Hernia Tulane University Department of Surgery

What is a Hernia? Congenital or Acquired defect in the abdominal wall Herniorrhaphy is one of the most commonly performed operations in all of surgery Incidence ~ 1-5%

Reducible: hernia returns to anatomical location Incarcerated: fixed hernia +/- intestinal obstruction Strangulated: s/s of ischemia and obstruction Physical Exam Characteristics

Abdominal Wall Anatomy 9 Layers Skin Subcutaneous fat Camper’s fascia Scarpa’s fascia External Oblique Internal Oblique Transversus Abdominus Transversalis fascia Peritoneum

Types 1. Inguinal 2. Femoral 3. Umbilical 4. Epigastric 5. Sliding 6. Littre’s 7. Internal 8. Obturator 9. Petit’s 10. Gryngelt’s 11. Coopers 12. Pantaloon 13. Richters 14. Incisional 15. Ventral 16. Hiatal 17. Parastomal 18. Etc. What is the most common Type?

Types 1. Inguinal 2. Femoral 3. Umbilical 4. Epigastric 5. Sliding 6. Littre’s 7. Internal 8. Obturator 9. Petit’s 10. Gryngelt’s 11. Lumbar 12. Pantaloon 13. Richters 14. Incisional 15. Ventral 16. Hiatal 17. Parastomal 18. Etc. What is the most common Type?

Differential Diagnosis (Inguinal Hernias) Lymphadenopathy Varicocele Undescended testicle Hematoma/Pseudoaneursym Sarcoma Lipoma

Contents of Spermatic Cord Vas deferans Spermatic vessels Genital branch of gentiofemoral nerve Cremasteric vessels

Inguinal Repairs Marcy Bassini McVay Shouldice LICHTENSTEIN – Tension Free

Acquired Causes Increased abdominal pressure Obesity Chronic cough Ascites Pregnancy

Hesselbach’s Triangle Indirect (50%) >> Direct (25%)

Indirect Hernia

Operative Repair—Mesh, Mesh, Mesh

Incisional Hernias Up to 11% of pts with previous laparotomy will develop hernia Previous hernia is a risk for development of future hernia Chances of successful closure decrease with each successive repair attempt

Incisional Hernia Repairs Repair Recurrence 3yr Recurrence 10yr Complication Suture42%63%8% Mesh24%32%17%

Abdominal Wall Reconstruction

1900- Silver Filigree Mesh Stainless Steel Cloth Nylon Mesh Marlex (Polyethylene) Prolene (Polypropylene) Mersilene (Polyester) Component Separation Tantalum Mesh (metal) Shift 2 Shift 1 Shift 3 - Bioprosthetics Paradigm for Repairs

Defined anatomic planes and range of advancement of rectus-internal/transversus muscle block Component Separation

Acellular Human Dermis Epidermis and all cellular compenents are removed Initially used in burn patients as a scaffolding for STSG Minimal inflammatory response Alloderm

Conclusion Hernias REQUIRE SURGERY to prevent further complications (intestinal obstruction and infarction) –If reducible----elective –If incacerated----semi-elective –If strangulated----emergent

Questions? According to the National Center for Health Statistics, approximately five million Americans have an abdominal hernia, but only a fraction of those seek treatment. Hernias do not go away and, if left untreated, may worsen over time, causing complications.