Abdominal wall & hernia

Prof M K Alam

ILOs

• At the end of this presentation students will be able to: Describe the aetiology, presentation of rectus sheath

hematoma. Describe the aetiology, presentation of desmoid tumor. State the anatomy of inguinal canal, femoral canal and

umbilicus. Describe the aetiology, risk factors, presentation,

complications and management of groin hernias. Differentiate between different types of groin hernia. Describe the presentation and management of other

abdominal wall hernias.

Diseases of Umbilicus

• Persistent vitello-intestinal duct: Persistent part- Meckel’s diverticulum. Whole patent duct forms fistula between ileum & umbilicus. Foul discharge. Treated by excision.

• Persistent urachus: Cyst or urinary fistula.• Tumours: Primary- SCC, Melanoma Secondary:

Tumour tracking along ligamentum teres.• Hernia

Rectus sheath haematoma

Aetiology: Spontaneous (anticoagulation)

Traumatic (excessive physical activity).

Bleeding from inferior epigastric artery.

Present as painful, tender swelling.

Diagnosis-U/S.

Treatment: Spontaneous

resolution or surgical evacuation.

Desmoid tumour

• Fibromatosis from fibroaponeurotic part of rectus abdominis.

• More common in young female of child bearing age, OC use.

• Other sites- extremity, intra-abdominal.

• Asymptomatic slow growing mass.

• Diagnosis: CT or MRI for delineation, core needle biopsy.

• Treatment: Wide local excision. Local

recurrence high if margins are involved. Recurrence

treated by radiotherapy, anti-oestrogen or NSAID

(Sulindac, indomethacin)

Rapid growing- chemotherapy

Abdominal wall hernia• Definition: Abnormal protrusion through weakness in

the wall of the cavity. It carries with a peritoneal sac.

• Contributing factors: Chronic cough, obesity, straining (constipation), repeated pregnancy, family history, ascites, defective collagen synthesis, heavy lifting, RLQ incision.

• Inguinal, femoral, PUH, epigastric & incisional

• Reducible & irreducible

• Obstructed & strangulated hernia

Inguinal hernia

• Incidence: • Indirect Inguinal Hernia (60%),• Direct Inguinal Hernia(25%) • Femoral hernia (15%)• Anatomy of inguinal canal:

Indirect Inguinal hernia

• Enters through deep ring within a sac.• Dragging discomfort• Lump• Cough impulse, reducibility• Deep ring occlusion test• Irreducible with features intestinal obstruction

(obstructed hernia)• Above features with severe pain in hernia, skin

redness and very tender- strangulated hernia

Direct inguinal hernia

• Bulges through weakness of Hasselbach’s triangle• Wide neck so rarely obstructs or strangulates• Appears as wide bulge• Often spontaneously reduces after cough or lying• Deep ring occlusion does not control

Management• All IH in children and most IH in adult ( if fit for

surgery) recommended repair.• Preoperative investigations for fitness.• Done mostly as a day case• Local, regional or general anaesthesia• Laparoscopic or open surgical repair• Open repair IH: Herniotomy + mesh repair• DH: No sac excision, sac reduced, weakness/

defect of fascia transversalis repaired, then mesh applied to posterior inguinal wall as in IH

Femoral hernia

• Projects through femoral ring and passes down the femoral canal (1.25 cm)

• Bound laterally by a thin septum separating it from Femoral vein, anteriorly- inguinal ligament, medially- lacunar ligament and posteriorly- superior ramus of pubis & pectineal ligament of Cooper.

• Appears through the saphenous opening in deep fascia, appear to lie in front of inguinal ligament

Clinical features

• Groin swelling (often small), groin pain on exercise • Sometimes difficult to distinguish with IH• Examination: Put a finger tip over pubic tubercle (How

to find it?).• IH- above & medial, FH- below & lateral• Often irreducible due to its curved course.• Obstruction, strangulation rate high (40%)• D/D: LN, saphenous varix (thrill on cough, disappears

on lying down), ectopic testis, psoas abscess

Treatment

• Advise Surgery to all• Surgery under local/ GA• Open surgery: Sac is dissected, contents

reduced & femoral ring obliterated by suturing inguinal ligament to pectineal ligament.

• Laparoscopic approach.

Epigastric hernia

• Protrusion through a defect in linea alba• Firm midline lump.• Often contains preperitoneal fat. • Sometimes peritoneal sac with omentum. • Open surgical repair by non-absorbable suture

or mesh• Laparoscopic repair- if large

Umbilical, Para-umbilical hernia

• UH: Protrusion through umbilicus. Seen infants when they cry. Most- spontaneous resolution by age 3, If not- surgical repair

• PUH: Protrusion through tissue around umbilicus• Hernia gradually enlarges, stretching overlying skin• Defect multilocular, irreducible due to adhesion• More common in female• Surgery advised- high risk of obstruction/ strangulation

Surgery for PUH

• Open Surgery: Transverse skin incision. Sac dissected, contents reduced, sac excised and defect repaired by simple suture, Mayo’s repair or mesh repair if large defect (>3cm)

• Laparoscopic repair

Incisional hernia• Hernia bulging through poorly healed abdominal

incisions• More common with midline vertical incisions• Predisposing factors: Poor surgical technique,

infection, obesity, chest infection and collagen disorders.

• Defects may be multiloculated• Cough impulse, defects felt on reducing hernia• Risk of obstruction/ starngulation

Surgical repair

• Open surgery: Prolene mesh repair• Laparoscopic mesh repair: Less postoperative

pain, shorter hospital stay• Mesh repair complications: Seroma, infection• Laparoscopic repair: Less hernia recurrence

Rare external hernias

• Spigelian hernia: through linea semilunaris at the lateral border of rectus abdominis. Surgical repair

• Lumber hernia bulges above iliac crest between posterior border of ext. oblique & latissimus dorsi.

• Obturator hernia through obturator canal. Common in female. Diagnosis usually made at laparotomy for intestinal obstruction due to strangulated hernia.

Complications of hernia

• Incarcerated: Hernia contents are irreducible but

not obstructed or strangulated.

• Obstructed: Irreducible hernia presenting with

intestinal obstruction.

• Strangulated: When blood supply to the contents

is jeopardized in an irreducible hernia.

Thank you!