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Hernia of the antero-Hernia of the antero-lateral abdominal walllateral abdominal wall
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Definition
Progressive protrusion through the abdominal wall of the peritoneum, with tendency to progress, together with an abdominal viscus
SO– An abdominal viscus will HAVE to leave the
abdominal cavity – There must be a peritoneal covering
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NOT real hernias by this definition
Embrionic or fetal hernia where there is an anomaly in development
Protrusions of the organs of the retroperitoneum without peritoneal cover.
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Common Common manifestations of manifestations of
herniahernia
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HERNIA? Pathological aspects
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Hernia developmentHernia development – HERNIATION POINT-
First step in develeopment The protrusion of serosa begins like a
small bulge through a small PARIETAL DEFECT
CLINICAL SIGNS:– Pain of variable intensity– Digital examination may be inconclusive,
except for a large defect
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Hernia developmentHernia development – Interstitial hernia-
Peritoneal diverticulum increases in size Protrusion within the muscular-fascial
structures of the abdominal wall Peritoneal serosa becomes thick and
becomes a herniation sac CLINICALLY:
– Pain through compression on viscera or traction on mesentery. Possible pain through interstitial compression
– All signs of a hernia can be identified
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Hernia developmentHernia development – COMPLETE HERNIA-
Herniation sac = completely passed through the wall
Clinical signs are complete both in uncomplicated and complicated form
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PATHOLOGIC CHANGES
Wall defect – the abnormality in the abdominal wall– Fibrous (umbilical hernia)– Fibro-muscular (epigastric hernia)– Fibro-osseous (obturator hernia)– True channel (inghuinal hernia)
Hernia wall or coverings Hernia content
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Complete hernia – structures of the wall
Skin and subcutaneous fat
Sac (peritoneum which is stretched + fat and structures migrating from under the peritoneum)– Fundus area– Neck area
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Causes
Conflict: pressure inside the abdominal cavity and possibility of the abdominal wall to content that pressure
Fragile balance – if imbalance appears a herniation point and a hernia will develop
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CausesCauses
Congenital: the sac preexists at birth or defect of development
Acquired hernia : in areas of minimal resistence of the abdominal wall
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CausesCauses-high intraabdominal pressure-
An increase in abdominal pressure acute (muscular rupture) or chronic (long term increase in stress over the abdominal wall) may increase the risk of hernia development– Increase respiratory effort: chronic respiratory diseases
associated with cough; jobs that require increase expiratory effort.
– Tumors or peritoneal effusion in large quantity (pregnancy, ascites, peritoneal dialyses)
– Straining or effort with closed epiglotis– Functional disorders with chronic effort (prostate adenoma,
chronic constipation)– Pathologic causes – colonic tumor!!!!!
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CausesCauses-wall defects-
Abdominal structure is not homogenous WEAK POINTS– Natural communications
between abdominal cavity and other cavities
– Passing of nerves or vessels towards superficial structures
– Scars (posttraumatic, postoperative)
– Intersection of fascial structures
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CausesCauses-wall defects
Other factors essential in hernia develoment– Loss of tissue elasticity and resistence –
usually associated with agging– Genetic factors – hernias predominant in some
families: defects in synthesis and structure of colagen fibers
– Trauma – tissue distruction + scars. Infection is a major contributor in incisional hernia
– Metabolic abnormalities
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Hernia formation
Hernia with preexisting sac: development abnormalities when the peritoneal diverticula is preexistent. There is no wall defect.
Pushing hernia: association of high intraabdominal hernia and weak point
Sliding henria: similar but organs attached to peritoneum slide in the sac.
Hernia with abnormally distended sac –peritoneum fixed at the level of the neck is blown up and loses its characteristics (umbilical hernia)
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Clinical signs in uncomplicated hernia
Pseudo-tumoral bulge with variable medical history that is apparent to the patient
Discomfort; difficulties in dressing +/- skin lesion through friction; the patient notices that it can be reduced and may need an orthopedic support.
Pain: traction or compression on nerves or mesentery. Usually it is bothersome but not major. Small hernia with small defects will be more painful.
Incomplete obstruction – when bowel is present in large hernia
Esthetic problem
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Clinical examination-uncomplicated hernia-
Positio of the patient :– Standing up : COMPULSORY as an initial
assesment– Laying down - compare the size and dynamic
of tumor when intraabdominal pressure changes
– ALL WEAK ABDOMINAL POINTS should be examined, as more hernias can be present
Protect the patient’s sensibility
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Clinical examination-uncomplicated hernia-
Inspection:Inspection:– Tumor, bulging, in an area known
as weak area of the abdominal wall
– “Tumor” is changing volume according to changes in abdominal pressure (standin/laying down, coughing, straining)
– Skin covering is normal – Volume increases while coughing– Progression of hernia follows a
trajectory which is the herniation channel
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Clinical examination-uncomplicated hernia-
Superficial palpationSuperficial palpation– Check the sensibility– Tumor has elastic consistency– Pear-like shape with a neck that
continues in the abdominal cavity!!! (very important)
– Content: diferentiate between bowel and non digestive structures
– Reduce the hernia content in the abdominal cavity REDUCTIBLE HERNIA
– Hernia forms back after reduction: COERCIBILE VS NONCOERCIBLE
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Clinical examination-uncomplicated hernia-
Palpation of the abdominal Palpation of the abdominal wall after reduction of the wall after reduction of the contentcontent– Evaluation of the well defect
(dimension, structure, position)– The “tumor” follows the finger
to progress during a coughing effort, following the direction of your finger EXPANSSION
– The “tumor” knocks your finger during a coughing effort PULSATE WITH COUGH
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Clinical examination-uncomplicated hernia-
PercussionPercussion– Tympanic – presence of air = bowel– Dull = omentum or retroperitoneal fat, but
bowel can also be present but does not contain air.
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Clinical examination-uncomplicated hernia-
AuscultationAuscultation– NOT significant but you may hear hydro-aeric
sounds characteristic for bowel content
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POSITIV DIAGNOSTIC IN UNCOMPLICATED HERNIA
“Tumor” or bulge + in a weak point Normal skin Volume changes with postural changes Pedicle inside the abdominal cavity Communication through a defect in the
abdominal wall - palpable Reducible + expansion during cough Pulsation during cough
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Lab exploration
Barium enema-colon in hernia + colonic tumors
Small bowel follow-up
Ultrasound scan - content
Laparoscopy – “gold standard” for small hernia
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Natural history
Hernia of the adult never heal spontaneously!!!
Hernia with a large defect are well tolerated but represent a handicap
Rigid defect: can produce a strangulation at any time
COMPLICATIONS – given enough time all hernias will complicate
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Complications Irreducible Incarceration To large to be adapted in the peritoneal cavity “no right
to stay in the abdomen” Strangulation Incomplete intestinal obstruction peritonitis in the sac Complications due to compression (testicular atrophie,
changes in urinary habits, respiratory disfunction) Trauma to the hernia Tumors in the hernia Foreign body in the hernia
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Strangulation
The most serious complication: transforms a benign pathology in one potentially lethal
CAUSES that favor strangulation:– Inextensible parietal defect (orifice)– Narrow or sclerotic neck of hernia sac– Adhesions in the sac
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Pathogenesis of strangulation Effort with sudden increase in intra-abdominal pressure A larger volume of bowel/viscus is pushed in the hernia Increases the pressure inside hernia sac
– Much more so at the level of the inextensible hernia orificeor neck of hernia
Impediment in the venous retur with consecutive edema. Further increase in intra-sacular pressure and of hernia
volume Pressure inside the hernia becomes bigger then arterial
pressure = ischemia SPEED OF PROGRESSION towards ireversible lesions is greater in tight strangulation.
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LesionsSac: same changes edematous – eritematous –
liquid initially serous+/- bloody the puss or fecal Intestinal loop: 3 stages
1. Congestion (venous stasis): congesitve loop, cyanosis, visible strangulation ridge. REVERSIBLE LESION
2. Intermediate bowel becomes purple – black, more rapidly at the strangulation area, the loop wall is destroyed and reduced to serosa 3. Necrosis and perforation the lopp becomes green (necrotic) like a dead leaf. Partial or total rupture of the wall + contamination of the peritoneum of the sac.
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Pathology Mesentery in strangulated area
– Edematous, friable with distended veins and trombosis
Omentum– Similar as above, can progress towards
necrosis
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Intestinal obstruction
Strangulation = (with few exception) a clinical manifestation of complete obstruction– Loops above hernia are dilated, with active peristalsis– Loops below hernia are emtpy
After perforation – peritonitis (either localized in the hernia sac or generalized peritonitis
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Unusual forms
Lateral pinch (Richter)– Strangulation of a segment of circumference on the
anti-mesenteric border– Incomplete clinical manifestations of intestinal
obstruction (lumen is free)– Manual reduction of hernia is possible but ischemic
lesion of the loop may progress in the abdomen – when the necrotic tissue is delimitated and falls of = PERITONITIS
– More frequent in femoral hernia
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Unusual forms
Retrograde strangulation “In W”– A large loop is in the hernia but strangulation
involves a segment of loop situated in the abdominal cavity with a part of mesentery in the hernia
– Greatest risk – during the surgical cure in the emergency settings – the intraabdominal loop may not be noticed - PERITONITIS
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Clinical signs in strangulation
SHARP PAIN at the level of hernia, continuous – SIGNAL - viability of the loop is threatened
INTESTINAL OBSTRUCTION Colicky abdominal pain (obstruction) Nausea, vomiting (at first food, the bile,
then fecal aspect) No intestinal transit but diarrhea is posible
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General signs
Very good at first Tachycardia Anxiety
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Clinica examination Patient is known to have a hernia BUT not
always (strangulation as a first symptom) Hernia is large and painful (in particular at the
level of the neck) DISAPPEAR impulsion and expansion with
cough Henria becomes irreducible: TAXISUL (forceful
reduction) is very dangerous – and more so after one hour from onset– En bloc reduction together with peritoneum– Non vital loop being reduced in the peritoneum
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Clinical examination Abdomen: classic appearance of intestinal
obstruction – Meteorism– Hyper-peristaltic loops – Borborism
Peritonitis;it is a “normal” evolution of clinical aspect a strangulated hernia neglected for too long
Abscess formation – may open spontaneously producing a digestive fistula
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Positive diagnosis
Hernia can not be reduced ANY MORE NO impulsion NO expansion Hernia becomes painful - continuous pain Intestinal obstruction Peritonitis
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Treatment of strangulation
URGENT: operated as soon as possible to save the loop
Hemo-dynamic control Gastric aspiration (naso-gastric tube) Surgical treatment using any type of
anesthesia
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Hernia SAC
Open but isolate as it may be contaminated Laparotomy – if abdominal contamination is probable!– Treat content– Resection of sac– Close peritoneum– Drain the contaminated area (+/-)
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Content
Incise the neck and decompress the strangulation area
Evaluate viability of bowel loop– If viable – reintroduce in the peritoneal cavity– Not viable – resect– In doubt: warm saline + infiltrations in the
mesenter; wait and see
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Orifice
Close the orifice and repair the defect Exception:
– Massive contamination. Repair can be put in danger by septic complications
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Peritoneal cavity
Non-contaminated (infection limited at the level of the neck) – nothing special but need to be checked intraoperatively
Contaminated– LAPAROTOMY (LAPAROSCOPY) irrigate
and drain– Intestinal resection
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Irreducible hernia Henria content can not be reduce anymore
– does not affect viability of the loop– In general it is progressive. The hernia is more
and more difficult to be reduced. BUT sudden henriation of a larger volume can induce this complication.
– Intra-sacular adherences Old hernia with step by step development
of irreducibility Differential diagnosis – strangulation: all
strangulated hernias are ireducible
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NO right to stay anymore in the abdomen (not welcome anymore)
Rare complication of very large hernia that recur immediately after reduction
Large volume outside the abdominal cavity for a long time = abdomen is reshaped on a smaller content
Reduction immediately increases the abdominal pressure and the whole volume can not be reduce or recurs immediately
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NO right to stay anymore in the abdomen (not welcome anymore)
Consequences :– hernia is incoercible– Forceful reduction and contention is
accompanied by respiratory distress– Treatment is very problematic
• Need to increase the abdominal volume in time
• Organ resections to reduce the pressure
• Large synthetic meshes
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Trauma to the hernia
Organs in the hernia are exposed. Much so if traumatized they do not have the liberty to retract in the abdomen. Entraped.
Diagnostic problems – Lesions that can progress in 2 steps– Intra-sacular peritonitis is non specific and
few symptoms may be present. May develop generalized peritonitis.
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Peritonitis in the hernia
Unusual complication Secondary to infectious complications of
intra-sacular organs (appendicitis, diverticulitis, etc)
Clinical signs: increase in volume, becomes painful, ireducible, local signs of inflamation