1. VENTRAL HERNIAS

2. Ventral hernia
• Any protrusion 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
.
• The umbilicus 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 hernias in 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 hernias in 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:
• Pain and 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 weight of 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:
• Hernia protruding 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: sudden strain 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 midline defect 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 ventral hernia
• 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 in postoperative 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 absorbable suture 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:
• Pain and 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:
• midline hernias with
large muscular defects,
• spontaneously
reducible
• Strangulation is rare

18. Type II:
• lateral part 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: deposit of 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

22. Components
separation
technique:
:

23. Endoscopic component separation
technique

24. Prosthetic repair:
• Onlay technique: 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 size of defect

31. Determine sites for placement 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 careful adhesiolysis
• Blunt and
sharp dissection
• Avoid use of
cautery
• Full extent of defect should
be identified
• Beware of the presence of
multiple defects

35. • Once the defect 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 visualization of 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 an enterotomy 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 case of 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:
• common complication 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
body placed in
apposition to the bowel
will cause
Erosion,obstruction

43. Spigelian hernia:
• A spigelian 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:
• more common 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:
• Obturator hernia
• Sciatic hernia
• Perineal hernia
Posterior hernias:
• Lumbar
- Superior triangle
- Inferior triangle

46. Obturator hernia:
• passes through 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:
• Difficult to 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 bowel is 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 general operative 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 the incarcerated 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 reducing the 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 extraperitoneal approach
• 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 hernia sac 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
• Protrusions of 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 perineal hernias 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 perineal hernia: (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 options for 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:
• Protrusion of 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 hernia sac 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 or transgluteal 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:
• 3 types 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 lumbar hernia:
- 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:
• Hernia tends 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:
• Under general 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's Surgical 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