Abdominal wall hernia git system definition

Git system

1. Abdominal wall herniaAbdominal wall hernia

2. Lecture plans.Lecture plans.
1. INDIRECT INGUINAL
HERNIA
2. DIRECT INGUINAL HERNIA
3. SURGICAL REPAIR OF
FEMORAL HERNIA
4. SURGICAL TREATMENT OF
STRANGULATED GROIN
HERNIA
5. SLIGHDING HERNIA
6. UMBILICAL HERNIA
7. FEMORAL HERNIA

3. Inguinal canal.
the canal has an oblique direction -
superiorly downwards, from outside to
inside and posteriorly forwards.
its length in males is 4-5 cm; in females
it is a little longer but more narrow.
they mark 4 walls and 2 rings in the
inguinal canal.

4. Inguinal canal.
the anterior wall aponeurosis of the
obliquus externus abdominis;
the posterior wall   transversalis fascia;
the superior wall  inferior free borders
of the obliquus internus and transversalis
muscles;
the inferior wall  inguinal ligament and
the iliopubic tract;
 

5. the superficial inguinal ring,  is
formed by two spreading crura
of the aponeurosis of the
obliquus externus;
the deep inguinal ring, is a
funnel-shaped recess in the
transversalis fascia,

6. Fig.1.Umbilicus layer.

7. An abdominal wall An abdominal wall
herniahernia is a protrusion of is a protrusion of
a viscus or part of a a viscus or part of a
viscus through an viscus through an
abnormal opening in the abnormal opening in the
wall of the abdominal wall of the abdominal
cavity.cavity.

8. Fig.2. Indirect inguinal hernia: Fig.2. Indirect inguinal hernia: when its hernial sac
enters the inguinal canal through the deep inguinal ring,
passes through the entire canal and exits through the
superficial inguinal ring. Inside the spermatic cord!

9. Fig.3. Direct inguinal hernia: a defect in
the floor of the inguinal canal
outside the spermatic cord!!!

10. INDIRECT INGUINAL INDIRECT INGUINAL
HERNIA TechniqueHERNIA Technique
1.Make an incision in the inguinal region in a skin 1.Make an incision in the inguinal region in a skin
crease 1-2 cm above the inguinal ligament, centred crease 1-2 cm above the inguinal ligament, centred
midway between the deep ring and the pubic midway between the deep ring and the pubic
symphysis (Figure 8.1). symphysis (Figure 8.1).
2. Visualize the external oblique aponeurosis with its 2. Visualize the external oblique aponeurosis with its
fibres running in a downward and medial direction. fibres running in a downward and medial direction.
Incise the aponeurosis along its fibres, holding the cut Incise the aponeurosis along its fibres, holding the cut
margins with forceps (Figures 8.2 and 8.3). margins with forceps (Figures 8.2 and 8.3).

11. 3.Using blunt dissection, deliver 3.Using blunt dissection, deliver
the spermatic cord together with the spermatic cord together with
the hernial sac as one mass and the hernial sac as one mass and
pass a finger around it (Figure 8.4). pass a finger around it (Figure 8.4).
It is easiest to mobilize the mass It is easiest to mobilize the mass
by starting medially in the inguinal by starting medially in the inguinal
canal. Secure the mass with a latex canal. Secure the mass with a latex
drain or gauze (Figure 8.5). drain or gauze (Figure 8.5).

12. 4.Open the sac between 4.Open the sac between
two pairs of small two pairs of small
forceps and confirm its forceps and confirm its
communication with the communication with the
abdominal cavity by abdominal cavity by
introducing a finger into introducing a finger into
the opening the opening (Figure 8.6).(Figure 8.6).

13. 5.Twist the sac to ensure that 5.Twist the sac to ensure that
it is empty (Figure 8.7). Suture it is empty (Figure 8.7). Suture
ligate the neck with 2/0 ligate the neck with 2/0
suture, hold the ligature and suture, hold the ligature and
excise the sac (Figures 8.8 and excise the sac (Figures 8.8 and
8.9). If there is adherent gut in 8.9). If there is adherent gut in
the sac, it may be a sliding the sac, it may be a sliding
hernia (see page 8-5).hernia (see page 8-5).

14. 6.Inspect the stump to be 6.Inspect the stump to be
sure that it is adequate to sure that it is adequate to
prevent partial slipping of prevent partial slipping of
the ligature. When the the ligature. When the
ligature is finally cut, the ligature is finally cut, the
stump will recede deeply stump will recede deeply
within the ring and out of within the ring and out of
view (Figure 8.10).view (Figure 8.10).

15. 7.If there is a defect in the 7.If there is a defect in the
posterior inguinal wall, posterior inguinal wall,
stitch the conjoined muscle stitch the conjoined muscle
and tendon to the inguinal and tendon to the inguinal
ligament. Do not place ligament. Do not place
sutures too deep medially sutures too deep medially
as the femoral vein will be as the femoral vein will be
injured.injured.

16. Begin the repair medially Begin the repair medially
using No. 1 nylon. Insert using No. 1 nylon. Insert
stitches through the stitches through the
inguinal ligament at inguinal ligament at
different fibre levels, as the different fibre levels, as the
fibres tend to split along fibres tend to split along
the line of the ligament.the line of the ligament.

17. Insert the first stitch to include Insert the first stitch to include
the pectineal ligament (Figure the pectineal ligament (Figure
8.11). Insert the next stitch 8.11). Insert the next stitch
through the conjoined tendon through the conjoined tendon
and the inguinal ligament and and the inguinal ligament and
continue laterally to insert continue laterally to insert
stitches in this manner (Figure stitches in this manner (Figure
8.12).8.12).

18. Then tie the stitches, Then tie the stitches,
beginning medially, and cut beginning medially, and cut
loose ends (Figure 8.13). As loose ends (Figure 8.13). As
the final stitch is tied, adjust the final stitch is tied, adjust
its tension so that the internal its tension so that the internal
ring just admits the tip of your ring just admits the tip of your
little finger (Figure 8.14).little finger (Figure 8.14).

19. 8 Close the external oblique 8 Close the external oblique
aponeurosis with aponeurosis with
continuous 2/0 absorbable continuous 2/0 absorbable
suture (Figure 8.15). Stitch suture (Figure 8.15). Stitch
the skin with interrupted the skin with interrupted
2/0 suture (Figure 8.16). 2/0 suture (Figure 8.16).
Apply a layer of gauze and Apply a layer of gauze and
hold it in place.hold it in place.

20. INDIRECT INGUINAL INDIRECT INGUINAL
HERNIAHERNIA

21. INDIRECT INGUINAL INDIRECT INGUINAL
HERNIA TechniqueHERNIA Technique

23. INDIRECT INGUINAL INDIRECT INGUINAL
HERNIA TechniqueHERNIA Technique

24. INDIRECT INGUINAL INDIRECT INGUINAL
HERNIA TechniqueHERNIA Technique

25. Wound closure of INDIRECT Wound closure of INDIRECT
INGUINAL HERNIA INGUINAL HERNIA

26. Direct inguinal herniaDirect inguinal hernia
•A direct hernia will appear as a bulge, often A direct hernia will appear as a bulge, often
covered by fascia transversalis and with a covered by fascia transversalis and with a
wide neck in the posterior inguinal wall. wide neck in the posterior inguinal wall.
Once recognized at operation, reduce the Once recognized at operation, reduce the
hernia but do not open or excise the sac. hernia but do not open or excise the sac.
Cover the reduced sac by completing the Cover the reduced sac by completing the
repair of the posterior wall of the inguinal repair of the posterior wall of the inguinal
canal as described above for indirect hernia canal as described above for indirect hernia
(Figures 8.17 and 8.18).(Figures 8.17 and 8.18).

27. Direct inguinal herniaDirect inguinal hernia

28. Plasty of the inguinal canal posterior wall: 1 - suturing
the obliquus internus and transversus abdominis borders
to the inguinal ligament; 2 - appositioning the edges of
the obliquus externus aponeurosis; 3 - a scheme of the
surgery

29. Sliding herniaSliding hernia
•Diagnosis of a sliding hernia is often Diagnosis of a sliding hernia is often
intraoperative, becoming apparent once you intraoperative, becoming apparent once you
open the inguinal canal and the hernia sac. A open the inguinal canal and the hernia sac. A
portion of the gut will appear to adhere to the portion of the gut will appear to adhere to the
inside wall of the sac: the caecum and appendix inside wall of the sac: the caecum and appendix
if the hernia is in the right groin, and the if the hernia is in the right groin, and the
sigmoid colon if the hernia is on the left. The sigmoid colon if the hernia is on the left. The
colon or caecum (depending on where the colon or caecum (depending on where the
hernia is located) actually forms part of the hernia is located) actually forms part of the
posterior wall of the hernia sac. Occasionally the posterior wall of the hernia sac. Occasionally the
bladder forms part of the sac in a sliding herniabladder forms part of the sac in a sliding hernia

30. Excise most of the sac, Excise most of the sac,
leaving a rim of sac below leaving a rim of sac below
and lateral to the bowel and lateral to the bowel
(Figures 8.19 and 8.20). (Figures 8.19 and 8.20).
Close the sac with a purse-Close the sac with a purse-
string suture (Figures 8.21 string suture (Figures 8.21
and 8.22).and 8.22).

31. Sliding herniaSliding hernia

32. The skin incision may The skin incision may
have to be extended have to be extended
laterally to improve access. laterally to improve access.
Repair the posterior Repair the posterior
inguinal wall as described inguinal wall as described
for indirect hernia.for indirect hernia.

33. SURGICAL REPAIR OF SURGICAL REPAIR OF
FEMORAL HERNIAFEMORAL HERNIA
TechniqueTechnique
1. In the groin approach for femoral hernia, make the 1. In the groin approach for femoral hernia, make the
same incision as for an inguinal hernia (Figures same incision as for an inguinal hernia (Figures
8.1, 8.2, 8.3 on page 8-2). Retract the spermatic 8.1, 8.2, 8.3 on page 8-2). Retract the spermatic
cord, taking care to protect the ileo-inguinal cord, taking care to protect the ileo-inguinal
nerve (Figure 8.23).nerve (Figure 8.23).
2.The findings and the procedure will now differ from an 2.The findings and the procedure will now differ from an
inguinal hernia. In femoral hernia, the floor of the inguinal hernia. In femoral hernia, the floor of the
inguinal canal is intact. Using gentle blunt dissection, inguinal canal is intact. Using gentle blunt dissection,
open the floor of the inguinal canal, enter the open the floor of the inguinal canal, enter the
properitoneal space and reduce the femoral hernia properitoneal space and reduce the femoral hernia
(Figure 8.24).(Figure 8.24).

34. 3.After reduction, the sac can be 3.After reduction, the sac can be
managed with a purse-string suture and managed with a purse-string suture and
reduced (Figures 8.25, 8.26). If you are reduced (Figures 8.25, 8.26). If you are
concerned that the sac contents are concerned that the sac contents are
gangrenous, open the sac and inspect the gangrenous, open the sac and inspect the
contents. If the femoral hernia sac cannot contents. If the femoral hernia sac cannot
be reduced, place an artery forceps at the be reduced, place an artery forceps at the
neck of the sac and divide the overlying neck of the sac and divide the overlying
inguinal ligament. Take care to cut along inguinal ligament. Take care to cut along
the artery forceps to avoid injury to the the artery forceps to avoid injury to the
femoral vessels (Figure 8.27).femoral vessels (Figure 8.27).

35. FEMORAL HERNIAFEMORAL HERNIA

36. SURGICAL REPAIR OF SURGICAL REPAIR OF
FEMORAL HERNIAFEMORAL HERNIA

37. SURGICAL REPAIR OF SURGICAL REPAIR OF
FEMORAL HERNIAFEMORAL HERNIA

38. 4.Repair the femoral hernia by 4.Repair the femoral hernia by
attaching the conjoined attaching the conjoined
tendon to the Cooper's tendon to the Cooper's
ligament, which is the ligament, which is the
periosteum of the pubic periosteum of the pubic
ramus medial to the femoral ramus medial to the femoral
canal.canal.

39. 5.Close the femoral defect by 5.Close the femoral defect by
inserting a transition stitch to include inserting a transition stitch to include
the conjoined tendon, Cooper's the conjoined tendon, Cooper's
ligament and the femoral sheath. ligament and the femoral sheath.
Remember that the femoral vein is Remember that the femoral vein is
just under the femoral sheath (Figure just under the femoral sheath (Figure
8.28). Figure 8.28 shows how the 8.28). Figure 8.28 shows how the
Cooper's ligamefit repair and the Cooper's ligamefit repair and the
transition suture are tiedtransition suture are tied

40. 6. Make an incision in the internal 6. Make an incision in the internal
oblique aponeurosis just under the oblique aponeurosis just under the
elevated external oblique (Figure elevated external oblique (Figure
8.29). As in inguinal hernia repair, 8.29). As in inguinal hernia repair,
the internal ring should admit a the internal ring should admit a
finger (Figure 8.14). Close the finger (Figure 8.14). Close the
external oblique and skin, as for an external oblique and skin, as for an
inguinal hernia (Figures 8.15, 8.16).inguinal hernia (Figures 8.15, 8.16).
. Make an incision in the internal oblique aponeurosis just under the elevated external oblique (Figure 8.29). As in inguinal hernia repair, the internal ring should admit a finger (Figure 8.14). Close the external oblique and skin, as for an inguinal hernia (Figures 8.15, 8.16).

41. SURGICAL REPAIR OF SURGICAL REPAIR OF
FEMORAL HERNIAFEMORAL HERNIA

42. SURGICAL TREATMENT OF SURGICAL TREATMENT OF
STRANGULATED GROIN HERNIASTRANGULATED GROIN HERNIA
Provide immediate treatment to Provide immediate treatment to
patients with a strangulated groin patients with a strangulated groin
hernia to relieve the obstruction. hernia to relieve the obstruction.
Begin an intravenous infusion with an Begin an intravenous infusion with an
electrolyte solution, hydrate the electrolyte solution, hydrate the
patient, insert a nasogastric tube and patient, insert a nasogastric tube and
aspirate the stomachaspirate the stomach

43. Retrograde strangulation of hernia. 1 - a strangulated loop of
intestine in the peritoneal cavity; 2 - a strangulating ring; 3 - a
strangulated loop in the hernial sac; 4 - the hernial sac

44. Surgical repairSurgical repair
•Open the skin, subcutaneous tissue Open the skin, subcutaneous tissue
and external oblique, as previously and external oblique, as previously
described (see Figures 8.1, 8.2 and 8.3). described (see Figures 8.1, 8.2 and 8.3).
The internal ring may have to be The internal ring may have to be
divided to relieve the obstruction in divided to relieve the obstruction in
indirect hernia and the inguinal indirect hernia and the inguinal
ligament in femoral hernia. ligament in femoral hernia.

45. Open the sac, being careful to Open the sac, being careful to
prevent gut from returning to the prevent gut from returning to the
abdomen, then carefully inspect it abdomen, then carefully inspect it
for viability. Give particular for viability. Give particular
attention to constriction rings. If attention to constriction rings. If
bowel falls back into the bowel falls back into the
abdomen prior to assessment of abdomen prior to assessment of
its viability, perform a its viability, perform a
laparotomy.laparotomy.

46. Apply warm, wet packs to the gut for a Apply warm, wet packs to the gut for a
few minutes. Gangrenous or nonviable few minutes. Gangrenous or nonviable
gut will be black or deep blue without gut will be black or deep blue without
peristalsis. The mesenteric veins of the peristalsis. The mesenteric veins of the
loop will appear thrombosedloop will appear thrombosed
•Resect any gangrenous loop of bowel Resect any gangrenous loop of bowel
and make an end-to-end anastomosis and make an end-to-end anastomosis
If the resection of gangrenous bowel If the resection of gangrenous bowel
can be performed easily and well can be performed easily and well
through the groin incision, continue through the groin incision, continue
with that with that approachapproach

47. SURGICAL REPAIR OF UMBILICAL SURGICAL REPAIR OF UMBILICAL
AND PARA
­UMBILICAL HERNIA
AND PARA
­UMBILICAL HERNIA

TechniqueTechnique
•Make a transverse incision just Make a transverse incision just
below the umbilicus (Figure 8.31).below the umbilicus (Figure 8.31).
•Clearly define the neck of the sac as it Clearly define the neck of the sac as it
emerges through the linea alba and make emerges through the linea alba and make
an opening in the neck (Figures 8.32 and an opening in the neck (Figures 8.32 and
8.33). 8.33).

48. UMBILICAL HERNIA UMBILICAL HERNIA

49. Carefully examine the Carefully examine the
contents of the sac (the gut contents of the sac (the gut
and omentum) and reduce and omentum) and reduce
them (Figures 8.34 and them (Figures 8.34 and
8.35).8.35).

50. SURGICAL REPAIR OF SURGICAL REPAIR OF
UMBILICAL HERNIA UMBILICAL HERNIA

51. 3 Using blunt dissection, clearly 3 Using blunt dissection, clearly
define the fibrous margins of the define the fibrous margins of the
defect and enlarge it laterally (Figure defect and enlarge it laterally (Figure
8.36). 8.36).
•Make the repair by inserting mattress Make the repair by inserting mattress
stitches of 0 non-absorbable suture stitches of 0 non-absorbable suture
through all layers of the wound so that the through all layers of the wound so that the
edges overlap; the peritoneum need not be edges overlap; the peritoneum need not be
closed separately (Figure 8.37). Apply a closed separately (Figure 8.37). Apply a
further row of stitches to approximate the further row of stitches to approximate the
overlapping edge to the linea alba overlapping edge to the linea alba (Figure 8.38). (Figure 8.38).

52. SURGICAL REPAIR OF SURGICAL REPAIR OF
UMBILICAL HERNIA UMBILICAL HERNIA