鼠径部付近のヘルニア(鼠径ヘルニア・大腿ヘルニア・閉鎖孔ヘルニア)を3次元的に理解する

消化器内科・外科

まずは腹部のヘルニアを大まかに把握する

[ヘルニアの定義]

ヘルニアとは体内の臓器が本来あるべき位置から脱出した状態を指す。

[外ヘルニアと内ヘルニア]

外ヘルニア:体腔内臓器が異常に生じた裂隙を通じて体腔外に脱出してしまった状態を指す。
体腔外で起こるので基本的には体表から確認できる。鼠径部付近のヘルニアは外ヘルニアに分類される。

内ヘルニア:体腔内臓器が体腔内において異常に生じた裂隙などに入り込んでしまった状態を指す。体腔内で起こるので体表からは確認できない。大網裂孔ヘルニア・食道裂孔ヘルニア・網嚢孔ヘルニア(Winslow孔ヘルニア)などが内ヘルニアに分類される。

腹部の外ヘルニアはどのようにして形成されるのか

腹腔と腹膜の存在を把握する

腹腔内は腹膜に覆われている。

腹部には解剖学的に圧力が掛かりやすい弱点となる部分や血管や神経が腹腔内に出たり入ったりするための裂隙がある。

ヘルニア嚢の形成

腹膜が先天的な要因や圧力を受けた結果として裂隙や腹壁の弱い部分から伸びてしまいヘルニア嚢が形成される。

腹部外ヘルニアは腹腔内を覆っている腹膜が裂隙や腹壁の弱い部分から突出してヘルニア嚢を形成してしまった後にそこに腹腔内臓器が脱出した状態を指す。

初期

ヘルニア嚢ができた後の初期では重力が掛かる立位において腹腔内臓器が突出するようになるが、重力が掛からない仰臥位では還納する。また、症状が出ない。

嵌頓

脱出した腹腔内臓器が元の位置に戻らなくなることを嵌頓と呼び、絞扼性腸閉塞の状態となってしまうので緊急手術が必要となる。

鼠径部付近のヘルニアの治療は

実際の臨床では異なるかもしれないが、医師国家試験問題を解くにあたっては嵌頓の場合は絶対的に緊急手術と覚えるのが良いのではないかと考える。

全身状態が良好で嵌頓していないようであれば用手還納(徒手的還納)を試みる。

鼠径ヘルニアについて

鼠径管は男性により発達するので、鼠径ヘルニアは男性に多い。

体表から分かりやすいので身体診察(視診・触診)が有効となる。

鼠径管を理解する

鼠径管とは前壁(外腹斜筋腱膜)・上壁(内腹斜筋)・下壁(鼠径靭帯)、後壁(腹横筋筋膜)で構成されるトンネル状の空間である。
鼠径管の入口を内鼠径輪(深鼠径輪)と呼び、出口を外鼠径輪(浅鼠径輪)と呼ぶ。
「管」と名前についているので「管状」の構造なのかと思ってしまいがちだが、実際には鼠径靭帯の上側に「トンネル状の空間がぽっかりと存在する」というイメージであることに注意する必要がある。

鼠径管の名前の由来

精巣(睾丸)は胎生期に腹腔内で発生して出生近くになると鼠径管を通過して陰嚢に移動する。この精巣(睾丸)の動きを鼠になぞらえて、鼠径管というのは「鼠=精巣(睾丸)」の通り道になるという意味から名付けられた。

鼠径管を通過するもの

男性では精索(索状組織であり内部に精管・精巣動静脈などを含む)、女性では子宮円索(子宮を固定する線維組織)が通過する。

鼠径ヘルニアの分類

下腹壁動静脈よりも外側から突出するものを外鼠径ヘルニアと分類して、内側から突出するものを内鼠径ヘルニアと分類する。

外鼠径ヘルニア

先天的要因が大きく、幼児と若年成人に多い。

内鼠径輪から鼠径管に侵入して外鼠径輪を通って鼠径部皮下に脱出するものを指す。身体の外側(がいそく)よりに発生する。

内鼠径ヘルニア

後天的要因が大きく、高齢男性(特に腹圧が上昇しやすい肥満者)に多い。

Hesselbach三角(下腹壁動静脈・鼠径靭帯・腹直筋外側縁に囲まれた部分)に存在する鼠径後壁を構成している横筋筋膜ごとヘルニア嚢が鼠径管に侵入して直接外鼠径輪を通って鼠径部皮下に脱出するものを指す。身体の内側(ないそく)よりに発生する。

大腿ヘルニアについて

女性は骨盤が広いので、大腿ヘルニアは女性に多い。

体表から分かりやすいので身体診察(視診・触診)が有効となる。

高齢女性に多く、嵌頓しやすく、手術治療が原則となる。

大腿輪から大腿管に侵入して伏在裂孔を通って大腿部皮下に脱出するものを指す。
鼠径ヘルニアは鼠径靭帯の上に位置するのに対して、大腿ヘルニアは鼠径靭帯の下に位置する。

大腿管を理解する

大腿管とは入口を大腿輪として出口を伏在裂孔とする大腿静脈に沿った空間である。
入口である大腿輪は外側縁(大腿静脈)・前縁(鼠径靭帯)・内側縁(裂孔靭帯)で構成され、出口である伏在裂孔は大伏在静脈が通過する。
大腿管も鼠径管のように「管状」の構造というわけではなく、大腿静脈の内側に沿って「空間がぽっかりと存在する」というイメージである。

閉鎖孔ヘルニアについて

女性は骨盤が広いので、閉鎖孔ヘルニアは女性に多い。

高齢女性に多く、嵌頓しやすく、手術治療が原則となる。

閉鎖孔ヘルニアは腹腔内臓器が閉鎖孔を通って腹腔外に脱出したものであるので外ヘルニアに分類される。しかし、体表面からだと閉鎖孔ヘルニアの前面には恥骨筋がくるので体表からは確認するのが難しく身体診察(視診・触診)が有効となりにくい。

他の鼠径部付近の外ヘルニア(鼠径ヘルニア・大腿ヘルニア)は全て恥骨筋よりもさらに前面に発生するので体表面から確認するのが容易となり身体診察(視診・触診)が有効となるため、閉鎖孔ヘルニアは外ヘルニアであるにも関わらず体表面から確認するのが難しいという例外的な特徴を持つといえる。

閉鎖孔ヘルニアはCTが有効

閉鎖孔ヘルニアは恥骨筋と外閉鎖筋に滑り込むような形で閉鎖孔を通過するので、CTにおいて恥骨筋と外閉鎖筋に挟まれた閉鎖孔を認めるという分かりやすい特徴的なCT所見を呈するので身体診察よりもCTが有効となる。

鼠径ヘルニアと大腿ヘルニアをCT所見のみで鑑別する必要はない

医師国家試験レベルではCTからは閉鎖孔ヘルニアなのか[鼠径ヘルニア・大腿ヘルニア]なのかを区別できれば十分である。恥骨よりも身体の深層(うちがわ)に発生するのが閉鎖孔ヘルニアであり、身体の浅層(そとがわ)に発生するのが[鼠径ヘルニア・大腿ヘルニア]である。

鼠径ヘルニアと大腿ヘルニアは発生する位置が近いので1枚のCTスライスで鑑別するのは難しく、医師国家試験レベルではそこまで求められない。そもそも、鼠径ヘルニアと大腿ヘルニアは体表から分かりやすいので身体診察(視診・触診)の方が有効である。

閉鎖孔ヘルニアの症状

絞扼性イレウス(腹痛・嘔気)

通常、外ヘルニアは嵌頓による絞扼性腸閉塞の症状が出る前に体表が膨らむので見た目から気付かれることが多い。しかし、閉鎖孔ヘルニアは外ヘルニアの中で唯一体表からは確認しにくいので、絞扼性腸閉塞の症状で見つかることが多い。

Howship-Romberg徴候(大腿内側の疼痛)

閉鎖孔ヘルニアによって閉鎖神経が圧迫されてしまうことで閉鎖神経圧迫症状が起こる。

コメント

  1. atslegal より:

    Your style is really unique in comparison to other people I have read stuff from. Thanks for posting when you’ve got the opportunity, Guess I will just bookmark this blog.

  2. Hi there, after reading this awesome article i am also glad to share my know-how here with colleagues.

  3. squid porn より:

    Outstanding quest there. What occurred after?Take care!My blog; high carb

  4. adult content より:

    This blog was how do I say it? Relevant!! Finally I have found something that helped me. Cheers!

  5. weng toto より:

    Can someone recommend Remote Control Toys? Cheers xxx

  6. ชาวสวนเพชรบูรณ์ดีใจเหมือนถูกหวย จากกระแสความนิยม ต้นกล้วยใบด่างหลังไปพบกล้วยใบด่างที่อยู่ในสวนกล้วยน้ำว้าและกล้วยไข่ โดยลำต้นสูง 2.5 เมตรใบด่างเป็นลายริ้วสีเขียวเหลือง คนเห็นขอซื้อ 45,000***เดซี่3/7/64***

  7. onlyfans 18+ より:

    ivermectin warnings ivermectin tablets for humans australia ivermectin ld50 human

  8. This blog was… how do you say it? Relevant!! Finally I havefound something which helped me. Thanks!

  9. Roxane より:

    Incredible loads of wonderful advice.how to write a cause and effect essay how to write a college scholarship essay dissertation writer

  10. Qrmejd – best canadian pharmacy Chmpeh iiiung

  11. visit より:

    online pharmacy australia tramadol canada pharmacy

  12. coupon code より:

    I’d like fasting to lose weightfind out more? I’d love to find out some additional information.

  13. Beatrice Pope より:

    I am no longer positive the place you are getting your information, however great topic. I must spend some time studying much more or figuring out more. Thanks for great information I used to be looking for this information for my mission.

  14. celana jeans より:

    causes of ed overcoming ed – erection problemsed pharmacy

  15. Enjoyed reading this, very good stuff, thankyou . “It is in justice that the ordering of society is centered.” by Aristotle.

  16. 貼海報 より:

    I needed to thank you for this good read!! I definitely enjoyed every littlebit of it. I have got you book-marked to check out new stuff you

  17. see より:

    What’s up, all is going nicely here and ofcourse every one is sharing facts, that’s really fine, keep up writing.Also visit my blog – Daftar Poker

  18. Sabra Hitch より:

    Terrific work! This is the type of information that should be shared around the web. Shame on the search engines for not positioning this post higher! Come on over and visit my website . Thanks =)

  19. We stumbled over here coming from a different web address and thought I might check things out. I like what I see so i am just following you. Look forward to looking into your web page repeatedly.

  20. Lorna Alampi より:

    I really appreciate this post. I have been looking all over for this! Thank goodness I found it on Bing. You have made my day! Thanks again

  21. There is certainly a lot to know about this issue. I love all of the points you made.

  22. preakness apartments rentberry scam ico 30m$ raised san ramon apartments

  23. Wow, marvelous blog layout! How long have you been blogging for? you make blogging look easy. The overall look of your web site is excellent, let alone the content!

  24. amlodipine and ed does norvasc cause hair loss

  25. Kolay Aşk Büyüsü

  26. USB Flash より:

    Appreciate you sharing, great blog article.Really looking forward to read more. Really Cool.

  27. 1xbet farsi より:

    hi!,I like your writing so a lot! share we be in contact extra about yourarticle on AOL? I need an expert on this space to unravel my problem.May be that’s you! Looking ahead to see you.

  28. visit より:

    Incredible. Master. You’re some sort of master. Appreciate you.

  29. astrologia より:

    Hi, just wanted to tell you, I liked this blog post.It was practical. Keep on posting! asmr 0mniartist

  30. to read more より:

    Leke Kremi En iyi marka ve ödüllü olduğumuz alanda sizleri de cilt tonu lekelerinizden kurtulmak için bekliyoruz

  31. An intriguing conversation deserves comment. I assume that you must write much more on this subject, it could not be a forbidden subject yet usually individuals are not enough to talk on such subjects. To the following. Thanks

  32. Major thankies for the article.

  33. Your style is unique compared to other folks I have read stuff from. Many thanks for posting when you have the opportunity, Guess I will just bookmark this blog.

  34. Great, thanks for sharing this blog article.Really looking forward to read more. Want more.

  35. dewapoker より:

    I do not even know the way I stopped up right here, but I assumed this post used to be good. I do not recognize who you are but definitely you’re going to a famous blogger in case you are not already Cheers!

  36. Really informative blog.Really thank you! Will read on…

  37. I am so grateful for your post.Thanks Again. Will read on…

  38. Appreciate you sharing, great article.Really looking forward to read more. Cool.

  39. for more info より:

    Hello there, just became aware of your blog through Google, and found that it is truly informative. I’m going to watch out for brussels. I will be grateful if you continue this in future. A lot of people will be benefited from your writing. Cheers!

  40. Enjoyed every bit of your article post.Really looking forward to read more. Cool.

  41. Hi there, just became alert to your blog through Google, and found that it is really informative. I?m gonna watch out for brussels. I will be grateful if you continue this in future. Numerous people will be benefited from your writing. Cheers!

  42. this website より:

    678482 968792I havent checked in here for some time as I thought it was obtaining boring, but the last couple of posts are wonderful quality so I guess Ill add you back to my everyday bloglist. You deserve it my friend 108361

  43. Thanks very nice blog!Here is my blog – interleads.net

  44. Hey there! I just wanted to ask if you ever have any issues with hackers?My last blog (wordpress) was hacked andI ended up losing many months of hard work due to noback up. Do you have any solutions to protect against hackers?

  45. pubg uc buy より:

    Appreciate you sharing, great blog post.Much thanks again. Really Great.

  46. Sweet blog! I found it while searching on Yahoo News.Do you have any suggestions on how to get listed in Yahoo News?I’ve been trying for a while but I never seem to get there!Appreciate it

  47. I really like and appreciate your post.Really thank you! Great.

  48. Looking forward to reading more. Great blog post.Really looking forward to read more. Much obliged.

  49. You expressed it fantastically. nyu college essay help writing paper theses meaning

  50. Enjoyed every bit of your article post.Thanks Again. Keep writing.

  51. Thanks so much for the blog article.Really thank you! Will read on…

  52. 佳文网 より:

    Looking forward to reading more. Great blog post.Much thanks again. Much obliged.

  53. 113955975B より:

    Wow! This can be one particular of the most beneficial blogs We ave ever arrive across on this subject. Actually Excellent. I am also an expert in this topic therefore I can understand your hard work.

  54. this website より:

    Very good blog.Really looking forward to read more. Will read on…

  55. Hi are using WordPress for your blog platform? I’m newto the blog world but I’m trying to get started and create my own.Do you require any coding knowledge to make your own blog?Any help would be really appreciated!

  56. sedací pytel より:

    Good day! Do you use Twitter? I’d like to follow you if that would be ok.I’m undoubtedly enjoying your blog and look forward tonew updates.

  57. I think this is a real great blog.Much thanks again. Really Great.

  58. Members of the Gucci household, on the other hand, are reportedly not pleasedwith the film.

  59. this website より:

    Hey there! Do you know if they make any plugins to help with Search Engine Optimization?I’m trying to get my blog to rank for some targeted keywords but I’mnot seeing very good results. If you know of any please share.Cheers!

  60. fortebet より:

    Heya i’m for the primary time here. I found this boardand I to find It truly useful & it helpedme out much. I am hoping to give something back and aidothers such as you helped me.

  61. Xoilac Tv Thẳng đá Bóng tỷ lệ nhà cáiĐội tuyển futsal Việt Nam đã có được một trận đấu đồng ý được trước đối thủ cạnh tranh đầy sức mạnh Lebanon. Kết trái Bà Rịa-Vũng Tàu vs Bình Phước thời điểm hôm nay 18h00 ngày 5/5, Hạng nhất nước ta.

  62. may bo dam より:

    ivermectin tractor supply dogs ivermectin for rabbits mites

  63. power analyzer より:

    fpovggtch dvwxi wdplepb empn hyufgryypcseyhn

  64. more details より:

    Thanks , I have just been looking for information about this subject for ages and yours is the best I’ve found out till now. However, what in regards to the conclusion? Are you sure in regards to the supply?

  65. check out より:

    I really like reading a post that will make people think. Also, thank you for allowing for me to comment!

  66. euro parts より:

    plaquenil weight gain chloroquine mechanism of action

  67. genuine parts より:

    Aw, this was an exceptionally nice post. Taking the time and actual effort to generate a really good article… but what can I say… I put things off a whole lot and never manage to get nearly anything done.

  68. mens ed pills erectile dysfunction pills – new ed treatments

  69. Im obliged for the post.Really thank you! Really Cool.

  70. A motivating discussion is definitely worth comment. I do believe that you need to publish more on this subject, it might not be a taboo matter but usually people don’t discuss these issues. To the next! Kind regards!!

  71. khoa hoc gia re より:

    Nice post. I was checking constantly this blog and I’m impressed!Extremely helpful info specifically the last part I care for such information much.I was looking for this particular information for a very long time.Thank you and good luck.

  72. Dich vu Tiktok より:

    Highly energetic post, I enjoyed that bit. Will there be a part 2?my blog; cannabis dispensaries-san diego

  73. Nice post. I was checking continuously this blog and I am impressed! Extremely useful info specially the last part I care for such information much. I was looking for this certain information for a very long time. Thank you and best of luck.

  74. Dich vu Youtube より:

    Excellent post. I was checking continuously this blog and I’m impressed! Very helpful info particularly the last part I care for such info much. I was looking for this particular info for a very long time. Thank you and good luck.

  75. I truly appreciate this post.Much thanks again. Want more.

  76. diane 35 ed pill side effects – erectile dysfunction treatment in surat maxx ed pills

  77. wow, awesome blog article.Really thank you! Awesome.

  78. It’s really a cool and helpful piece of information. I am happy that you just shared this usefulinfo with us. Please stay us up to date like this.Thank you for sharing.

  79. Aw, this was an exceptionally good post. Finding the time and actual effort to produce a good article… but what can I say… I hesitate a lot and don’t seem to get anything done.

  80. internet pharmacy manitoba – erectile dysfunction pills walmart pharmacy online or canadian pharmacy 24h com

  81. I enjoy, cause I found just what I was taking a look for.You’ve ended my four day lengthy hunt! God Bless you man. Have a greatday. Bye

  82. This very blog is no doubt entertaining and besides diverting. I have picked helluva helpful tips out of this source. I ad love to go back every once in a while. Thanks a bunch!

  83. visit より:

    plaquenil weight gain what are the side effects of hydroxychloroquine plaquenil hydroxychloroquine sulfate

  84. visit website より:

    Bardzo interesujący temat, dzięki za wysłanie wiadomości antybakteryjne chusteczki antybakteryjne chusteczki.

  85. enfejar より:

    bedava hesap bulmak çok kolay, ücretsiz hesaplar için doğru adresburası. Bedava Hesaplar bazen işimize yarıyor bazen de yaramıyor.Eğer böyle bir ihtiyacın varsa gelip alabilirsin ücretsiz hesap.bedava hesap

  86. safe canadian pharmacy online neurontin canadian pharmacy

  87. Hey There. I found your blog using msn. This is a really well written article. I’ll be sure to bookmark it and return to read more of your useful info. Thanks for the post. I will definitely return.

  88. Mua view より:

    durvet ivermectin paste equine dewormer ivermectin wormers for horses

  89. I really like your wordpress design, exactly where would you get a hold of it through?

  90. Thanks for the marvelous posting! I seriously enjoyed readingit, you’re a great author. I will make certain to bookmark your blog and will often come back from now on.I want to encourage you continue your great work, have a nice holidayweekend!

  91. Very nice post. I just stumbled upon your blog andwished to say that I have truly enjoyed surfing around your blog posts.After all I will be subscribing to your feed and I hope you write again very soon!

タイトルとURLをコピーしました