Anatomical and Physiological Substantiations of Operative Interventions on Ventral Abdominal Wall

Ventral Abdominal Wall Regions

Organs Projection

Muscles of the Trunk

4 Levels of Rectus Abdominis Muscle Sheath Structures

Layer Structure of the Ventral Abdominal Wall

Abdominal Incisions  Must be located nearest to the organ.  Must have sufficient length for surgeon’s activities.  Must be atraumatic.

Skin Incisions of the Ventral Abdominal Wall

Superficial Inguinal Ring

Ventral Abdominal Wall (lower internal view)

Internal Inguinal Ring

The Walls Of The Inguinal Canal ANTERIOR WALL  laterally - muscles fibers of the external oblique  medially - aponeurosis of the external oblique  most medially there is not wall but there is a deficiency called the superficial inguinal ring. SUPERIOR - arching fibers of the internal oblique and sometimes transverse abdominis. These fibers start anterior and lateral, pass over the spermatic cord and the medially forms part of the posterior wall of the canal. POSTERIOR – laterally - deep inguinal ring. Medially the posterior wall is made up of the aponeuroses of the internal oblique and transverse abdominis. INFERIOR - inguinal ligament.

Male Inguinal Canal

Female Inguinal Canal

HERNIA Hernia of the abdominal wall or external hernia is such surgical disease, which is characterized by outlet of the visceral organs from the place of their physiological placement through the natural canals or defects of the abdominal and pelvic wall. In such case all visceral organs covered by parietal peritoneum and skin are not damaged. Hernia of the abdominal wall or external hernia is such surgical disease, which is characterized by outlet of the visceral organs from the place of their physiological placement through the natural canals or defects of the abdominal and pelvic wall. In such case all visceral organs covered by parietal peritoneum and skin are not damaged.

HERNIA Internal hernia is such disease, visceral organs hit the peritoneum pouch. It formed in the place of natural peritoneum fold or recess and generally kept in the abdominal cavity. Internal hernia is such disease, visceral organs hit the peritoneum pouch. It formed in the place of natural peritoneum fold or recess and generally kept in the abdominal cavity.

Anatomy of an Inguinal Hernia Elements of a Hernia: 1. Hernial gate; 2. Hernial sac; 3. Hernial contents; Elements of hernial sac: а) neck; б) body; в) fundus.

Weak Places of the Ventral Abdominal Wall

Hernial Gates for Hernias of Ventral Abdominal Wall 1. Umbilical hernia – umbilical ring; 2. Midline hernia – artificial hole or alba line holes, through which intercostals nerves pass; 3. Indirect inguinal hernia – deep ring of inguinal canal; 4. Direct inguinal hernia – inguinal space.

Differences Between Inguinal Hernias Indirect Hernia Gate – internal inguinal ring Sac - is laterally to spermatic cord and is laterally to inferior epigastric artery Form is oval It can be acquired or congenital Direct Hernia Gate – inguinal space Sac - is medially to spermatic cord and is medially to inferior epigastric artery Form is round It can be only acquired

Levelling Factors of the Inguinal Canal Weakness  Except in the newborn infant, the canal is an oblique passage with the weakest areas, namely, the superficial and deep rings, lying some distance apart.  The anterior wall of the canal is reinforced by the fibers of internal oblique muscle immediately in front of the deep ring.  The posterior wall of the canal is reinforced by the strong conjoint tendon of the internal oblique and transversus muscles immediately behind the superficial ring.  In case of sharp temporary increasing of intra- abdominal pressure the muscles of superior wall contract and bring superior wall nearer to the inferior wall (so that the canal is virtually closed).

Steps of Surgery: 1. access 2. extraction of hernial sac: а) incision of hernial sac; b) reposition of hernial contents inside of abdominal cavity; c) stitching of neck of hernial sac; d) cutting of hernial sac; 3. grafting.

А) Lexer’s Grafting (umbilical hernia)

B) Lexer’s grafting (umbilical hernia, final view)

Treatment of an Umbilical Hernia (Mayo's Method) The defect of ventral abdominal wall in umbilical ring region is stitched by H- shaped suture in transversal direction. The defect of ventral abdominal wall in umbilical ring region is stitched by H- shaped suture in transversal direction.

Treatment of an Umbilical Hernia (Sapezhko’s Method) Forming of abdominal midline duplication by stitching in longitudinal direction. Forming of abdominal midline duplication by stitching in longitudinal direction.

Martynov’s Grafting of Anterior Wall of Inguinal Canal

Inguinal Repair with Mesh

Liechtenstein's Grafting Mesh patch fixation

Liechtenstein's Grafting View of interrupted suture

Sliding Hernia

Putting in the Purse-string Suture in Case of Sliding Hernia

Richter’s (Parietal) Strangulation of Intestine

Retrograde Strangulation

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