Abdominal Wall Hernia power point121.ppt

Abd hernia

1. Abdominal Wall Hernia
Dr. Bukenya Ali
Mmed Surgery year Two

2. Abdominal Wall Hernia
•Definition
–External
–Interparietal
–Internal
–Reducible
–Non-reducible (aka incarcerated)
–Strangulated

3. Abdominal Wall Hernia
•Richter’s hernia
•Littre’s hernia

4. Groin hernia
•Indirect inguinal
–scrotal
•Direct inguinal
•Femoral

5. Location
•Groin
•Umbilicus
•Linea alba (epigastric)
•Surgical incisions
•Semi-lunar line
•Diaphragm
•Lumbar triangles
•Pelvis

6. Groin Hernia
•Men > women
•Right > left
•10% of premature babies
•5% of adult population

7. Indirect Hernia Anatomy
•Indirect hernia
–Dilated persistent processus vaginalis
–Within spermatic cord
–Follows indirect course
–Complete vs. incomplete sac
–Sliding hernia

8. Direct Hernia Anatomy
•Hesselbach’s triangle
–Inguinal ligament (base), rectus (medial),
inferior epigastric vessels (lateral)
•Sliding hernia

9. Femoral Hernia Anatomy
•Inferior to inguinal ligament
•Women> men
•Cloquet’s node
•Usually on medial aspect of femoral sheath

10. Diagnosis
•Groin swelling that resolves with supine
position
•Precipitating factors
–Increased intra-abdominal pressure
–Defects in collagen synthesis
–Smoking
•Examine erect and supine
•Does not transilluminate

11. Groin Hernia Differential Diagnosis
•Hydrocele
•Varicocele
•Epididymoorchitis
•Torsion of testis
•Undescended testis
•Ectopic testis
•Testicular tumor
•Femoral artery aneurysm
•Lipoma
•Lymphadenopathy

12. Treatment
•Expectant management
•Surgical repair
–Mesh
–Open
–Laparoscopic
•TEP (totally extra-peritoneal)
•TAPP (transabdominal pre-peritoneal)

13. Complications
•Recurrence
•Neuralgia
–Ilioinguinal
–Iliohypogastric
–Genitofemoral
–Lateral cutaneous
•Ischemic orchitis
•Injury to vas deference
•Wound infection
•Bleeding

14. Umbilical Hernia
•Women> men
•Risk factors
•Obesity
•Pregnancy
•May rupture with ascites
•Repair primarily or with mesh

15. Umbilical Hernia
•Common in infants
•Close spontaneously if <1.5 cm
•Repair if > 2 cm or if persists at age 3-4
years
•Repair primarily or with mesh

16. Epigastric Hernia
•Incidence 1-5%
•Men> women
•Pre-peritoneal fat protrusion through
decussating fibers at linea alba
•Between xiphoid and umbilicus
•20% multiple
•Repair primarily

17. Incisional Hernia
•Risk factors
–Technical
–Wound infection
–Smoking
–Hypoxia/ ischemia
–Tension
–Obesity
–Malnutrition
•Laparoscopic vs. open repair

18. Parastomal Hernia
•Variant of incisional hernia
•Paracolostomy > paraileostomy
•Low rate if through rectus muscle
•Traditionally relocate stoma, repair defect
•Laparoscopic repair

19. Spieghelian Hernia
•Rare
•Hernia through subumbilical portion of semi-
lunar line
•Difficult to diagnose
–Clinical suspicion (location)
–CT scan
•Repair primarily or with mesh

20. Lumbar Hernia
•Congenital, spontaneous or traumatic
•Grynfeltt’s triangle
–12
th
rib, internal oblique and sacrospinalis
muscle
–Covered by latissimus dorsi
•Petit’s triangle
–Latissimus dorsi, external oblique and iliac crest
–Covered by superficial fascia

21. Gastroschisis
•Deformity caused by involution of secondary
umbilical vein and results in a full thickness
defect of the abdominal wall to the right of the
umbilical cord
•Herniation of small bowel and large bowel
•The loops of intestine lie uncovered in the
amniotic fluid and become thickened,
edematous and matted

22. •Incidence 1 in 10,000
•Infrequent congenital malformations
•High association prematurity
•Herniated contents rarely liver
•Associated cryptorchidism – 30%
•Intestinal atresia bowel common- 10%

23. Risk Factors
•4X more common in women < 20 years of age
•Smoking
•Stressed and undernourished mothers
•Over the counter meds: Vasoactive, aspirin,
ephedrine propertiespseudoephedrine

24. Diagnosis of Gastroschisis
•Before Birth
•Excess amniotic fluid
•Ultrasound
•Maternal serum alpha-fetoprotein levels
elevated
•After Birth
•Visible

25. Treatment
• Immediately after birth exposed part it
wrapped in sterile saline soaked gauze
• Tx: plastic “silo” slowly compressed over
the next week
•Surgical closure of the defect
•Infants are feed TPN for 2-5 weeks until
normal bowel function begins

26. Surgical Options for Treatment
•Primary Closure
•+/-Mesh
•Staged closure with
•Spring loaded Silo
•Dacron reinforced Silastic Sheet- Sutured to
medial aspect of rectus fascia

27. “The Gentle Touch”
•Treated 52 babies with gastroschisis
•Used “gentle touch” approach vs manual
reduction
•Fascial Closure 5.5 days vs 7 days
•Feeding 11 to 24 days vs 12 to 30 days
Conclusions: Gravity reduction of intestine in
babies with gastroschisis is both gentle and
effective

28. “Gentle Touch” Protocol
•Vaginal Delivery and ET Intubation
•Gastric and Colonic Decompression
•Broad Spectrum IV Abx
•Sedation
•Placement of Silo
•Gravity Based Bowel reduction
• Delayed Primary Fascial Closure
•TPN until bowel function returns

29. Omphalocele
•Incidence 2.5 in 10,000
•Results from failure of normal embryonic
regression of the mid-gut from the umbilical
stalk into the abdominal cavity
•Can include intestines liver or spleen covered
by a sac of parietal peritoneum and
amnionwhich can rupture
• Herniates into the base of the umbilical cord.

30. Embryology
•6th wk – midgut loop elongates and herniates
out through umbilical cord
•Midgut rotates 270 degrees
•Returns to abdomen by 10
th
wk
•Anterior abdominal wall
•progressively closes leaving only umbilical ring

31. Etiology
•Three Theories:
•1. Persistence of the primitive body stalk
•2. Failure of the bowel to return to the
abdomen
•3. Failure of complete lateral-body fold
migration and body wall closure

32. Omphalocele
•Associated Abnormalities in 60%
•Cardiac, Renal, Limb and facial anomalies
•Genetic Syndromes- Pentalogy of Cantrell,
•Beckwith-Wiedemann
• Associated with Trisomy 13, 14 , 15, and 18
•Small Omphalocele without liver-
•Increased Chromosomal abnormalities

33. Prognosis
•Gastroschisis: Overall survival is 90%
•Low survival if associated with intestinal atresia
•Omphalocele: Mortality increased if associated
•with chromosome syndrome or cardiac defect.
•Giant Omphalocele associated with pulmonary
hypoplasia: worse prognosis