1. Femoral hernia
Is the third most common type of hernia, it accounts for 20% of hernias in women and 5% in men. It is the most liable hernia to become strangulated.
Clinical features: The right side is affected twice as often as the left. Because a small hernia usually unnoticed or disregarded by the patient Strangulation is the initial presentation in 40% of cases, and gangrene rapidly occurs. This is due to the narrow unyielding femoral ring.. But sometimes dragging pain is present due to adhesion. It is more common in multiparous elderly women. It appears just below the inguinal ligament.

2. It is rare in young people, the prevalence increases with age.
Absent cough impulse with the pear shaped lump of the inguinal area.
Can not be controlled by a truss
Operation as soon as possible

3. Anatomy
The femoral canal contains, fat, lymphatic vessels and the LN of Cloquet. Closed above by the septum crurale, and below by the cribriform fascia.
The femoral ring bounded:
Anteriorly by inguinal ligament.
Posteriorly by ileopectineal ligament
Medially by the lacunar ligament.
Laterally by a thin septum separating it from the femoral v.

4. Femoral hernia- etiology
All are acquired.
Is secondary to an expanded femoral ring.
Due to increased intra-abdominal pressure, the sac migrates down with the femoral vessels into the thigh.

5. Differential diagnosis:
An inguinal hernia
A saphena varix
An enlarged femoral l.n.
Lipoma
A femoral aneurysm
A psoas abscess: fluctuating swelling
A distended psoas bursa : diminishes when hip joint is flexed.
Rupture of the adductor longus with hematoma

6. Treatment of femoral hernia: several approaches have been advocated.
The low operation (Lockwood)
The high operation (McEvedy)
The inguinal operation (lotheissen)

24. Epigastric hernia
It occurs through the linea alba between xiphoid process and umbilicus.
It is a protrusion of the extra peritoneal fat occurred at a site of blood vessels pierced the linea alba. Or it occurs as a result of weakened linea alba. Or due to sudden stress tearing the fibers of the linea alba.
The mouth of the hernia is rarely large enough to permit the protrusion of a viscus or omentum

26. Treatment: Only in symptomatic patient operation is indicated.
Clinical features: It may be symptomless discovered during abdominal examination.
Local pain, worse on physical exertion, and tender on touch. Referred pain which may be suggestive as peptic ulcer.
As the majority of these hernias are asymptomatic, symptoms should not be ascribed to the hernia until gastrointestinal pathology has been excluded.
Treatment: Only in symptomatic patient operation is indicated.

27. Burst abdomen and Incisional hernia
Etiology
Technique of wound closure: (poor closure technique).
- Choice of suture material
- Method of closure
- Drainage
Factors relating to incisions (vertical or transverse incisions).
Reasons for initial operation (pancreatic and obstruction operations, or peritonitis). Deep wound infection.

28. 4. Coughing, vomiting and distension: any violent coughing by removal of endotracheal tube, or suction of laryngopharynx, and in postoperative ileus. 5. Metabolic state of the patient: obesity, jaundice, malignant diseases, hypoprotinemia and anemia, are factors conductive to disruption of wounds.

29. Burst abdomen
Clinical features: A serosanguinous discharge from the wound between the sixth and eighth day after operation is the first sign of disruption in 50% of cases. It is pathognomonic sign of impending wound disruption and signifies that intraperitoneal contents are lying extraperitoneally.
If the skin sutures have been removed, omentum and coils of intestine may be forced through the wound.
Pain and shock are absent. May be there are symptoms and signs of intestinal obstruction.

30. Treatment While awaiting the operation:
An emergency operation is required to replace the bowel, relieve any obstruction and resuture the wound.
While awaiting the operation:
Reassure the patient and cover the wound with a sterile towel.
NG tube, IVF, antibiotics and sedation.
The edges approximated by through and through monofilament nylon and by tension sutures.
Contrary to what is expected peritonitis rarely supervenes and healing is satisfactory.

31. Incisional hernia

32. Incisional hernia Clinical features
Starts as symptomless partial disruption of the deeper layers of laparotomy wound during the early postoperative period. It is passed unnoticed if the skin wound remains intact after the skin sutures have been removed.
Bulging of part or all the scar
Increases steadily in size
The skin overlying it becomes thin and atrophied
Attacks of intestinal obstruction and strangulation

33. Occur within the first two years after primary operation.
Increased protrusion with valsalva or standing.
Cosmetic concerns or interference with work or activity are common complaints.

36. Kocher or Right Subcostal Incision: oblique abdominal incision paralleling the thoracic cage on the right of the abdomen for cholecystectomy.
Pfannenstial Incision: A transverse incision through the external sheath of the rectus muscles, about an inch above the pubes.
Lanz incision: muscle splitting transverse abdominal incision employed in appendectomy.

37. Treatment Palliative: An abdominal belt. Weight reduction.
Simple apposition: The layers are repaired with non absorbable sutures, the muscles and remaining facial layers are approximated.
Plastic fiber mesh closure: These are now the method of choice for all but the small hernias < 4cm. If the defect is more than 4 cm mesh is indicated.
Laparoscopic surgery can be used to close incisional hernia.
Careful hemostasis and meticulous asepsis are essential during these operations. Postoperative collection of serum can be removed by drainage.

38. Complications of Incisional Hernia Repair
Enterotomy
Superficial wound Infection
Mesh Infection
Seroma
Prolonged Pain
Ileus
Bleeding/Hematoma
Recurrence
Respiratory Distress
Abdominal Compartment syndrome or IVC compression

40. Postoperative care Gastric decompression IV fluid Nothing by mouth
Early ambulation
Gentle physical exercise

41. Tearing of the inferior epigastric artery
Occurs in three types of patients
Elderly women, thin and feeble
Athletic muscular men
Pregnant woman late in pregnancy
The site of the hematoma at the level of the arcuate line
Clinical features: Following a bout of coughing, or a sudden blow to the abdominal wall, a tender lump appears in relation to the rectus abdominis.
The diagnosis may be difficult if there is no ecchymosis of the skin

42. Differential diagnosis
Twisted ovarian cyst
Appendicular mass
Strangulated spigelian hernia
Treatment: a small hematoma may resolve,
It is safer to operate and evacuate the clot and ligate the artery.

43. Neoplasm of the abdominal wall
Desmoid tumor: it is a hard tumor arising in the musculoaponeorotic structures of the abdominal wall, specially below the level of the umbilicus. it is an unencapsulated fibroma . Etiology: 80% in women, occur in scars of old operation wounds. Trauma, stretching of muscle fibers during pregnancy, or hematoma of the abdominal wall are aetiological factors. It can occur in cases of familial adenomatous polyposis.

44. Pathology: no metastasis or sarcomatous changes
Pathology: no metastasis or sarcomatous changes. Treatment: The tumor should be excised widely with a margin of 2.5 cm of healthy tissue Fibrosarcoma adenocarcinoma