12. hernias, umblicus and abdominal wall

DR Javed swati

1

Presentation

By

Dr. Javed SwatiFCPS

Associate Professor of Surgery Department Peshawar medical college

javedswati2

HERNIAS, UMBLICUS AND ABDOMINAL WALL

Introduction?Definition:-G.F Common to all herniasAetiological factors

I. Raised intra abdominal pressure

a) Power full mascular effort examples are whooping cough, chronic cough, straining on micturtion, straining on defecation intra abdominal malignancy

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II. Muscular weakness like excessive smoking, obesity, old age, multipara woman

III. a) Congenital P.P.Vb) Acquired P.P.V eg peritoneal dialysis

000Dr. Javedswati4

- Epigastric - Para umblical- Umblical- Spigelian- Divarication- Inguinal- Femoral- Incisional- Obturator- Superior lumber- Inferior lumber- Gluteal- Sciatic

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External Hernias

Internal Hernias in abdomen

- Hiatus hernias

- Hernia around ilioceal area

- Hernias around D.J junction


- Sac

- Coverings of Sac

- Contents of Sac


Composition of HerniasMain three parts are:

Possible contents could heOmentum

Intestinal

Portion of circumfernce of Gut

Portion of Bladder

Ovary + fallopian tube

Meckels diverticulumAppendixFluid


ClassificationsI. Site

a) Externalb) Internal

II. Reducible?III. Irreducible?

Obstructed? Strangulator? Inflamed?


Reducible Hernia.?

Irreducible Hernia?

Obstructed Hernia?

Incarcerated Hernia?

Strangulated Hernia?


Pathology?Clinical Feature

- Pain:-

- Nausea Vomiting

- Increase in size of Hernia

- O/E Hernia is Tense, Tender, Irreducible, no expancile impulse.


Strangulated Hernia’s

If not treated may lead to ischemia perforation, Peritonitis.

Richters Hernia?

Strangulated Richters Hernia?

Strangulated omentocoele?

Inflamed Hernia?


Surgical anatomy

a) Superficial inguinal ring?b) Deep inguinal ring?c) Inguinal cannal?

Types

I. Indirect inguinal HerniaII. Direct inguinal Hernia


Inguinal Hernia

Indirect (Oblique) Inguinal Hernia

G.F ?Types

1. Bubonocele

2. Funicular

3. Complete (Scrotal)

C.F?000Dr. JavedswatiAfter Correction/Elective14

Points to be cleared on Examination

- Is the hernia right, left or bilateral

- Is it inguinal or Femoral

- Is it direct or indirect

- Is it reducible or irreducible

- Is the inguinal hernia incomplete or complete

- What are the contents? 000Dr. JavedswatiAfter Correction/Elective15

D/D in male

1. Vaginal hydrocoele

2. Encysted hydrocoele of the cord

3. Spermotocoele

4. Femoral hernia

5. Incomplete disended testis

6. Lipoma of the cord000Dr. JavedswatiAfter Correction/Elective16

D/D in female1. Hydrocoele of cannal of nuck

2. Femoral hernia

Treatment Herniotomy Herniotomy + Herniorrphy with or without mesh Trus


Introduction?G.F?C.F?

Funicular direct inguinal hernia (Prevesical hernia)?

Dual (Saddle bag. Pantaloon hernia)


Direct Inguinal Hernia

Operation for direct hernia?

Laparoscopic herniorraphy?Strangulated Inguinal herniaC.F?Pathology?Treatment

a) Generalb) Operation


Treatment of Strangulated Inguinal Hernia

Pre-operative:Avoid unnecessary delay and treat it as

emergencyVigrous resucitation with I/V fluidNasogastric aspirationAntibioticsCatheterisation


Operation:- Inguinal herniotomy for strangulation? Conservation measure in children and

infants? Taxis? NB it is condemnedDangers of taxisi. Contusion or rapture of the intestinal wallii. Reduction en massiii. Reduction into the loculus of the saciv. Rapture of the sac at neck


Non operative treatment of hernia1. Only indicated in children2. Forcible. Reduction must never be

attempted.

Maydl’s Hernia (Hernia en W)?

Results of operation for inguinal herniaSliding hernia (Hernia englissade)?


Femoral HerniaG.F- More common in woman- Can not be controlled with truss- Have a high incidence of strangulation- Should be operated as soon as possible


Surgical Anatomy of Femoral Hernia?Boundaries of femoral ring

Anterior Inguinal ligamentPosterior Astley coopers (ilio

pectineal ligament)Medially Knife like edge of

Gimbernets (Larcunar ligament)

Laterally Thin septum of femoral sheet separating it from femoral vein.


Sex incidence?Pathology?C.FRare before pubertyCommon between 20-40yrs and increasing

ageTwice common on Rt side20% bilateralLess symptomatic than inguinalDragging pain due to Omentum


D.D of femoral hernia1. An inguinal hernia2. A sephana varix3. An enlarged femoral lymphnode4. Lipoma5. A femoral aneurysm6. A psoas abscess7. A distended psoas bursa8. Repture of the adductor longus with

haematoma formation


Hydrocoele of femoral hernial Sac

Laugiers femoral hernia?Narathas femoral hernia?Cloquets hernia?


Umblical Hernia

I Exomphlos (omphalocoele)TypesSmall

A) Primary closureB) Large?

Treatment1. Non operative thrapy 2. Skin flap closure3. Staged closure4. Primary closure


II. Congenital umblical hernia

III. Umblical Hernia of Infants and children

Treatment after 2 years

Operation Herniorraphy


Para Umblical hernia?

(Supra umblical hernia, infra umblical hernia)

C.F- Female to male ration is 5:1- Patient is usually over weight between 35 and

50yearsIncreasing obesity and flabiness of abdominal

musculature and repeated pregnancies are important itiological factors

- Usually irreducible


- Dragging pain

- G.I symptoms

- Intestinal colic

- Intertrigo of the adjacent surface of skin and trophic ulcer are trouble some complication


Treatment- Advised in all cases- If no emergency advise weight loss

Umblical herniorraphyi. Primary closure if defect is smallii. Myo’s repairiii. Prosthetic buttressing if defect is large or

hernia is recurredAdditional laptectomyStrangulation?Operation of strangulation?


Epigastric hernia (Fatty hernia of the

linea alba)

Introduction


C.FCommon in manual workers between 30 to 45 years

Symptoms- Small hernia better felt than seen- May be symptomless- Painful- Referred pain


Treatment- Treated if gives symptoms

- Operations

Rare external hernias1. Inter parital hernia (Interstitial hernia)?

Other verities2. Spigelian hernia3. Lumber herniaa. Inferiorb. Superior


D/D of lumber hernia

1. Lipoma

2. Cold abscess

3. Phantom hernia (Poliomyelitis)


Parineal Hernia?Types- Post operative hernia

- Median sliding perineal hernia

- Antero-lateral perineal hernia

- Postero lateral perineal hernia

Obturator hernia?Gluteal and sciatic hernia?


D/D

i. Lipoma

ii. Cold abscess

iii. Gluteal anurysm


INFLAMMATION OF UMBLICUS:

INFECTION OF UMBLICAL CORD:

OMPHALITIS?


COMPLICATION:Abscess of abdominal wallExtensive ulceration of abdominal wallSepticaemiaJaundice in new bornPortal vein thrombosis and subsequent

portal hypertensionPeritonitisUmblical hernia


UMBLICAL GRANULOMA???DERMATITIS OF AND AROUND THE

UMBLICUS??

PILONIDAL SINUS???

(UMBLICAL CALCULUS UMBOLITH) ?

UMBLICAL FISTULAE???


THE VITELLOINTESTINAL DUCT???

POSSIBLE PRESENTATION OF VITELLOINTESTINAL DUCT:

INTRA ABDOMINAL CYST? INTRAPERITONEAL BAND MECKEL’S DIVERTICULUM PULLED IN UMBLICAL HERNIA. BAND ATTACHED WITH ANOTHER LOOP LEADING TO

INTESTINAL OBSTRUCTION BAND ATTACHED WITH MESENTRY NEAR DISTAL ILLEUM.

TREATMENT:


PATENT URACHUS????

TREATMENT: TREAT DISTAL

OBSTRUCTION UMBLECTOMY+EXCISION OF

THE URACHUS


NEOPLASMS OF THE UMBLICUS:

BENIGN: UMBLICAL ADENOMA , ENDOMETRIOMA

MALIGNANT: SECONDARY CARCINOMA OF UMBLICUS(SISTER JOSEF’S NODULE)

FROM STOMACH ,COLON ,OVARY, BREAST


ABDOMINAL WALL

Burst Abdomen and Incision Hernia

Introduction?

Factor related to the incidence of Burst abdomen and Incisional Hernia


1. Technique of wound closure

a) Choice of suture material

b) Methods of Closure

c) Drainage

2. Factor related to incision?


3. Resons for initial of operation(Infection, Pancratitis, Obstruction)

4. Coughing, Vomiting, Distention

5. General condition of the patient(Obesity, Jaundice, Malignant disease, Hypoproteinemia, Anemia, Pregnancy steroid)


Burst Abdomen (Abdominal Dehiscence)

C.F- Serosangitinous (Pink) discharge from the

wound

- Feeling something giving way

- Viscera lie on skin

- Pain and shock are often absent

- There may be sign and symptoms of intestinal obstruction 000Dr. JavedswatiAfter Correction/Elective48

Treatment

- Emergency closure of wound

- N.G tube

- I/V fluids

- Antibiotics


Incisional Hernia?

Precursors are

- Obesity- Post operative persistent cough- Post operative abdominal distension- Peritonitis- Placement of drain through wound


C.F

- Size varies

- May be irreducible and strangulation

- May be asymptomatic

- All the features of any hernia


Treatment

- Paliative (Abdominal belt)

- Operation?- Simple opposition- Complex opposition- Plastic fiber mesh net closures

Divarication of rectus abdominus?


Tearing of the inferior epigastric artery?

Common In- Elderly women

- Thin and feeble atheletic

- Muscular man usually below middle age

- Pregnant woman mainly multipara late in pregnancy


C.F?D/D

- Twisted ovarian cyst in woman- On right side appendicular lump- Strangutor spigelian hernia

Treatment- Evacultion of clot and ligation of vessel


Infection of Abdominal Wall

Cellutlitisa.Saperficialb.Deep

Progressive postoperative bacterial syngistic gangrene?Amoebic cutis?


Neoplasma of Abdominal Wall

- Desmoid tumor?

- Fibrosarcoma of abdominal wall?

- Adenocarcinoma?


12. hernias, umblicus and abdominal wall

Documents

irreducible hernia

direct hernia

inguinal hernia incomplete

obstructed hernia

inflamed hernia

size of hernia oe hernia

incarcerated hernia

strangulated richters