Abdl Wall Hernias......................pptx

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1. Abdominal Wall Hernias BEIMNET H

2. Abdominal Wall Anterior wall Lateral walls (Flanks) Posterior wall Boundary between anterior and lateral walls is indefinite thus called anterolateral wall .

3. layers of anterolateral abdominal wall

4. 1. skin; 2. fatty layer of superficial fascia (Camper fascia) 3. neurovascular supply of superficial fascia 4 membranous layer of superficial fascia (Scarpa fascia); 5. space with areolar tissue 6. deep fascia (outer investing fascia of external oblique muscle) 7. external oblique muscle 8 inner investing fascia of external oblique muscle and outer investing fascia of internal oblique muscle (they fuse; here presented separately for didactic reasons) 9. internal oblique muscle 10. inner investing fascia of internal oblique muscle and outer investing fascia of trnasversus abdominis muscle (they fuse; here presented separately) 11. neurovascular bundle of abdominal muscles (between internal oblique and transversus abdominis muscles) 12. transversus abdominis muscle 13. transversalis fascia (the inner investing fascia of the transversus muscle) 14. parietal compartment of preperitoneal space; 15, membranous layer of preperitoneal tissue 16. preperitoneal fat in the visceral compartment of preperitoneal tissue 17. peritoneum

5. Abdominal Wall Hernias Definition Hernia is a protrusion of a viscus or part of a viscus through an abnormal opening in the walls of its containing cavity.

6. Causes Any condition which raises an intra-abdominal pressure : Whooping cough (in childhood) COPD Straining on micturaion/ defecation Intra-abdominal malignancies Obesity Pregnancy Ascites Heavy lifting (powerful musc. effort) B.Other factors : Familial Abnormal embryogenesis Age (extreme ages) Sex Occupation Congenital connective tissue disorders Defective collagen synthesis Persistent processus vaginalis sac: chief cause of indirect hernia. Postappendicectomy-injury to ilioinguinal nerve.

7. Contents Any abdom. Wall hernia consists of 3 parts: Sac (diverticulum of the peritoneum, having mouth , neck, body and fundus) Coverings of the sac (layers of abdominal wall) contents

8. Classification of abdominal wall hernia NATURE CONTENTS CLINICAL FEATURES SITE OTHERS

9. Classification According to its nature: 1. Congenital (due to abnormality in embryogenesis) 2. Acquired (postnatal)

10. Cont. of abdom. Wall hernia classific . B.according to its contents : 1.enterocele 2.omentocele 3.gastric 4.vesical 5.Richter’s hernia(portion of the circumference of the intest.) 6.Littre’s hernia (Meckel’s diverticulum) 7. ovaric with/without Fallopian tube

11. Cont. of abdom. Wall hernia classific . C.according to its clinical features : 1.reducible 2.irreducible 3.obstructed (incarcerated) 4.strangulated 5. inflamed (when its content is inflamed) 6.sliding hernia 7. hernia with loss of domain 8. sliding hernia

12. Cont. Classif. of Hernia D.according to the site: 1.Inguinal 2.Femoral 3.Epigastric 4.Paraumblical 5.Lumbar (high / low ) 6.Obturator(obtrutor canal) 7.Gluteal (greater sciatic orifice) 8.Sciatic (lesser sciatic orifice) 9. Umblical 10.Rectus diasthesis 11.Spigelion (at arcuate line) 12.Perineal (after APR

13. CONT. CLASSIF. OF ABDOM. WALL HERNIA E . others : 1. incisional 2. recurrent 3.diaphragmatic (dome ) 4. paradiaphragmatic (Bochdalek) 5.parasternal/ anterior defect (Morgagni ) 6.hiatus hernia etc.

14. Incidence of abdominal wall hernias Common Inguinal (75%) Umbilical Femoral Paraumbilical Epigastric Not unusual Rectus diasthesis Rare Obtrutor Lumbar Gluteal Sciatic Perineal Spigelion

15. Common clinical features Symptoms of Groin Hernia (History taking) Usually presents with complaint of s welling in groin Swelling fluctuates in size and typically is: More pronounced after working or late in day Less pronounced or has disappeared when patient wakes up in the morning Typically groin swelling is asymptomatic, but patient may have minor pain or vague discomfort Incarceration is usually painful

16. I f patient has pain in groin without history of swelling and no obvious hernia on exam, think of a different etiology Remember not all groin masses are caused by hernias – differential diagnoses include: Inguinal or femoral hernia Lipoma Ectopic testicle Lymphadenopathy (infectious, neoplastic ) Femoral aneurysm Hydrocele Tumors Torsion of testis

17. Examination of Groin Region Need to examine patient in both the standing and lying position to assess for reducibility Steps of examination: Inspect groins for asymmetry & for visible swelling Have patient cough or perform Valsalva maneuver to accentuate swelling Place fingertip at external ring and repeat cough or Valsalva If patient has history of intermittent groin swelling , but you cannot demonstrate hernia on exam: Have patient ambulate or stand for a period of time Have patient return later in day for another examination Believe the patient who reports a history of groin swelling even when you cannot demonstrate it on examination

18. Examination of Groin Region Differentiating between a direct and indirect inguinal hernia on examination: Can be difficult Is not essential because both are repaired through the same incisional approach Should recognize if swelling is below inguinal ligament  femoral hernia

19. Investigations Routine investigations Others accordingly Chest x-ray ECG U/S CT scan MRI

20. Treatment of hernias Herniotomy (in children with ing. Hernias) Herniorrhaphy (diff. modalities) Hernioplasty ( using mesh )

21. Complications of hernia operations Reactionary bleeding Haematoma Seroma Abscess Granuloma Recurrence Spermatic cord division Testicular ischemia Testicular atrophy Other postop. complications

22. 1. Groin H ernia Hernias of the groin include: Inguinal Direct Indirect Femoral

23. Boundaries of inguinal canal • Anterior : External oblique aponeurosis and a few fibres of the conjoined muscle (especially of internal oblique) laterally. • Superior : Arched fibres of the conjoined muscle . • Inferior : Inguinal ligament and the lacunar ligament on the medial side (Gimbernat's ligament). • Posterior : Fascia transversalis and the conjoined tendon medially. Thus, the inguinal canal is strong in the lateral part anteriorly and the medial part posteriorly

24. GROIN HERNIA

25. Contents of inguinal canal 1. Spermatic cord 2. Ilioinguinal nerve 3. Genital branch of genitofemoral nerve 4. Round ligament in females 5. Vestigeal remnant of processus vaginalis sac.

26. CONTENTS OF THE SPERMATIC CORD • Vas deferens • Testicular artery • Artery to the vas • Cremasteric artery • Pampiniform plexus of veins • Lymphatics • Sympathetic nerves • Genital branch of genitofemoral nerve • Processus vaginalis

27. Incidence of inguinal hernia True incidence is unknown 5% of population will develop abdominal hernia 75% of all hernias occur in inguinal region 2/3 rd are indirect 1/3 rd are direct Femoral hernia comprise only 3-10% of all groin hernia common in women. Men are 25x more likely to have groin hernia than women Indirect hernias are by far the most common type of hernia in women Direct Hernia is not common in women & children Right sided groin hernias are more common The prevalence increase with age

28. Indirect Versus Direct inguinal hernias Indirect Inguinal Hernia Direct Inguinal Hernia Pass through inguinal canal. Bulge from the posterior all of the inguinal canal Lateral to inferior epigastric vessels. Medial to inferior epigastric vessels. Reduced: upward, then laterally and backward. Reduced: upward, then straight backward. Controlled: after reduction by pressure over the internal (deep) inguinal ring. Not controlled: after reduction by pressure over the internal (deep) inguinal ring. The defect is not palpable (it is behind the fibers of the external oblique muscle). The defect may be felt in the abdominal wall above the pubic tubercle. After reduction: the bulge appears in the middle of inguinal region and then flows medially before turning down to the scrotum. After reduction: the bulge reappears exactly where it was before. Common in children and young adults. Common in old age.

29. Groin hernia Hesselbach’s triangle

30. Treatment of inguinal hernia Options of treatment of inguinal hernia W atchful waiting Truss or abdominal binder Surgical

31. Treatment of inguinal hernia cont.. Truss or Abdominal binder Indications Large uncomplicated hernia in elderly unfit Problems with external devices Hot to wear Difficult to keep in position Expensive Often unsuccessful at maintaining hernia reduction

32. Treatment of Acute I ncarceration Reduction & elective repair If no sign of strangulation 2 . Immediate exploration If diagnosis is not clear Reduction method Sedate Put on trendelenburg position Maneuver of taxis complication of Reduction??

33. Post Operative Compliacations Thromboembolic complications This is due to compression of the femoral vein by transition sutures placed too far laterally in Cooper's ligament Surgical site infection (SSI): Postoperative pain The published recurrence rates using a Cooper ligament repair is between 2% and 15 %. A Cooper ligament repair is typically performed for repair of a femoral hernia in the setting when a prosthetic mesh is contraindicated, e.g., strangulated bowel. In this setting , a Cooper ligament repair provides acceptable results .

34. 2.Umblical Hernia Definition: A hernia located from 3 cm above to 3 cm below the umbilicus( European Hernia Society ) second most common -6%-14% 90% aquaired in adult . 20% in cirrhotic patient It more common in women or individuals with increased intra-abdominal pressure as in pregnancy, obesity, ascites, or chronic abdominal distention

35. Umblical Hearnia cont.... has narrow neck compared with the size of the herniated sac, hence, incarceration and strangulation are common treatment Adult = elective repair (tissue or mesh repair). pediatrics= conservative management till the age of 4-5 years old.

36. 3. Epigastric Hernia locate any where between the xiphoid process and the umbilicus,usually midway. usually <1 cm and contained preperitonial fat more than one site can be painfull due to partial strangulation of fat Treatment surgery if symptomatic

37. 4. Spigelian Hernia These hernias are uncommon They arise through a defect in the spigelian fascia more common in elderly Most SH appear below the level of the umbilicus near the edge of the rectus sheath Treatment Surgery is recommended because the narrow and fibrous neck predisposes to strangulation

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