hernia- good notes for DCM COMPLETE.pptx

Very nice notes that u can use, for surgery, for DCM

1. HERNIA OJALE MOSES 21-May-23 MOSES OJALE 1

2. DEFI N I TION Hernia means— ’To bud’ or ‘to protrude’ ‘off sho o t’ (Gre e k) Hernia is defined as an abnormal protrusion of a viscus or a part of a viscus through an opening, a r tificial o r n a tural with a sac, cov e ri n g i t . 21-May-23 MOSES OJALE 2

3. TY P ES 21-May-23 MOSES OJALE 3

4. Inguinal hernia is the commonest hernia (73%) because the muscular anatomy in the inguinal r e gi o n is we a k an d also d u e to the p r es e nce of natural weakness like deep ring and cord structures Femoral is 17% Umbilical is 8.5% Others are 1.5% 21-May-23 MOSES OJALE 4

5. AETIOLOGY Straining Lifting of heavy weight Chronic cough (tuberculosis, chronic bronchitis, bronchial asthma, emphysema) Chronic constipation (habitual, rectal stricture) Urinary causes Old age: BPH, carcinoma prostate Y oun g age: strict u re ureth r a Very young age: phimosis, meatal stenosis Obesity Pregnancy Smoking Ascites Appendicectomy Congenital Familial-collagen disorder— Prune Belly syndrome 21-May-23 MOSES OJALE 5

6. P A R T S O F HERNIA Covering Sac Content Coverings of the sac are the layers of the abdominal wall through which the sac pass e s 21-May-23 MOSES OJALE 6

7. Sac is a div e rticul u m of peritoneum with mouth, neck, body and fundus Neck is narrow in indirect hernia but wide in direct hernia Body of the sac is thin in infants, children and in indirect sac thick in direct and long standing hernia 21-May-23 MOSES OJALE 7

8. Contents of Sac Omentum— Omentocele (Epiplocele) initially it can be reduced easily difficult to reduce the sac later Intestine —Enterocele— commonly small bowel, but sometimes even large bowel difficult to reduce the sac initially Richter’s hernia- A portion of circumference of bowel is the content Cystocele- Urinary bladder may be the content or part of the posterial wall of the sac Ovary, often with fallopian tube Meckel’s diverticulum— Littre’s hernia 21-May-23 MOSES OJALE 8

9. Classification I (Clinical) 1- Reducible hernia : Hernia gets reduced on its own or by the patient or by the surgeon. Intestine reduces with gurgling and it is difficult to reduce the first portion. Omentum is doughy, and it is difficult to reduce the last portion. Expansile impulse on coughing present. 2- irreducible hernia : Here contents cannot be returned to the abdomen due to narrow neck, adhesions, overcrowding. Irreducibility predisposes to strangulation. MOSES OJALE 21-May-23 9

10. Clinical cont. 3- Obstructed hernia : It is an irreducible hernia with obstruction, but blood supply to the bowel is not interfered. It eventually leads to strangulation. 4- Inflamed hernia : It is due to inflammation of the contents of the sac e.g. appendicitis, salpingitis . Here hernia is tender but not tense; overlying skin is red and oedematous . 5. Strangulated hernia . It is an irreversible hernia with obstruction to blood flow. The swelling is tense, tender, with no impulse on coughing and with features of intestinal obstruction MOSES OJALE 21-May-23 10

11. Classification II Congenital. Acquired III: According to the contents. Omentocele --- omentum . Enterocele -intestine. Cystocele-urinary bladder. Sliding hernia. Richter's hernia- part of the bowel wall. MOSES OJALE 21-May-23 11

12. Classification IV: Based on sites • Inguinal hernia-occurring in inguinal canal. • Femoral hernia-occurring in femoral canal. • Obturator hernia. Diaphragmatic hernia. • Lumbar hernia. • Spigelian hernia. • Umbilical hernia. • Epigastric hernia. MOSES OJALE 21-May-23 12

13. INGUINAL HERNIA INGUINALCANAL It is an oblique passage in lower part of abdominal wall, 4 cm long extending from deep inguinal ring to superficial inguinal ring 21-May-23 MOSES OJALE 13

14. 21-May-23 MOSES OJALE 14

15. Superficial inguinal ring triangular opening in the external oblique aponeurosis and is 1.25 cm above the pubic tubercle bounded by a superomedial and inferolateral crus Deep inguinal ring U-shaped condensation of the transversalis fascia, lies 1.25 cm above the inguinal ligament midway between the symphysis pubis and the anterior superior iliac spine 21-May-23 MOSES OJALE 15

16. Hesselbach’s triangle Boundries medially : lateral border of rectus muscle laterally : inferior epigastric artery below : inguinal ligament 21-May-23 MOSES OJALE 16

17. Co n t e n ts of sperm a tic co r d V a s deferens Artery to vas Testicular and cremasteric artery Genital branch of genitofemoral nerve Pampiniform plexus of veins The artery to vas Remains of processus vag i na l is 21-May-23 MOSES OJALE 17

18. 21-May-23 MOSES OJALE 18

19. Defence mechanism of inguinal canal Obliquity of inguinal canal (flap valve mechanism ) Arching of conjoint tendon ‘ Shutt e r me c hanis m ’ of int e r n al o b lique ‘ Ball v a lve me c hani s m ’ d u e to co n tracti o n of cremaster muscle which plugs to superficial ring When external oblique muscle contracts intercrural fibres of superficial ring appose causing ‘ slit valve mechanism ’ 21-May-23 MOSES OJALE 19

20. CLASSIFICATION OF INGUINAL HERNIA 1)Anatomical classification Indirect hernia: It comes out through internal ring along with the cord lateral to the inferior epigastric artery Direct hernia: It occurs through the posterior wall of the inguinal canal through ‘Hesselbach’s triangle medial to the inferior epigastric artery 21-May-23 MOSES OJALE 20

21. 21-May-23 MOSES OJALE 21

22. NYHUS classification Type I: Indirect hernia with normal deep ring Type II: Indirect hernia with dilated deep ring Type III: Posterior wall defect Direct Pantaloon hernia Femoral hernia Type IV: Recurrent hernia 21-May-23 MOSES OJALE 22

23. INDIRECT (OBLIQUE) INGUINAL HERNIA This is the most common type of hernia (65%) It is more common in younger age group as compared to direct inguinal hernia which is more common in elderly 21-May-23 MOSES OJALE 23

24. Co v erings o f indi r ect hernia(f r om inside out) Extraperitoneal tissue Internal spermatic fascia Cremasteric fascia External spermatic fascia Skin 21-May-23 MOSES OJALE 24

25. TYPES OF INDIRECT HERNIA Bubonocele: Where the hernia is limited to inguinal canal Funicular : hernia present at the root of the scrotum Processus vaginalis is closed just above the epididymis . Contents of the sac can be felt separately from testis, which lies below the hernia Complete (Scrotal): hernia present in the bottom of the scrotum T e s t i s ap p ears to l i e with i n the l o w e r part of hernia 21-May-23 MOSES OJALE 25

26. DIRECT HERNIA 35% o f i n guinal hern i as a r e di r ect. It is common in fe males . I t is al w a y s acqu i r ed, d u e t o w ea k en i n g of posterior wall of inguinal canal. Hernia is medial to the inferior epigastric artery 21-May-23 MOSES OJALE 26

27. Coverings of direct hernia (from inside out) Extraperitoneal tissue Fascia transversalis Conjoined tendon External spermatic fascia Skin 21-May-23 MOSES OJALE 27

28. CLINICAL EXAMIN A TIO N Indirect hernia is most common in males and and direct is uncommon in females Direct hernia is reducible on lying down Indirect is irreducible Shape : pyriform in indirect spherical in direct 21-May-23 MOSES OJALE 28

29. If swelling is soft and elastic : enterocele firm and granular: omentocele Cough impulse : a characteristic feature of hernia can be felt on palpation seen as bulging in inspection Get above the swelling : complete scrotal swelling its positive Inguinoscrotal swelling will not be able to get above the swelling 21-May-23 MOSES OJALE 29

30. Internal ring occlusion test Internal ring is located half inch above the mid-inguinal point (center point between anterior superior iliac spine and pubic symphysis) After reducing the contents, in lying down position, internal ring is occluded using the thumb Patient is asked to cough If a swelling appears medial to the thumb, then it is a direct hernia , If swelling does not appear and on releasing the thumb swelling appears during coughing, then it is an indirect hernia 21-May-23 MOSES OJALE 30

31. Ring invagination test After reduction of hernia, the little finger/index finger of the examiner is used to invaginate from the bottom of the scrotum, gradually pushed up and rotated to enter the superficial inguinal ring impulse on coughing if impulse is felt at the tip of the invaginated finger:indirect Pulp of the inaginated finger : direct This test is done only in males 21-May-23 MOSES OJALE 31

32. Zieman’s test The examiner places his index finger on the deep inguinal ring and middle finger on the superficial inguinal ring, ring finger over saphenous Opening, patient is asked to cough or to hold the nose and blow , If the impulse is felt on the index finger it is indirect hernia , middle finger its direct hernia , Ring finger femoral hernia 21-May-23 MOSES OJALE 32

33. Head or leg rising test D one to look for abdominal wall muscle tone and Malgaigne bulgings Malgaigne bulgings are protrusion of abdominal wall muscles during leg rising test as weak, soft, supple, swelling, which signifies poor abdominal muscle tone 21-May-23 MOSES OJALE 33

34. MOSES OJALE 21-May-23 34

35. Indirect inguinal hernia Can occur in any age from childhood to adult Occurs in a pre-existing sac Protrusion through the deep ring Pyriform/oval in shape; descends obliquely and downwards Can become complete by descending down into scrotum Direct inguinal hernia Common in elderly Always acquired Protrusion occurs through posterior wall Globular/round in shape descends directly forward wards bulge Descent down into the scrotum is rare 21-May-23 MOSES OJALE 35

36. Neck of the sac is narrow and lateral to inferior epigastric artery Sac is antero-lateral to the cord Ring occlusion test does not show any impulse after occluding the ring R ing Invagination test shows impulse on the tip of the of the little finger Zieman’s test shows impulse on the index finger Commonly unilateral but can be bilateral Obstruction/strangulation are common Sac should be opened during surgery Neck of sac is wide and medial to inferior epigastric artery Sac is posterior to the cord T e s t s ho w s im p u l se ev e n after occluding the deep ring Impulse is felt over the pulp little fin g er T e s t s ho w s im p u l se on the mid d le finger Commonly bilateral Rare occurrence Sac is not necessarily opened unless obstruction 21-May-23 MOSES OJALE 36

37. Differential diagnosis Hydrocele Undescended testis Femoral hernia Lipoma of the cord Inguinal lymph node enlargement Groin abscess 21-May-23 MOSES OJALE 37

38. INVESTIGATIONS Routine investigations Chest xray USG abdomen & pelvis 21-May-23 MOSES OJALE 38

39. Treatment Treat the precipitating cause first Surgeries are the treatment of choice In children always HERNIOTOMY is done In adults HERNIOPLASTY HE R NIORAPHY 21-May-23 MOSES OJALE 39

40. Herniotomy excision of hernial sac Anaesthesia: Spinal or G/A Procedure : After cleaning and draping, skin is incised 1.25 cm above and parallel to the medial two/third of inguinal ligament T w o lay e rs of su p e r ficial fascia ( o ute r Ca m p e r ’ s fascia and inner Scarpa’s fascia) are incised 21-May-23 MOSES OJALE 40

41. External oblique aponeurosis is incised Upper leaf is reflected above and lower leaf is reflected downwards to visualise and expose the inguinal ligament Ilioinguinal nerve is safeguarded Cremasteric muscle is opened Cord structures are dissected Sac which is anterior and lateral to cord is identified and is pearly white in colour Dissection is usually started from the fundus and extended towards the neck which is identified by extraperitoneal fat Sac is opened at the fundus. Finger is passed to release any adhesions Sac is twisted so as to prevent the content from coming back It is transfixed using absorbable suture material (chromic 21-May-23 MOSES OJALE 41

42. Herniorr h aphy Shouldice Mac Vay Modified Bassini high recurrence rate as it is repair with tension 21-May-23 MOSES OJALE 42

43. Modified Bassini’s Herniorrhaphy It is strengthening of the posterior wall of the inguinal canal by approximation of the conjoint tendon to inguinal ligament using INTERUPPTED monofilament nonabsorbable suture material External oblique is closed and other layers are also closed Commonly used suture material is either polypropylene [prolene (blue in colour)] or polyethylene [ethylon (black in colour)]. 21-May-23 MOSES OJALE 43

44. 21-May-23 MOSES OJALE 44

45. Shouldice Repair multilayered repair After doing herniotomy ,transversalis fascia is incised from deep ring to pubic tubercle Lower flap of fascia is sutured to posterior part of the upper flap Upper flap is sutured to the inguinal ligament It is called DOUBLE BREASTING of transversalis fascia 21-May-23 MOSES OJALE 45

46. Then conjoint tendon and inguinal ligament is further approximated by two layers of continuous sutures. External oblique aponeurosis is sutured in two layers (double-breasting) in front of the cord. Hence the original Shouldi c e repair is 6 layered procedure. First two layers of transversalis fascia, Next two layers of conjoint tendon and last two layers of external oblique apponeurosis. 21-May-23 MOSES OJALE 46

47. Complications of herniorrhaphy Haemorrhage Haematoma Infection–1-5% Haematocele Post-herniorrhaphy hydrocele, lymphocele Hyperaesthesia over the medial side of inguinal canal due to injury to ilioinguinal nerve - neuralgia Recurrence Osteitis pubis Injury to urinary bladder/bowel Testicular atrophy, penile oedema rarely can occur 21-May-23 MOSES OJALE 47

48. Lytle’s Repair Often internal ring is narrowed by placing interrupted sutures over the medial side of the ring to the transversalis fascia using either thread or silk. (To narrow the ring) 21-May-23 MOSES OJALE 48

49. Hernioplasty It is strengthening of posterior inguinal wall in case of indirect hernia or in any large hernia with weak abdominal wall using a supportive material. This allows and supports good fibroblast proliferation which in turn strengthens the weak posterior wall of inguinal canal or abdominal wall 21-May-23 MOSES OJALE 49

50. Hernioplasty is the present choice (ideal) for all inguinal and groin hernias. Mesh is placed either over conjoint tendon to inguinal ligament or in preperitoneal space Polypropylene mesh is used Herniotomy is done prior to mesh placement Ex-Lichtenstein, Rives, Gilbert, 21-May-23 MOSES OJALE 50

51. Material Used Synthetic: Prolene mesh (white in colour) Dacron mesh, Morlex mesh, Mersilene sheath Biolo g ical: T en s o r fascia lata, temp o r a l fascia (presently biological materials are not well accepted as infection is common and its efficacy is not proved 21-May-23 MOSES OJALE 51

52. Indications Direct hernia. Recurrent hernia. Re-recurrent hernia. Incisional hernia. Old age. Hernia with weak abdominal muscle tone. Sliding hernia. Complications Infection. Mesh extrusion. Foreign body reaction 21-May-23 MOSES OJALE 52

53. LICHENSTIEN METHOD Tension free , simple , flat polypropylene mesh repair After HERNIOTOMY a piece of mesh is placed over posterior wall and split to wrap the spermatic cord at deep inguinal ring interrupted sutures are made between mesh, inguinal ligament and conjoint tendon 21-May-23 MOSES OJALE 53

54. 21-May-23 MOSES OJALE 54

55. Laproscopic & preperitoneal repairs TAPP Trans abdominal Pre-peritoneal Patch TEPP Totally Extraperitoneal Pre-peritoneal Patch Both place a Mesh patch over the hernial defect inside the abdominal muscle layer, outside the peritoneum. 21-May-23 MOSES OJALE 55

56. TAPP (transabdominal prepeitoneal procedure): P eritoneal space entered by conventional lap at umbilicus and peritoneum overlaying inguinal floor is dissected away as flap. TEP (Total extraperitoneal repair): P reperitoneal space is developed with a balloon inserted between posterior rectus sheath and peritoneum  balloon inflated to dissect the peritoneal flaps awau from posterior abdomianl wall and the direct and indirect spaces, other ports inserted into this preperitoneal space without entering peritoneal cavity. 21-May-23 MOSES OJALE 56

57. 21-May-23 MOSES OJALE 57

58. Conservative treatment : Taxis: Patient is placed in supine positionwith hip and knee flexed and hip internally rotated. Contents are pushed with one hand directing with other hand U se o f T r u ss: R at- t a i l ed s p r un g tr u ss i s u se d . Measurement is taken from the tip of greater trochanter to third piece of sacrum circumferentially – C o m plications are disco m f o r t , ulceratio n , str ang u la t i on , infla mm ation – It m ay be used in elderly people, w ho are not fit for anaes t h e s ia and surgery – Conservative treatment should be avoided in hernia as m uch a s possible –Truss is absolutely contraindicated in femoral and sliding hernia 21-May-23 MOSES OJALE 58

59. Complications of hernia 21-May-23 MOSES OJALE 59

60. Irreducible hernia : Here contents cannot be returned to the abdomen due to narrow neck, adhesions, overcrowding Irreducibility predisposes to strangulation Obstructed hernia : It is an irreducible hernia with obstruction, but blood supply to the bowel is not interfered It eventually leads to strangulation. Garrey’s stricture: Constriction that occurs due to ischaemic narrowing of small bowel which has reduced from an obstructed hernia Inflamed hernia : It is due to inflammation of the contents of the sac e.g. appendicitis, salpingitis. Here hernia is tender but not tense; overlying skin is red and oedematous . 21-May-23 MOSES OJALE 60

61. STRANGULATED HERNIA It occurs when blood supply of the contents of hernia is seriously impaired leading to formation of gangrene Strangulation commonly occurs in the small bowel and also in large bowel Occasionally strangulated omentocele also can occur without any intestinal obstruction Strangulation can occur in inguinal, femoral, obturator , umbilical or any hernias. Indirect inguinal hernia is more prone for strangulation than direct inguinal hernia. It is due to narrow neck, adhesions, narrow external ring in children 21-May-23 MOSES OJALE 61

62. Obstruction ↓ Initially venous return is impaired ↓ Congestion of the bowel ↓ Further dilatation of the bowel which becomes purple coloured ↓ Fluid collects in the sac ↓ Eventually arterial blood supply is impaired ↓ Bowel becomes dark, brownish black coloured with flabby and friable wall ↓ Bacteria migrate transerosally and multiply in fluid of the sac ↓ Perforation occurs at the site of constriction ring ↓ Peri t o n i t is oc c u rs . 21-May-23 MOSES OJALE 62

63. TR E A TMENT The patient is admitted. Ryle’s tube aspiration. Intr a venous flui d s to co r r e ct d e hy d ration and electrolyte imbalance. Antibiotics. Cat h eterisation to m a int a in a d e q uate u r ine output. Emergency HERNIOTOMY 21-May-23 MOSES OJALE 63

64. Maydl’s Hernia (Hernia-in-W ) Here a loop of bowel in the form of ‘W’ lies in the hernial sac and the centre portion of the ‘W’ loop is strangulated and lies within The abdominal cavity 21-May-23 MOSES OJALE 64

65. TYPES OF HERNIA 21-May-23 MOSES OJALE 65

66. 21-May-23 MOSES OJALE 66

67. Hiatal Hernia - Part of the stomach protrudes up diaphragm into the chest - 2 types hiatal hernia i .) Sliding Hiatus Hernia - The distal oesophagus and cardia slides into the thorax with an intact gastro- oesophageal junction and therefore usually asymptomatic ii.) Rolling Hiatus Hernia - Most of the stomach rolls into the thorax, the stomach may also undergo a twist MOSES OJALE 21-May-23 67

68. Pictorial MOSES OJALE 21-May-23 68

69. FEMORAL HERNIA Surgical Anatomy of Femoral Canal It is the medial, most compartment of the femoral sheath, which extends from femoral ring above to saphenous opening below It contains fat, lymphatics, lymph node of Cloquet It is 1.25 cm long and 1.25 cm wide at the base. Below it is closed by cribriform fascia. Femoral ring is bounded anteriorly by inguinal Ligament posteriorly by ilio pectineal ligament of Cooper, pubic bone and fascia covering the pectineus muscle; medially by concave, sharp lacunar Ligament laterally by a thin septum separating from femoral vein 21-May-23 MOSES OJALE 69

70. Pictorial MOSES OJALE 21-May-23 70

71. 21-May-23 MOSES OJALE 71

72. Clinical Features Common in females (2:1 ratio), common in multipara Rare before puberty. 20% occurs bilateral, however more common on right side Presents as a swelling in the groin below and lateral to the pubic tubercle. (Inguinal hernia is above and medial to the pubic tubercle) Swelling, impulse on coughing, reducibility, gurgling sound during reduction, dragging pain, are the usual features When obstruction and strangulation occurs which is more common, presents with features of intestinal obstruction—painful, tender, inflamed, irreducible swelling without any impulse They also pre s ent with abdominal distensio n , vom i ting and fea t ures of toxicity. 21-May-23 MOSES OJALE 72

73. History Age ; uncommon in children , most common in old age female . Sex; women > men (but still commonest hernia in women the inguinal hernia ) The patient came with local symptoms 1- discomfort and pain 2- swelling in the groin General ; femoral hernia is more likely to be strangulated than the inguinal hernia Multiplicity ; often bilateral MOSES OJALE 21-May-23 73

74. Femoral hernia versus inguinal hernia MOSES OJALE 21-May-23 74

75. Femoral hernia repair Lockwood low operation Mc’Evedy-High operation Lotheissen’s operation H enr y ’ s appro a ch . 21-May-23 MOSES OJALE 75

76. Lotheissen‘s trans-inguinal approach The incision is made superior and parallel to inguinal ligament extending from pubic tubercle to mid inguinal point. Approximation of inguinal ligament to cooper ligament and Conjoint muscle to cooper ligament.. 21-May-23 MOSES OJALE 76

77. McEvedy’s high approach Vertical incision is made over the femoral canal and continued upwards above the inguinal ligament. This incision provides good access to the preperitoneal space and then to the peritoneum itself. Use finger dissection to sweep peritoneum from anterior abdominal wall , so the neck of the sac can be identified. Dissect the sac , reduce the contents and repair the defect by mesh or sutures. Conjoint muscle to cooper ligament. 21-May-23 MOSES OJALE 77

78. Lockwood’s infra-inguinal approach The sac is dissected out below the inguinal ligament via groin crease incision. Then the sac is opened and the contents are inspected and reduced into the abdomen. Then the neck of the sac is pulled down , ligated and allowed to retract through femoral canal. Then close the femoral canal by mesh plug or non absorbable sutures. Approximation of inguinal ligament to cooper liga ment.. 21-May-23 MOSES OJALE 78

79. Henry procedure Midline abdomen extraperitonial aproach Does not damage transversalis fascia Hence recurrence is low. 21-May-23 MOSES OJALE 79

80. PANTALOON HERNIA (DOUBLE HERNIA ) SADDLE HERNIA, ROMBERG HERNIA Here both direct and indirect inguinal sacs are present and clinically present as direct hernia. During surgery, indirect sac may be missed and so leads to recurrent hernia through indirect sac 21-May-23 MOSES OJALE 80

81. SLIDING HERNIA (HERNIA-EN- GLISSADE Here posterior wall of the sac is not only formed by the parietal peritoneum but by bowel. sigmoid colon on left side; caecum on right side and often with portion of the bladder (Both sides) Content of the sac is usually small bowel or omentum. Sliding hernia occurs exclusively in males. Mainly on the left side, if it occurs on right side appendix and caecum will be present on the posterior wall 21-May-23 MOSES OJALE 81

82. Large globular swelling will be present over the inguinal region Treatment is always surgery Posterior wall of Sac should not be seperated from the colon and other structures 21-May-23 MOSES OJALE 82

83. Umbilical hernia Develops due to absence of umbilical fascia or incomplete closure of umbilical defect It can be congenital or acquired Acquired through weak umbilical scar Congenital will be presented few months after birth which presents as a swelling in the umbilical region which increase during crying TREATMENT Initially conservative INDICATIONS FOR SURGERY Persists after 3 years of age >2 cm size acquired 21-May-23 MOSES OJALE 83

84. Examination Inspection Site ; in the center of the umbilicus Size and shape ; size can vary from vary small to very large . Shape is usually hemispherical. Palpation Composition ; contain bowel , which makes it resonant to percussion . They reduce spontaneously when the child lies down . Reducibility ; easy Cough impulse; invariably present . MOSES OJALE 21-May-23 84

85. Acquired umbilical hernia Hernia through the umbilical scar , so it is a true umbilical hernia. Not common and is usually secondary to increase intra abdominal pressure. The most common causes 1- pregnancy 2- ascitis 3- ovarian cyst 4- fibrodis 5- bowel distention MOSES OJALE 21-May-23 85

86. Umbilical hernia MOSES OJALE 21-May-23 86

87. Incisional/ ventral hernia occur at the site of previous surgical incision) results from inadequate healing of the incision cause be postoperative wound infection, inadequate nutrition, and obesity MOSES OJALE 21-May-23 87

88. Incisional hernia MOSES OJALE 21-May-23 88

89. Clinical features Previous operation or accidental trauma Age ; all ages , but more common in old age. Symptom ; lump ,pain ,intestinal obstruction ( distention ,colic, vomiting ,constipation , sever pain in the lump ) Examination 1- reducible lump 2- expansive cough impulse 3- if the lump dose not reduce and dose not have cough impulse , than it may be not a hernia Ddx Tumor Chronic abscess Hematoma Foreign body granuloma MOSES OJALE 21-May-23 89

90. Spigelian hernia It is a type of interparietal hernia(between external oblique and internal oblique) Hernial sac lies either deep to the internal oblique or between external and internal oblique muscles Clinical Features Presents as a soft, reducible mass lateral to the rectusmuscle and below the umbilicus impulse on Coughing Strangulation is common Treatment l eng t h y tr a nsve r se i n cisi o n he r nioto m y and closure of the defect layer by layer using Nonabsorbable interrupted sutures mesh is required to cover the defect properly 21-May-23 MOSES OJALE 90

91. Obturator hernia It is hernia occurring through obturator canal between superior ramus of pubis and obturator membrane Presents with features of intestinal obstruction Howship-Romberg sign Referred pain in knee joint through geniculate branch of obturator nerve Treatment Laparotomy is done and the sac is identified dissected and ligated If strangulation is present resection and anastomosis is done Mesh place m e nt is the ideal way of repai r ing obturator defect 21-May-23 MOSES OJALE 91

92. Epigastric hernia (Fatty hernia of linea alba) It occurs usually through a defect in the decussation of the fibres of linea alba, any where between xiphoid process and umbilicus. Extraperitoneal fat protrudes through the defect as fatty hernia of the linea alba presenting like a swelling in the upper midline with an impulse on coughing. It is sacless hernia 21-May-23 MOSES OJALE 92

93. Clinical Features Often symptomless Swelling in the epigastric region which is tender. Pain in epigastric region TREATMENT Through a vertical incision, sac is dissected Defectis closed with non-absorbable interrupted sutures Large defect is supported with preperitoneal mesh 21-May-23 MOSES OJALE 93

94. RICHTER’S HERNIA It is a hernia in which the sac contains only a portion of the circumference of the intestine (small bowel). It Is usually seen in femoral and obturator hernia. Clinical Features It mimics gastroenteritis with pain abdomen, diarrhoea,t oxicity, vomiting,Gangrene (strangulation) of a part of bowel occurs, eventually leading to peritonitis Treatment Resection and anastomosis 21-May-23 MOSES OJALE 94

95. Than k s + 21-May-23 MOSES OJALE 95