Dr. Samir Al-Saffar FICS - Iraq MRCS - England Abdominal Wall Hernia Dr. Samir Al-Saffar FICS - Iraq MRCS - England

Abdominal Wall Hernia Definition A protrusion of a viscus or part of a viscus through an abnormal opening in the walls of its containing cavity الدكتور سمير الصفار

سمير الصفار

Types الدكتور سمير الصفار 10 % of the population 75% of all abdominal wall hernias are in the groin Of which: 95% are inguinal hernias Males are 9 times more prone to develop inguinal hernia than females Types الدكتور سمير الصفار

Introduction Hernias by themselves usually are harmless, but nearly all have a potential risk of Obstruction if their content is part of bowel. Cut off blood supply of their content ( becoming strangulated). الدكتور سمير الصفار

Aetiology Acquired: Any condition that increase intra-abdominal pressure; Strong muscular effort Chronic coughing Straining Obesity Chronic smoking الدكتور سمير الصفار

Aetiology Congenital: Patent processus vaginalis الدكتور سمير الصفار

Composion of hernia Each Hernia consist of Defect or weak point Peritoneal sac Mouth Neck Body Fundus Covering of the sac Contents of the sac الدكتور سمير الصفار

Contents of the sac Omentum Intestine Portion of circumference of intestine “Richter “ Portion of bladder Ovary with or without Fallopian tube Meckel’s diverticulum “Littre “ Fluid الدكتور سمير الصفار

Abdominal Wall Hernia Anatomical types: External Interparietal Internal Sliding الدكتور سمير الصفار

Pathological Types: Reducible Irreducible Obstructed Incarcerated Strangulated Inflamed الدكتور سمير الصفار

Reducible The hernia either reduces itself when the patient lies down, or can be reduced by the patient or the surgeon. الدكتور سمير الصفار

Irreducible Here the contents can not be retuned to the abdomen, but there is no evidence of other complications. الدكتور سمير الصفار

Obstructed This is an irreducible hernia containing an intestine which is obstructed but there is no interference of blood supply to the bowel. الدكتور سمير الصفار

Strangulated A hernia become strangulated when the blood supply of its contents seriously impaired rendering the contents ischaemic. الدكتور سمير الصفار

Inflamed Inflammation of its contents; Inflammation of overlying wall Appendix Fallopian tube Inflammation of overlying wall الدكتور سمير الصفار

Locational Types Groin Umbilicus Epigastric (Linea alba ) Surgical incisions Spigelian (Semi-lunar line) Diaphragm Lumbar triangles Pelvis (Obturator) الدكتور سمير الصفار

Locational Types الدكتور سمير الصفار

Groin hernia Inguinal Femoral الدكتور سمير الصفار

Inguinal Hernia Inguinal hernia: Makes up 75% of all abdominal wall hernias and occurring up to 25 times more often in men than women. الدكتور سمير الصفار

Inguinal Hernia Indirect Direct الدكتور سمير الصفار

Anatomy of Groin الدكتور سمير الصفار

Anatomy of Inguinal Canal 3.75cm in length 1.25 cm cephalad and parallel to inguinal ligament Extends from deep to superficial inguinal rings الدكتور سمير الصفار

Anatomy of Inguinal Canal In infants; the canal is almost not present as the DIR and SIR superimposed الدكتور سمير الصفار

Boundaries of Inguinal Canal Anterior EOA, CT Posterior CT , TF Upper (roof) CT Lower (floor) IL الدكتور سمير الصفار

Contents of Canal Spermatic cord in male and round ligament in female Ileo-inguinal nerve Genital br of genito-femoral nerve الدكتور سمير الصفار

Indirect Inguinal Hernia Is the most common of all forms of hernia Most common in young Men > women Right > left 10% of premature babies 5% of adult population الدكتور سمير الصفار

Indirect Inguinal Hernia In adults: 65% of all inguinal hernia is indirect 55% right 12 % bilateral الدكتور سمير الصفار

Indirect Inguinal hernia Incomplete Bubonocele Funicular Complete Inguinoscrotal الدكتور سمير الصفار

الدكتور سمير الصفار

Pathogenesis of Indirect Hernia Congenital Acquired الدكتور سمير الصفار

Pathogenesis of Indirect Hernia Congenital: Persistent processus vaginalis Within spermatic cord Follows indirect course Complete vs. incomplete sac الدكتور سمير الصفار

Pathogenesis of Indirect Hernia Acquired Precipitating factors Increased intra-abdominal pressure Defects in collagen synthesis Smoking الدكتور سمير الصفار

Clinical Features Any age Right < Left Male < Female (20 times) الدكتور سمير الصفار

Presenting symptoms Swelling appear on standing or coughing Pain in the groin الدكتور سمير الصفار

Swelling in the groin الدكتور سمير الصفار

Swelling in the groin descended to scrotum الدكتور سمير الصفار

Examination Apparent on standing Expensile cough impulse Controlled on pressing over the DIR الدكتور سمير الصفار

المحاضرة الثانية الدكتور سمير الصفار

Umbilical hernia Spigelian Hernia Inguinal hernia Epigastric hernia الدكتور سمير الصفار

الدكتور سمير الصفار

Diagnosis Groin swelling that disappear with supine position Examine erect and supine Does not transilluminate Expensile cough impulse الدكتور سمير الصفار

How to differentiate IIH from DIH Indirect Inguinal Hernia May descend into scrotum Protrude through DIR Its neck lateral to inferior epigastric vessels Can be Controlled by pressing on the DIR More liable for irreducibility Could be congenital Not always needs repair during surgery Direct Inguinal Hernia Almost never descend into scrotum Protrude directly through Hesselbach’s triangle. Medial to inferior epigastric vessels Can be controlled by pressing on SIR Less liable Almost always acquired Repair is mandatory الدكتور سمير الصفار

When the swelling localized to groin The differential diagnosis: Femoral hernia Lipoma of cord Inguinal lymphadenopathy Incompletely descended testis Ectopic testis Femoral artery aneurysm

Differential Diagnosis الدكتور سمير الصفار

When the swelling is inguino-scrotal Vaginal hydrocele Encysted hydrocele of cord Spermatocele Varicocele Epididymoorchitis Torsion of testis Testicular tumor الدكتور سمير الصفار

In female Femoral hernia Hydrocele of canal of Nuck Inguinal lymphadenopathy الدكتور سمير الصفار

الدكتور سمير الصفار

Treatment Operation is treatment of choice: Open surgery The standard method Laparoscopic hernia repair should be reserved for bilateral or recurrent hernia الدكتور سمير الصفار

Open surgery Herniotomy Herniorrhaphy الدكتور سمير الصفار

Open surgery Anaesthesia Local Spinal General الدكتور سمير الصفار

Herniotomy Indications: Steps of surgery: In infants, children and adolescents Steps of surgery: Dissection of sac Open of sac Reduction of contents Transfixation of neck Cut of reminder الدكتور سمير الصفار

Herniorrhaphy Repair of stretched DIR and transversalis fascia Reinforcement of posterior wall by: Shouldice repair Mesh repair الدكتور سمير الصفار

Complications Bleeding Retention of urine Wound infection Skin bruises, SC hematoma Scrotal hematoma Retention of urine Wound infection الدكتور سمير الصفار

Complications Recurrence >1% Injury to vas deference Ischemic orchitis Neuralgia Ilioinguinal Iliohypogastric Genitofemoral Lateral cutaneous Recurrence >1% الدكتور سمير الصفار

Direct Inguinal Hernia الدكتور سمير الصفار

Direct Inguinal Hernia Acquired Adults 35% of inguinal hernia 12% bilateral Not occur in females الدكتور سمير الصفار

Anatomy of Direct Hernia Hesselbach’s triangle Inguinal ligament (base), rectus (medial), inferior epigastric vessels (lateral) الدكتور سمير الصفار

Hesselbach’s triangle الدكتور سمير الصفار

Direct Inguinal Hernia Pathogenesis: Through weak posterior wall of inguinal canal Medial to Inferior epigastric vv Not attain large size or descent into scrotum Lies behind spermatic cord Wide neck الدكتور سمير الصفار

Direct Inguinal Hernia Varieties Dual ( Pantoloon,saddle bag) Funicular (Prevesical) الدكتور سمير الصفار

Clinical Features Swelling in the groin On examination: controlled on pressing on SIR ECI الدكتور سمير الصفار

Treatment Surgical repair Dissection of sac Inverted Repair of transversalis fascia Mesh(Lichtenstein) or Shouldice repair الدكتور سمير الصفار

Strangulated Inguinal Hernia Can occur at any time More liable to occur in patients with irreducible hernia. More commonly occur in IIH Less often in DIH الدكتور سمير الصفار

Constricting agent Neck of sac External inguinal ring Adhesions within the sac الدكتور سمير الصفار

Content of hernia Small intestine Omentum Both الدكتور سمير الصفار

Clinical features Severe pain in the groin Vomiting General upset Fever ? الدكتور سمير الصفار

Swelling with skin discoloration in the groin Severely tender Abdominal signs الدكتور سمير الصفار

Treatment Urgent surgery Pinciples: Dissection of sac Open the sac Exploration of content Excision of gangrenous tissues الدكتور سمير الصفار

Gangrenous bowel الدكتور سمير الصفار

Femoral Hernia الدكتور سمير الصفار

Anatomy of the femoral canal الدكتور سمير الصفار

Anatomy of the femoral canal Boundaries of femoral ring Anterior border is the inguinal ligament Posterior border is the pectineal ligament Medial border is the lacunar ligament Lateral border is the femoral vein الدكتور سمير الصفار

Femoral Hernia Women> men 20% of hernias in women More in parous Most liable for strangulation الدكتور سمير الصفار

Clinical features Rare before puberty May be un-noticed by the patient الدكتور سمير الصفار

Strangulated hernia Sudden painful swelling in the groin Abdominal symptoms الدكتور سمير الصفار

Examination The swelling is inferior to inguinal ligament and lateral to pubic tubercule Mostly irreducible الدكتور سمير الصفار

Differential Diagnosis Inguinal hernia Lymphadenopathy Saphena varix Ectopic testis Psoas abscess Distended Psoas bursa Lipoma Rupture of adductor longus الدكتور سمير الصفار

Treatment Uncomplicated hernia: Strangulated hernia Operation as early as possible Strangulated hernia Urgent surgery الدكتور سمير الصفار

Approaches for the surgery Low approach – Lookwood High approach - McEvedy Inguinal approach - Lotheissen الدكتور سمير الصفار

Principle of surgery Dissection of sac Open sac Reduction of contents if healthy otherwise gangrenous tissue must be excised. Repair of femoral ring الدكتور سمير الصفار

Abdominal wall Hernia المحاضرة الثالثة الدكتور سمير الصفار

Richter’s hernia Frequent complication of femoral hernia Only part of circumference of bowel enclosed in the hernia sac which may become gangrenous Clinically; abdominal symptoms of IO but with no constipation. الدكتور سمير الصفار

Diagnosis: High index of suspicion Urgent surgical interference Almost always the diagnosis made at surgery الدكتور سمير الصفار

Umbilical hernia In neonates Exomphalos 1/6000 of births Failure of all or part of midgut to return to the coelom الدكتور سمير الصفار

Umbilical hernia In infants and children Defect in the umbilical cicatrix Equal sex incidence Black infants 8 times more الدكتور سمير الصفار

Clinical features Symptomless More prominent during crying Obstruction or strangulation is rare below 3 years of age Most of cases resolve by itself within 2 years الدكتور سمير الصفار

Diagnosis Swelling with umbilical cicatric at fundus of swelling Reducible ECI +ve -----Crying

Treatment Conservative below the age of 2 years – reassurance of parents After 2 years needs surgical repair الدكتور سمير الصفار

Paraumbilical Hernia Adults Women> men Risk factors Obesity Pregnancy Repair primarily or with mesh الدكتور سمير الصفار

Pathogenesis Weak point in the linea alba just above or just below the umbilical cicatrix Round or oval in shape May sag downwards May become a large size الدكتور سمير الصفار

The neck of sac is often remarkably small in size Contents; mostly small intestine or omentum or both Sometimes part of transverse colon الدكتور سمير الصفار

Clinical features Classical patient; Adult Female (F:M ; 5:1) Aged between 35 and 50 years Overweight multipara الدكتور سمير الصفار

Symptoms Abdominal swelling Dragging pain Intestinal colics—obstruction Epigastric pain (stomachache) الدكتور سمير الصفار

Complications Irreducibility with possibility of IO Ulceration of skin over fundus of sac Intertrigo الدكتور سمير الصفار

Diagnosis Clinical Swelling just above or below the umbilicus Prominent on standing Disappear on lying Expensile cough impulse الدكتور سمير الصفار

Treatment Operation is advised in nearly all patients: Indications: Liable for complication Cosmetic The operation is Herniotomy and Repair; Either Myo’s repair Mesh repair

Mesh repair is indicated for Large defect < 4 cm Recurrent hernia

Postoperative complications Local and specific Collection Hematoma Seroma Infection Wound infection Pus collection Recurrence

Epigastric Hernia (Fatty hernia of linea alba) Incidence 1-5% Men> women Between xiphoid and umbilicus 20% multiple Repair primarily الدكتور سمير الصفار

Pathogenesis Extraperitoneal fat protrusion through decussating fibers at linea alba At sites of blood vessels

Clinical features Symptomless Painful ---local pain and tenderness Accidental finding The size of a Pea Felt not seen Painful ---local pain and tenderness Referred pain----DU like symptoms

Treatment Operation

Spieghelian Hernia Rare Hernia through subumbilical portion of semi-lunar line Difficult to diagnose Clinical suspicion (location) CT scan Repair primarily or with mesh

Incisional Hernia This occurs after 2-10% of all abdominal surgeries, although some people are more at risk. After surgical repair, these hernias have a high rate of returning (20-45%).

Incisional Hernia Risk factors Laparoscopic vs. open repair Technical Wound infection Smoking Hypoxia/ ischemia Tension Obesity Malnutrition Laparoscopic vs. open repair الدكتور سمير الصفار

Lumbar Hernia Congenital, spontaneous or traumatic Grynfeltt’s triangle 12th rib, internal oblique and sacrospinalis muscle Covered by latissimus dorsi Petit’s triangle Latissimus dorsi, external oblique and iliac crest Covered by superficial fascia

Pelvic Hernia Obturator hernia Sciatic hernia Perineal hernia Most commonly in women Howship-Romberg sign Sciatic hernia Perineal hernia

Parastomal Hernia Variant of incisional hernia Paracolostomy > paraileostomy Low rate if through rectus muscle Traditionally relocate stoma, repair defect Concern for mesh erosion Laparoscopic repair الدكتور سمير الصفار

Abdominal Wall Hernia Richter’s hernia Littre’s hernia Hernia in W Pantallon الدكتور سمير الصفار

Umbilical Hernia Common in infants Close spontaneously if <1.5 cm Repair if > 2 cm or if persists at age 3-4 years Repair primarily or with mesh