Abdominal wall hernias

14-12-2014

Introductory

• Definition: a bulge of part of the abdominal contents through a weakness in the abdominal wall.

• Causes: anatomical weakness due to structures entering or leaving the abdomin

developmental failure

collagen disease

abdominal trauma

surgical incisions

Types of hernias and complications

• Occult: undetected but may cause pain

• Reducible

• Irriducible

• Strangulated

• Obstructed

• Infarcted

• Richters hernia: part of the wall in the sac

Richter hernia

Clinical picture

• Site

• Incisions

• Visible and palpable cough impulse

• Pain

• Redness

• Tenderness

• NB: +ve cough impulse is not always a hernia

-ve cough impulse could be a hernia

Investigations

• In general all investigations are not diagnostic nor necessary.

• Just history and clinical examination in most cases

Ttreatment

• Not all hernias require repair

• Small hernias can be more dangerous

• Indications of surgery: symptoms

irriducible

femoral hernia

Methods of surgery

• Herniotomy: cutting the sac and closure

• Repair of the defect using sutures to approximate the adjacent tissues

• Using mesh to reinforce the weak tissue

• Tension free repair is the best using mesh

• Open or laproscopic

Specific types

• Epigastric

• Paraumbilical

• Umbilical

• Inguinal

• Femoral

• lumbar

Specific types

Inguinal hernia

• Indirect: lateral to inferior epigastric vessels, inside the spermatic cord through the internal ring

• Direct: medial to the vessels through the posterior wall, tranversalis fascia

• Inflammatory or malignant lymph node may look like strangulated hernia

• It is the most common type of hernia in both sexes

• More in Rt side, may be bilateral

Inguinal canal anatomy

• Floor: inguinal ligament from anterior superior iliac spine to pubic tubercle

• Roof: conjoint tendon of internal oblique and tranversus abdominus muscles

• Anterior wall: external oblique aponeurosis

• Posterior wall: fascia trasversalis

• Ilioinguinal nerve inside the canal

Inguinal canal anatomy

Femoral hernia

• Inferior and lateral to the pubic tubercle

• Below the inguinal ligament outside the inguinal canal

• Medial to femoral vein

• High risk of strangulation

• Surgery is indicated

Umbilical and paraumbilical hernias

• Umbilical: everted umbilicus

• Para umbilical: crescent shape umbilicus

• More common in adult females

• High risk of strangulation

• Surgery indicated in symptomatic cases and if the content is bowel

Paraumbilical hernia

Epigastric hernia

• Supra umbilical, normal shape umbilicus

• Usually contains extraperitonial fat

• Commonly multiple

• Surgery indicated for symptoms

Epigastric hernia

Divercation recti

• Not true hernia

• Wide distance between both rectus abdominus muscles

• Mostly in multiparous women

• Surgery usually cosmetic

• Recurrence is high

Incisional hernia

• Usually after abdominal surgery

• May be after penetrating abdominal trauma

• Commonly multiple defects

• 20 to 30 percent after surgery

• Open and laparoscopic repair

Rare abdominal wallhernias

• Spigelian

• Lumbar

• Parastomal

• Obturator

• Gluteal

• Sciatic