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Abdominal Wall Hernias
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Hernia
Definition: A hernia is an abnormal protrusion of a viscus through the wall of a cavity which normally contains it.
It may be through a congenital/acquired opening
in the presence of continued or repeated intra-abdominal pressure
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Types of Hernias
Direct inguinal hernia
Indirect inguinal hernia
Femoral hernia Obturator hernia Sciatic hernia Perineal hernia
Umbilical hernia Paraumbilical
hernia Epigastric hernia Hiatus hernia Diaphragmatic
hernia Incisional hernia Spigelian hernia
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Development of a hernia
In young age group: congenital potential space
In old age group: gradual onset and slow enlargement due to weakness in the abdominal wall
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Predisposing factors
Congenital defect, e.g. persistence of processus vaginalis incomplete obliteration of umbilicus persistent communication between abd.
and thorax
• Acquired defect, e.g surgical incisions muscle weakness due to ageing/ nerve injury
and wasting/ fatty infiltration/ pregnancy
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Precipitating factors
Chronic cough constipation straining at micturition childbirth vomiting severe muscular effort ascites - fluid may increase the size
of an existing sac
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Contents in a Hernia
Usual: omentum, small bowel Sliding hernia: content with partial
peritoneal cover such as: sigmoid colon, urinary bladder
Ritcher’s hernia: part of the small bowel wall was in the hernia with perforation but no obstruction
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The contents of the sac
Reducible irreducible obstructed, or strangulated
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ILIUM
The inguinal ligament runs from the anterior superior iliac spine to the pubic tubercle
SACRUMILIUM
Anatomy
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Site / Origin
Inguinal Inguino-scrotal Isolated in scrotum
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Groin hernias
indirect inguinal direct inguinal femoral
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Nyhus Classification
Type I--indirect inguinal hernia
•Internal inguinal ring normal (i.e. paediatric hernia)
Type II--indirect inguinal hernia •Dilated internal inguinal ring with posterior inguinal wall intact
Type III--posterior wall defects •Direct inguinal hernia •Indirect inguinal hernia: dilated internal ring with large medial encroachment on the transversalis fascia of the Hesselbach's triangle (i.e. massive scrotal, sliding hernia) •Femoral hernia
Type IV--recurrent hernia
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Inguinal Hernias - Anatomy
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Indirect inguinal hernia
most common in young males enters the inguinal canal through
the deep ring the sac often extends, following the
line of the spermatic cord (over the pubic crest) into the scrotum
the neck of the sac is narrow
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Direct inguinal hernia
Common in older men with weak abdominal muscles
Often bilateral the sac bulges forward thro’ the
posterior wall of the inguinal canal, medial to the inferior epigastric vessels
Does not extend into scrotum the neck of the sac is wide
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Femoral hernia
Less common than inguinal hernias occur more frequently in females the sac descends thro’ the femoral
ring and canal, thro’ the saphenous opening of the fascia lata.
Blunts the groin crease (both types of inguinal hernia increase
the crease) it has a narrow neck
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Main Points in History
Age: young or old? Factors for increase abdominal
pressure Started with a smaller swelling Disappears on lying down Gurgling noise inside the swelling Pain and dragging discomfort Intestinal obstruction
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Physical Examination
Three important steps MUST be taken Patient standing for the examination - cough
impulse and cannot get above the swelling Lying down to reduce the hernia by patient Try to hold back the hernia with the thumb
at the internal ring while standing will distinguish direct from indirect inguinal hernia
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Anatomical Landmarks
Anterior superior iliac spine Pubic tubercle Inguinal ligament Mid-inguinal point Interrnal inguinal ring To distinguish direct/indirect hernia
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Examination of the patient with a hernia
With the patient supine look for signs of systemic toxicity intestinal obstruction or inflammation of the abdominal wall visible bulge, effect on groin crease
and a visible impulse on coughingallow the patient to attempt reduction of
the hernia in the supine position
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palpate for cough impulse in the area of abdominal
wall weakness, note any tendernessReducible hernia;
place a finger over the deep ring and allow the patient to stand
ask the patient to hold nose and blow if the hernia appears after release of
your finger, then it is an INDIRECT inguinal hernia
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Scrotal Masses
Can you get ABOVE the swelling? Where is the mass arising from? The mass itself cystic/transilluminate? The mass hard and the surface
irregular?
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Scrotal swellings
Painful + firm Torsion Acute inflammation (orchitis/ epididymitis)
Painless + firm Neoplasm Chronic inflammation haematoma
Soft Varicocele Hydrocele Epididymal cyst
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Varicocele
Grade 1 - palpable with Valsalva Grade 2 - palpable without straining Grade 3 - can be seen on inspection Bag of worms in 15% of young man More common on the left side 30% infertile patients have varicocele
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Varicocele
Usually cause discomfort after running Spermatogenesis impaired due to
hypoxia, elevated temperature and reflux of metabolites
Treatment by Ligation of the veins Varicocele in older man may indicate
left renal carcinoma with renal vein involvement
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Torsion of Testis
To distinguish from Orchitis Both are acute painful swelling of the
testis Treatment is different Age, fever, venereal exposure… Types of torsion - extra-vaginal, intra-
vaginal, Torsion of the undescended testis
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Empty Scrotum
Undescended testis Ectopic testis Retractile testis
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Hydrocele
Accumulation of fluid in the tunica vaginalis
Short history - thin wall and transilluminate Long history - thick wall and ?previous
trauma Cystic mass, the testis is within the sac
and therefore NOT palpable Can get above the swelling Surgery - Jaboulay’s operation
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Trauma to the Scrotum
Haematocele of the testis Rupture of the testis Fracture of the penis Trauma to the bulbous urethra Laceration of the scrotal skin
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Testicular Tumour
Hard and irregular swelling of the testis
Spermatic cord normal Types - germ cell, non germ cell,
secondary metastasis, paratesticular tissues
Must palpate the abdomen for central supra-umbilical masses (lymph nodes)
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Indication for Surgery
Risk of complications such as strangulation and intestinal obstruction
Pain and mass interfere with function Conservative treatment
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Principles of Surgery
Reduction of the contents Excision of the hernial sac Repair of the defect Difficult in case of large hernia
and large defects
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Historical developments
1700 BC: Hammurabi (Babylon) – Hernia reduction / bandaging1363 : Guy de Chauliac – Distinguished inguinal from femoral hernia for the first time in
Chirugia Magna
1. Reinforcing the anterior wall and narrowing the external ring Eg Repair by ligation of hernial sac and cicatrization with healing by secondary intention
(Caspar Stromayr, 1559)
2. Reinforcing the posterior wall and narrowing the internal ring 1881 Splitting of external oblique + ligation of sac at internal ring (Lucas-
Championnière) 1889 Suturing of threefold layer (internal oblique, tranversus abdominis + transversalis
fascia) to inguinal ligament (Bassini) 1939 Subcutaneous shift of spermatic cord (Kirschner) 1969 Duplication of transversalis fascia (Shearburn – as per Shouldice) 1987 Application of alloplastic material (Lichtenstein)
3. Reinforcing the posterior wall and narrowing the internal ring from intraabdominally 1891 During laparotomy for other indication (Tait) 1990 Laparoscopic hernia repair (Popp)
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Hernien
CHIRURGISCHE KLINIK UK BENJAMIN FRANKLIN FU BERLIN
Bassini
Shouldice
Lichtenstein
Robbins-Rutkow
Prolene Hernia System
Open hernia repair
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Repair under Tension
1889 Bassini - Suturing of threefold layer (internal oblique, tranversus abdominis + transversalis fascia) to inguinal ligament
Tension created during repair with recurrence rates generally around 10%
Best results reported by Shouldice using his technique in a dedicated hernia hospital – recurrence of only 0.8%
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Hernioplastik n. Bassini
CHIRURGISCHE KLINIK UK BENJAMIN FRANKLIN FU BERLIN
Bassini
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Hernioplastik n. Shouldice
CHIRURGISCHE KLINIK UK BENJAMIN FRANKLIN FU BERLIN
Shouldice
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Hernioplastik n. Lichtenstein
CHIRURGISCHE KLINIK UK BENJAMIN FRANKLIN FU BERLIN
Lichtenstein
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Preperitoneal Approach
Originally described by Stoppa Mesh placed between peritoneum and abdominal
wall Precursor to laparoscopic repair techniques
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The Lichtenstein Technique
Mesh repair popularised by Lichtenstein – published a series of 1000 patients with no recurrences in 1-5 yr follow-up Mesh repair for ALL hernias Local anaesthetic Day case surgery Same day ambulation
Am J Surg, 1989. 157 (2): 188-93
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Lichtenstein Hernia Repair
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Local anaesthetic
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Prolene Hernia System
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Hernien
CHIRURGISCHE KLINIK UK BENJAMIN FRANKLIN FU BERLIN
TEP (total extraperitoneal plasty)
TAPP (transabdominal preperitoneal plasty)
Laparoscopic hernia repair
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TEP - total extraperitoneale Hernioplastik
CHIRURGISCHE KLINIK UK BENJAMIN FRANKLIN FU BERLIN
TEP (mesh between fascia transversalis and peritoneum)
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TAPP - transabdominelle praeperitoneale Hernioplastik
CHIRURGISCHE KLINIK UK BENJAMIN FRANKLIN FU BERLIN
TAPP (mesh between fascia transversalis and peritoneum)
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Hernien
CHIRURGISCHE KLINIK UK BENJAMIN FRANKLIN FU BERLIN
Relapse (no mesh: 10% - 20 %, mesh: ~ 2%)
Hematoma (10%)
Wound infection (< 5%)
Chronic pain (< 5%)
Scrotal edema with or w/o orchitis (< 2%)
Complications
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Plug and mesh
Claimed advantages: Decreased operating time Smaller incisions Low recurrence rates
Evidence from trials: Little difference in operating times Recurrence rates 0 – 2% No difference in post-op pain / rehab
Review (ANZ J Surg, 2002, 72: 573-9): No strong evidence for benefits over traditional mesh
repair
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Preperitoneal Approach
Advantages:Recurrent hernia – different approach avoids operating on distorted anatomy / scar tissue
May repair bilateral hernias through Pfannenstiel or midline incisions
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Complications of Inguinal Hernia Repair
Chronic pain Infections Others
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Chronic pain
Persistent pain is the most troublesome complication following inguinal hernia repair
Postulated mechanisms: Nerve injury Tension Infection Suture placement
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Chronic Pain
Operative strategies to minimise chronic pain: Avoid placing periosteal sutures on the pubic
tubercle Avoid undue tension on the inguinal ligament Careful preservation of ilioinguinal and
genitofemoral nerves
Strategies to treat chronic post-op pain: Division of ilioinguinal or genitofemoral nerve Removal of mesh / sutures Pain service referral - Tricyclics / anti-depressants
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Infections
Infection rate in inguinal hernia wounds 1-2% Superficial infections more common than deep
infections involving prosthesis
Operative techniques to avoid infection: Meticulous asepsis Minimise necrotic tissue / diathermy / desiccation Wound lavage Monofilament sutures Perioperative antibiotics ? Topical antibiotics
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Hiatal Hernia Overview
Chronic relapsing condition Significant morbidity Estimated lifetime prevalence of 25-
35 % 44% have heartburn once a month 14% have weekly symptoms 7 % have daily symptoms
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Gastroesophageal Reflux
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Diagnosis
History Response to a PPI Radiologic findings Endoscopy Ambulatory pH monitoring
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History
Heartburn, regurgitation
High specificity, low sensitivity
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Atypical Symptoms
Atypical chest pain Hoarseness Nausea Cough Odynophagia Asthma
Globus sensation Onset after age 45 Recurrent
laryngitis Recurrent sore
throat Subglottic stenosis Dental enamel loss
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Complications of Gerd
Dysphagia Odynophagia Early satiety GI bleeding Iron deficiency anemia Vomiting Weight loss
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Response To PPI
Omeprazole 40 mg BID X 14 days as specific and sensitive for diagnosis as 24 hour pH monitoring
Failure to respond warrants further investigation into patients symptoms
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Radiologic Findings
Only 1/3 of patients have radiologic findings Hiatal hernia Erosions Ulcerations Strictures Thickening of mucosal folds
Not the test of choice for diagnosis
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Endoscopy
Useful for diagnosing complications of GERD Barrett’s Esophagitis Strictures
Not sensitive for GERD itself Only 50% of patients manifest
evidence on endoscopy
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EGD
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EGD
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EGD
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Ambulatory pH Monitoring
Diagnostic gold standard pH monitor placed in esophagus
above sphincter Patient symptom log Correlate symptoms with low pH
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Treatment
Lifestyle modifications Antacids Histamine H2 receptor antagonists Prokinetic Agents Proton Pump inhibitors Anti-reflux surgery Newer endoscopic treatments
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Lifestyle Modification
Head of bed elevated six inches Decreased fat intake Smoking cessation Weight loss Avoidance of recumbency for 3 hours
post-prandially Avoidance of large meals and trigger
foods Avoidance of exacerbating medications
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Dietary Factors
Caffeine
Peppermint
Fatty foods
Chocolate
Spicy foods
Citrus fruits
Tomato products
Alcohol
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Antacids
Antacids are appropriate initial tx
1/3 of patients use twice weekly
More effective than placebo
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Adverse Effects Of Antacids
Aluminum: constipation, hypophosphatemia, osteomalacia
Calcium: constipation, milk-alkali syndrome, rebound hyperacidity
Magnesium: diarrhea, accumulation in pts. with renal impairment
Sodium bicarb: milk-alkali in high doses
Mag-Aluminum: minor changes in bowel function
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H2 Blockers
70% with reported relief within 2 weeks of initiating treatment
faster healing rates in patients with erosive esophagitis compared with placebo
Higher dosages increase effectiveness
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Prokinetic Agents
Do not neutralize acid Increase both gastric emptying,
improve peristalsis and increase lower esophageal sphincter pressure
Side-effects: abdominal cramping, diarrhea, prolonged QT and fatal arrhythmias
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Proton Pump Inhibitors
Failure of twice daily H2 blockers 83% of patients showed improvement
with PPI vs 50% with H2 blocker For erosive esophagitis, faster healing
rates than H2 blocker At one year, pts tx’d with daily PPI
less likely to relapse No significant difference between the
PPIs
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Potential Long-term Complications
Hypergastrinemia, gastric carcinoid tumors in rats
Atrophic gastritis with use of prilosec > 5 years—potential development of gastric CA
Increased risk of enteric infections—campylobacter
Vitamin B malabsorption
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Antireflux Surgery
Indications Failed medical management Patient preference for surgery despite
successful medical management Complicated GERD Large Hiatal Hernia Atypical symptoms with reflux
documented on 24-hour pH monitoring
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Surgical Candidates
Reflux esophagitis documented by EGD
Normal esophageal motility by manometry
Should have at least a partial response to trial of acid suppression therapy
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Basic Tenets Of Surgery
Reduction of hiatal hernia Repair of diaphragmatic hiatus Strengthening of the GE junction-
diaphragm attachment Strengthening of antireflux barrier
though gastric wrap around GE junction (fundoplication)
75-90% effective at alleviating heartburn and regurgitation
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Surgical options for hiatal hernia
Nissen fundoplication Collis gastroplasty Partial fundoplication Burma gastropexy
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Nissen Fundoplication
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Collis Gastroplasty
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240o Partial fundoplication Belsey Mk IV
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Post-surgical Complications
Solid food dysphagia: 10% Gas/bloating: 7-10% Diarrhea, nausea and early satiety:
< 10% Within 3-5 years, 52% of patients
taking antireflux meds again
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New Endoscopic Treatments
Stretta procedure: radiofrequency heating of GE junction
Endoscopic gastroplasy (endocinch) Less costly than conventional
surgery Initial studies show decreased or
eliminated use of acid suppressant meds in 50-75% of patients
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Incisional Hernia Any laparotomy associated with incisional
hernia rate of 14% Technical failure in closure: tension, bites,
layers Associated factors
Obesity Infected case/wound Diabetes Multiple operations malnourished
Genetically predetermined:collagen defect
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Types of Surgery
Onlay Sublay Inlay
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„Sublay” Mesh Insertion Technique
Posterior layer of rectus abdominis sheath
Rectus abdominis
Anterior layer of rectus abdominis sheath
Peritoneum
Mesh
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„Onlay” Mesh Insertion Technique
Posterior layer of rectus abdominis sheath
Rectus abdominis
Anterior layer of rectus abdominis sheath
Peritoneum
Mesh
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„Inlay” Mesh Insertion Technique
Posterior layer of rectus abdominis sheath
Rectus abdominis
Anterior layer of rectus abdominis sheath
PeritoneumMesh
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Bibliography
1. ACS Surgery: Principles and Practice by Douglas W., Md. Wilmore (Editor), Laurence Y., Md. Cheung (Editor), Alden H., Md. Harken (Editor), James W., Md. Holcroft (Editor), Jonathan L., Md. Meakins (Editor), Nathaniel J., Md. Soper (Editor), Douglas W. Wilmore, Laurence Y. Cheung, Alden H. Harken, James W. Holcroft, Jonathan L. Meakins, Nathaniel J. Soper Publisher: WebMD Professional Publishing; 2nd edition (February 1, 2003)
2. Sabiston Textbook of Surgery: the Biological Basis of Modern Surgical Practic. Courtney M. Townsend, Jr., editor-in-chief; associate editors, R. Daniel Beauchamp, B. Mark Evers, Kenneth L. Mattox. W.B. Saunders Company 2001
3. Oxford Textbook of Surgery (3-Volume Set) 2nd edition (January 15, 2000): by Peter J. Morris (Editor), William C. Wood (Editor) By Oxford Press
4. Essentials of Surgery: Scientific Principles and Practice 2nd edition (January 15, 1997): by Lazar J., Md. Greenfield (Editor), Michael W. Mulholland (Editor), Keith T. Oldham (Editor), Gerald B. Zelenock (Editor), Keith D. Lillimoe (Editor), Keit Oldham By Lippincott Williams & Wilkins Publishers
5. Current Surgical Diagnosis and Treatment, 11th Ed 2003: Lawrence W. Way, Gerard M. Doherty By McGraw-Hill/Appleton & Lange
6. Principles of Surgery Seventh Edition Editor-in-Chief Seymour I. Schwartz, M.D. The McGraw-Hill Companies, Inc. 1999