Dr. Muhammad Ayoub JalbaniAssistant ProfessorSurgical UNIT III

Anatomy of the Abdominal Wall

Anatomy of the Abdominal Wall

Function of Musculofascial Layers5 paired muscles (3 flat, 2 vertical)3 flat – int/ext oblique and transversalisIncrease abdominal pressure to facilitate

defecation, micturition, and parturitionStabilizes trunk 2 vertical – rectus abdominus and pyramidalisRectus - tensor of the abdominal wall, flexor of

the vertebrae, stabilize the pelvis during walking, protects the abdominal viscera, aids in forced expiration

Anatomy

INCISIONAL HERNIA

It is herniation through a weak abdominal scar (scar of previous surgery).

It is common in old age and obese individuals.

Predisposing FactorsVertical scar, midline scar, lower

abdominal scar— may injure the nerves of the abdominal muscles.

Scar of major surgeries (biliary, pancreatic).

Scar of emergency surgeries (peritonitis, acute abdomen).

Cont..Faulty technique of closure.Poor nutritional status of the patient.Presence of cough, tuberculosis,

jaundice, anaemia, hypoproteinaemia.

Cont..Malignancy, immunosuppression.Smoking in postoperative period.Causes which increases the intra-

abdominal pressure (BPH, straining, stricture urethra or rectum, ascites).

Factors responsible for development of Incisional hernia

Vertical incision has got higher chances of incisional hernia than horizontal incision

Layered closure of the abdomen has got higher chance than single layer

Continuous closure has got higher chances than interrupted closure

Cont..Using absorbable suture material has got higher

chances of hernia than non-absorbable sutures

Emergency surgical wound has higher chances than elective surgical wound

Laparotomy for peritonitis, acute abdomen, and trauma can commonly cause incisional hernia

Drainage through the main laparotomy wound may precipitate formation of incisional hernia

Chronic cough, smoking, obstructive uropathy, constipation can precipitate incisional hernia

Diabetes, old age, malnutrition, malignancy, anaemia, hypoproteinaemia, jaundice, ascites, liver disease, uraemia, steroid therapy, immunosuppressive diseases are other precipitating factors

Clinical Features

Swelling in the scar region.Pain.Impulse on coughing.Gurgling sound.Often bowel peristalsis may be visible

under the skin.

Eventually features of irreducibility, obstruction,

strangulation is seen.Hernia is common in lower abdomen.It may be small or large; huge or

massive (diffuse)

Scar, its extent and location, whether healed primarily or secondarily, skin over the scar and swelling is noted. Details of the swelling with expansile impulse on coughing and examination both in lying down and standing are done.

Gap cannot be assessed in an irreducible hernia.

Type of defects in Incisional Hernia

Small defectLarge and wide defectVery large defectMassive / diffuseMultiple defects

Investigations:

Always the precipitating factors must be looked for:

Chest X-ray.U/S abdomen.Tests relevant for causes.

Complications of incisional hernia

Irreducibility,Obstruction, Strangulation, Incarceration.