~Teachingcenter的醫學筆記~

小腸阻塞
Small Bowel Obstruction
1. 常見成因：postoperative adhesions, neoplasm and hernias
2. 在治療計畫上，務必要先確認以下：
=(1). 水分、電解質、營養缺乏的情形
=(2). 何時要放棄內科(保守)治療，轉手術處理？
3. 手術介入Operative intervention
=(1). 懷疑腸絞扼(strangulation)
=(2). 腸阻塞的住院病人，約有5成會需要手術治療
=(3). 應由腸阻塞的成因，決定手術的術式
=(4). 腹部電腦斷層影像，相比於其他影像學，有最佳協助判斷是否要手術的功能

腸阻塞的可能造成原因
Causes of small bowel obstruction
1. Extrinsic lesions: Adhesions, Hernia, Volvulus
2. Intrinsic lesions: Congenital malformations, Duplication, Atresia, Stenosis, Neoplasm, Inflammatory stricture, Radiation enteritis
3. Obstruction of normal bowel lumen: Intussusception, Gallstones, Feces or meconium, Bezoar, Traumatic intramural hematoma

腹股溝疝氣
Inguinal hernia
1. 腹股溝管inguinal canal
= 內口：深環/外口：淺環
= 前壁：腹外斜肌腱膜，外1/3為腹內斜肌
= 後壁：腹膜和腹橫筋膜，內1/3為腹股溝鐮
= 上壁：腹內斜肌、腹橫肌的弓狀緣下緣、腹股溝韌帶和腔隙韌帶
2. 間接型腹股溝疝氣(indirect inguinal hernia)是從內環(internal inguinal ring)疝出，位於腹壁下動脈(inferior epigastric artery)外側，精索在疝氣囊後方，好發兒童、青壯年
3. 直接型腹股溝疝氣(direct inguinal hernia)是從海氏三角(腹股溝三角Hesselbach's triangle)疝出，位於腹壁下動脈(inferior epigastric artery)內側，精索在疝氣囊外前方，好發老年人
= Hesselbach's triangle formed by
---the inguinal ligament inferiorly
---the inferior epigastric vessels laterally
---the rectus muscle superiorly
4. 腹股溝疝氣若合併腸壞死，先處理腸壞死，而且考量到感染、發炎、沾黏等問題，不會在切除腸壞死的那次手術中修補疝氣開口，會另外安排疝氣修補的手術時間
5. Nyhus Classification of Inguinal Hernias
I: Indirect sac, normal internal ring
II: Indirect sac, dilated internal ring
IIIA: Direct hernia
IIIB: Indirect hernia with weak inguinal floor; sliding hernia
IIIC: Femoral hernia
IV: Recurrent hernia (A=direct; B=indirect; C=femoral; D=other)

股疝氣
Femoral hernia
1. 股管Femoral canal
= 上口：股環/下口：卵圓窩
= 前緣：腹股溝韌帶
= 後緣：恥骨梳韌帶(Pectineal ligament)
= 內緣：腔隙韌帶
= 外緣：股靜脈
2. 通過股環經股管向卵圓窩突出，發生於股管內側，在腹股溝韌帶下方(inferior to the inguinal ligament)
3. 與生理、解剖學結構及妊娠腹內壓增高相關，多見於中年經產婦女，右側多於左側
4. 依據位置，可分為：
= 典型股疝 (typical femoral hernia)
= 血管前疝 (prevascular hernia)
= 外股疝 (exfemoral hernia)
= 恥骨梳韌帶股疝 (femoral hernia of pectineal ligament)
= 恥骨疝 (pectineal hernia)
= 血管後疝 (retrovascular hernia)

Risk factors of incisional hernia:
1. Wound infection
2. Excessive wound tension
3. Fractured sutures
4. Poor technique
5. Emergency surgery
6. Obesity
7. Smoking
8. Malnutrition
9. Medications such as immunosuppressives
10. Connective tissue disorders