Abdominal wall

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Abdominal wall
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• Paraumbilical hernia of adults
• (syn. supra- or inftaumbilical hernia). In
  adults the hernia does not occur through the
  umbilical scar. It is a protrusion through the
  linea alba just above or sometimes just below the
  umbilicus. As it enlarges, it becomes rounded or
  oval in shape with a tendency to sag downwards.
  Paraumbilical hernias can become very large. The
  neck of the sac is often remarkably narrow as
  compared with the size of the sac and the volume
  of its contents, which consist of greater omentum
  often accompanied by small intestine and,
  alternatively or in addition, a portion of the
  transverse colon. In long-standing cases the sac
  sometimes becomes loculated due to adherence of
  omentum to its fundus.

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• Clinical features
• Women are affected five times more
  frequently than men. The patient is usually
  between the ages of 35 and 50. Increasing
  obesity, with flabbiness of the abdominal
  muscles, and repeated pregnancy are important
  antecedents. These hernias soon become
  irreducible because of omental adhesions within
  the sac. A large umbilical hernia causes a local
  dragging pain by its weight. Gastrointestinal
  symptoms are common and are probably due to
  traction on the stomach or transverse colon.
  Often there are transient attacks of intestinal
  colic due to subacute intestinal obstruction. In
  long-standing cases, intertrigo of the adjacent
  surfaces of the skin is a troublesome
  complication.

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• Treatment
• Untreated, the hernia increases in size,
  and more and more of its contents become
  irreducible. Eventually, strangulation may occur.
  Therefore without undue delay operation should
  be advised in nearly all cases. When small, the
  defect can be closed by a simple repair using
  interrupted unabsorbable sutures for larger
  hernias, a Mayo technique is advisable.
• Or mesh repair can be done

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• Epigastric hernia
• A midline epigastric hernia (syn. fatty
  hernia of the linea alba) occurs through the
  linea alba anywhere between the xiphoid process
  and the umbilicus, usually midway between these
  structures. Such a hernia commences as a
  protrusion of extraperitoneal fat through the
  linea alba, where it is pierced by a small blood
  vessel.
• More than one hernia may be present and
  recurrence can happen due to failure of
  identification of other defect at time of
  original repair.
• A swelling the size of a pea consists of a
  protrusion of extraperitoneal fat only (fatty
  hernia of the linea alba). If the protrusion
  enlarges, it drags a pouch of peritoneurn after
  it, and so becomes a true epigastric hernia. The
  mouth of the hernia is rarely large enough to
  permit a portion of hollow viscus to enter it
  consequently, either the sac is empty or it
  contains a small portion of greater omentum.

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• Clinical features.
• Symptomless. A small fatty hernia of the linea
  alba can be felt better than it can be seen, and
  may be symptomless, being discovered only in the
  course of routine abdominal palpation.
• Painfnl. Sometimes such a hernia gives rise to
  attacks of local pain (worse on physical
  exertion) and also tenderness to touch and tight
  clothing possibly because the fatty contents
  become nipped sufficiently to produce partial
  strangulation.
• Referred pain (dyspeptic cases). It is not
  uncommon to find that the patient, who may not
  have noticed the hernia, complains of pain
  relating to digestion. Which may simulate
  features of peptic ulcers.
• Treatment. If the hernia is giving rise to
  symptoms, operation should be undertaken. It is
  essential to mark the hernia before the
  anaesthesia is given as it may be impossible to
  locate the defect if the fatty protrusion
  retracts into the abdomen.

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• ABDOMINAL WALL
• BURST ABDOMEN AND INCISIONAL HERNIA
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• Factors relating to the incidence of burst
  abdomen and incisionsal hernia.
• Technique of wound closure
• choice suture materials catgut leads to a
  higher incidence of bursts than the use of
  non-absorbable monofilament polypropylene.
  Polyamide.

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• method closure interrupted suturing has a
  low incidence. Thru and Thru suturing is good
  for the obstructed case. A one-layer closure has
  low incidence but it is higher than that
  following a two-layered closure. Interrupted far
  and near sutures are a recommended technique for
  single layer mass closures. When continuous
  suturing of layers (one or two) is performed a
  particular fault is the use of a short length of
  material, pulled tightly, for in an anaesthetised
  relaxed patient the incision is shortened
  thereby, and made taut so that the material will
  act as if it were a cheese wire cutter when the
  patient is conscious and coughing.
• drainage directly through a wound leads to a
  higher incidence of bursts than employing
  drainage through a separate (stab) incision.

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• Factors relating to incisions.
• Midline and vertical incisions have a tendency to
  burst which is higher than those which are
  transverse.
• Reason for operation
• Infected case deep wound infection has a
  notorious reputation for causing burst abdomen
  and/or late incisional hernia. Operations on the
  pancreas, with leakage of enzymes, and on
  obstructed cases are other reasons for
  disruption.
• Coughing, vomiting distension. At the
  completion of an operation any violent coughing
  set off by the removal of an endotracheal tube
  and suction of the laryngopharynx strains the
  sutures. Likewise cough, vomiting and distension
  (e.g. due to ileus) in the early postoperative
  period. Overvigorous postoperative ventilation in
  sedated patients can lead to wound disruption.

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• Causes of burst abdomen
• Poor closure technique
• Deep wound infection
• Coughing or vomiting
• Poor metabolic state of patient

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• General condition of the patient.
• Obesity, jaundice, malignant disease,
  hypoproteinaemia. anaemia are all factors
  conducive to disruption of a laparotomy wound
  Abdominal wounds in pregnancy are notorious for a
  high risk of disruption.

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• Burst abdomen and incisional hernia
• In 12 of cases, mostly between the sixth and
  eighth day after
• operation, an abdominal wound bursts open and
  viscera are
• extruded. The disruption of the wound tends to
  occur a few days
• Before hand when the sutures apposing the deep
  layers (peritoneum,posterior rectus sheath) tear
  through or even become untied. An incisional
  hernia usually starts as a symptomless partial
  disruption of the deeper layers during the
  immediate or early postoperative period, the
  event passing unnoticed if the skin wound remains
  intact after the skin sutures have been removed.

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• Burst abdomen (syn. abdominal dehiscence)
• Clinical features. A serosanguineous (pink)
  discharge from the wound is a forerunner of
  disruption in fully 50 per cent of cases. It is
  the most pathognomonic sign of impending wound
  disruption, and it signifies that intraperitoneal
  contents are lying extraperitoneally. Patients
  often volunteer the information that they felt
  something give way. If skin sutures have been
  removed, omentum or coils of intestine may be
  forced through the wound and will be found lying
  on the skin. Pain and shock are often absent. It
  is important to note that there may be symptoms
  and signs of intestinal obstruction.
• Treatment. An emergency operation is required to
  replace the bowel, relieve any obstruction, and
  to resuture the wound. While awaiting operation,
  reassure the patient and cover the wound with a
  sterile towel. The stomach is emptied by a
  gastric tube and intravenous fluid therapy
  commenced.

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• Incisional hernia (syn. ventral hernia
  postoperative hernia)
• Aetiology. Incisional hernia occurs most often in
  obese individuals, and a persistent postoperative
  cough and postoperative abdominal distension are
  its precursors. There is a high incidence of
  incisional hernia following operations for
  peritonitis because, as a rule, the wound becomes
  infected. The placing of a drainage tube through
  a separate stab incision, as opposed to bringing
  such a tube through the laparotomy wound, reduces
  the frequency.
• An incisional hernia usually starts as a
  symptomless partial disruption of the deeper
  layers of a laparotomy wound during the immediate
  or very early postoperative period. Often the
  event passes unnoticed if the skin wound remains
  intact after the stitches have been removed. A
  serosanguineous discharge is often the signal of
  dehiscence, and resuture of the deeper disrupted
  layers of the incision obviates the more
  difficult repair of an established and much
  larger hernia later on

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• Clinical features.
• There are great variations in the degree of
  herniation. The hernia may occur through a small
  portion of the scar, often the lower end. More
  frequently there is a diffuse bulging of the
  whole length of the incision. A postoperative
  hernia, especially one through a lower abdominal
  scar, usually increases steadily in size, and
  more and more of its contents become irreducible.
  Sometimes the skin overlying it is so thin and
  atrophic that normal peristalsis can be seen in
  the underlying coils of intestine. Attacks of
  subacute intestinal obstruction are common, and
  strangulation is liable to occur at the neck of a
  small sac or in a loculus of a large one,
  Nevertheless, most cases of incisional hernia are
  asymptomatic and broad-necked and do not need
  treatment.

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• Treatment.
• Palliative. An abdominal belt is sometimes
  satisfactory, especially in cases of a hernia
  through an upper abdominal incision.
• Operation. Many procedures are advocated, which
  is testimony to the facts that the repairs may be
  difficult to accomplish and no single procedure
  is dearly superior to the rest.

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