1. Abdominal wall & hernia
Prof M K Alam

2. ILOs At the end of this presentation students will be able to:
Describe the aetiology, presentation of rectus sheath hematoma.
Describe the aetiology, presentation of desmoid tumor.
State the anatomy of inguinal canal, femoral canal and umbilicus.
Describe the aetiology, risk factors, presentation, complications and management of groin hernias.
Differentiate between different types of groin hernia.
Describe the presentation and management of other abdominal wall hernias.

3. Diseases of Umbilicus
Persistent vitello-intestinal duct: Persistent part- Meckel’s diverticulum. Whole patent duct forms fistula between ileum & umbilicus. Foul discharge. Treated by excision.
Persistent urachus: Cyst or urinary fistula.
Tumours: Primary- SCC, Melanoma Secondary: Tumour tracking along ligamentum teres.
Hernia

4. Rectus sheath haematoma
Aetiology: Spontaneous (anticoagulation) Traumatic (excessive physical activity) Bleeding from inferior epigastric artery Present as painful, tender swelling Diagnosis-U/S Treatment: Spontaneous resolution or surgical evacuation.

5. Desmoid tumour
Fibromatosis from fibroaponeurotic part of rectus abdominis.
More common in young female of child bearing age, OC use.
Other sites- extremity, intra-abdominal.
Asymptomatic slow growing mass.
Diagnosis: CT or MRI for delineation, core needle biopsy.
Treatment: Wide local excision Local recurrence high if margins are involved Recurrence treated by radiotherapy, anti-oestrogen or NSAID (Sulindac, indomethacin) Rapid growing- chemotherapy

6. Abdominal wall hernia
Definition: Abnormal protrusion through weakness in the wall of the cavity It carries with a peritoneal sac.
Contributing factors: Chronic cough, obesity, straining (constipation), repeated pregnancy, family history, ascites, defective collagen synthesis, heavy lifting, RLQ incision.
Inguinal, femoral, PUH, epigastric & incisional
Reducible & irreducible
Obstructed & strangulated hernia

7. Inguinal hernia Incidence: Indirect Inguinal Hernia (60%),
Femoral hernia (15%)
Anatomy of inguinal canal:

10. Indirect Inguinal hernia
Enters through deep ring within a sac.
Dragging discomfort
Lump
Cough impulse, reducibility
Deep ring occlusion test
Irreducible with features intestinal obstruction (obstructed hernia)
Above features with severe pain in hernia, skin redness and very tender- strangulated hernia

12. Direct inguinal hernia
Bulges through weakness of Hasselbach’s triangle
Wide neck so rarely obstructs or strangulates
Appears as wide bulge
Often spontaneously reduces after cough or lying
Deep ring occlusion does not control

13. Management
All IH in children and most IH in adult ( if fit for surgery) recommended repair.
Preoperative investigations for fitness.
Done mostly as a day case
Local, regional or general anaesthesia
Laparoscopic or open surgical repair
Open repair IH: Herniotomy + mesh repair
DH: No sac excision, sac reduced, weakness/ defect of fascia transversalis repaired, then mesh applied to posterior inguinal wall as in IH

16. Femoral hernia
Projects through femoral ring and passes down the femoral canal (1.25 cm)
Bound laterally by a thin septum separating it from Femoral vein, anteriorly- inguinal ligament, medially- lacunar ligament and posteriorly- superior ramus of pubis & pectineal ligament of Cooper.
Appears through the saphenous opening in deep fascia, appear to lie in front of inguinal ligament

21. Clinical features Groin swelling (often small), groin pain on exercise
Sometimes difficult to distinguish with IH
Examination: Put a finger tip over pubic tubercle (How to find it?).
IH- above & medial, FH- below & lateral
Often irreducible due to its curved course.
Obstruction, strangulation rate high (40%)
D/D: LN, saphenous varix (thrill on cough, disappears on lying down), ectopic testis, psoas abscess

22. Treatment Advise Surgery to all Surgery under local/ GA
Open surgery: Sac is dissected, contents reduced & femoral ring obliterated by suturing inguinal ligament to pectineal ligament.
Laparoscopic approach.

23. Epigastric hernia Protrusion through a defect in linea alba
Firm midline lump.
Often contains preperitoneal fat.
Sometimes peritoneal sac with omentum.
Open surgical repair by non-absorbable suture or mesh
Laparoscopic repair- if large

24. Umbilical, Para-umbilical hernia
UH: Protrusion through umbilicus. Seen infants when they cry. Most- spontaneous resolution by age 3, If not- surgical repair
PUH: Protrusion through tissue around umbilicus
Hernia gradually enlarges, stretching overlying skin
Defect multilocular, irreducible due to adhesion
More common in female
Surgery advised- high risk of obstruction/ strangulation

26. Surgery for PUH
Open Surgery: Transverse skin incision. Sac dissected, contents reduced, sac excised and defect repaired by simple suture, Mayo’s repair or mesh repair if large defect (>3cm)
Laparoscopic repair

27. Incisional hernia
Hernia bulging through poorly healed abdominal incisions
More common with midline vertical incisions
Predisposing factors: Poor surgical technique, infection, obesity, chest infection and collagen disorders.
Defects may be multiloculated
Cough impulse, defects felt on reducing hernia
Risk of obstruction/ starngulation

29. Surgical repair Open surgery: Prolene mesh repair
Laparoscopic mesh repair: Less postoperative pain, shorter hospital stay
Mesh repair complications: Seroma, infection
Laparoscopic repair: Less hernia recurrence

30. Rare external hernias
Spigelian hernia: through linea semilunaris at the lateral border of rectus abdominis. Surgical repair
Lumber hernia bulges above iliac crest between posterior border of ext. oblique & latissimus dorsi.
Obturator hernia through obturator canal. Common in female. Diagnosis usually made at laparotomy for intestinal obstruction due to strangulated hernia.

31. Complications of hernia
Incarcerated: Hernia contents are irreducible but not obstructed or strangulated.
Obstructed: Irreducible hernia presenting with intestinal obstruction.
Strangulated: When blood supply to the contents is jeopardized in an irreducible hernia.

32. Thank you!