anatomy, pathphysiology, investigation and managment

2. VENTRAL HERNIASVENTRAL HERNIAS
BYBY
DR’ ARSHAD TMO SURGICAL B WARDDR’ ARSHAD TMO SURGICAL B WARD
SAIDU GROUP OF TEACHING HOSPITAlSAIDU GROUP OF TEACHING HOSPITAl
SWATSWAT

3. Anatomy of Abdominal wall
 The abdominal wall is made up of skin,
superficial fascia, deep fascia, muscles,
extra peritoneal fascia, and parietal
peritoneum.


4. Hernia

 “Abnormal Protrusion of whole or part of
a viscous through an abnormal opening in the wall of
the cavity in which it is contain”.

5. Pathophysiology of hernia
formation
 A normal abdominal wall has sufficient strength to
resist high abdominal pressure and prevent
hernia formation
 Causes are:
1. Basic design weakness
2. Weakness due to structure entering and leaving
the abdomen
3. Develpmental failure
4. Genetic weakness of the collagen
5. Truma/surgery
6. Weakness due to ageing and pregnancy
7. Neurological and muscle diseases
8. Excessive intra-abdominal pressure
9. smoking

6. Pathophysiology of hernia
formation
Current views:
 Histological evidence and relationships between
hernia and other diseases related to collagen
proves that it is a “collagen disease”.
 It has been shown that hernia is no more
common in Olympic weight lifters than the
general population, suggesting that high
pressure is not a major factor in causing
hernia.
 A recent Studies shows that hernia risk is being
negatively related to body mass index (BMI),
contrary to widespread belief.

7. Clinical history in hernia case
 Patient are usually aware of a lump
 Self diagnosis is common
 Usually painless, sometime itching and
heavy feeling
 Sharp intermittent pain suggest pinching of
tissue
 Severe pain should alert the surgeon
 It is important to know whether it is
primary or recurrent, recurrent are more
difficult to treat
 Ask about respiratory symptoms, urinary
and bowel habits.


8. Check for:
 Reducibility
 Cough impulse
 tenderness, temperature
 Overlying skin colour changes
 Multiple defects/ contralateral side
 Signs of previous repair
 Associated pathology in respiratory,
urinary, GIT, muscular and nevous
systems



9. Investigations for hernia
Ø For most hernia no specific investigation is
required, diagnosis made clinically
Ø Chest X-ray (hiatus and diaphragmatic hernia)
Ø Ultrasound (where the nature of the content in
doubt and post operatively to differentiate
between early recurrence and collection)
Ø CT (In complex incisional hernia to look for
number, size of defects , contents, adhesions
and excluding other intra-abdominal
pathology.
Ø CT angiogram (for occult sac)
Ø MRI (sportsman groin, whether pain is due to
occult hernia or orthopaedic injury)

10.  Not all hernias require surgical repair
 The surgeon should recommend repair when complications are likely the
most worrying being , strangulation with bowel obstruction and bowel
infarction
 Any case of irreducible hernia especially when there is pain and
tenderness should be offered repair unless coexisting medical factors
place the patient at very high risk from surgery or anaesthesia
 Increasing difficulty in reduction and increase in size are indication for
surgery
 Surgery should be offered to younger adult patient as symptoms and
complication are likely over time.
 In elderly if the hernia is asymptomatic, small in size, can be reduced
easily and is not causing anxiety then observation alone should be
sufficient.
 Truss can be used to control a hernia but few surgeons would recommend
this approach.

Management principles of hernia

11. Operative approaches to hernia
 Reduction of content into abdominal
cavity with the removal of any
nonviable tissue and bowel repair if
necessary
 Excision and closure of a peritoneal sac if
present or replacing it deep to the
muscle
 Re-approximation of the walls of the
neck of the hernia if possible
 Permanent reinforcement of the
abdominal wall defect with suture or
mesh


12. Types of ventral hernias:
1) Epigastric hernia
2) Umblical hernia
3) Paraumblical hernia
4) Spigelian hernia
5) Incisional hernia
6) Parastomal hernia
7) Lumbar hernia
8) Traumatic hernia
9)
10)

13. Epigastric hernia
 Anywhere between the xiphoid process and
the umbilicus, usually midway.
 Usually less than 1cm



14. Ø Protrusion of extraperitoneal fat through
the linea alba- site where small blood
vessels pierced the linea alba.
Ø More likely that the defect occurs as a
result of a weakened linea alba due to
abnormal decussation of the fibres of the
aponeurosis.
Ø A swelling the size of a pea(<1cm)
-protrusion of extraperitoneal fat only
Ø
Ø
Ø

15.  Enlarges, it drags a pouch of peritoneum
after it
 The mouth of the hernia is rarely large to
permit a portion of hollow viscus to enter
it.
 It is likely that an epigastric hernia is the
direct result of a sudden strain, tearing
the interlacing fibres of the linea alba.

16. Clinical presentation
 Often in fit, healthy male between 25 and
40 years of age.
 May be very painful even if pea size due
to narrow neck
 Can be felt easily than it can be seen.
 Cough impulse may or may not be
positive.

 Mainly clinically
Diagnosis

17. Treatment
q conservative:
 Very small – disappear(infarction)
 Small to moderate - If the hernia is giving
rise to symptoms, operation should be
undertaken.
Ø

18. Operation (open or lap)
Ø
Ø The protruding extraperitoneal fat is
cleared from the hernial orifice by
gauze dissection.
Ø After ligating the pedicle, the small
opening in the linea alba is closed
with non-absorbable sutures in
adults and with absorbable sutures
in children.
Ø
Ø

19. Ø When a hernial sac is present, it is
opened and any contents reduced,
after which the sac neck is
transfixed and the sac excised
before repairing the linea alba.
Ø If the hernia is large (defect greater
than 4 cm diameter), the repair
should be reinforced with
polypropylene mesh positioned in
the retro-muscular plane.
TYPES OF MESH
1) synthetic mesh
2) biological mesh
3) absorbable mesh
4) tissue separating mesh
Ø

20. Umbilical hernia
 Common disorder in children.
 Most undergo spontaneous closure during
the first 3 years of life.
 Umbilical hernias are commonly found in
low-birth-weight infants (75% of infants
weighing < 1500 g), most will resolve.

21. Presentation
Ø May be symptomless.
Ø Bulge typically slightly to one side of the
umbilicus.
Ø In children It may increase in size during
crying which may cause pain & thus
more crying.
Ø Skin changes may be seen in larger
hernias.
Ø Small hernias are Spherical, Large hernias
are Conical.
Ø Obstruction and strangulation is
uncommon below the age of three
years.

22.  COMPLICATIONS:

ü Cosmetic disfigurement
ü Intermittent obstruction.
ü Strangulation.
ü Related to skin
ü
ü


23. TREATMENT
Principles
1. Tension free repair
2. Studies have shown that although primary
repair remains a popular choice, but
mesh is superior in terms of reduce
recurrence
3. Primary repair only for only <3cm defects
Ø Conservative treatment is indicated under
the age of two years when the hernia is
symptomless.
Ø 95% will resolve spontaneously.
Ø Spontaneous closure after 2 years is
unlikely.


24. Surgical treatment
 Less than 1cm, closed with simple figure of eight
or darn with non-absorbable suture.
 Up to 2cm, then mayo repair (double breasted).
 Crdiff repair
 Larger than 2cm,
then mesh repair is
recommended which can
be placed in different
planes in the abdominal wall.
1)


25. Para umbilical hernia
Ø In adults most hernias in the umbilical
region occurs above (common) or below
the umbilicus, result from weakness in
the linea alba, rather than directly
through the umbilicus.
Ø Are more common in women than in men
by a factor of five fold.
Ø They rarely occur in children and are most
common in adults between 35 and 50
years.
Ø Often, the hernial sac has multiple
loculations containing omentum and
occasionally small and large bowel.

26.  The hernial neck is narrow compared to the
size of the fundus predisposing to
incarceration and strangulation.
Treatment
 Strangulated hernia should be repaired as an
emergency
 Long standing hernia is repaired electively
 If small can be repaired quite easily
Repairing a large PUH
Difficult because:
1) The viscera in the sac stick to its wall and
when freeing them you may damage
gut
2) Usually there are several loculi, divided by
fibrous septa

27. 3) The sac often extend to the skin
4) You have to rise flaps under which blood
and exudate can collect and become
infected postoperatively.
Mayo repair is commonly used
Ø In this technique the contents are freed
from its wall and reduced, then sac is
reduced, the fascial defect is closed with
upper flap overlying the lower, thereby
doubling the strength of its repair.


28. Ø
Ø If the defect is to large you may have to
extend it longitudinally, making relaxing
incisions in the rectus sheath on either
side, and then overlap the aponeurosis
laterally.
Ø
Ø Cardiff (double breasted) repair
Ø Mesh repair

29. Incisional Hernia
 “Defect in the musculofascial layer of the
abdominal wall in the region of post
operative scar”.
 10-50% of laparotomy scars.
 1-5% of laparoscopic port size incision.

31. Predisposing factors:
Patient related:
Ø Obesity
Ø Malnutrition
Ø immunosuppression/ steroid therapy
Ø Chronic cough
Ø Anemia
Ø cancer

32. wound related:
Ø Poor quality tissue
Ø Wound infection
Surgical factors:
Ø In appropriate suture material
Ø Incorrect suture placement

33. Clinical features
Ø Localized bulge
Ø Multiple swellings along the length of scar
Ø Atrophy and thinning of the overlying skin
Ø Peristalsis can be observed
Ø obstruction

34. Treatment
Asymptomatic:
Ø Abdominal binder and belt is sufficient
Symptomatic:
Ø Surgical repair
Principles of surgery:
Ø Repair should cover the whole length of the
previous incision
Ø Approximation with minimal tension
Ø Prosthetic mesh should be placed to reduce
the risk of recurrence
Ø Appropriate systemic antibiotics

35. Open/laparoscopic:
Ø Open closure without mesh is not
recommended even with layered closure
because of high recurrence.
Ø Only recommended in gross contamination.
Ø Mesh can be placed in different planes as
mentioned for umbilical henia.
Management of very large
incisional hernia:
Ø If volume of sac is more 25% (calculated
from CT images) of the volume of
abdominal cavity, then repair will cause
loss of abdominal domain.
Ø Even if domain is not a concern, closure is
still difficult and special technique are
required.
Ø

36. Techniques to overcome
these difficulties:
1) Progressive pre-operative pneumoperitoneum
over several weeks.
2) Resection of the omentum or resection of the
colon at the time of repair.
3) Prosthetic mesh to span the uncloseable gap in
the musculofascial layer.
4) Musculofascial advancement or transposition
flaps to achieve closure.
5) “Ramirez component separation technique”,
giving relaxing incisions in external oblique
aponeurosis or posterior sheath.

37. Reducing the risk of incisional
hernia:
 Improving the patient’s general condition
 Closing wound with Non-absorbable suture or
very slowly absorbable suture
 Smaller and closure bites
 Suture length to the wound length should be
4:1 (Jenkin’s rule)
 Drain should be brought out through separate
incision
 Prophylactic mesh placement

38. Spigelian haernia
 “Arise through spigelian fascia
(aponeurosis of the transversus
abdominus muscle)”
 Uncommon.
 Common in elderly.
 Common below the umbilicus.
 In young, contents are usually
extraperitonial fats while in older
patients there is often a peritoneal sac.



42. Clinical presentation
 Intermittent pain due to pinching of fats.
 Bulge
 In older patients usually reducible swelling
with intermittent obstruction.
 Diagnosis confirmed by CT scan.


43. Treatment
 Surgery is recommended as the narrow neck
may predispose to strangulation.
 No abnormality will be seen until external
oblique is opened.
 Spigelian fascia can be repaired with suture
or mesh can be placed.


44. Lumber hernia
 Lumber hernia occurs either through
superior lumber triangle or inferior
lumber triangle of petit.
 Superior lumber triangle is bounded above
12th rib, quadratus lumborum medially and
posterior border of internal oblique
laterally.
 Inferior lumber triangle is bounded below by
iliac crest, external oblique laterally and
latissimus dori medially.
 Most primary hernias occur through inferior
lumber triangle.



48. Differential diagnosis
 Lipoma
 Tuberculous abscess
 Pseudo hernia due to muscular paralysis (most
common cause is injury to subcostal nerve
during a renal surgery)


49. Treatment
 Natural history is increase in size and
surgery is recommended
 Can be approached by open laparocopic
surgery
 A TAPP laparoscopic approach is common
nowadays
 In this surgery patient is positioned in
semi-lateral position, ports inserted far away
from the defect, peritoneum incised above the
hernia, dissected back, defect exposed, mesh
placed, peritoneum re-sutured over the mesh.

50. Parastomal hernia
 The muscle defect created during stoma
formation tend to increase in size,
ultimately leads to massive herniation
around the stoma.
 Occurs in over 50% cases
 Once occurs causes ill fitting of stoma bag
leading to leakage and subsequent
complications




54. Treatment
 Ideal treatment is to rejoin the bowel and
remove the stoma
 Both suture and mesh repair have high
chances of failure
Current recommendations:
Ø Prophylactic mesh should be placed in the
retro-muscular space at the time of
stoma formation so that the bowel passes
through a whole in the centre of the
mesh

55. Traumatic hernia
 “ Hernias through non-anatomic defects
caused by injury’’
Types:
1. Through stab wound sites (incisional hernias)
2. Through splits or tears in the abdominal
muscles following blunt trauma
3. Abdominal bulging secondary to muscle
atrophy which occurs as a result of nerve
injury

56. Clinical features
 Bulge
 Intermittent pain
 Signs of obstruction
 Non-anatomical location
Treatment
Ø If asymptomatic, conservatively
Ø If symptomatic or narrow neck hence chances
of obstruction or strangulation then surgery
is indicated
Ø If there is diffuse bulge then some form of
plication of the stretched musculofascial
layer with mesh reinforcement is required.