12. hernias, umblicus and abdominal wall
DESCRIPTION
Hernias, Umblicus and Abdominal WallTRANSCRIPT
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DR Javed swati
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Presentation
By
Dr. Javed SwatiFCPS
Associate Professor of Surgery Department Peshawar medical college
javedswati2
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HERNIAS, UMBLICUS AND ABDOMINAL WALL
Introduction?Definition:-G.F Common to all herniasAetiological factors
I. Raised intra abdominal pressure
a) Power full mascular effort examples are whooping cough, chronic cough, straining on micturtion, straining on defecation intra abdominal malignancy
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II. Muscular weakness like excessive smoking, obesity, old age, multipara woman
III. a) Congenital P.P.Vb) Acquired P.P.V eg peritoneal dialysis
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- Epigastric - Para umblical- Umblical- Spigelian- Divarication- Inguinal- Femoral- Incisional- Obturator- Superior lumber- Inferior lumber- Gluteal- Sciatic
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External Hernias
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Internal Hernias in abdomen
- Hiatus hernias
- Hernia around ilioceal area
- Hernias around D.J junction
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- Sac
- Coverings of Sac
- Contents of Sac
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Composition of HerniasMain three parts are:
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Possible contents could heOmentum
Intestinal
Portion of circumfernce of Gut
Portion of Bladder
Ovary + fallopian tube
Meckels diverticulumAppendixFluid
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ClassificationsI. Site
a) Externalb) Internal
II. Reducible?III. Irreducible?
Obstructed? Strangulator? Inflamed?
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Reducible Hernia.?
Irreducible Hernia?
Obstructed Hernia?
Incarcerated Hernia?
Strangulated Hernia?
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Pathology?Clinical Feature
- Pain:-
- Nausea Vomiting
- Increase in size of Hernia
- O/E Hernia is Tense, Tender, Irreducible, no expancile impulse.
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Strangulated Hernia’s
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If not treated may lead to ischemia perforation, Peritonitis.
Richters Hernia?
Strangulated Richters Hernia?
Strangulated omentocoele?
Inflamed Hernia?
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Surgical anatomy
a) Superficial inguinal ring?b) Deep inguinal ring?c) Inguinal cannal?
Types
I. Indirect inguinal HerniaII. Direct inguinal Hernia
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Inguinal Hernia
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Indirect (Oblique) Inguinal Hernia
G.F ?Types
1. Bubonocele
2. Funicular
3. Complete (Scrotal)
C.F?000Dr. JavedswatiAfter Correction/Elective14
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Points to be cleared on Examination
- Is the hernia right, left or bilateral
- Is it inguinal or Femoral
- Is it direct or indirect
- Is it reducible or irreducible
- Is the inguinal hernia incomplete or complete
- What are the contents? 000Dr. JavedswatiAfter Correction/Elective15
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D/D in male
1. Vaginal hydrocoele
2. Encysted hydrocoele of the cord
3. Spermotocoele
4. Femoral hernia
5. Incomplete disended testis
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D/D in female1. Hydrocoele of cannal of nuck
2. Femoral hernia
Treatment Herniotomy Herniotomy + Herniorrphy with or without mesh Trus
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Introduction?G.F?C.F?
Funicular direct inguinal hernia (Prevesical hernia)?
Dual (Saddle bag. Pantaloon hernia)
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Direct Inguinal Hernia
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Operation for direct hernia?
Laparoscopic herniorraphy?Strangulated Inguinal herniaC.F?Pathology?Treatment
a) Generalb) Operation
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Treatment of Strangulated Inguinal Hernia
Pre-operative:Avoid unnecessary delay and treat it as
emergencyVigrous resucitation with I/V fluidNasogastric aspirationAntibioticsCatheterisation
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Operation:- Inguinal herniotomy for strangulation? Conservation measure in children and
infants? Taxis? NB it is condemnedDangers of taxisi. Contusion or rapture of the intestinal wallii. Reduction en massiii. Reduction into the loculus of the saciv. Rapture of the sac at neck
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Non operative treatment of hernia1. Only indicated in children2. Forcible. Reduction must never be
attempted.
Maydl’s Hernia (Hernia en W)?
Results of operation for inguinal herniaSliding hernia (Hernia englissade)?
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Femoral HerniaG.F- More common in woman- Can not be controlled with truss- Have a high incidence of strangulation- Should be operated as soon as possible
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Surgical Anatomy of Femoral Hernia?Boundaries of femoral ring
Anterior Inguinal ligamentPosterior Astley coopers (ilio
pectineal ligament)Medially Knife like edge of
Gimbernets (Larcunar ligament)
Laterally Thin septum of femoral sheet separating it from femoral vein.
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Sex incidence?Pathology?C.FRare before pubertyCommon between 20-40yrs and increasing
ageTwice common on Rt side20% bilateralLess symptomatic than inguinalDragging pain due to Omentum
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D.D of femoral hernia1. An inguinal hernia2. A sephana varix3. An enlarged femoral lymphnode4. Lipoma5. A femoral aneurysm6. A psoas abscess7. A distended psoas bursa8. Repture of the adductor longus with
haematoma formation
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Hydrocoele of femoral hernial Sac
Laugiers femoral hernia?Narathas femoral hernia?Cloquets hernia?
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Umblical Hernia
I Exomphlos (omphalocoele)TypesSmall
A) Primary closureB) Large?
Treatment1. Non operative thrapy 2. Skin flap closure3. Staged closure4. Primary closure
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II. Congenital umblical hernia
III. Umblical Hernia of Infants and children
Treatment after 2 years
Operation Herniorraphy
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Para Umblical hernia?
(Supra umblical hernia, infra umblical hernia)
C.F- Female to male ration is 5:1- Patient is usually over weight between 35 and
50yearsIncreasing obesity and flabiness of abdominal
musculature and repeated pregnancies are important itiological factors
- Usually irreducible
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- Dragging pain
- G.I symptoms
- Intestinal colic
- Intertrigo of the adjacent surface of skin and trophic ulcer are trouble some complication
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Treatment- Advised in all cases- If no emergency advise weight loss
Umblical herniorraphyi. Primary closure if defect is smallii. Myo’s repairiii. Prosthetic buttressing if defect is large or
hernia is recurredAdditional laptectomyStrangulation?Operation of strangulation?
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Epigastric hernia (Fatty hernia of the
linea alba)
Introduction
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C.FCommon in manual workers between 30 to 45 years
Symptoms- Small hernia better felt than seen- May be symptomless- Painful- Referred pain
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Treatment- Treated if gives symptoms
- Operations
Rare external hernias1. Inter parital hernia (Interstitial hernia)?
Other verities2. Spigelian hernia3. Lumber herniaa. Inferiorb. Superior
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D/D of lumber hernia
1. Lipoma
2. Cold abscess
3. Phantom hernia (Poliomyelitis)
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Parineal Hernia?Types- Post operative hernia
- Median sliding perineal hernia
- Antero-lateral perineal hernia
- Postero lateral perineal hernia
Obturator hernia?Gluteal and sciatic hernia?
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D/D
i. Lipoma
ii. Cold abscess
iii. Gluteal anurysm
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INFLAMMATION OF UMBLICUS:
INFECTION OF UMBLICAL CORD:
OMPHALITIS?
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COMPLICATION:Abscess of abdominal wallExtensive ulceration of abdominal wallSepticaemiaJaundice in new bornPortal vein thrombosis and subsequent
portal hypertensionPeritonitisUmblical hernia
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UMBLICAL GRANULOMA???DERMATITIS OF AND AROUND THE
UMBLICUS??
PILONIDAL SINUS???
(UMBLICAL CALCULUS UMBOLITH) ?
UMBLICAL FISTULAE???
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THE VITELLOINTESTINAL DUCT???
POSSIBLE PRESENTATION OF VITELLOINTESTINAL DUCT:
INTRA ABDOMINAL CYST? INTRAPERITONEAL BAND MECKEL’S DIVERTICULUM PULLED IN UMBLICAL HERNIA. BAND ATTACHED WITH ANOTHER LOOP LEADING TO
INTESTINAL OBSTRUCTION BAND ATTACHED WITH MESENTRY NEAR DISTAL ILLEUM.
TREATMENT:
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PATENT URACHUS????
TREATMENT: TREAT DISTAL
OBSTRUCTION UMBLECTOMY+EXCISION OF
THE URACHUS
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NEOPLASMS OF THE UMBLICUS:
BENIGN: UMBLICAL ADENOMA , ENDOMETRIOMA
MALIGNANT: SECONDARY CARCINOMA OF UMBLICUS(SISTER JOSEF’S NODULE)
FROM STOMACH ,COLON ,OVARY, BREAST
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ABDOMINAL WALL
Burst Abdomen and Incision Hernia
Introduction?
Factor related to the incidence of Burst abdomen and Incisional Hernia
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1. Technique of wound closure
a) Choice of suture material
b) Methods of Closure
c) Drainage
2. Factor related to incision?
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3. Resons for initial of operation(Infection, Pancratitis, Obstruction)
4. Coughing, Vomiting, Distention
5. General condition of the patient(Obesity, Jaundice, Malignant disease, Hypoproteinemia, Anemia, Pregnancy steroid)
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Burst Abdomen (Abdominal Dehiscence)
C.F- Serosangitinous (Pink) discharge from the
wound
- Feeling something giving way
- Viscera lie on skin
- Pain and shock are often absent
- There may be sign and symptoms of intestinal obstruction 000Dr. JavedswatiAfter Correction/Elective48
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Treatment
- Emergency closure of wound
- N.G tube
- I/V fluids
- Antibiotics
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Incisional Hernia?
Precursors are
- Obesity- Post operative persistent cough- Post operative abdominal distension- Peritonitis- Placement of drain through wound
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C.F
- Size varies
- May be irreducible and strangulation
- May be asymptomatic
- All the features of any hernia
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Treatment
- Paliative (Abdominal belt)
- Operation?- Simple opposition- Complex opposition- Plastic fiber mesh net closures
Divarication of rectus abdominus?
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Tearing of the inferior epigastric artery?
Common In- Elderly women
- Thin and feeble atheletic
- Muscular man usually below middle age
- Pregnant woman mainly multipara late in pregnancy
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C.F?D/D
- Twisted ovarian cyst in woman- On right side appendicular lump- Strangutor spigelian hernia
Treatment- Evacultion of clot and ligation of vessel
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Infection of Abdominal Wall
Cellutlitisa.Saperficialb.Deep
Progressive postoperative bacterial syngistic gangrene?Amoebic cutis?
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Neoplasma of Abdominal Wall
- Desmoid tumor?
- Fibrosarcoma of abdominal wall?
- Adenocarcinoma?
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