Abdominal Wall HerniasJohn Morton, M.D.University of North Carolina

ObjectivesGeneral principlesDiscuss pertinent history and examReview anatomyDiscuss common hernia repairs

HerniaAbdominal Wall DefectCongenital or acquiredPotential for bowel obstructionIncarcerationStrangulationMay suggest underlying pathologyHepatic disease, BPH, COPD, obstructing colon mass

Common HerniaUmbilicalIncisionalInguinalDirect and indirectFemoral

Pertinent HistoryDuration/onsetSymptomsLocalObstructiveNausea, emesis, pain, distension, obstipationPrior IncarcerationRelated comorbidityCough/Urinary flow/ConstipationOperative risk

Pertinent examDistensionBowel obstruction ScarsIncisional herniasRecurrenceContraindications for certain approachesRectal--blood/masses

Pertinent ExamLocationReducible?Tender?Skin changes?Palpable edgesGenitaliaRectal

Umbilical HerniaCongenitalMost close by age 3May remain small and asymptomaticCan increase with obesity, pregnancy, ascites, peritoneal dialysisTypical umbilicus

Umbilical Hernia Repair

Ventral HerniaUsually incisionalMay be associated with adhesions

Ventral Hernia

Laparoscopic Ventral Hernia

Laparoscopic Ventral HerniaTechnique

Laparoscopic Ventral HerniaTechnique

Groin Anatomy--AnteriorInguinal ligamentLayersExternal ringInternal ringSpermatic cordInferior epigastricsHesselbachs triangleFemoral vessels

Groin Anatomy--Posterior

Groin Anatomy--Nerves

Groin HerniaIndirect InguinalCongenitalPatent processus vaginalisDirect InguinalAcquiredInguinal floor defectFemoralBelow inguinal ligament

Femoral Hernia Repair

Bassini RepairConjoined tendon (internal oblique, transverse abdominal, transversalis fascia) Shelving edge Inguinal ligament

McVay (Coopers Ligament)Like Bassini but medial approximation to Coopers ligamentInguinal and Femoral hernia repairFemoral Vessels

Shouldice RepairImbricated, running repair

Mesh repairTension freeLess painfulForeign body

Open Preperitoneal RepairGiant prosthetic reinforcement of visceral sacStoppaBilateral herniaRecurrent herniaPrecursor laparoscopic repairs

Unilateral Preperitoneal repair

Balloon Dissector

[Source: GSI Spacemaker II product brochure or UNC image or generate new image][Central graphic for balloon dissector]

Laparoscopic Inguinal Hernia Technique

Transperitoneal Anatomy

Groin Anatomy--Posterior