Femoral hernia with umbilical hernia

clinical anatomy, surgical aspect of femoral hernia and umbilical hernia for UG mbbs

1. FEMORAL AND UMBILICAL HERNIA BY RAMAGOPALAN S Final year M.B.B.S.,

2. BASIC ANATOMY: Femoral triangle: triangular depressed area located in upper part of the medial aspect of thigh, just below the inguinal ligament. Boundaries Base : inguinal ligament Medial border: medial border of adductor longus Lateral border: medial border of sartorius muscle Apex: meeting of medial and lateral border

3. BASIC ANATOMY: Femoral sheath: The femoral sheath is a funnel-shaped distal prolongation of extraperitoneal fascia, formed of transversalis fascia anterior to the femoral vessels, and of the iliac fascia posteriorly. The femoral sheath encloses a mass of connective tissue in which the vessels are embedded. Distal end fuses with the vascular adventitia The medial wall is pierced by the long(great) saphenous vein and lymphatic vessels.

4. BASIC ANATOMY: Femoral sheath: The femoral sheath is a funnel-shaped distal prolongation of extraperitoneal fascia, formed of transversalis fascia anterior to the femoral vessels, and of the iliac fascia posteriorly. Divided into three compartment by intervening septa Lateral compartment – Femoral artery Intermediate compartment – Femoral vein Medial compartment – called Femoral Canal

5. BASIC ANATOMY: Femoral ring: Proximal(wider) end of the femoral canal and filled with condensed extraperitoneal tissue called femoral septum Boundaries: Superiorly: Inguinal ligament Inferiorly: iliopectineal ligament, pubic bone Medially: crescentic, lateral edge of lacunar ligament Laterally: Femoral septa Iliopectineal ligament

6. OUTLINE: A femoral hernia is the abnormal protrusion of a viscus from the abdominal or pelvic cavity, through the femoral canal. Retort shaped due to firm attachment of Scarpa fascia 4% of all groin hernia(70% in women)

7. Clinical presentation: UNCOMPLICATED HERNIA: Mild pain or discomfort in groin Swelling appears below and lateral to the pubic tubercle Mild tenderness Difficult to reduce Cough impulses +/- OBSTRUCTIVE HERNIA: Vomiting, colicky abdominal pain, obstipation Abdominal distension STRANGULATED HERNIA: Painful lump, inflamed skin and signs of septic shock

8. TYPES DESCRIBTION NARATH’S HERNIA Occurs behind femoral artery, in congenital dislocation of hip LAUGIER’S HERNIA Through a gap in the lacunar ligament CALLISON- CLOQUET’S Sac lies under the pectineus fascia SERAFINI’S HERNIA Behind femoral vessels without congenital dislocation TEALE’S HERNIA In front of the femoral vessels HESSELBACH’S HERNIA Lateral to the femoral vessels Variants of femoral hernia:

9. Investigations: Clinical examination Routine investigation for anaesthetic purpose Ultrasound

10. Treatment: ( Only surgery ) Operative surgery: Lockwood or low approach Lotheissen or inguinal approach McEvedy or high approach Laparoscopic approach: TEP and TAPP

11. Lockwood or Low approach: Under general or local anaesthesia Transverse incision is made over the infra inguinal region Sac of the hernia is opened and its contents reduced Non absorbable sutures placed between the inguinal and iliopectineal ligament

12. Lotheissen or Inguinal approach: Inguinal incision and enter into the inguinal canal Transversalis fascia is divided in the line of incision Hernia can be reduced by pulling from above and pushing from below Neck closed by suture

13. Lotheissen or Inguinal approach: Approximate the conjoint tendon with iliopectineal ligament. Alternatively a polypropylene mesh is inserted into the preperitoneal space Prevents inguinal hernia also

14. Lotheissen or Inguinal approach:

15. Lotheissen or Inguinal approach:

16. McEvedy or High approach: Very useful for irreducible and strangulated hernia. An vertical incision is put parallel to the outer border of the rectus muscle 2.5cm above the superficial inguinal ring. By Gauze dissection the hernial sac entering the femoral canal is identified

17. McEvedy or High approach: Fundus of the sac is opened below and dealt with before delivering the sac upwards. After freeing the sac, the neck is ligated. The conjoined tendon is sutured to the iliopectineal ligament with nonabsorbable sutures. Advantage of this technique is that if resection of the intestine is required, it can be easily carried out.

18. UMBILICAL HERNIA

19. UMBILICUS The umbilicus is the normal scar in the anterior abdominal wall formed by the remnants of the root of umbilical cord. It is the meeting point of the four folds of embryonic plate and three systems Digestive – Vitello intestinal duct Excretory – urachus Vascular – umbilical vessels

20. BASIC ANATOMY: The Rectus abdominis is a long, strap-like muscle that extends along the entire length of the anterior abdominal wall. Enclosed by rectus sheath formed by the bilaminar aponeuroses of the three flat muscles that divide and pass anteriorly and posteriorly around the muscle. which are fused in the midline at the linea alba.

21. BASIC ANATOMY:

22. BASIC ANATOMY:

23. Umbilical hernia: Spectrum

24. Umbilical hernia: In children Etiology : Complication of umbilical sepsis Higher incidence in premature Male child Black infants Clinical presentation: Symptomless Appears within a few weeks of birth ↑ size on crying and conical shape Complication uncommon below three years

25. Umbilical hernia: In children Treatment: Up to 2 years – conservative and assurance 95% will resolve spontaneously Surgical correction: Indication: Persists beyond 2 years, symptomatic and > 2cm defects Small curved incision Immediately below the umbilicus Sac is opened and returned to the peritoneal cavity Defect in the Linea alba is closed with interrupted sutures.

26. Umbilical hernia: In Adult Etiology : Its not true umbilical hernia Defect in the median raphe, paraumbilical M: F = 1:5, pregnancy Obesity, liver disease with cirrhosis Clinical presentation: Bulge is slightly to one side of the umbilical depression and crescent appearance ↑size on straining and coughing Expansile impulse on coughing Prone to become irreducible, obstructed and strangulation

27. Umbilical hernia: In Adult Treatment: Open tissue repair Mesh repair Laparoscopic procedure repair

28. Umbilical hernia: In Adult Open umbilical hernia repair: Mayo’s repair Up to 2cm defect Transverse incision is made After content reduced to create an upper and lower flap Lower flap is then inserted beneath the upper flap and sutured to it with non absorbable sutures by double breasting method.

29. Umbilical hernia: In Adult Mesh repair: For defects larger than 2 cm in diameter Mesh placed in one of several anatomical plane Underlay or intraperitoneal Retromuscular or Retrorectus Extraperitoneal space Overlay or Subcutaneous plane

30. Umbilical hernia: In Adult Mesh repair: Underlay mesh By using tissue separating mesh ( PTFE) Underside of the abdominal cavity Overlap of 5 cm in each direction

31. Umbilical hernia: In Adult Mesh repair: Retro muscular Both right and left posterior rectus sheath are incised and sutured in the midline To develop retro muscular space into which a sheet of mesh is placed and fixed by sutures.

32. Umbilical hernia: In Adult Mesh repair: Extraperitoneal space To develop the plane below the posterior rectus sheath, just outside the parietal peritoneum Mesh placed outside the peritoneum and the linea alba is closed over the mesh.

33. Umbilical hernia: In Adult Mesh repair: Subcutaneous plane After reducing the hernia Linea alba closed vertically with sutures and a disc of mesh is placed on the anterior rectus sheath Prone to infection