1. Abdominal Wall Hernia

2. DefinitionDefinition –External –Interparietal –Internal –Reducible –Non-reducible ( incarcerated) –Strangulated

3. Abdominal Wall Hernia Richter’s herniaRichter’s hernia Littre’s herniaLittre’s hernia

4. Location GroinGroin UmbilicusUmbilicus Linea alba (epigastric)Linea alba (epigastric) Surgical incisionsSurgical incisions Semi-lunar lineSemi-lunar line DiaphragmDiaphragm Lumbar trianglesLumbar triangles PelvisPelvis

5. ……………..

6. Groin hernia Indirect inguinalIndirect inguinal –scrotal Direct inguinalDirect inguinal FemoralFemoral

7. Groin Hernia Men > womenMen > women Right > leftRight > left 10% of premature babies10% of premature babies 5% of adult population5% of adult population

8. Indirect Hernia Anatomy Indirect herniaIndirect hernia –Dilated persistent processus vaginalis –Within spermatic cord –Follows indirect course –Complete. incomplete sac –Sliding hernia –Cord lipoma

9. Direct Hernia Anatomy Hesselbach’s triangleHesselbach’s triangle –Inguinal ligament (base), rectus (medial), inferior epigastric vessels (lateral) Sliding herniaSliding hernia

10. Femoral hernia

11. Femoral Hernia Anatomy Inferior to inguinal ligamentInferior to inguinal ligament Women> menWomen> men Usually on medial aspect of femoral sheathUsually on medial aspect of femoral sheath

12. Diagnosis Groin swelling that resolves with supine positionGroin swelling that resolves with supine position Precipitating factorsPrecipitating factors –Increased intra-abdominal pressure –Defects in collagen synthesis –Smoking Examine erect and supineExamine erect and supine Does not transluminateDoes not transluminate

13. Groin Hernia Differential Diagnosis HydroceleHydrocele VaricoceleVaricocele EpididymoorchitisEpididymoorchitis Torsion of testisTorsion of testis Undescended testisUndescended testis Ectopic testisEctopic testis Testicular tumorTesticular tumor Femoral artery aneurysmFemoral artery aneurysm LipomaLipoma LymphadenopathyLymphadenopathy

14. Treatment Expectant managementExpectant management Surgical repairSurgical repair –Mesh –Open –Laparoscopic TEP (totally extra-peritoneal)TEP (totally extra-peritoneal) TAPP (transabdominal pre-peritoneal)TAPP (transabdominal pre-peritoneal)

15. Complications RecurrenceRecurrence NeuralgiaNeuralgia –Ilioinguinal –Iliohypogastric –Genitofemoral –Lateral cutaneous Ischemic orchitisIschemic orchitis Injury to vas deferenceInjury to vas deference Wound infectionWound infection BleedingBleeding

16. Umbilical Hernia Women> menWomen> men Risk factorsRisk factors ObesityObesity PregnancyPregnancy May rupture with ascitesMay rupture with ascites Repair primarily or with meshRepair primarily or with mesh

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

18. Epigasteric hernia …………..…………..

19. Epigastric Hernia Incidence 1-5%Incidence 1-5% Men> womenMen> women Pre-peritoneal fat protrusion through decussating fibers at linea albaPre-peritoneal fat protrusion through decussating fibers at linea alba Between xiphoid and umbilicusBetween xiphoid and umbilicus 20% multiple20% multiple Repair primarilyRepair primarily

20. Incisional Hernia Risk factorsRisk factors –Technical –Wound infection –Smoking –Hypoxia/ ischemia –Tension –Obesity –Malnutrition Laparoscopic. open repairLaparoscopic. open repair

21. Parastomal Hernia Variant of incisional herniaVariant of incisional hernia Paracolostomy > paraileostomyParacolostomy > paraileostomy Low rate if through rectus muscleLow rate if through rectus muscle Traditionally relocate stoma, repair defectTraditionally relocate stoma, repair defect Laparoscopic repairLaparoscopic repair

22. …………… Parastomal hernia

23. Spigel hernia …………..…………..

24. Spieghelian Hernia RareRare Hernia through subumbilical portion of semi-lunar lineHernia through subumbilical portion of semi-lunar line Difficult to diagnoseDifficult to diagnose –Clinical suspicion (location) –CT scan Repair primarily or with meshRepair primarily or with mesh

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

26. Pelvic Hernia Obturator herniaObturator hernia –Most commonly in women –Howship-Romberg sign Sciatic herniaSciatic hernia Perineal herniaPerineal hernia

27. Obteratour hernia ……

28. Sciatic hernia ……………

29. ………….