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- presentation & 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/ neoplasm: 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.

7. Types of hernias Groin hernias: Inguinal (direct/ indirect), femoral PUH, epigastric Incisional Each type can be: Reducible & irreducible Obstructed & strangulated

9. Inguinal hernia Incidence: Indirect Inguinal Hernia (60%), Direct Inguinal Hernia(25%) Femoral hernia (15%) Anatomy of inguinal canal:

12. 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

14. 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

15. Management All IH in children and most IH in adult ( if fit for surgery): surgical repair. Preoperative investigations for fitness. Done mostly as a day case Local, regional or general anaesthesia Laparoscopic or open surgical repair

16. Inguinal hernia repair Open repair IH: Herniotomy + mesh repair- adult Only herniotomy-children DH: No sac excision, sac reduced, weakness/ defect of fascia transversalis repaired, then mesh applied to posterior inguinal wall as in IH

19. 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

24. Clinical features of Femoral hernia 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

25. 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.

26. 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

28. 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

29. PUH, UH

31. 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

32. 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/ strangulation

35. 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

36. 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.

37. 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.

38. Thank you!