abdominal wall hernias. abdominal wall hernia hernia is an abnormal protrusion of the whole or a...
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Abdominal wall hernias
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Abdominal wall hernia
• Hernia is an abnormal protrusion of the whole or a part of viscus through an opening in the wall of the cavity.
• Types:– External– Internal
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Aetiology
• Increased abdominal pressureCough, urinary trouble, constipation, straining, ascites,
intraabdominal malignancy.
• Weakness of abdominal musculature :– Congenital sacs as processes vaginalis, patent canal of nuck in
females– Acquired
• Excess fat (obesity)• Muscle weakness following pregnancy• Surgical incisions – Nerve damage, Improper repair
– Destruction of connecting tissue as smoker, Marfan’s syndrome
• Familial
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INTRODUCTION
high insertion of the internal oblique muscle widening of the internal inguinal ring persistency of the vaginal peritoneum conduct
anatomical abnormalities + intra-abdominal pressure
ETIOPATHOGENY
Rev Col Bras Cir 1976;3(2):66-80. Clin North Am 1998;78:953-72.
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INTRODUCTION
COLLAGENproportion
COLLAGENtype I and IIIdeficiency
COLLAGENquantity
FASCIA TRANSVERSALIS
HERNIOGENESE
Ann Surg 1993;218:754-60.Eur J Clin Invest 1997;27:863-8.
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Parts of the hernia
3 parts•Sac•Contents•Covering of sac
mouthneck
Body
Fundus
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Contents
• Omentum- Omentocoel / epiplocele
• Intestine - Enterocoel
• Bladder - Cystocoel
• Part of Intestine - Richter’s
• W type intestine - Maydl’s Hernia
• Meckel’s diverticulum - Littre’s hernia
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Common hernias
• Inguinal (indirect or direct), Femoral, Umblical, Incisional
Epigastric,
• Rare Hernias:– Lumbar, Spegilian,
Obturator
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Hernia sites
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Some terms related to hernia
• Reducible - Reducibility, cough impulse• Irreducible - Irreducible, impulse –ve
• Obstructed - irreducibility + intestinal obstruction
• Strangulated - irreducibility + obstruction + arrest of blood supply
• Inflammed
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Causes of irreducibility
• adhesions of content to each other
• adhesions of content with the sac
• adhesions of one part of sac to other part
• narrowed neck of sac
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INGUINAL HERNIA
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•The majority of abdominal wall hernias occur in the groin, totaling approximately 75% of the total incidence.•majority of inguinal hernias occur in males •Of inguinal hernia repairs, 90% are performed in males and 10% in females.•Approximately 70% of femoral hernia repairs are performed on female patients•females undergo nearly five times the number of inguinal hernia repairs as femoral hernia repairs•The most common type of groin hernia presenting in females remains the indirect inguinal hernia.
Epidemiology
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Anatomy of Inguinal Canal
• 4 cm in length from deep to superficial ring.• Deep ring is ‘U’ shaped in fascia transversalis
which lies 1.25 cm above the mid inguinal point. • Superficial / External ring is in external oblique
aponeurosis situated just above and lateral to crest of pubis.
• Passes downward and medially from deep ring to superficial ring.
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Anatomy of inguinal canal
Boundaries of inguinal canal
•Ant : External oblique aponeurosis and few fibres of internal oblique laterally•Post : Fascia transversalis and conjoined tendon•Superior : Arched fibres of conjoined tendon•Inferior : Inguinal ligament
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AnatomyContents of inguinal canal
•Spermatic cord, ilioinguinal nerve, genital br. of genitofemoral nerve. •Round ligament in females. •Vestigial remnant of processes vaginalis.
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HASSELBACH TRIANGLE
inferior epigastric vessels
abdominal rectus muscle
internal inguinal ringinguinal ligament
Hasselbach triangle
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INGUINAL HERNIA
• Types:– Indirect– Direct– Combined
(Pantaloon)
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Classification
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Direct Inguinal Hernia
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Clinical Features
• Swelling• Dragging pain• Features of
complication• H/o increased
abdominal pressure• Symptomless
discovered accidentally
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Examination
• Inguino scrotal swelling
• Expansile cough
• Cannot get above the swelling
• Reducibility
• Finger Invagination Test
• Deep Ring occlusion Test
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Inguinal hernia
External ring test
(finger Invagination test)
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Enterocoel vs. Omentocoel
• Visible peristalsis
• Consistency
• Reduction of contents
• Percussion Note
• Bowel sounds
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Differential Diagnosis of Inguinal Hernia
• Inguinoscrotal swelling – Encysted hydrocoel of cord, varicocoel, lymph
varix, funiculitis, lipoma of cord, torsion of testis, retractile testis
• Groin swelling– Femoral hernia, sephana varix, enlarged
nodes, psoas abscess, psoas bursa, undescended testis, ectopic testis, lipoma, aneurysm
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Diagnosis
• History• Physical Examination• Imaging (US, CT,
Herniography)
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Herniography
• Suspected hernia, but clinical diagnosis is unclear• Procedure done under flouroscopy following injection of
contrast medium• Frontal and oblique radiographs are taken with and without
increased intra-abdominal pressure
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Complications
• Irreducibility : Dull aching pain / irreducible• Obstructed : irreducible + obstruction to lumen
of bowel. Features of intestinal obstruction• Strangulated : irreducible + obstruction +
impairment of blood supply. Tense / Tender / Toxic
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Treatment
• Surgical
• Watchful waiting for elderly pt. with small asymptomatic hernia
• Truss !!!!!!
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Surgery
• Herniotomy: Excision of hernia sac, sufficient in children
• Herniorrhaphy:– Bassini’s Repair– Shouldice Repair– Mc Vay– Preperitoneal
• Hernioplasty : Lichtenstein, Mesh graft application
Laparoscopic Repair – TEP / TAPP
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Bassini’s repair
EDUARDO BASSINI
Bassini (early 20th Century)
Transversus abdominis and internal oblique musculoaponeurotic arches or conjoined tendon to the inguinal ligament
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Shouldice repair
Shouldice (1930s)Multilayer imbricated repair of the posterior wall of the inguinal canal
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Mc Vay repair
McVay (1948)
Edge of the transversus abdominis aponeurosis to Cooper’s ligament; incorporate Cooper’s ligament and the iliopubic tract (transition suture)
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Lichtenstein repair
First pure prosthestic, tension-free repair to achieve low recurrence ratesFirst pure prosthestic, tension-free repair to achieve low recurrence rates
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Types of Prosthesis • Polypropylene mesh most common and
preferred – allows for a fibrotic reaction to occur between
the inguinal floor and the posterior surface of the mesh, thereby forming scar and strengthening the closure of the hernia defect
• Polytetrafluoroethylene (PTFE) mesh– often used for repair of ventral or incision
hernias in which the fibrotic reaction with the underlying serosal surface of the bowel is best avoided
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Hernia mesh
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Laparoscopic repair
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Conservative treatment
Trusses can provide symptomatic relief
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Treatment Algorithm
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Complications
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Different Types of Indirect Inguinal Hernia
• Sliding Hernia (Hernia en glissade)• Richter Hernia : Part of Bowel• Littre’s hernia : Meckel’s diverticulum• Pantaloon Hernia : Both Direct and
Indirect Hernia• Maydl’s hernia: a few segment of bowel• Amiand’s hernia: hernia contains the
appendix
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Spigelian Hernias
• Lateral ventral hernia– Junction of vertical semilunar line and horizontal semicircular line
(arcuate line)
• This rare hernia occurs along the edge of the rectus abdominus muscle, which is several inches to the side of the middle of the abdomen.
• 90% located 0 - 6 cm above anterior superior iliac spine – Sharp pain, swelling, easily reducible– 20% present with incarceration– median age = 50 years– more common in males and on (R)– Rare
• PE– Difficult to diagnose– U/S or CT can aid in diagnosisTreatment:– Repair primarily or with mesh
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Lumbar Hernia
• Congenital, spontaneous or traumatic• Grynfeltt’s triangle
– 12th rib, internal oblique and sacrospinalis muscle– Covered by latissimus dorsi
• Petit’s triangle– Latissimus dorsi, external oblique and iliac crest– Covered by superficial fascia
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Pelvic Hernia
• Obturator hernia– Most commonly in women
• Sciatic hernia• Perineal hernia
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Parastomal Hernia
• Variant of incisional hernia• Paracolostomy > paraileostomy• Low rate if through rectus muscle• Traditionally relocate stoma,
repair defect• Concern for mesh erosion• Laparoscopic/open repair
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Incisional Hernia
• Risk factors– Technical– Wound infection– Smoking– Hypoxia/ ischemia– Tension– Obesity– Malnutrition
• Laparoscopic vs. open repair
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Epigastric Hernia
• Incidence 1-5%• Men> women• Pre-peritoneal fat protrusion
through decussating fibers at linea alba
• Between xiphoid and umbilicus• 20% multiple• Repair primarily
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Femoral Hernia
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Anatomy of femoral triangle
Anatomy of Femoral Canal
•Closed above by femoral septum and on lower side – cribriform fascia•Most medial compartment of femoral sheath•Extends from femoral ring to sephanous opening below•1.25 cm long and 1.25 cm wide at base•Contents : fat, lymphatic, lymph node of Cloquet
•Oval opening ½” in diameter bounded
Anteriorly - Inguinal ligament
Posteriorly- Iliopectineal ligament, pubic bone and fascia over pectineus muscle
Medially - Lacunar ligament
Laterally - Septum separating form femoral vein
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Femoral Hernia
• Clinical features : More in females, age >50, Rt. Side 70%, bilateral 20%
• Covering of femoral hernia :– Skin, superficial fascia,
cribriform fascia, anterior layer of femoral sheath, fatty contents of femoral canal, femoral septum, peritoneum
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Differential diagnosis of Femoral Hernia
• Inguinal hernia, sephano varix, lymph
• node, lipoma, Aneurysm, Psoas abscess,
• psoas bursa, Ruptured adductor longus
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Operation for Femoral Hernia
• Low (lockwood) Inguinal ligament to Ileopectineal line
• High (McEvedy) conjoint tendon to ileopectineal line. For strangulated hernia
• Lotheissen (Through inguinal canal) conjoint tendon or inguinal ligament to pectineal ligament
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Umbilical Hernia
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Umbilical Hernia in adults
• May be supraumbilical or infraumbilical.• Contents are usually omentum / small bowel /
Transverse colon• Seldom reducible• C/F : Mostly in females, obesity, usually >40
years, flabby abdominal muscles, repeated pregnancy
• Pain, swelling, GI symptoms• Treatment : Surgery (Reduction of wt.)
– Mayo’s op. Transverse elliptical incision. Double breasting of linea alba.
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Take Home Points• Hernias can involve the small bowel, appendix, a Meckel’s
diverticulum, ureter
• Incarceration with frank pain or strangulation are operative emergencies and bowel can be saved if done within 4-6 hours
• An attempt at reduction should be made with a hernia, but operative reduction is the only definitive treatment
• Femoral hernias have a high rate of incarceration and should be repaired, but other inguinal hernias may be watched if asymptomatic
• With abdominal incisions, try not to put excessive tension or damage the suture in any way as it can promote incisional hernias