abdominals hernia

8/8/2019 Abdominals Hernia

1/30

Abdominal wall herniasAbdominal wall hernias

general consideration

inguinal hernias femoral hernia

incisional hernia

umbilial hernia

hernia of linea alba


2/30

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 anopening or fascial defect in the abdominal wall.

most occur in the grion


3/30

Etiology1. intensity of abdominal wall decreased

common factors:

1) site that some tissues pass through the abdominal wall, eg. Spermatic

cord, round ligament of uterus2) 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


4/30

Pa

thologica

la

na

tomycomposed of:

covering tissue: skin, subcutanous tissue

hernial sac: protrusion of peritonum,

neck of the sac: is narrow where the sac emerges fromthe abdomen body of the sac

hernial contents: small intestine, major omentum


5/30

Clinical types1. 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 bereturned 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


6/30

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 incarceratedhernia: reduction of the hernial contents

( intestine ) into abdominal cavity.


7/30

Inguinal hernias

inguinal hernia: a protrusion of part of the contents of the abdomen throughthe

inguinal region of the abdominal wall.

indirect inguinal hernia: the internal inguinal ringp the inguinal canalp

external

inguinal ringp scrotum

direct inguinal hernia: Hesselbachs triangle

Anatomy

1. Anatomic layers

1) skin, subcutaneous tissue2) 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.


8/30

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.


9/30

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


10/30

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.


11/30


12/30

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 manifestationand 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


13/30


14/30


15/30

Differential diagnosis 1dydrocele 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:


16/30

2. operations for inguinal hernia

conventional repairsPrinciples: 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


17/30

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


18/30


19/30


20/30


21/30


22/30


23/30

3. management rule of incarcerated and strangulated herniaIndications for manual reduction:

1) duration


24/30

Femoral hernia

introduction

Femoral hernia is a protrusion of peritoneum through the femoral canal.

Usually in women >40 years

Causes: laxity of groin tissue elevated intra-abdominal canal

Anatomy of femoral canalFemoral ring fossa ovalis

Anterior: inguinal ligament

Posterior: pectineal ligament

Medial: lacunar ligamentLateral: femoral vein


25/30

Pathologicanatomyfemoral ring

femoral canal

fossa ovalis

subcutaneous tessue of the thighHigh incidence of strangulation


26/30

Clinical findingsand diagnosis

Reducible femoral hernia: asymptomatic lump, localized intermittent

discomfort

Irreducible femoral hernia: constant lump and localized discomfort

Strangulated femoral hernia

Differential diagnosis1. indirect inguinal hernia

2. lipoma

3. groin lymph nodes

4. long saphenous varix5. iliolumbar tuberculous abscess


27/30

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 ofinguinalhernia


28/30

Other abdominal external hernia

Incisional hernia

Incisional hernia: an abnormal protrusion of a viscus through the

musculoaponeurotic layers of a surgical scar.

Wound dehiscence

EtiologyPreoperative 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.


29/30

Clinical featuresand 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 lump3) usually disappear by the age of 2 years

4) rarely incarcerate

5) surgical repair >2 years


30/30

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

abdominals hernia

Documents