Download - Hernia & abd wall lecture
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BY
PROF. TAREK GOBRANPROF. OF GENERAL AND PEDIATRIC
SURGERY
HERNIA and ABDOMINAL WALL DEFECTS
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DEFINITION
Protrusion of a viscus or part of it through a defect in the wall of the containing cavity
It is either internal or external
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ETIOLOGY
Predisposing factors:- Increase of intra-abdominal pressure- Pregnancy- Congenital preformed sac- Undescended testis- Obesity- Collagen abnormalities
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COMPOSITION
Sac
Coverings
Contents
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Sac
Neck
Body
Fundus
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Coverings
Layers of abdominal wall through which the sac passes
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Contents
Omentum ----- omentoceleIntestine ------ entroceleOvary ,tubesPortion of intestinal wall ---- Richter’s HMeckel’s diverticulum ---- Littre’s H
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Complications
Irreducible
Obstructed
Inflamed
Strangulated
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Contents can not reduced back to abdomen
Causes:- Adhesions- Large contents and
narrow neck
IRREDUCIBLE HERNIA
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Hernia content balloons over external ring when reduction is attempted.
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Obstructed Hernia
Irreducible hernia with obstructed intestinal lumen without interference with blood supply
Clinically ----- colic, constipation, vomiting, .......
Sometimes it is difficult to differentiate from strangulation so it is better to be managed as strangulated hernia
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Strangulated hernia
= Serious impairment of blood supply of the contents with or without obstruction ----- ischemia ----- if not treated within 5-6 hrs ------ gangrene
In strangulation venous impairment occurs first ---- intestinal congestion & edema ------- more congestion &edema ----- arterial impairment ------ ischemia ---- exudation of blood into the sac + bacterial transudation through the wall ( infected toxic fluid in the sac ) ------ gangrene ----- perforation
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Clinical Features
Sudden onset of pain +/- signs of intestinal obstruction
Local signs:- Irreducible- No impulse with cough- Tense- TenderIf not treated early ----- perforation -----
peritonitis ----- septic shock
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Strangulated hernia without obstruction
- Strangulated omentum
- Strangulated ovary- Richter’s hernia- Littre’s hernia
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Inflamed Hernia
Source of infection:-Inflamed contents as appendix- From skin infection as ulcerationsClinical features:- Hernia is painful, hot red and tender but not
tense
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TREATMENT OF HERNIA
Truss ???????????????????????????????????????????
Surgery Herniotomy Hernioplasty Herniorrhaphy
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CAUSES OF RECURRENCE
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PREOPERATIVE CAUSES
Causes of increased intra-abdominal pressure as chronic cough ----
Debilitating diseaseWeak musculature
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OPERATIVE
Repair undertensionImperfect hemostasis and devitalization of
tissues ----- infectionUse of absorbable sutureMissed sac or failure to completely excise the
sac
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POSTOPERATIVE
Persistence of predisposing factors as------Wound infectionLifting heavy objects early postoperatively
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Incidence:
Excluding incisional h75% inguinal15% umbilical8.5% femoral1.5% rare hernias
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INGUINAL HERNIA
Indirect Hernia (oblique inguinal hernia )
Direct hernia
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INDIRECT INGUINAL HERNIA
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ANATOMY of INGUINAL CANAL
Inguinal canal is an oblique canal extending from internal (deep) ring to external (superficial) ring
It is about 4 cm in adult and in infants the two rings are opposite each others
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INTERNAL (DEEP) RING
Opening in in fascia transversalis ½ an inch above the mid-inguinal point medial to inferior epigastric vessels
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External Ring
opening in external oblique apponeurosis ½ an inch above pubic tubercle bounded by supromedial and infrolateral crus of ext ob . Normally it just admit the little finger
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Contents
Male ------ spermatic cord + ilio-inguinal n +genital branch of genitofemoral n.
Females: Round ligament + -------
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Boundaries
Anterior:
- External oblique apponeurosis +
- Conjoint tendon medially
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Posterior- Fascia tranversalis
+- Conjoint tendon
laterally
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Superior- Conjoint tendon
Inferior -Inguinal ligament
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Mechanisms that prevent hernia
Shutter mechanism
Valvular mechanism
Plugging mechanism
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Indirect Hernia (OIH)
It is a hernia that pass through the internal ring and enter inguinal canal (bubonocele) and may pass through external ring and descend in scrotum (complete)
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INCIDENCE
Commonest type of hernia Male: female 20:1Common in right sideBilateral in 30%
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Etiology
Congenital preformed sac ( patent procesus vaginalis) ------- most accepted
- More common on the RT side- Herniotomy only in children is curative- PPV is found in many autopsy of individual
with no history of hernia
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Incidence
It is most common hernia
More common on RT side ------- why?
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Types of the sacCongenital
Infantile
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Funicular
Saddle hernia
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Bubonocele
Complete hernia
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Sliding hernia
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Contents
As before
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Descent
Downward, forward and medially ( reduction in reverse direction)
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Coverings
Extrapertitonial fat internal spermatic fascia |(fascia
tranversalis) cremastric muscle and fascia
(from internal oblique) External spermatic fascia (external oblique) skin and superficial fascia
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Complications
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Clinical features
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INSPECTION
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Palpation
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Scrotal neck test
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External Ring Test
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3 fingers
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Testicular exammination
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Hernia can be reduced by medial pressure applied first.
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Translumination
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Differential diagnosis
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Treatment
Correct predisposing causes
Surgery
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DIRECT INGUINAL HERNIA
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INCIDENCE
15% of inguinal herniasAlways in maleMore than 50% bilateral
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Hernia through weak Hasselbach’s triangle
Lateral defect : Malgaigne bulge
Medial defect; narrow neck
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ETIOLOGY
Acquired- Weak conjoint tendon- Injury of ilioinguinal nerve- Precipitating factors
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CONTENTS
Sliding urinary bladder is common
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COVERINGS
Extraperitonial fatFascia transversalisConjoint tendonExternal oblique
aponeurosisSkin and sc tissues
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Descent
Forward ( very rarely pass through external ring)
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COMPLICATIONS
Rare ---- why?
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Treatment
surgery
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FEMORAL HERNIA
Herniation through femoral canalAbout 20% of hernia in women & 5 % in menFemale to male 2:1 ( elderly females and 30
to 40 years old males)More in multipara. Most liable to become strangulated and may
be the first presentation why?
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More in females:
Wider canalPelvic tiltRepeated pregnancy
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Surgical Anatomy
Femoral Sheath:
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Femoral Canal
Most medial compartment of femoral sheath
Extend from femoral ring to saphenous opening
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Boundaries of femoral ring
Anterior ---- Inguinal ligament
Posterior ------ Pectineal ligament
Medially ----- Lacunar ligament ( Cooper’s lig.)
Laterally ----- Femoral vein
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Contents
FatLymphaticsL.N of Cloquet
Closed by cribriform fascia (below) & condensation of extraperitoneal tissue – septum crural ( above)
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Abnormal Obturator Artery
30% of cases Replaces obturator art. Arises from epigastric art (pubic branch) ----
passes behind lacunar ligament ---- obturator foramen
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Descent
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Coverings
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Contents
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Complications
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TRETMENT
Low approach
Poupart, lig to pectineal lig
Easy & rapidDon,t disturb ing canal
anatomyBut ----Sac is not completely
excisedInjury of abnormal
obturator art
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High approach
Cooper iliopectineal),
to conjoint or
Poupert to pectinal or the 3 lig
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Umbilical Hernia
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Umbilical Hernia
Congenital
Infantile
U.H. in adults
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Congenital = Exomphlos= Omphalocele
= Persistence of the physiologic hernia of fetal life
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Coverings
2 layers
- Inner peritonial- Outer amniotic membrane
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Types
Minor --- small defect with cord attach to its center
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Major ----
wide defect with the cord attach to its lower part
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Contents
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Complications
Intestinal injury during labr---- fecal fistula
Rupture ---- peritonitis
Associated anomalies
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Treatment
Small defect ------- primary closureLarge defect - Primary closure -Skin flap closure - Nonoperative ---- repeated painting with
betdine, gentian violot, etc ------ ventral hernia --- repair
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Infantile Umbilical Hernia
Due to weak umbilical scar
Rarely complicatesSpontaneous cure If persist for 2-4
years or large --- repair
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Umbilical Hernia in adult= Paraumbilical
Protrusion through linea alba just above or may be below the umbilicus (supra or infra umbilical)
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SacThe neck is often
remarkably narrow compared to the size of the sac ------ complication
Longstanding ----- loculated & adhesions
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Contents
As any hernia but commonly omentum
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Predisposing factors
+ Obesity , weak abdominal ms, repeated pregnancy
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Clinical features
As any herniaMore in women 5
times menUsually obese35-50 years
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Complications
+ dyspepsia ( dragging on colon & stomach)Large hernia --- intertrigo
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Treatment
Preop ----- + weight loss
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Herniorrhaphy by primary closure ( small defect)
Mayo, repairHernioplasty ---- large defects & recurrent
cases+/- lipectomy & abdominplasty
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Epigastric Hernia = Fatty hernia of the linea alba
Site: Through linea alba anywhere between the umbilicus & xiphoid process usually midway ( MORE THAN ONE DEFECT MAY BE PRESENT
Contents --- extraperitoneal fat ( fatty hernia of-----
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Clinical Features
No symptomsSymptoms of peptic dyspepsis
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Rare Hernias
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Lumbar Hernia
Primary - Inf lumbar triangle ( commonest) -Between iliac crest ,
ext oblique , latissmus dorsi
Sup lumbar triangle ----12th rib ,internal oblique , sacrospinalis
Secondary commoner
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D.D
LipomaCold abscessPhntom hernia
( paralysis of muscles)
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Spigilian Hernia
Hernia thr ough linea semilunaris lateral to rectus m. midway between umbilicus and symp pubis
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Divarication of the Recti
In multiparous women, ascitis ……. EtcInfants
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Incisional Hernia = Ventral = Postoperative
HERNIA at the site of abdominal scar
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Aetiology
Preoperative ----as in rec hernia
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Operative
Type of the incsion --- -Vertical transvrse- Muscle cutting muscle splitting
Sepsis --- pertonitis
Injury top nerve supply
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Closure of the wound under tension --- ischemia --- weak scar
Improper hemostasis -- hemastoma --- infection
Improper technique --- devitalization of the tissues ---- infection
Improper closure of the woundImprpoer anaethesiaImproper suture material
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Postoperative
As in rec hernia + wound infection
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Clinical Features
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Treatment
Palliative : very poor risk patients with uncomplicated hernia with wide neck
Surgery
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Surgery
Preoperative:- As U.H
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Surgical Procedures
Anatomical repairCattle, 5 layers Keel, ( historical)Hernioplasty
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Burst Abdoen = Abdominal Dehiscence
Etiology as in incisional hernia
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Types
Complete
Incomplete
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Incidence
1-2 %
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Clinical Features
6th to 8th postop day ---- serosanguinous discharge ( pathognomonic -------
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Treatment
Emergency operationPreoperative:- Reassure - - Resuscitate - NGT- Cover the intestine with sterile towel
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Diseases of the Umbilicus
CongenitalInflammatoryNeoplasticFistulaOthers
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Congenital
HerniaUrachus- Urachal cyst- -Patent Urachus
(fistula)Vitellointestinal- Fistula- Entrogenos cyst- Band
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Inflammatory
Neonatal omphalitis --- infection of umbilical stump
Adult omphalitisPilonidal sinus
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Benign Neoplasms
Adenoma (Raspbery tumor) in infants from vitellointestinal duct mucosal reminant
Endometriosis
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Malignant Neoplastic
Primary epithelioma (rare) ----- inguinal & axillary LN
Secondaries ( sister Joseph nodule) --- breast, stomach, colon,
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Fistula
Fecal --- congenital , malignant infiltration of cancer colon, T.B. peritonitis
UrinaryBiliary (subacute perforation of gall bladder)
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Others
Umbilical stoneUmbilical polyp
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DESMO = TENDON LIKE
Desmoid Tumor
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Incidence Adult multiparous female (80% females)
Site Rectus sheath usually below the umbilicus never in the mid-line but other abdominal muscles can be affected
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Aetiology
Female who have borne childrenRarely arises from old abdominal scarMay be associated with familial polposis
( Gardner sayndrome)
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Pathology
Composed of fibrous tiossues containing multinucleated masses resemble F.B giant cells , infiltrate muscles
No distant metastasisMyxomatous degenration --- rapid increase in
sizeNever undergoes sarcomatous changes
( unlike fibroma)
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Treatment
Wide excision ( at least 2.5 cm safty margin)
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Rupture inferior epigastric artery
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Incidence
Old age, thin weak femalesAthletic below middle age malesPregnant multi female ( late in pregnancy)
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Site
Usually at the level of arcuate ligament where post rectal sheath is defecient
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Clinical features
Severely tender rctus muscle lump following a bout of cough or trauma to abd wall
Sometimes, bruising
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D.D.
Twisted ov cystAppendicular abscessStrangulated spigilian h
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Treatment
Small hematoma ---- restEarly operation and evacutiuon of the
hematoma and ligation of inf epigastric is safer as bleedind mar recur and mar ruture intra peritneal