GIT

Abdominal Wall Hernia

Dr. Samir Al-Saffar FICS - Iraq MRCS - England

Abdominal Wall Hernia

Definition A protrusion of a viscus or part of a viscus through an abnormal opening in the walls of its containing cavity
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Types
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Hernias by themselves usually are harmless, but nearly all have a potential risk of Obstruction if their content is part of bowel. Cut off blood supply of their content ( becoming strangulated).
Introduction
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Aetiology

Acquired: Any condition that increase intra-abdominal pressure; Strong muscular effort Chronic coughing Straining Obesity Chronic smoking
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Aetiology
Congenital: Patent processus vaginalis
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Composion of hernia

Each Hernia consist of Defect or weak point Peritoneal sac Mouth Neck Body Fundus Covering of the sac Contents of the sac
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Contents of the sac

OmentumIntestinePortion of circumference of intestine “Richter “Portion of bladderOvary with or without Fallopian tubeMeckel’s diverticulum “Littre “Fluid الدكتورسمير الصفار

Abdominal Wall Hernia

Anatomical types: External Interparietal Internal Sliding
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Pathological Types: Reducible Irreducible Obstructed Incarcerated Strangulated Inflamed
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Reducible

The hernia either reduces itself when the patient lies down, or can be reduced by the patient or the surgeon.
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Irreducible
Here the contents can not be retuned to the abdomen, but there is no evidence of other complications.
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Obstructed

This is an irreducible hernia containing an intestine which is obstructed but there is no interference of blood supply to the bowel.
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Strangulated

A hernia become strangulated when the blood supply of its contents seriously impaired rendering the contents ischaemic.
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Inflamed

Inflammation of its contents; Appendix Fallopian tube Inflammation of overlying wall
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Locational Types

Groin Umbilicus Epigastric (Linea alba ) Surgical incisions Spigelian (Semi-lunar line) Diaphragm Lumbar triangles Pelvis (Obturator)
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Locational Types

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Groin hernia
Inguinal Femoral
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Inguinal Hernia

Inguinal hernia: Makes up 75% of all abdominal wall hernias and occurring up to 25 times more often in men than women.
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Inguinal Hernia

Indirect Direct
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Anatomy of Groin

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Anatomy of Inguinal Canal

3.75cm in length 1.25 cm cephalad and parallel to inguinal ligament Extends from deep to superficial inguinal rings
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Anatomy of Inguinal Canal

In infants; the canal is almost not present as the DIR and SIR superimposed
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Boundaries of Inguinal Canal
Anterior EOA, CT Posterior CT , TF Upper (roof) CT Lower (floor) IL
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Contents of Canal

Spermatic cord in male and round ligament in female Ileo-inguinal nerve Genital br of genito-femoral nerve
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Indirect Inguinal Hernia

Is the most common of all forms of hernia Most common in young Men > women Right > left 10% of premature babies 5% of adult population
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Indirect Inguinal Hernia

In adults: 65% of all inguinal hernia is indirect 55% right 12 % bilateral
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Indirect Inguinal hernia

Indirect inguinal Incomplete Bubonocele Funicular Complete Inguinoscrotal
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Pathogenesis of Indirect Hernia
Indirect hernia Congenital Acquired
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Pathogenesis of Indirect Hernia

Congenital: Persistent processus vaginalis Within spermatic cord Follows indirect course Complete vs. incomplete sac
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Pathogenesis of Indirect Hernia

Acquired Precipitating factors Increased intra-abdominal pressure Defects in collagen synthesis Smoking
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Clinical Features

Any age Right < Left Male < Female (20 times)
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Presenting symptoms

Swelling appear on standing or coughing Pain in the groin

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Swelling in the groin
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Swelling in the groin descended to scrotum

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Examination Apparent on standing Expensile cough impulse Controlled on pressing over the DIR
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Epigastric hernia
Umbilical hernia
Spigelian Hernia
Inguinal hernia
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Diagnosis
Groin swelling that disappear with supine position Examine erect and supine Does not transilluminate Expensile cough impulse
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How to differentiate IIH from DIH
Indirect Inguinal Hernia May descend into scrotum Protrude through DIR Its neck lateral to inferior epigastric vessels Can be Controlled by pressing on the DIR More liable for irreducibility Could be congenital Not always needs repair during surgery
Direct Inguinal HerniaAlmost never descend into scrotumProtrude directly through Hesselbach’s triangle.Medial to inferior epigastric vesselsCan be controlled by pressing on SIRLess liableAlmost always acquiredRepair is mandatory الدكتورسمير الصفار

When the swelling localized to groin

The differential diagnosis: Femoral hernia Lipoma of cord Inguinal lymphadenopathy Incompletely descended testis Ectopic testis Femoral artery aneurysm

Differential Diagnosis

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When the swelling is inguino-scrotal

Vaginal hydrocele Encysted hydrocele of cord Spermatocele Varicocele Epididymoorchitis Torsion of testis Testicular tumor
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In female Femoral hernia Hydrocele of canal of Nuck Inguinal lymphadenopathy

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Treatment
Operation is treatment of choice: Open surgery The standard method Laparoscopic hernia repair should be reserved for bilateral or recurrent hernia
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Open surgery Herniotomy Herniorrhaphy
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Open surgery

Anaesthesia Local Spinal General
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Herniotomy

Indications: In infants, children and adolescents Steps of surgery: Dissection of sac Open of sac Reduction of contents Transfixation of neck Cut of reminder
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Herniorrhaphy

Repair of stretched DIR and transversalis fascia Reinforcement of posterior wall by: Shouldice repair Mesh repair
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Complications

Bleeding Skin bruises, SC hematoma Scrotal hematoma Retention of urine Wound infection
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Complications

Injury to vas deference Ischemic orchitis Neuralgia Ilioinguinal Iliohypogastric Genitofemoral Lateral cutaneous Recurrence >1%
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Direct Inguinal Hernia

Acquired Adults 35% of inguinal hernia 12% bilateral Not occur in females
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Anatomy of Direct Hernia

Hesselbach’s triangleInguinal ligament (base), rectus (medial), inferior epigastric vessels (lateral) الدكتورسمير الصفار

Hesselbach’s triangle الدكتورسمير الصفار

Direct Inguinal Hernia
Pathogenesis: Through weak posterior wall of inguinal canal Medial to Inferior epigastric vv Not attain large size or descent into scrotum Lies behind spermatic cord Wide neck
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Direct Inguinal Hernia

Varieties Dual ( Pantoloon,saddle bag) Funicular (Prevesical)
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Clinical Features

Swelling in the groin On examination: controlled on pressing on SIR ECI
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Treatment
Surgical repair Dissection of sac Inverted Repair of transversalis fascia Mesh(Lichtenstein) or Shouldice repair
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Strangulated Inguinal Hernia

Can occur at any time More liable to occur in patients with irreducible hernia. More commonly occur in IIH Less often in DIH
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Constricting agent

Neck of sac External inguinal ring Adhesions within the sac
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Content of hernia

Small intestine Omentum Both
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Clinical features

Severe pain in the groin Vomiting General upset Fever ?
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Swelling with skin discoloration in the groin Severely tender Abdominal signs

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Treatment
Urgent surgery Pinciples: Dissection of sac Open the sac Exploration of content Excision of gangrenous tissues
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Gangrenous bowel

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Anatomy of the femoral canal
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Anatomy of the femoral canal

Boundaries of femoral ring Anterior border is the inguinal ligament Posterior border is the pectineal ligament Medial border is the lacunar ligament Lateral border is the femoral vein
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Femoral Hernia

Women> men 20% of hernias in women More in parous Most liable for strangulation
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Clinical features

Rare before puberty May be un-noticed by the patient
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Strangulated hernia Sudden painful swelling in the groin Abdominal symptoms
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Examination

The swelling is inferior to inguinal ligament and lateral to pubic tubercule Mostly irreducible
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Differential Diagnosis

Inguinal hernia Lymphadenopathy Saphena varix Ectopic testis Psoas abscess Distended Psoas bursa Lipoma Rupture of adductor longus
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Treatment

Uncomplicated hernia: Operation as early as possible Strangulated hernia Urgent surgery
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Approaches for the surgeryLow approach – LookwoodHigh approach - McEvedyInguinal approach - Lotheissen الدكتورسمير الصفار

Principle of surgery Dissection of sac Open sac Reduction of contents if healthy otherwise gangrenous tissue must be excised. Repair of femoral ring
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Abdominal wall Hernia

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Richter’s herniaFrequent complication of femoral herniaOnly part of circumference of bowel enclosed in the hernia sac which may become gangrenousClinically; abdominal symptoms of IO but with no constipation. الدكتورسمير الصفار


Diagnosis: High index of suspicion Urgent surgical interference Almost always the diagnosis made at surgery
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Umbilical hernia

In neonates Exomphalos 1/6000 of births Failure of all or part of midgut to return to the coelom
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Umbilical hernia

In infants and children Defect in the umbilical cicatrix Equal sex incidence Black infants 8 times more
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Clinical features

Symptomless More prominent during crying Obstruction or strangulation is rare below 3 years of age Most of cases resolve by itself within 2 years
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Diagnosis

Swelling with umbilical cicatric at fundus of swelling Reducible ECI +ve -----Crying

Treatment

Conservative below the age of 2 years – reassurance of parentsAfter 2 years needs surgical repair الدكتورسمير الصفار

Paraumbilical Hernia

Adults Women> men Risk factors Obesity Pregnancy Repair primarily or with mesh
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Pathogenesis

Weak point in the linea alba just above or just below the umbilical cicatrix Round or oval in shape May sag downwards May become a large size
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The neck of sac is often remarkably small in size Contents; mostly small intestine or omentum or both Sometimes part of transverse colon
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Clinical features

Classical patient; Adult Female (F:M ; 5:1) Aged between 35 and 50 years Overweight multipara
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Symptoms

Abdominal swellingDragging painIntestinal colics—obstructionEpigastric pain (stomachache) الدكتورسمير الصفار


Complications
Irreducibility with possibility of IO Ulceration of skin over fundus of sac Intertrigo
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Diagnosis

Clinical Swelling just above or below the umbilicus Prominent on standing Disappear on lying Expensile cough impulse
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Treatment

Operation is advised in nearly all patients:Indications:Liable for complicationCosmeticThe operation is Herniotomy andRepair;Either Myo’s repairMesh repair

Mesh repair is indicated for Large defect < 4 cm Recurrent hernia

Postoperative complications
Local and specific Collection Hematoma Seroma Infection Wound infection Pus collection Recurrence

Epigastric Hernia(Fatty hernia of linea alba)

Incidence 1-5% Men> women Between xiphoid and umbilicus 20% multiple Repair primarily
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Pathogenesis
Extraperitoneal fat protrusion through decussating fibers at linea alba At sites of blood vessels

Clinical features

Symptomless Accidental finding The size of a Pea Felt not seen Painful ---local pain and tenderness Referred pain----DU like symptoms

Treatment

Operation

Spieghelian Hernia

Rare Hernia through subumbilical portion of semi-lunar line Difficult to diagnose Clinical suspicion (location) CT scan Repair primarily or with mesh

Incisional Hernia

This occurs after 2-10% of all abdominal surgeries, although some people are more at risk. After surgical repair, these hernias have a high rate of returning (20-45%).

Incisional Hernia

Risk factors Technical Wound infection Smoking Hypoxia/ ischemia Tension Obesity Malnutrition Laparoscopic vs. open repair
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Lumbar Hernia
Congenital, spontaneous or traumaticGrynfeltt’s triangle12th rib, internal oblique and sacrospinalis muscleCovered by latissimus dorsiPetit’s triangleLatissimus dorsi, external oblique and iliac crestCovered by superficial fascia

Pelvic Hernia

Obturator hernia Most commonly in women Howship-Romberg sign Sciatic hernia Perineal hernia

Parastomal Hernia

Variant of incisional hernia Paracolostomy > paraileostomy Low rate if through rectus muscle Traditionally relocate stoma, repair defect Concern for mesh erosion Laparoscopic repair
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Abdominal Wall Hernia

Richter’s herniaLittre’s herniaHernia in W Pantallon الدكتورسمير الصفار

Umbilical Hernia

Common in infants Close spontaneously if <1.5 cm Repair if > 2 cm or if persists at age 3-4 years Repair primarily or with mesh