCULO TRANSVERSOMUSCULO TRANSVERSO
INSERCIONES:INSERCIONES:• VERTEBRAS LUMBARESVERTEBRAS LUMBARES• LINEA ALBALINEA ALBA• 7 CARTILAGOS Y COSTILLAS INF7 CARTILAGOS Y COSTILLAS INF• PUBISPUBIS• 1/3 EXTERNO DEL ARCO CRURAL1/3 EXTERNO DEL ARCO CRURAL
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MUSCULOS DE LA PARED ABDOMINALMUSCULOS DE LA PARED ABDOMINAL
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FASCIA TRANSVERSALISFASCIA TRANSVERSALIS
REFORZAMIENTOS: REFORZAMIENTOS: • LIGAMENTO DE HENLELIGAMENTO DE HENLE• LIGAMENTO DE HESSELBACHLIGAMENTO DE HESSELBACH• HAZ ILIOPECTINEOHAZ ILIOPECTINEO
• LIGAMENTO DE COOPERLIGAMENTO DE COOPER
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LIGAMENTOSLIGAMENTOS
POUPARTPOUPART GIMBERNATGIMBERNAT COOPERCOOPER HENLEHENLE HESSELBACHHESSELBACH COLLESCOLLES HAZ ILIOPECTINEOHAZ ILIOPECTINEO
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FOSAS SUPRAINGUINALESFOSAS SUPRAINGUINALES
FOSA SUPRAVESICALFOSA SUPRAVESICAL
FOSA MEDIALFOSA MEDIAL
FOSA LATERALFOSA LATERAL
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ORIFICIO MIOPECTINEO DE ORIFICIO MIOPECTINEO DE FRUCHAUDFRUCHAUD
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VISTA POSTERIOR DE LA VISTA POSTERIOR DE LA REGION INGUINALREGION INGUINAL
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PLANOS PLANOS REGIONREGION INGUINAL INGUINAL
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PROCESO PERITONEO VAGINALPROCESO PERITONEO VAGINAL
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PLEXO LUMBARPLEXO LUMBAR
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CANAL INGUINALCANAL INGUINAL
CARACTERISTICAS:CARACTERISTICAS:
• HENDIDURA OBLICUAHENDIDURA OBLICUA• LONGITUD: 4 CMLONGITUD: 4 CM• LIMITES: 4LIMITES: 4• DOS ANILLOSDOS ANILLOS
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LIMITES CANAL INGUINAL DELLIMITES CANAL INGUINAL DEL
• ANTERIOR.ANTERIOR.
• POSTERIOR (PISO).POSTERIOR (PISO).
• SUPERIOR (TECHO).SUPERIOR (TECHO).
• INFERIOR.INFERIOR.
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CONTENIDOS CANAL INGUINALCONTENIDOS CANAL INGUINAL
CORDON ESPERMATICOCORDON ESPERMATICO• CONDUCTO DEFERENTECONDUCTO DEFERENTE• ARTERIASARTERIAS• VENAS VENAS • NERVIOSNERVIOS• FASCIASFASCIAS• LIGAMENTO REDONDOLIGAMENTO REDONDO• VASOS LINFATICOSVASOS LINFATICOS
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EDOUARDO BASSINI (1844-1924)EDOUARDO BASSINI (1844-1924)
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CHESTER BIDWELL MC VAY (1911-1987)CHESTER BIDWELL MC VAY (1911-1987)
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EARLE SHOULDICE (1890-1965)EARLE SHOULDICE (1890-1965)
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FRANCIS USHER (1908-1980)FRANCIS USHER (1908-1980)
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LLOYD M. NYHUS (1923-2008)LLOYD M. NYHUS (1923-2008)
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IRVING L. LICHTENSTEINIRVING L. LICHTENSTEIN
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IRA M. RUTKOWIRA M. RUTKOW
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PLASTIA TIPO LICHTENSTEINPLASTIA TIPO LICHTENSTEIN
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HERNIA FEMORALHERNIA FEMORAL
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CANAL FEMORALCANAL FEMORAL
• Diámetro transverso: 10-14 Mm Diámetro transverso: 10-14 Mm
• Diámetro antero posterior: 12-16 MmDiámetro antero posterior: 12-16 Mm• Forma cónicaForma cónica
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CANAL FEMORALCANAL FEMORAL
LIMITES ANATOMICOS:LIMITES ANATOMICOS:• LATERALLATERAL• POSTERIORPOSTERIOR• ANTERIORANTERIOR• MEDIALMEDIAL
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HERNIA CRURAL TIPICAHERNIA CRURAL TIPICA
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HERNIAS CRURALESHERNIAS CRURALES
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HERNIA UMBILICALHERNIA UMBILICAL
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HERNIA DE SPIEGELHERNIA DE SPIEGEL
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HERNIA DE SPIEGELHERNIA DE SPIEGEL
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HERNIA EPIGASTRICAHERNIA EPIGASTRICA
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HERNIA EPIGASTRICAHERNIA EPIGASTRICA
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HERNIA EPIGASTRICAHERNIA EPIGASTRICA
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HERNIAS LUMBARESHERNIAS LUMBARES
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HERNIA OBTURATRIZHERNIA OBTURATRIZ
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HERNIAS CIATICASHERNIAS CIATICAS
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HERNIAS PERINEALESHERNIAS PERINEALES
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GRACIASGRACIAS