Abdominal Wall Hernias

John Morton, M.D.

University of North Carolina

Objectives

• General principles

• Discuss pertinent history and exam

• Review anatomy

• Discuss common hernia repairs

Hernia

• Abdominal Wall Defect– Congenital or acquired

• Potential for bowel obstruction– Incarceration– Strangulation

• May suggest underlying pathology– Hepatic disease, BPH, COPD, obstructing

colon mass

Common Hernia

• Umbilical

• Incisional

• Inguinal– Direct and indirect

• Femoral

Pertinent History• Duration/onset

• Symptoms– Local– Obstructive

• Nausea, emesis, pain, distension, obstipation

• Prior Incarceration

• Related comorbidity– Cough/Urinary flow/Constipation– Operative risk

Pertinent exam• Distension

– Bowel obstruction

• Scars– Incisional hernias– Recurrence– Contraindications for certain approaches

• Rectal--blood/masses

Pertinent Exam

• Location

• Reducible?

• Tender?

• Skin changes?

• Palpable edges

• Genitalia

• Rectal

Umbilical Hernia

• Congenital• Most close by age 3• May remain small and

asymptomatic• Can increase with

obesity, pregnancy, ascites, peritoneal dialysis

• Typical umbilicus

Umbilical Hernia Repair

Ventral Hernia

• Usually incisional• May be associated

with adhesions

Ventral Hernia

Laparoscopic Ventral Hernia

L a p a r o s c o p i c V e n t r a l H e r n i aT e c h n i q u e

Laparoscopic Ventral HerniaTechnique

Groin Anatomy--Anterior

• Inguinal ligament• Layers• External ring• Internal ring• Spermatic cord• Inferior epigastrics• Hesselbach’s triangle• Femoral vessels

Groin Anatomy--Posterior

Groin Anatomy--Nerves

Groin Hernia• Indirect Inguinal

– Congenital

– Patent processus vaginalis

• Direct Inguinal– Acquired

– Inguinal floor defect

• Femoral– Below inguinal ligament

Femoral Hernia Repair

Bassini Repair

• Conjoined tendon (internal oblique, transverse abdominal, transversalis fascia)

• Shelving edge Inguinal ligament

McVay (Cooper’s Ligament)

• Like Bassini but medial approximation to Cooper’s ligament

• Inguinal and Femoral hernia repair

• Femoral Vessels

Shouldice Repair• Imbricated, running

repair

Mesh repair

• Tension free• Less painful• Foreign body

Open Preperitoneal RepairGiant prosthetic reinforcement of

visceral sac• Stoppa• Bilateral hernia• Recurrent hernia• Precursor laparoscopic

repairs

Unilateral Preperitoneal repair

Balloon Dissector

Laparoscopic Inguinal Hernia Technique

Transperitoneal Anatomy

Groin Anatomy--Posterior