1. Hernia
-Ventral hernia
By Dr.Teo Zue Hiong

2. Contents
 Definition
 Classification
 Incisional hernia
management
 Spigelian hernia
management

3. Hernia
• Definition
– An abnormal protrusion of an organ or tissue
outside its normal body cavity or restraining
sheath

4. Anatomical structure
Fundus
Covering of
hernia sac
Contents of sac
(usually bowel)
Neck/Mouth

5. Causes of Hernia
• May exploit natural openings(inguinal,femoral and
obturator canals, umbilicus and oesophageal hiatus) or
weak areas caused by stretching, surgical incision or
laparotomy
• Any condition that increases the pressure of the abdominal
cavity may contribute to the formation or worsening of a
hernia.
– Obesity
– Heavy lifting
– Coughing
– Straining during a bowel movement or urination
– Chronic ling disease
– Fluid in the abdominal cavity
– Hereditary

6. Classification of abdominal hernia
 Inguinal hernia/Groin hernia
Direct inguinal hernia
Indirect inguinal hernia
Femoral hernia
 Ventral hernia
Epigastric hernia
Umbilical hernia
Para-umbilical hernia
Spigelian hernia
Incisional hernia
 Other rare and specific interparietal hernia

8. Sign and symptoms
• The signs and symptoms of a hernia can range from
noticing a painless lump to the painful, tender,
swollen protrusion of tissue that you are unable to
push back into the abdomen—possibly a
strangulated hernia.
– Reducible hernia
– Irreducible hernia
– Obstructed hernia
– Strangulated hernia
– Inflammed hernia

9. Reducible hernia
– Asymptomatic reducible hernia
• New lump and the groin or other abdominal wall area
• May ache but is not tender when touched.
• Sometimes pain precedes the discovery of the lump.
• Lump increases in size when standing or when abdominal pressure
is increased (such as coughing)
• May be reduced (pushed back into the abdomen) unless very large

10. Irreducible hernia
– Irreducible hernia
• Usually painful enlargement of a previous hernia that
cannot be returned into the abdominal cavity on its
own or when you push it
• Some may be long term without pain
• Can lead to strangulation
• Signs and symptoms of bowel obstruction may occur,
such as nausea and vomiting

11. Strangulated hernia
– Strangulated hernia
• Irreducible hernia where the entrapped intestine has
its blood supply cut off
• Pain always present followed quickly by tenderness and
sometimes symptoms of bowel obstruction (nausea
and vomiting)
• You may appear ill with or without fever
• Surgical emergency
• All strangulated hernias are irreducible (but all
irreducible hernias are not strangulated)

12. Ventral hernia

13. Ventral hernia

16. Incisional hernia
• One that occurs through the wound of a
previous operation
• Same features as a hernia that is caused by
non-surgical injury to the abdominal wall
• 1% of transparietal abdominal incisions are
followed by a hernia

17. Aetiology
• A postoperative complication,can be
considered in terms of three factor
– Preoperative factors
– Operative factors
– Postoperative factors

18. Preoperative factors
• Age: older usually need more time to heal
• Malnutrition
• Sepsis: worsen
• Uraemia: inhibit fibroblast division
• Jaundice: impedes collagen maturation
• Obesity
• Diabetes mellitus
• Steroids
• Peritonitis

19. Operative factors
 Type of incisions
vertical are more prone to hernia than transverse
 Technique and materials
Tension in the closure decrease the blood supply
in wound
Loosen knots
Closure using rapidly absorbable suture materials
 Type of operation
Operations involve bowel or urinary tract are
more likely to develop wound infection
 Drain tube

20. Postoperative factors
• Wound infection:
– Same important with the wrong choice of suture
material
– Enzyme destruction of healing tissues
– Inflammatory swelling raises tissue tension and impedes
blood supply
– 5-20% of wound infections result in a hernia
• Abdominal distension
– Postoperative ileus increase the tension on a wound
– Stitches may cut out
• Coughing:generates wound tension

21. Signs and symptoms
• A bulge in the scar
• As the hernia enlarges and loculates, symptoms of
subacute I/O are common
• Overlying skin:thin and atrophic,eventually ulcer and
rupture
• Strangulation is a surgical emergency
• P/E:
– Usually reducible
– Hernia with a cough impulse at the site of an old scar
– When the patient lies flat, hernias deceptively small,any
manoeuvre that raise intra-abdominal pressure
produces the hernia in all its glory

22. Management
 Even small symptomatic hernias should be repaired early
 Prolonged observation simply increase the difficulties of
subsequent repair and hazardous
 Surgical technique:same as for para-umbilical hernia
 Exicision of the sac after reduction of its contents
 Insertion of overlapping sutures into the rectus sheath

23. Spigelian hernia
• Rare but clinically important, less than 1% of total
• An interparietal hernia in the line of the linea
semilunaris(the lateral margin of the rectus sheath)
• Usually at the level of the arcuate line:due to all
aponeurotic layers are reflected anterior to the rectus
muscle
• The hernial sac emerges and enlarges like a mushroom
deep to the external oblique

24. S&S
Symptoms
 Local pain that is worse on straining
 Lumps
 Non-specific lower quadrant discomfort which needs to be
investigated
 Features of obstruction or strangulation
Signs:
 Tenderness at the site of the hernial orifice
 Lump which may be difficult or even impossible to feel

25. Management
• Abdominal USG/CT:useful in the demonstration of these
hernias
• Repair:A simple matter of excising the sac and closing the
defect/Laparoscopic repairs

26. References
1. Clincal surgery 2nd edition
2. Principle and practice of surgery 5th edition

27. Thank you