Alnahrain university

ABDOMINAL WALL HERNIA

printed and prepared by:- Jafar AL-Salamy
dr.hassan

2011
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MON 2/5/2011

surgery

Dr.Hasan A. Hasan

Abdominal wall hernia

Hernia:- is a protrusion of a viscus through an opening in the wall of the cavity its either :- internal or external internal hernia :- from cavity to a cavity e.g :- from abdominal cavity to thoracic cavity ( Diaphragmatic hernia) external hernia:- appears to the outside like umbilical hernia , or femoral hernia ... ETIOLOGY:for a hernia to appear we must predisposing factors which predispose to the development of hernia and when these factors are available then we should have precipitating factors to lead to the appearance of hernia the predisposing factors :1- congenital defects:normally processus vaginalis in male obliterate at birth ,but if persist it will lead to hernia (external hernia) in female the persistence of canal of nuck can cause hernia incomplete obliteration of the umbilicus when we have a defect in the diaphragm like a defect in the foramen of morgagni or complete
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MON 2/5/2011

surgery

Dr.Hasan A. Hasan

diaphragm absence that is replaced by a weak membrane and this type of hernia called eventration of the diaphragm ( an example of the internal hernia :- the abdominal content are pushed to the chest) 2- Acquired defects:weak surgical incision ( weakness of the muscles as in:- paralysis, in obesity( adipose tissue lie between the muscle fibers), when we have a poliomyelitis , aging , and pregnancy precipitating factors :increase intra-abdominal pressure rapidly and repeatedly ( not continuous) like coughing and constipation ,rapidly growing tumor ,benign prostatic hypertrophy which lead to difficulty in passing urine and straining that lead to increase in intra-abdominal pressure COMPOSITION OF THE HERNIA:As a rule, a hernia consists of three parts the sac, the coverings of the sac and the contents of the sac. The sac:- The sac is a diverticulum of peritoneum, consisting of mouth, neck, body and fundus The neck is usually well defined but in some direct inguinal hernias and in many incisional hernias there is no actual neck

MON 2/5/2011

surgery

Dr.Hasan A. Hasan

The diameter of the neck is important because strangulation of bowel is a likely complication when the neck is narrow, as in femoral and paraumbilical hernias the sac can be purely formed by the peritoneum, some times the part of the sac may be formed by the intestine The coverings:- Coverings are derived from the layers of the abdominal wall through which the sac passes so they vary according to the type of hernia e.g ;- femoral hernia consist of sac (peritoneum) , extraperitoneal fat, transversalis fascia , fascia lata, superficial fascia , and subcutaneous tissue The content: might be empty contains only the peritoneal fluid contains omentum = called omentocele (synonym: epiplocele); intestine = enterocele; more commonly small bowel but may be large intestine or appendix; a portion of the circumference of the intestine = Richters hernia; a portion of the bladder (or a diverticulum) may constitute part of or be the sole content of a direct inguinal, a sliding inguinal or a femoral hernia; ovary with or without the corresponding fallopian tube

MON 2/5/2011

surgery

Dr.Hasan A. Hasan

CLASSSIFICATION OF THE HERNIA:1- reducible:- we can reduce the content back to the cavity and this hernia might become irreducible 2- irreducible hernia:- In this case the contents cannot be returned back to the containing cavity It is usually due to adhesions between the sac and its content in the long standing hernia if the irreducibility appeared within the last few hours this is due to narrowing of the neck or swelling of the content 3- obstructed hernia:- if there is a lumen of bowel inside it and compressed at the neck this will lead to intestinal obstruction ( colicky abdominal pain , vomiting, constipation....) 4- strangulated hernia:-if this obstruction persist and become more sever the veins will be occluded when the veins are occluded and the arteries still patent ( the blood goes in but not goes out) the content become edematous , the diameter of the content will become larger this will increase the pressure more and more until it occludes the artery and when it occludes the artery there will be necrosis and gangrene 5- inflamed hernia:- Inflammation can occur from inflammation of the contents of the sac, e.g. acute appendicitis or salpingitis, or from external causes, like a subcutaneous abscess or long duration using of the truss ( pressure lead to necrosis which will lead to inflammation that extends inside ) when there is obstruction the impulse with coughing will not occur
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MON 2/5/2011

surgery

Dr.Hasan A. Hasan

when there is inflammation or gangrene the skin will become red , swollen and the hernia will become tender hernia is not a problem its self and even does not cause pain if it is not complicated , mainly the patient presented with swelling and discomfort but we have to treat the hernia because it may develop life threatening complications .

principles of treatment of hernia:1- The treatment of a hernia is mainly operative 2- in some cases we may use conservative treatment. it is used when: there is a long operative list to avoid complication as the patient waiting for his surgery . or if the patient refuse the surgery the patient is not fit for surgery to avoid complications until the patient become fit for surgery the conservative treatment is the use of truss Operations :before we do surgery we have to deal with the predisposing and precipitating factors so that the patient does not develop hernia in the future ( avoid recurrence) 1-herniotomy:-to reduce the content of the sac and excise the whole sac we do this surgery in children and with young muscular people who have good musculature in the abdominal wall 2- herniorrhaphy:-strength the posterior wall of the hernia by using different types of suture materials or using mesh
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MON 2/5/2011

surgery

Dr.Hasan A. Hasan

there will be fibrosis that strengthen th wall 3- hernioplasty :- take tissue from the patient its self to strengthen the posterior wall of the hernia ( like the use of fascia lata) causes of recurrence:1- the predisposing and precipitating factors are not solved 2- infection after surgery 3 if we have hematoma in the wound which will lead to infection and weakening of the area 4- the sac is not removed completely operations can be done by classical methods or laparoscopic methods

Individual features of hernia:1-Indirect inguinal hernia:surgical anatomy of the inguinal canal:superficial inguinal ring:-is a triangle aperture in the opponeurosis of the external oblique muscle about 1.25 cm above the pubic tubercle deep inguinal ring:-it is a U shaped condensation of the transversalis fascia about 1.25 cm above the mid inguinal point( mid inguinal point :- the middle of the distance from the anterior superior ileac spine to the pubic symphysis ) inguinal canal :-potential space about 3.75 cm extending from the internal ring to the external ring, in children the internal and external ring are one over the other and when the child grow older the ring will separated and we will have internal and external rings and a canal between them
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MON 2/5/2011

surgery

Dr.Hasan A. Hasan

boundaries of inguinal canal:anteriorly:-skin, superficial fascia , and external oblique opponeurosis , laterally:-internal oblique and transvers muscle when it curve medially its called the conjoint tendon posteriorly:-inferior epigastric artery , fascia transversalis and conjoint tendon medially superiorly:- conjoint muscle inferiorly :- inguinal ligament Hesselbach triangle:the inferior border:- inguinal ligament the medial border :- the lateral border of the rectus abdominus muscle the lateral border :- inferior epigastric artery structures passes through the external inguinal ring:1-aretry to the testes and veins to the testis 2- vas and the artery to the vas 3- vessels to cremastric muscle 4-genital branch of the genitofemoral nerve 5-ilioinguinal nerve

MON 2/5/2011

surgery

Dr.Hasan A. Hasan

oblique ( indirect) inguinal hernia:its direction is oblique downward and medially most common type of hernia its seen 20 times more in males than females can occur at any age ( but most common in young aged groups ) only in the first decade of life in children the right inguinal hernia is most common than the left ( left testis descends first so the possibility of processus vaginalis persistance at its side is less common than the right) symptoms:1-the patient may be aware of a lump , this lump may cause pain in the beginning as its finding its way through the abdomen but generally hernia does not cause pain it may cause discomfort 2- when there is pain this means there is obstruction signs:-visible impulse on coughing , look for general causes of hernia by inspection palpation Differential diagnosis :1- Encysted hydrocele of the cord can be moved whith movement of the cord 2-spermatocele :- is a cystic swelling in the upper part of epididymus 3- vaginal hydrocele:-is a collection of fluid in the tunica vaginalis of testis 4-femoral hernia:-bellow and lateral to the pubic tubercle 5-incomplete descend of the testis :- appears as swelling and abscence of the testis in the scrotum
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MON 2/5/2011

surgery

Dr.Hasan A. Hasan

6- lipoma of the cord :- appear as swelling in the cord

treatment of oblique inguinal hernia:indirect inguinal hernia is mainly treated with surgery and if we have a reason to do a conservative treatment , we ,might use a truss ,it is a specific one for this type of hernia and called ( a rat tailed spring truss) with a perineal band otherwise we do surgery because of possibility of having complications and herniotomy :- which usually enough in children and babies ,when the musculature is alright in young adult so it is quiet enough sometimes the posterior wall of the hernia is weak ( it is more weak in direct than indirect inguinal hernia) in that case we have to strength the posterior wall and there is so many methods one of them is repair of the transversalis fascia (strengthen the internal ring) in addition to herniotomy we might do herniorrahphy which might be only for internal ring of transversalis fascia or , more commonly done, enforcement or strength of the posterior wall of the inguinal canal and there is so many methods some of them are:1-Bassini method ( old method):-suture the conjoint tendon with inguinal ligament 2-continous suture 3-a darn suture :- it is a foreign body and there will be reaction to it ( fibrosis that strengthen the wall) 4-mesh for strengthening of the wall :- such operation is done in classical way or laproscopically
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MON 2/5/2011

surgery

Dr.Hasan A. Hasan

when we have recurrence of hernia , we might (for old aged males) remove the testis because removing the testis will lead to obliteration of the weak area of the deep inguinal ring

printed and prepared by:- Ja'afar Abdul- Sahib AL-Salamy Special thanks to;- Taha Mohammad and Ali Shamil

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