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VENTRAL HERNIA.pptx
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- 2. ABDOMINAL WALL Abdominal wallis made of these layers: Skin Subcutaneous tissue Fascia: Camper's fascia - fatty superficial layer. Scarpa's fascia - deep fibrous layer. Muscle: External oblique abdominal muscle Internal oblique abdominal muscle Rectus abdominis Transverse abdominal muscle Pyramidalis muscle Fascia transversalis Peritoneum
- 3. VENTRAL HERNIA Itrefers to hernia of the anterior abdominal wall except groin hernias. It includes: Umblical Hernia Paraumblical Hernia Epigastric Hernia Incisional Hernia Spigelian Hernia Lumbar Hernia Traumatic
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- 5. It refersto the herniation of abdominal contents through the umblical defect. The umbilical defect is present at birth but closes as the stump of the umbilical cord heals, usually within a week of birth. This process may be delayed, leading to the development of herniation in the neonatal period. The umbilical ring may also stretch and reopen in adult life.
- 6. IN CHILDREN INCIDENCE: Boys= Girls Black infants (8x) > White 10% of infants, having higher incidence in premature babies. Hernia appears within a few weeks of birth. CLINICAL FEATURES: It is usually Symptomless. Increases in size on crying. It has Classical conical shape. Obstruction/strangulation are extremely uncommon in <3 years of age.
- 7. TREATMENT: Conservative: Most ofthe hernia close spontaneously without any treatment within two years of age. So the methods are: masterly inactivity, reassure parents and strapping over a coin. Operative: Herniorrhaphy is indicated when the hernia is still present after 2 years of age.
- 8. IN ADULTS Inadults it is called Paraumblical Hernia as the defect is not through the true umblicus. Reopening of umbilical defect caused by conditions that cause thinning and stretching of midline raphe (linea alba) Repeated pregnancies weaken the abdominal wall Obesity causes flabby abdominal muscle Ascites, especially in cirrhotic patients
- 9. ON EXAMINATION: Round swellingwith well defined fibrous margin. Contents: Small umbilical hernia often contain extraperitoneal fat or omentum. Larger hernia contain small or large bowel. Very large hernia have narrow neck of the sac and prone to become irreducible, obstructed and strangulated (unlike children).
- 10. Clinical features: Swellingin the umbilical region - increase on coughing/straining Expensile cough impulse is present Patient may also have inguinal hernia Reducibility can be present Crescent-shaped appearance of the umbilicus Patient complaint of pain due to tissue tension, and symptom of intermittent bowel obstruction. Dermatitis in case of large hernia (due to thinned & stretched of overlying skin)
- 11. TREATMENT: • Reduce weightof the patient • Treat the underlying cause. • Surgical treatment Open or Laproscopic.
- 12. SURGICAL PROCEDURES: Verysmall defects < 1 cm Closed with a simple figure-of-eight suture. OR Repaired by darn technique Defects up to 2 cm Sutured primarily with minimal tension. (Herniorrhaphy) OR Classical repair by Mayo Defects > 2 cm Mesh repair is the treatment of choice
- 13. Mesh isplaced in one of the several anatomical planes (A) Onlay - mesh is placed anterior to the anterior rectus sheath. (B) Sublay - mesh is placed immediately above the posterior rectus sheath. (C) Intraperitoneal - mesh is placed directly beneath the peritoneum as the final layer of the abdominal wall. Hernia Repair can also be done Laproscopically
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- 15. It occursin the linea alba anywhere between the xiphoid process and the umbilicus. Its called “Fatty hernia of linea alba” as it usually contains extra peritoneal fat. When enlarges drags a pouch of peritoneum and becomes a true epigasric hernia. Etiology: Sudden strain leading to tearing of interlacing fibres of the linea alba. Usually occurs in Males of age 25 to 40 years.
- 16. CLINICAL FEATURES: Symptomlessin most of the cases. Painful- if partial strangulation of fat occurs. It may mimic pain of PUD. ON EXAMINATION: Less likely to be reducible. Maybe locally tender. Cough impulse may or may not be felt. It may be more than one at a time.
- 17. TREATMENT: Conservativetreatment – if very small hernia or symptomless If sufficiently symptomatic – Open surgery. Anatomic repair. Mesh repair. • Recurrence: May be due to failure to identify a second defect at the time of original repair.
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- 19. It isdiffuse extension of peritoneum and abdominal contents through a weak abdominal scar (scar of previous surgery). CAUSES: Obesity Advanced age Coughing, vomiting, straining Steroids and chemotherapy Multiparity. Poor metabolic state of patient. Causes that increase intraabdominal pressure. Inapropriate suture material Poor closure technique Incision Emergency procedures.
- 20. CLINICAL FEATURES: Painand swelling in the vicinity of previous scar Obstruction of contents is common but strangulation is rare Attacks of subacute intestinal obstruction. – abdominal colic, vomiting, constipation and distension of abdomen On Examiation: Often multiple defects within same scar Reducibility may be complete or partial Expansile impulse on cough Skin over the hernia is thin and atrophic
- 21. TREATMENT: Preventive measures: Reductionof weight in obese before elective procedures Treat any respiratory diseases Very careful closure of abdomen Prevent Post op wound infection Conservative approach: Symptomless hernia with no signs of pain or obstruction. Operative Treatment: The indications are: Symptomatic hernia which is showing signs of increasing in size Large hernia with a small defect Subacute intestinal obstruction Irreducibility and Strangulation
- 22. Mesh repair:is always better and ideal choice of treatment with less chances of recurrence. Sublay or Intraperitoneal onlay mesh IPOM aare preferable Anatomical repair and Keel’s operation are not usually used
- 23. SPIGELIAN HERNIA Herniationthrough the defect in spigelian fascia. Spigelian fascia is the aponeurosis of transversus abdominis muscle Its almost above the arcuate line Most common site is below the level of umblicus, near the edge of rectus sheath, at the junction of spigelian line (linea semilunaris) and arcuate line (linea semicircularis)
- 24. CLINICAL FEATURES: Soft,reducible mass lateral to the rectus muscle and below the umbilicus Cough impulse present. Strangulation is common Common in females after 50 years of age. TREATMENT: High risk of complications due to narrow neck Primary Repair or Mesh repair
- 25. LUMBER HERNIA Itrefers to the herniation through the Lumber triangle. Three types of lumber hernia : Incisional Lumber Hernia - Most common cause Superior Lumber Hernia – From superior lumber triangle bounded by: 12th rib superiorly Post border of internal oblique laterally Sacrospinalis muscle medially Inferior Lumber Hernia – from inferior lumber triangle bounded by: Iliac crest inferiorly Laterally external oblique Latissimus dorsi medially MC site for primary lumber hernia
- 27. DIFFERENTIAL DIAGNOSIS: Lipoma Paravertebral cold abscess Phantom hernia CLINICAL FEATURES: Focal pain associated with movement over the site of the defect Vague dullness in the flank or lower back Hernia tends to increase in size over time ON EXAMINATION: Swelling in the lower posterior abdomen Reducible without much difficulty
- 28. TREATMENT: Small defects– primary repair Large defects – prosthetic mesh repair Retromuscular sublay mesh repair is the preferred procedure for lumber hernia.