Anatomy of anterior abdominal wall Types of ventral hernias Clinical features Causes of hernia Differential diagnosis History/Examination Investigations Management ABDOMINAL WALL IS MADE OF THESE LAYERS: Skin Subcutaneous tissue Fascia: fatty superficial layer Camper's fascia membranous layer Scarpa's fascia Muscle: External oblique abdominal muscle Internal oblique abdominal muscle Rectus abdominis Transverse abdominal muscle Pyramidalis muscle Fascia transversalis Peritoneum

1. VENTRAL HERNIAS
PRESENTED BY
AWAIS IRSHAD (202005)

2. Learning Objectives:
■ Anatomy of anterior abdominal wall
■ Types of ventral hernias
■ Clinical features
■ Causes of hernia
■ Differential diagnosis
■ History/Examination
■ Investigations
■ Management

3. Anatomy of Abdominal Wall
 ABDOMINAL WALL IS MADE OF THESE
LAYERS:
 Skin
 Subcutaneous tissue
 Fascia:
 fatty superficial layer Camper's fascia
 membranous layer Scarpa's fascia
 Muscle:
 External oblique abdominal muscle
 Internal oblique abdominal muscle
 Rectus abdominis
 Transverse abdominal muscle
 Pyramidalis muscle
 Fascia transversalis
 Peritoneum

4. Anatomy of abdominal wall.

5. What is Hernia?
Protrusion of a viscous or a part of viscous
through an abnormal opening in the walls
of its containing cavity.

6. Ventral hernias:
• Umbilical hernia.
• Due to defect in umblical ring closure
• Weakend Richet’s(umbilical) fascia ,
• delayed healing
• infants
• symptomless
• size increase while crying
• conical shape
• surgery after 2 years
• Para-umbilical hernia.
• Herniation occuring through the linea alba
around umblical region(not through umbilicus
itself)
• Due to thinning/stretching of linea alba (e.g
obesity, pregnancy etc)
• In adults
• females are affected > males
• pain due to bowel obstruction
• crescent shaped
• surgery due to strangulation

7. ■ Epigastric hernia.
• Fatty hernia of linea alba
• Protrusion of extraperitoneal fat through
interlacing fibres of linea alba.
• anywhere b/w xiphisternum and umbilicus
• mushroom shape
• 25-40 years of males
• Mascular man/manual labourers
• typically asymptomatic may cause pain and
may be taken as peptic ulcer.
• may resemble a lipoma
■ Incisional hernia.
Due to defect in musculofascial layers of
abdominal wall in the area of postoperative
scar.
• early postoperative period
• due to wound,patient,surgeon factors
• mostly in emergency surgeries
• multiple defects within single scar

8. • Spigelian hernia.
• Arising from a defect in aponeurosis of
transverses abdominis ( spigelian fascia)
• below the level of umbilicus near the edge of
rectus sheath
• always above the arcuate line
• Associated with high risk of stangulation
■ Lumbar hernia.
Protrousion of organs through fascial deffects in
posteriolateral wall
• arising through flank incisions (renal surgery) that’s why
mimicking the Incisional hernia, may be by trauma.

9. Parastomal hernia.
• when surgeon create stoma (colostomy, iliostomy) they
effectively creating hernia by bringing bowel out through
the abdominal wall.
Non anatomic defects due to injury.
• stab wounds
• tears
• traumatic denervation leading to muscular
atrophy
Traumatic hernia

10. Types on the basis of complexity:
■ Occult: causes severe pain (clinically not detectable)
■ Reducible: appears and disappears
■ Irreduceable: high risk of complications
■ Strangulated: painful emergency condition
■ Infarcted: gangrenous contents (high mortality)
■ Obstracted/incarcerated: tissues become traped leading to strangulation

11. Causes of abdominal hernia:
■ Basic design weakness ( anterior wall defect)
■ Weakness due to structures entering and leaving the abdomen (diaphargmatic hernia)
■ Weakness due to pregnancy/ageing
■ Developmental failure (omphalocele,gastroschisis)
■ Sharp blunt trauma
■ Increased intra-abdominal pressure (copd)
■ Muscular and neurological diseases (muscular dystrophy)
■ Genetic weakness of collagen (marfin syndrome)

12. Clinical Features of hernia:
■ Swelling/lump on abdominal wall
■ Usually painless
■ Discomfort
■ Feeling of heaviness
■ Severe pain ~ Strangulation (due to blood supply compromise)
■ Reducibility

13. Differential diagnosis:
■ Abscess
■ Lipoma
■ Granuloma
■ Malignant mass

14. History in hernia:
■ Age
■ Gender (Para-umbilical/inguinal hernia)
■ Occupation
■ Feeling of heaviness
■ Pain
■ Systemic questions (GIT, Respiratory, CVS)
■ Drug history (steroids)
■ Trauma
■ Previous surgery (Incisional hernia)

15. Examination:
■ Lying down and standing position (size)
■ Overlying skin colour
■ Tenderness
■ Cough impulse (increase pressure)
• mostly present
• absent in irreduceable hernia ~ misdiagnosed
■ Multiple defects
■ Previous surgical marks

16. Investigations of hernia:
■ Mostly clinical based diagnosis
■ CX-ray (copd)
■ Ultrasound (irreduceable hernia)
■ CT scan (Incisional hernia)
■ MRI (Distinguish occult hernia from orthopaedic injury)
■ Laparoscopy (Identify occult contralateral hernia)

17. How to manage hernia?
■ Conservative management
■ Surgery
• open repair with sutures/mesh
1-Herniotomy 2-Herniorraphy 3-Hernioplasty
•laparoscopic repair
■ Types of mesh.
•synthetic
•absorbable
•biological
•tissue - separating