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Ventral hernias
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- 2. Ventral hernia • Anyprotrusion of viscera through anterior abdominal wall is called as Ventral hernia. • categorized as spontaneous or acquired • Spontaneous –primary defects in abdominal fascia includes- Umbilical & paraumbilical hernia Epigastric hernia Spigelian hernia • Acquired - Incisional hernia - parastomal hernia
- 3. Umbilical hernia . • Theumbilicus is formed by the umbilical ring of the linea alba. Intra-abdominally, the round ligament (ligamentum teres) and the paraumbilical veins join into the umbilicus superiorly, and the median umbilical ligament (obliterated urachus) enters inferiorly . • Umbilical hernia occurs when the umbilical scar closes incompletely in the child or fails and stretches in later years in the adult patient.
- 4. • Umbilical herniasin infants are congenital and are quite common. They close spontaneously in most cases by the age of 2 years. Those that persist after the age of 5 years are frequently repaired surgically. • Operation: umbilicus should be preserved
- 5. • Umbilical herniasin adults are largely acquired - known to occur more commonly in adult females with a female:male ratio of 3:1 • In adults the hernia does not protrude through umbilical cicatrix. It is a protrusion through the linea alba just above the the umbilicus - (supraumbilical) or occasionally below the umbilicus (infraumbilical) – so called as paraumbilical hernia
- 6. Etiology - multifactorial,commonly found in association with processes that increase intra- abdominal pressure – • pregnancy, • obesity, • ascites, • persistent or repetitive abdominal distention in bowel obstruction, or peritoneal dialysis.
- 7. Clinical features: • Painand swelling are the main ssymptoms • Pain increases on prolonged standing or heavy exercise • Content: mostly omentum Differential diagnosis: • Abdominal wall varices associated with advanced cirrhosis, • umbilical granulomas • metastatic tumor implants in the umbilical soft tissue (Sister Joseph's node).
- 8. Treatment: • Reduce weightof the patient • Treat the cause of ascites • Mayo’s operation – vest over pants repair : imbrication of superior and inferior fascial edges • For smaller defects – open umbilical hernia repair • For larger defects - >2 cm – mesh repair – open or laparoscopic
- 10. Epigastric hernia: • Herniaprotruding through interlacing fibres of the linea alba anywhere between umbilicus and xiphisternum • protrusion of extraperitoneal fat - fatty hernia of linea alba • They are multiple in upto 20% of patients and appeoximately 80% are in midline
- 11. • Etiology: suddenstrain leading to tearing of interlacing fibres of the linea alba • Clinical features: 1. Symptomless 2. Painful- in partial strangulation of fat 3. Referred dyspepsia On palpation – feels firm, no cough impulse and cannot be reduced Differential diagnosis : lipoma
- 12. Treatment • The midlinedefect is usually elliptical in nature, with the long axis oriented transversely • The hernia will often not be seen on laparoscopy owing to the lack of peritoneal involvement through the hernia defect • Open repair - Primary suturing
- 13. Incisional hernia:Postoperrative ventralhernia • It is herniation through a weak abdominal scar (scar of previous surgery). • Causes- • Factors related to patients: 1. Obesity – due to fat encroaching in between the muscle layers 2. Advanced age 3. Multiparity,malnutrition,peritoneal dialysis,jaundice,hypoproteinemia,anaemia, malignant diseases 4. Coughing,vomting and overzealous venetilation in early postoperative period 5. Steroids and chemotherapy
- 14. • Smoking inpostoperative period. • Causes which increases the intra-abdominal pressure (BPH, straining, stricture urethra or rectum, ascites) Factors related to procedure: • Vertical incision has got higher chances of incisional hernia than horizontal incision • Layered closure of the abdomen has got higher chance than single layer • Continuous closure has got higher chances than interrupted closure
- 15. • Using absorbablesuture material has got higher chances of hernia than non-absorbable sutures • Emergency surgical wound has higher chances than elective surgical wound • Laparotomy for peritonitis, acute abdomen, and trauma can commonly cause incisional hernia • Drainage through the main laparotomy wound may precipitate formation of incisional hernia
- 16. Clinical features: • Painand swelling in the vicinity of previous scar • bulging more prominent on standing and coughing,reduces spontaneously on lying down • Attacks of subacute intestinal obstruction – abdominal colic,vomiting,constipation and distention of abdomen • reducibility may be complete or partial • expansile impulse on cough • skin over the hernia is thin and atrophic • On Palpation, the edge of the defect can be delineated - rising test,divarcation of recti H/O previous operation,stormy postoperative period, discharge through requiring prolonged dressing
- 17. Types: Type I: • midlinehernias with large muscular defects, • spontaneously reducible • Strangulation is rare
- 18. Type II: • lateralpart of abdomen, • defect in the musculature is relatively small and irregular • Bowel loops are usually matted with adhesions to the sac • High risk for strangulation
- 19. • D/D: depositof tumor old abscess foreign body granuloma Complications: • Loss of abdominal domain • Respiratory dysfunction -paradoxical respiratory abdominal motion • bowel edema, stasis of the splanchnic venous system, urinary retention, and constipation • abdominal compartment syndrome, and acute respiratory failure- return of displaced viscera
- 20. Treatment : Preventive measures: •Reduction of weight in obese before elective procedures • Treat any respiratory diseases- chr.bronchitis • Very careful closure of abdomen • all precautions to prevent immediate postoperative wound infection should be taken Conservative management: In elderly – not fit for surgery due to general condition In type I incisional hernias
- 21. Operative treatment: Anatomical restoration: small hernias with minimal scar tissue Approximation of the rectus sheath KEEL operation - hernial sac is not opened - fundus of the sac is is pleated with non adsorbable sutures and pushed into the peritoneal cavity - the cross section of this looks like the ‘keel’ of a ship Cattle’s operation Lattice or Darning muscle pedicle flaps – tensor fascia lata / rectus femoris
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- 24. Prosthetic repair: • Onlaytechnique: after primary closure of the fascial defect mesh is placed over the anterioe fascia • Advantages: no direct contact with viscera Disadvantages: a) large subcutaneous dissection leads – more chances of seroma formation b) superficial location of mesh- more prone for infection • Inlay technique: interposition of prosthetic mesh between the fascial edges. - Very high recurrence rates • Sublay/ underlay technique:prosthetic mesh placed below the fascial components
- 26. • Retromuscular technique: -also called as Rives-Stoppa-Wantz Retrorectus Repair - placement of mesh under the rectus muscle & above the posterior rectus sheath Advantage: • intraabdominal forces hold the prosthesis against the muscles. • The forces that created the hernia now are used to prevent its recurrence.
- 28. • Intraperitoneal mesh placement: -dual type or composite mesh can be placed in intra peritoneal position - about 4cm beyond the fascial defect and fixed to abdominal walls.
- 29. Laparoscopic repair: ▫ wound complications ▫ recurrence rate ▫ pain ▫ coverage of “Swiss cheese” abdomen • Placing the mesh intraperitoneally under the defect • Dual mesh or composite meshes are in use • Procedure is done under general anaesthesia • Surgeon and cameraman standing on left side of patient • Monitor is placed on right side at footend • Port placement and number- varies according to site and size of the hernia
- 30. Identify approximate sizeof defect
- 31. Determine sites forplacement of ports
- 32. Sizing the mesh •3 options: Intracorporeal with pneumoperitoneum, extracorporeal with pneumoperitoneum, extracorporeal desufflated • With extracorporeal measurement, the diameter of the outer (skin) circle is larger than the inner (peritoneal) circle. • This difference is proportional to the size of the patient.
- 33. Access to abdomen ▫Blunt trocar with open technique/ visiport o Verres needle ▫ Remote from hernia site Trocar Requirements depend on hernia size ▫ 10 mm or 12 mm and 5 mm trocars
- 34. • Begin carefuladhesiolysis • Blunt and sharp dissection • Avoid use of cautery • Full extent of defect should be identified • Beware of the presence of multiple defects
- 35. • Once thedefect is measured a mesh is selected that provides at least 3 cm of overlap around the defect. • Some surgeons use a 4 – 6 cm overlap. • This may be particularly important in the recurrent hernia or in the morbidly obese patient. • Dual or four layered mesh with non adhesive surface facing towards abdominal contents is placed • All four corners are are sutured using transfascial fixation • Tackers (heical )are placed all around at a distance of 5mm – 1cm
- 36. Advantages: • Proper visualizationof entire abdomen • Avoidance of unnecessary dissection • Identification of multiple/swiss cheese defects • Less recurrence rates • Short hospital stay • Less morbid surgery • Faster recovery • Better in obese patients
- 37. Complications • Prolonged ileus •Seroma • Suture site pain • Intestinal/bladder injury • Cellulitis of trocar site • Mesh infection • Hematoma or post-op bleeding • Respiratory distress • Trocar site herniation
- 38. • When anenterotomy occurs – ▫ Contamination repair injury and delay hernia repair ▫ No spillage repair hernia ▫ Bladder injury repair hernia ▫ Delayed bowel injury remove mesh and delay repair
- 39. • In caseof Large Seroma ▫ Observation: most of them will resolve without intervention ▫ Repetitive sterile aspiration ▫ When persistent beyond 8 weeks or longer: removal of mesh and excision of hypertrophic mesothelium • Pain at transabdominal suture site > 8 weeks -Nonsteroidal anti-inflammatory agents/oral narcotics -Subfascial injection of combination lidocaine and bupivacaine
- 40. Parastomal hernia: • commoncomplication of stoma creation • incidence is highest in colostomies – almost 50% • usually asymptomatic • complications like bowel obstruction and strangualtion are rare Treatment: • Primary fascial repair – high recurrences • Stoma relocation • Prosthetic repair
- 41. Sugarbaker repair Diasadvantage: permanent foreign bodyplaced in apposition to the bowel will cause Erosion,obstruction
- 43. Spigelian hernia: • Aspigelian hernia occurs along the semilunar line - represent the line of transition from the muscular fibers of the transversus abdominis muscle to the posterior aponeurosis of the rectus. • The widest portion of the spigelian fascia is the area where the semilunar line intersects the arcuate line of Douglas • most common type of interparietal hernias
- 44. Clinical features: • morecommon in 4th to 7th decade • small swelling lateral to rectus muscle- above level of umbilicus(10%),below umbilicus(90%) • sharp pain or tenderness at this site • ultrasound abdomen and CT scan are useful to establish the diagnosis • Complications: high risk of incarceration due to narrow neck • Treatment: Primary Repair or Mesh repair
- 45. Pelvic hernias: • Obturatorhernia • Sciatic hernia • Perineal hernia Posterior hernias: • Lumbar - Superior triangle - Inferior triangle
- 46. Obturator hernia: • passesthrough the obturator canal • Weakness of obturator membrane at its superomedial portion pierced by obturator nerve and vessels resluts in formation of hernial sac • occurs six times more frequently in women than in men
- 47. Clinical features: • Difficultto diagnose ,as the swelling is covered by the pectineus • Hernia becomes apparent only when the hip is flexed,abducted and rotated outwards • The leg is usually kept in a semiflexed position and movement increases the pain • Compression of obturator nerve causes pain in anteromedial surface of thigh(Howship Romberg sign) – relieved by thigh flexion
- 48. • Small bowelis the most common content to be found in an obturator hernia, rare cases- appendix, Meckel's diverticulum, omentum, bladder, and ovary incarcerated in the hernia. • Narrow neck - > 50% present with complete or partial obstruction,incarceration or strangulation • Pain is referred to knee joint by articulate branch of obturator nerve • Only rectal/vaginal examination can detect a tender swelling in the region of obturator foramen
- 49. Treatment: • Three generaloperative approaches 1. lower midline transperitoneal approach 2. lower midline extraperitoneal approach 3. Anterior thigh exposure The lower midline transperitoneal approach: • most common method for repair of obturator hernias • dilated small bowel is runs deep into the pelvis, where it is found to enter the obturator canal alongside the obturator vessels and nerve.
- 50. • reduce theincarcerated bowel with gentle traction • The pelvic side of the obturator canal has a rigid opening that cannot be digitally dilated, making reduction of the hernia sac more difficult. • If traction alone does not allow reduction of the bowel, the obturator membrane can be carefully incised from anterior to posterior to facilitate exposure. • Care should be taken to avoid injury to both the incarcerated bowel and the obturator vessels • If these maneuvers are unsuccessful, a counter incision can be made in the medial groin to facilitate reduction from both sides of the canal
- 51. • After reducingthe hernia, the intestine is assessed for viability and resected as needed • The hernia opening is then closed around the obturator vessels with a running layer of polypropylene or nylon suture applied in the thin layer of fascia that encircles the inner circumference of the canal. • In a clean case without bowel contamination, a piece of mesh can be placed over the obturator foramen and fixed to cooper’s ligament to prevent migration
- 52. The midline extraperitonealapproach • Used when the diagnosis of obturator hernia is made preoperatively • It allows complete exposure of the opening of the obturator canal • Incision: vertical midline incision from umbilicus to pubis • The preperitoneal plane is entered deep to the rectus muscle,and the bladder is peeled from the peritoneum • The space is opened so that the superior pubic ramus and the obturator internus muscle are exposed
- 53. • The herniasac is seen as a projection of peritoneum passing inferiorly into the obturator canal • The sac is incised at the base, the contents are reduced, and the neck of the sac is transected • The internal opening to the obturator canal is closed with a continuous suture • The bites of tissue should include the periosteum of the superior pubic ramus and the fascia on the internal obturator muscle. • preperitoneal mesh can be placed to cover the defect
- 54. The thigh/femoral approach: •A vertical incision in the upper medial thigh placed along the adductor longus muscle • The muscle is retracted medially to expose the pectineus muscle, which is cut across its width to expose the sac • The sac is carefully incised, the contents inspected and reduced if viable, and the sac is excised • The hernial opening is closed with a continuous suture layer
- 55. PERINEAL HERNIAS • Protrusionsof the intra-abdominal contents through a weakened pelvic floor Includes • pelvic hernias, • ischiorectal hernias, • pudendal hernias, • subpubic hernias • hernias of the pouch of Douglas
- 56. • Primary perinealhernias are extremely rare • Secondary,or postoperative, perineal hernias are more commonly seen and occur in patients status post abdominoperineal resection Etiology : • Common in 5th – 7th decade • 5 times more common in women • Predisposing factors to a primary perineal hernia include - deep or elongated pouch of Douglas, obesity,chronic ascites, history of pelvic infection, and obstetric trauma
- 57. The anterior perinealhernia: (pelvic or pudendal) • The sac enters in front of the broad ligament and lateral to the bladder, emerging anterior to the transversus perinei musculature. • The sac may pass between the ischiopubic bone and the vagina, thereby producing a swelling in the posterior portion of the labia majus. • Posterior perineal hernias(hernia of pouch of Douglas): The hernia enters between the rectum and the uterus to pass posteriorly to the broad ligament.
- 58. Lateral pelvic hernia– ischiorectal hernia • occur through the hiatus of Schwalbe when the levator ani muscle is not firmly attached to the internal obturator fascia • Presents posteriorly in the ischiorectal fossa Clinical features: • Complains of soft protuberance that is reduced in the recumbent position. • Anterior perineal hernia- minor urinary retention or discomfort • In posterior perineal hernias – difficulty in sitting posture,rarely constipation or the feeling of incomplete defecation
- 59. • Three optionsfor repair of the perineal hernia I. Transperitoneal II. Perineal III. Combined Transperitoneal approach: • ideal for complete repair – wide exposure • Ideal for repair of secondary perineal hernias • Primary repair for small defects Mesh repair for large defects/atrophied musculature Perineal approach: • repair is more direct and avoids a laparotomy • Suitable for small hernia defect in an unhealthy patient • The risk of recurrence is high
- 60. Sciatic hernias: • Protrusionof peritoneum and intra-abdominal contents through the greater or lesser sciatic notch • Greater sciatic notch: suprapiriform (60%) infrapiriform (30%) • Lesser sciatic notch - subspinous hernias (10%)
- 61. • The herniasac passes laterally, inferiorly, and ultimately posteriorly to lie deep to the gluteus maximus muscle – usually reducible • Pain deep in the buttocks,radiating down the leg in the sciatic nerve distribution • Rarely, ureteral obstruction occurs because the ipsilateral ureter is contained within the hernia contents. • Incarceration of the hernia can occur, and sciatic hernia has been known to present with bowel obstruction.
- 62. • Treatment: I. Transperitoneal II.Transgluteal III. Combined Transperitoneal approach: • Preferred in cases of incarceration, bowel obstruction • care must be taken to avoid injury to the many nerves and vessels found in this region • The defect is repaired using interrupted nonabsorbable suture or a prosthetic mesh plug or patch for larger hernia defects.
- 63. The posterior ortransgluteal technique: • For uncomplicated, reducible sciatic hernias diagnosed preoperatively • The patient is placed in the prone position • The gluteus maximus muscle is approached through a gluteal incision starting at the posterior edge of the greater trochanter and is detached at its origin to expose the hernia defect • This exposure allows visualization of the piriformis muscle, the gluteal vessels and nerve, and the sciatic nerve
- 64. LUMBAR HERNIAs: • 3types of lumbar hernias I. Superior lumbar hernia II. Inferior lumbar hernia III. Incisional lumbar hernia • Commonly seen in 5th decade • Male :female – 2:1 • Left sided hernias are more common • Congenital type are rare • Acquired hernias are commonly associated with back or flank trauma, poliomyelitis, back surgery – infected kidney,drainage of lumbar abscess, and the use of the iliac crest as a donor site for bone grafts.
- 65. I. Superior lumbarhernia: - Protrusion of abdominal contents through superior lumbar triangle of Grynfeltt Boundaries: Above: 12th rib medially – sacrospinalis laterally - posterior border of internal oblique muscle II.Inferior lumbar hernia: - Protrusion of abdominal contents through inferior lumbar triangle of Petit Boundaries: Below – crest of ilium medially – ant.border of lattismus dorsi laterally – posterior border of external oblique muscle
- 67. Clinical features: • Herniatends to increase over time and may assume large proportions and overhang the iliac crest • vague dullness in the flank or lowerback • focal pain associated with movement over the site of the defect • On physical examination-swelling in the lower posterior abdomen – reducible without much difficulty • Ultrasound abdomen and CT abdomen will aid in diagnosis • Strangulation is rare • Differential diagnosis: lipoma,paravertebral cold abscess,phantom hernia
- 68. Operative repair: • Undergeneral anesthesia • Patient kept in modified lateral decubitus position with kidney rest • oblique skin incision in the region of the hernia • Sac is identified and reduced • Small defects – primary repair • Large defects – prosthetic mesh repair • Recently - intraperitoneal laparoscopy/ retroperitoneoscopy have been reported as minimally invasive procedures
- 69. References: • Lee McGregor'sSurgical anatomy • Skandalakis surgical anatomy • Schwartz principles of surgery 9th edition • Sabiston text book of 19th edition • Bailey and love 26th edition • Fischer mastery of surgery 6th edition • DAS manual on clinical surgery • Text book of das 8th edition • ZOLLINGER’S atlas of surgical operations