abdominal wall hernia p. marco fisichella, md assistant professor department of surgery
TRANSCRIPT
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Abdominal Wall HerniaAbdominal Wall Hernia
P. Marco Fisichella, MDP. Marco Fisichella, MD
Assistant ProfessorAssistant Professor
Department of SurgeryDepartment of Surgery
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Abdominal Wall HerniaAbdominal Wall Hernia
• DefinitionDefinition– ExternalExternal– InterparietalInterparietal– InternalInternal
– ReducibleReducible– Non-reducible (aka incarcerated)Non-reducible (aka incarcerated)– StrangulatedStrangulated
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Abdominal Wall HerniaAbdominal Wall Hernia
• Richter’s herniaRichter’s hernia• Littre’s herniaLittre’s hernia
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LocationLocation
• GroinGroin• UmbilicusUmbilicus• Linea alba (epigastric)Linea alba (epigastric)• Surgical incisionsSurgical incisions• Semi-lunar lineSemi-lunar line• DiaphragmDiaphragm• Lumbar trianglesLumbar triangles• PelvisPelvis
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Groin herniaGroin hernia
• Indirect inguinalIndirect inguinal– scrotal scrotal
• Direct inguinal Direct inguinal • FemoralFemoral
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Groin HerniaGroin Hernia
• Men > womenMen > women• Right > leftRight > left• 10% of premature babies10% of premature babies• 5% of adult population5% of adult population
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Indirect Hernia AnatomyIndirect Hernia Anatomy
• Indirect herniaIndirect hernia– Dilated persistent processus vaginalisDilated persistent processus vaginalis– Within spermatic cordWithin spermatic cord– Follows indirect courseFollows indirect course– Complete vs. incomplete sacComplete vs. incomplete sac– Sliding herniaSliding hernia– Cord lipomaCord lipoma
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Direct Hernia AnatomyDirect Hernia Anatomy
• Hesselbach’s triangleHesselbach’s triangle– Inguinal ligament (base), rectus Inguinal ligament (base), rectus
(medial), inferior epigastric vessels (medial), inferior epigastric vessels (lateral)(lateral)
• Sliding herniaSliding hernia
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Femoral Hernia AnatomyFemoral Hernia Anatomy
• Inferior to inguinal ligamentInferior to inguinal ligament• Women> menWomen> men• Cloquet’s nodeCloquet’s node• Usually on medial aspect of Usually on medial aspect of
femoral sheathfemoral sheath
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DiagnosisDiagnosis
• Groin swelling that resolves with Groin swelling that resolves with supine positionsupine position
• Precipitating factorsPrecipitating factors– Increased intra-abdominal pressureIncreased intra-abdominal pressure– Defects in collagen synthesisDefects in collagen synthesis– SmokingSmoking
• Examine erect and supineExamine erect and supine• Does not transilluminateDoes not transilluminate
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Groin Hernia Differential Groin Hernia Differential DiagnosisDiagnosis
• HydroceleHydrocele• VaricoceleVaricocele• EpididymoorchitisEpididymoorchitis• Torsion of testisTorsion of testis• Undescended testisUndescended testis• Ectopic testisEctopic testis• Testicular tumorTesticular tumor• Femoral artery aneurysmFemoral artery aneurysm• LipomaLipoma• LymphadenopathyLymphadenopathy
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TreatmentTreatment
• Expectant management Expectant management • Surgical repairSurgical repair
– MeshMesh– OpenOpen– LaparoscopicLaparoscopic
• TEP (totally extra-peritoneal)TEP (totally extra-peritoneal)• TAPP (transabdominal pre-peritoneal)TAPP (transabdominal pre-peritoneal)
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ComplicationsComplications
• RecurrenceRecurrence• NeuralgiaNeuralgia
– IlioinguinalIlioinguinal– IliohypogastricIliohypogastric– GenitofemoralGenitofemoral– Lateral cutaneous Lateral cutaneous
• Ischemic orchitisIschemic orchitis• Injury to vas deferenceInjury to vas deference• Wound infectionWound infection• BleedingBleeding
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Umbilical HerniaUmbilical Hernia
• Women> menWomen> men• Risk factorsRisk factors
• ObesityObesity• PregnancyPregnancy
• May rupture with ascitesMay rupture with ascites• Repair primarily or with meshRepair primarily or with mesh
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Umbilical HerniaUmbilical Hernia
• Common in infantsCommon in infants• Close spontaneously if <1.5 cmClose spontaneously if <1.5 cm• Repair if > 2 cm or if persists at Repair if > 2 cm or if persists at
age 3-4 yearsage 3-4 years
• Repair primarily or with meshRepair primarily or with mesh
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Epigastric HerniaEpigastric Hernia
• Incidence 1-5%Incidence 1-5%• Men> womenMen> women• Pre-peritoneal fat protrusion Pre-peritoneal fat protrusion
through decussating fibers at linea through decussating fibers at linea albaalba
• Between xiphoid and umbilicusBetween xiphoid and umbilicus• 20% multiple20% multiple• Repair primarilyRepair primarily
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Incisional HerniaIncisional Hernia
• Risk factorsRisk factors– TechnicalTechnical– Wound infectionWound infection– SmokingSmoking– Hypoxia/ ischemiaHypoxia/ ischemia– TensionTension– ObesityObesity– MalnutritionMalnutrition
• Laparoscopic vs. open repairLaparoscopic vs. open repair
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Parastomal HerniaParastomal Hernia
• Variant of incisional herniaVariant of incisional hernia• Paracolostomy > paraileostomyParacolostomy > paraileostomy• Low rate if through rectus muscleLow rate if through rectus muscle• Traditionally relocate stoma, repair Traditionally relocate stoma, repair
defectdefect• Concern for mesh erosionConcern for mesh erosion• Laparoscopic repairLaparoscopic repair
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Spieghelian HerniaSpieghelian Hernia
• RareRare• Hernia through subumbilical Hernia through subumbilical
portion of semi-lunar lineportion of semi-lunar line• Difficult to diagnoseDifficult to diagnose
– Clinical suspicion (location)Clinical suspicion (location)– CT scanCT scan
• Repair primarily or with meshRepair primarily or with mesh
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Lumbar HerniaLumbar Hernia
• Congenital, spontaneous or Congenital, spontaneous or traumatictraumatic
• Grynfeltt’s triangleGrynfeltt’s triangle– 1212thth rib, internal oblique and rib, internal oblique and
sacrospinalis musclesacrospinalis muscle– Covered by latissimus dorsiCovered by latissimus dorsi
• Petit’s trianglePetit’s triangle– Latissimus dorsi, external oblique and Latissimus dorsi, external oblique and
iliac crestiliac crest– Covered by superficial fasciaCovered by superficial fascia
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Pelvic HerniaPelvic Hernia
• Obturator herniaObturator hernia– Most commonly in womenMost commonly in women– Howship-Romberg signHowship-Romberg sign
• Sciatic herniaSciatic hernia• Perineal herniaPerineal hernia