Ventral hernia

Ventral hernia

1. Ventral hernia Prepared by Dr. Pranjal Rokaya Resident General Surgery Moderator Dr. Ellina Dangol 25th September 2022

2. Outline Anatomy of the ventral abdominal wall Introduction Classification History and examination of hernia Specific hernia: Management.

3. Anatomy of anterior abdominal wall

4. Anatomy: Rectus sheath

5. Hernia Protrusion or bulging of part of the contents of abdominal cavitiy through a weakness in the abdominal wall.

6. Biomechanical basis of herniation Pascal’s law of pressure Laplace law of wall tension

7. …Pathophysiology The Abdominopelvic cavity is a cylinder enveloped by muscles, tendons, and bony structures. If intraabdominal pressure > abdominal wall pressure, the wall ruptures at the weakest point causing herniation. Once hernia forms will continue to enlarge due to increased wall tension.

8. Anatomical causes of hernia Excessive intraabdominal pressure Basic design weakness Weakness due to structures entering and leaving the abdomen. Developmental failures. Genetic weakness of collagen. Sharp and blunt trauma. Weakness due to aging and pregnancy.

9. Risk factors Constipation Prostatic symptoms Chronic cough Obesity

10. Types of hernia Based on Complexity Occult Reducible Irreducible Strangulated Infarcted Based on location Internal External Ritcher’s hernia : Only a part of bowel enters the hernia

11. Based on location Ventral wall hernia Epigastric hernia Umbilcal hernia Spiegelian hernia Incisional hernia Parastomal hernia Flank hernia Superior lumbar hernia Inferior lumbar hernia Groin hernia Inguinal hernia Femoral hernia Pelvic hernia Sciatic hernia Obturator hernia Perineal hernia

12. Hernia: Locations

13. European Hernia Society Classification

14. History Self-diagnosis common Usually painless but may complain of aching or heavy sensation. Severe pain suggests strangulation. Symptoms of bowel obstruction. History of previous surgery.

15. Examination Examined lying down initially, then standing. Cough impulse Reducibility Tenderness Overlying skin color changes Multiple defects Signs of the previous repair. Scrotal content for groin hernia

16. Investigation For most, no investigation required, just clinical examination. Chest Xray: diaphragmatic hernia/ hiatus hernia. Ultrasound: In irreducible hernia when differential includes mass or fluid collection. CT scan: In complex incisional hernia (number and size of defects, identifying content, presence of adhesions). Laparoscopy: Feasibility of lap repair.

17. Principles of hernia repair Reduction of hernia content into the abdominal cavity with the removal of any nonviable tissue and bowel repair if necessary. Excision and closure of peritoneal sac or replacing it back. Reapproximation of walls of neck of hernia. Permanent reinforcement of wall defect with sutures or mesh.

18. Mesh in hernia repair To bridge a defect To plug a defect To augment a repair Should have good overlap, at least 2 cm up to 5 cm.

19. Mesh characteristics Woven, knitted, or sheet. Synthetic vs biologic. Light, medium, or heavyweight. Large pore vs small pore Intraperitoneal use or not. Noabdorbable vs absorbable.

20. Locations of mesh placement

21. Ventral hernias

22. a. Umbilical hernia: Children Occurs in upto 10% of infants. Within few weeks of birth, often symptomless. Increases in size on crying and assumes conical shape. Obstruction extremely rare below 3 years. 95% will resolve spontaneously. If persist beyond 2 years, sugical repair indicated.

23. Umbilical hernia: Adult Conditions that stretch linea alba predisposes to opening of umbilical defect. Defect rounded with well defined fibrous margin. Small hernia: Peritoneal fat or omentum Larger hernia : small or large bowel

24. Clinical picture: Umbilical hernia Commonly overweight with thinned and attenuated midline raphae. Bulge typically to one side of umbilical depression creating crescent appearance. Women > Men Pain due to tissue tension or symptoms of bowel obstruction. Overlying skin may become thinned, stretched and develop dermatitis.

25. Treatment: Umbilical hernia Open umbilical hernia repair Defects less than 2 cm Very small defects (<1 cm)closed with the simple figure of 8 suture or darn technique.

26. Mayo’s repair of small umbilical hernia

27. Defects larger than 2 cm: Mesh repair recommended i. Within peritoneal cavity Tissue separating mesh placed through defect on the underside of abdominal wall. Ideally 5 cm overlap. Expensive mesh.

28. ii.In retromuscular space Linea alba opened vertically, b/l posterior sheath incised exposing rectus. Muscle elevated, mesh placed and sutured. Mesh should overlap midline by 5 cm laterally and umbilicus vertically. Very secure but requires extensive dissection.

29. iii. In extraperitoneal space Plane between posterior rectus sheath and peritoneum. Care taken to avoid button holing peritoneum. If peritoneum damaged suring repair, alternative sought. d. In subcutaneous plane (Onlay) Mesh placed over anterior rectus sheath and sutured. Prone to infection

30. b. Lap umbilical hernia repair Three ports placed laterally. Contents of hernia reduced by traction and external pressure. Falciform ligament and median umbilical fold may be taken down. Nonadherent mesh introduced, centered and fixed to peritoneum and posterior rectus sheath. May cause severe pain lasting 24-48 hours.

31. b. Epigastric hernia Through linea alba between xiphoid process and the umbilicus. Defect where small blood vessels pierce linea alba or due to abnormal decussation of aponeurotic fibres. Usually less than 1 cmm, contains usually extraperitoneal fat . Rarely contains bowel. More than one hernia may be present. Frequency: 3-5% among all hernias

32. Clinical picture: Epigastric hernia Fit healthy men aged 20 to 45 years. May be very painful due to partial strangulation of fat. Soft midline swelling often felt rather than seen. Unlikely to be reduced. May resemble lipoma. Cough impulse may or may not be felt.

33. Treatment: Epigastric hernia Very small hernia known to diappear due to infarction of fat. Small to moderate sized hernia w/o sac not inherently dangerous. Surgery for symptomatic hernia: open or laparoscopic . At open surgery, vertical or transverse incision made. Protuding extraperitoneal fat simply excised or pushed back.

34. Treatment: Epigastric hernia Defect closed with nonabsorbable sutures in adult and absorbable in children. In large hernia, approach similar to umbilical hernia. Lap repair also similar except defect is hidden behind falciform ligament.

35. Repair of small epigastric hernia

36. c. Spiegelian hernia Spiegelian fascia extend between transversus muscle and lateral edge of rectus sheath. Most hernia appear below the level of umbilicus but can be found anywhere along spiegelian line. More common in elderly, male and female equally affected.

37. Clinical picture: Spiegelian Intermittent pain due to pinching of fat. Lump may or may not be palpable. Older patients: reducible swelling at edge of rectus sheath with symptoms of intermittent obstruction. Diagnosis usually confirmed with CT scan.

38. Treatment: Spiegelian hernia Surgery recommended as narrow and fibrous neck predisposes to strangulation. In open surgery, no abnormality seen until external oblique (EO) opened. Sac and contents dealt with, defect repaired with suture or mesh, laid deep to EO aponeurosis. Lap approach if no sac visible.

39. d. Incisional hernia Arise through defect in musculofascial layers of abdominal wall in region of postoperative scar. Reported in 10-50% of laparotomy incisions and 1-5% of laparoscopic port sites. Predisposing factors: Patient factors Wound factors Surgical factors Obesity SSI Inappropriate suture material Malnutrition Incorrect suture placement Steroid therapy Chronic cough

40. Clinical picture: Incisional hernia Localized swelling in small scar but may also bulge in the entire incision length. May have several discrete hernias along the length of the incision. Unsuspected defects may be found during surgery. Attacks of partial bowel obstruction. Most incisional hernia broad necked and thus low risk of strangulation.

41. Incisional hernia grading system Stage I : Low recurrence, low SSO Les than 10 cm, clean II: Moderate recurrence, moderate SSO L ess than 10 cm, contaminated 10-20 cm, clean III: High recurrence, high SSO M ore than 10 cm, contaminated Any more than 20 cm Combined from Ventral hernia working group grading scale and EHS classification

42. Treatment: Incisional hernia Asymptomatic hernia may not require treatment. Use of abdominal binder prevent increase in size. Surgical repair should cover whole length of previous incision. Approximation done with minimal tension and mesh placed. Mesh contraindicated in a contaminated field.

43. Treatment: Incisional hernia Open repair Previous incision opened to full length to reveal unsuspected defects. Hernial sac isolated, sac opened, contents reduced and local adhesions divided. Mesh can be placed in several planes, retrorectus sublay popular.

44. Incisional hernia: Retrorectus sublay repair Vertical incision through the fascia to separate and elevate muscles. Medial edges of posterior sheath sutured. Mesh must be large enough to ensure a 5 cm overlap. Anterior sheaths are sutured together over the mesh. Suction drainage to prevent seroma.

45. Incisional hernia: Laparoscopic repair Laparoscopy and division of adhesions. Hernial content reduced and margins of defect exposed. Falciform ligament and median umbilical fold taken down. Fix the mesh under defect with adequate overlap. Tissue separating mesh is essential. Mesh fixed with staples or transfascial sutures passing through all muscle layers.

46. Very large incisional hernia If volume of sac more than 25% of volume of abdominal cavity. Content may not fit back or if they do, result in high tension. Techniques: Preoperative abdominal expansion with progressive preoperative pneumoperitoneum over several weeks. Resection of omentum and colon. Use of mesh to span unclosable gap. Relaxing incisions in EO aponeurosis or posterior sheath

47. Risk reduction: Incisional hernia Optimize patients prior to surgery. Closure of fascial layers with nonabsorbable or slowly absorbable suture. The optimal length of suture length to wound length is 4:1. Classical teaching: suture 1 cm deep and 1 cm wide is out of favor. Drains are brought out through the separate incision. Placement of prophylactic mesh.

48. e. Parastomal hernia Muscle defect created suring stoma formation tend to increase in size. Rate of formation over 50%. Ideal solution is to rejoin bowel and remove stoma altogether. Stoma may be resited but recurrence likely. Mesh best placed in retromuscular space. Use of prophylactic mesh at time of stoma creation.

49. Pros and Cons of Lap repair PROS CONS 1. Accurately identifies all fascial defects. 1. Adhesiolysis may be difficult with increase potential for enterotomy. 2. May identify unsuspected intraperitoneal pathology. 2. Hard to get good fixation for defects at margin of cavity. 3. Approaches fascia through ‘ clean field’

50. References Bailey and Love 27th edition. Maingot’s abdominal operation. Sabiston’s textbook of surgery.

51. Thank You.