Abdominal wall hernias

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Abdominal wall hernias

• general consideration
• inguinal hernias
• femoral hernia
• incisional hernia
• umbilial hernia
• hernia of linea alba

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• general consideration
• Definition
• Hernia means a sprout, and protrusion.
• External abdominal wall hernia is an abnormal
  protrusion of intra-abdominal tissue or the
  whole or part of a viscera through an opening or
  fascial defect in the abdominal wall.
• most occur in the grion

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• Etiology
• 1. intensity of abdominal wall decreased
• common factors
• 1) site that some tissues pass through the
  abdominal wall, eg. Spermatic
• cord, round ligament of uterus
• 2) bad development of abdominal white line
• 3) incision, trauma, infection et al.
  
• defect in collagen synthesis or
  turnover
• 2. any condition which increases
  intra-abdominal pressure
• chronic cough, chronic constipation,
  dysuria, ascites, pregnancy, cry

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• Pathological anatomy
• composed of
• covering tissue skin, subcutanous tissue
• hernial sac protrusion of peritonum,
• neck of the sac is narrow where the
  sac emerges from
• the abdomen body of the sac
• hernial contents small intestine, major omentum

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• Clinical types
• 1. reducible hernia is one in which the
  contents of the sac return to the abdomen
  spontaneously or with manual pressure when the
  patient is recumbent.
• 2. irreducible hernia is one whose contents
  or part of contents cannot be returned to the
  abdomen, without serious symptoms.
• hernias are trapped by the narrow neck
• Sliding hernia is one in which the wall of
  a viscus forms a portion of the wall of the
  hernia sac. It is may be colon ( on the left),
  caccum (on the right) or bladder (on either
  side).
• Belongs to irreducible hernia

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• 3. incarcerated hernia is one whose contents
  cannot be returned to the abdomen, with severe
  symptoms.
• 4. strangulated hernia denotes compromise to
  the blood supply of the contents of the sac.
• incarcerated hernia and strangulated hernia
  are the two stages of a pathologic course
• Richters hernia (intestinal wall hernia )
• a hernia that has strangulated or
  incarcerated a part of the intestinal wall
  without compromising the lumen.
• Littre hernia a hernia that has incarcerated
  the intestinal diverticulum (usually Meckel
  diverticulum).
• Reductive incarcerated hernia reduction of
  the hernial contents ( intestine ) into abdominal
  cavity.

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• Inguinal hernias
• inguinal hernia a protrusion of part of the
  contents of the abdomen through the
• inguinal region of the
  abdominal wall.
• indirect inguinal hernia the internal inguinal
  ring ? the inguinal canal ? external
• inguinal ring ? scrotum
• direct inguinal hernia Hesselbachs triangle
• Anatomy
• 1. Anatomic layers
• 1) skin, subcutaneous tissue
• 2) external oblique muscle, aponeurosis
• Subcutaneous (external) inguinal ring
• Triangular opening, in the aponeurosis of
  the external oblique just superior and lateral to
  the pubic tubercle.

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• Inguinal ligament it is formed as the lateral
  edge of the aponeurosis of external oblique rolls
  upon itself and thickens into a cord, extending
  from the anterior superior iliac spine to the
  pubic tubercle.
• Lacunar ligament
• Coopers ligament (pectineal ligament)
• Sensory nerves iliohypogastric nerve,
  ilioinguinal nerve
• 3) internal oblique muscle and tranverse
  abdominal muscle
• Conjoined tendon ( flax inguinalis) the lower
  fibers of the internal oblique muscle fuse with
  the lower most arching fibers of the transverse
  muscle of the abdomen and insert with them into
  the pubic tubercle, forming the conjoined tendon.
  

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• 4) Transversalis fascia
• Internal inguinal ring is the point at which the
  spermatic cord or round ligament passes through
  the transversalis fascia to enter the inguinal
  canal.
• surface marking 2cm superior to the point
  midway between the anterior superior iliac spine
  and the pubic tubercle.
• Iliopubic tract it is the thickest portion of
  the transversalis fascia in the inguinal region.
  It parallels and lies just medial to the inguinal
  ligament.
• 5) extraperitoneal fat and peritoneum

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• 2. Anatomy of inguinal canal
• Contents spermatic cord, round ligament,
  ilioinguinal nerve
• Walls
• anterior skin, superficial fascia, and
  external ablique aponeurosis
• posterior transversalis fascia
• superior conjoined tenden
• inferior inguinal ligament
• 3 Hesselbachs triangle
• Bounded by the inguinal ligament, the
  inferior epigastric vessels, and the lateral edge
  of rectus muscle.

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• Causes of indirect inguinal hernia
• 1. congenital abnormality of anatomy
• due to failure of fusion of the
  processus vaginalis peritonei after the
• testis has descended into the scrotum.
• 2. acquired weakness or defect of abdominal
  wall
• Clinical manifestation and diagnosis
• Symptoms pain, discomfort, dragging
  sensation
• Sign reducible or irreducible lump,
  expansile cough impulse
• Reducing the hernia fully, compress the
  internal ring
• be controlled indirect not
  controlled -- direct

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Differences between indirect and direct hernia
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• Differential diagnosis
• 1 dydrocele of testis translucent test ()
• 2 communicated hydrocele
• 3 hydrocele of cord not reducible
• 4 undescended testis
• 5 acute intestinal obstruction
• Treatment
• 1. nonoperative therapy
• Indications
• lt1 year old
• elderly patients or with severe systemic
  disease--truss

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• 2. operations for inguinal hernia
• conventional repairs
• Principles excision or reduction of the hernial
  sac, high ligation of the sac,
• and repair the walls of the
  inguinal canal
• A high ligation of hernia sac
• Used in infants, and patients with
  severe local infection
• B repair of walls of the inguinal cancal
• I repair of the anterior wall of the
  inguinal canal
• Ferguson repair
• II Repair of the posterior wall
• Bassini repair
• Halsted repair placing the latter in
  a subcutanous position

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• McVay repair lower edge of internal oblique
  muscle and the conjoined tendon are approximated
  to Coopers ligament on the iliopectineal line of
  the pubis.
• Shouldice repair the posterior wall of the
  inguinal canal is repaired by dividing the
  transversalis fascia from the pubis to adjacent
  to the inferior epigastric vessel, then imbricate
  sutures.
• Internal ring pass a fingertip
• 2) tension-free hernioplasty
• insertion of a prosthetic mesh
• 3) laparoscopic repair of inguinal hernia

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• 3. management rule of incarcerated and
  strangulated hernia
• Indications for manual reduction
• 1) duration lt3-4 hours, no local tenderness, no
  abdominal tenderness, no rigidity of abdominal
  muscle
• 2) elderly patients or with other severe
  diseases, and the intestinal loop is still alive
• Usually requires emergency operation
• 4. Management rule of recurrent inguinal hernia
• 1) true recurrent hernia
• 2) concomitant hernia
• 3) new occurring hernia

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• Femoral hernia
• introduction
• Femoral hernia is a protrusion of peritoneum
  through the femoral canal.
• Usually in women gt40 years
• Causes laxity of groin tissue elevated
  intra-abdominal canal
• Anatomy of femoral canal
• Femoral ring fossa ovalis
• Anterior inguinal ligament
• Posterior pectineal ligament
• Medial lacunar ligament
• Lateral femoral vein

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• Pathologic anatomy
• femoral ring
• femoral canal
• fossa ovalis
• subcutaneous tessue of the thigh
• High incidence of strangulation

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• Clinical findings and diagnosis
• Reducible femoral hernia asymptomatic
  lump, localized intermittent
• discomfort
• Irreducible femoral hernia constant lump
  and localized discomfort
• Strangulated femoral hernia
• Differential diagnosis
• 1. indirect inguinal hernia
• 2. lipoma
• 3. groin lymph nodes
• 4. long saphenous varix
• 5. iliolumbar tuberculous abscess

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• Treatment
• Not be treated conservatively
• Rule operation excision or reduction of the
  hernial sac, and narrowing of the stretched
  femoral opening
• methods
• McVay repair
• tension-free hernioplasty
• laparoscopic repair of inguinal hernia

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• Other abdominal external hernia
• Incisional hernia
• Incisional hernia an abnormal protrusion of a
  viscus through the
• musculoaponeurotic layers of a surgical scar.
• Wound dehiscence
• Etiology
• Preoperative factors
• Operative factors
• types of incision vertical incision,
  transrectus incision, midline
• incision, standard parmedian incision
• technique of closure
• suture materia
• Postoperative factors increased intra-abdominal
  pressure, et al.

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• Clinical features and diagnosis
• Swelling and mass in the incision
• Hernial ring
• Rarely incarcerate
• Treatment
• Operative repair the same way as a laparotomy
  wound is repaired, or use mesh
• Umbilical hernia
• 1 infantile umbilical hernia
• 1) failure of fusion of umbilical ring, or
  weakened umbilical tissue
• 2) symptomless, reducible lump
• 3) usually disappear by the age of 2 years
• 4) rarely incarcerate
• 5) surgical repair gt2 years

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• 2 Adult umbilical hernia
• 1) acquired hernia
• 2) more common in females
• 3) incarceration is common
• 4) surgical repair excision of the sac, suture
  the hernia ring
• Hernia of linea alba
• Epigastric hernia
• It is a protrusion of preperitoneal fat and / or
  peritoneal sac through a gap
• in the decussating fibers of the linea alba,
  usually the supraumbilical
• portion of the linea alba.
• Most are asymptomatic, or vague upper abdominal
  pain and nausea may
• be present.
• Surgical repair