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ABDOMINAL WALL ABDOMINAL WALL DEFECTSDEFECTS
Celso M. Fidel, MD, FPCS,FPSGSCelso M. Fidel, MD, FPCS,FPSGSDiplomate Philippine Board of SurgeryDiplomate Philippine Board of Surgery
IntroductionIntroduction
ABDOMINAL WALL ABDOMINAL WALL
Complex musculo-aponeurotic structure Complex musculo-aponeurotic structure
Attached to the :Attached to the :
Vertebral column posteriorly Vertebral column posteriorly
Ribs superiorly Ribs superiorly
Bones of the pelvis inferiorlyBones of the pelvis inferiorly
Derived embryonically in a segmental, Derived embryonically in a segmental,
metameric manner, and is reflected metameric manner, and is reflected
in blood supply and innervation.in blood supply and innervation.
IntroductionIntroduction
ABDOMINAL WALLABDOMINAL WALL
Protects and restrains the abdominal Protects and restrains the abdominal viscera, viscera,
and its musculatureand its musculature
Acts indirectly to flex the vertebral Acts indirectly to flex the vertebral column.column.
Integrity is essential to the prevention of Integrity is essential to the prevention of
hernias, whether they be:hernias, whether they be:
CongenitalCongenital
Acquired Acquired
IatrogenicIatrogenic
IntroductionIntroduction
ABDOMINAL WALLABDOMINAL WALL
It is the repository of the panniculus It is the repository of the panniculus adiposus adiposus
May reach considerable proportions May reach considerable proportions in some members of the species in some members of the species afflicted with morbid obesityafflicted with morbid obesity..
IntroductionIntroduction
ABDOMINAL WALLABDOMINAL WALL
Variety of pathology difficult to assess on Variety of pathology difficult to assess on
physical examination.physical examination.
Computed tomography (CT) often delineates Computed tomography (CT) often delineates
these abnormalitiesthese abnormalities
GENERAL CONSIDERATIONSGENERAL CONSIDERATIONS
VENTRAL HERNIAVENTRAL HERNIA
UMBILICAL HERNIASUMBILICAL HERNIAS
EPIGASTRIC HERNIAEPIGASTRIC HERNIA
INCISIONAL HERNIAINCISIONAL HERNIA
TROCAR HERNIATROCAR HERNIA
Emergency Abdominal wall DefectsEmergency Abdominal wall Defects
Difficult Abdominal Wall ClosureDifficult Abdominal Wall Closure
ABDOMINAL WALL HERNIASABDOMINAL WALL HERNIAS
UMBILICAL HERNIASUMBILICAL HERNIAS
UMBILICAL HERNIAUMBILICAL HERNIA
GENERAL CONSIDERATIONSGENERAL CONSIDERATIONS
Other Abdominal Wall HerniaOther Abdominal Wall Hernia Spigelian HerniaSpigelian Hernia Lumbar HerniaLumbar Hernia 1. Petit’s or inferior triangle hernia1. Petit’s or inferior triangle hernia 2. Grynfelt’s or sup. Triangle hernia2. Grynfelt’s or sup. Triangle hernia
Pelvic Floor HerniaPelvic Floor Hernia 1. Obturator Hernia1. Obturator Hernia 2. Perineal Hernia2. Perineal Hernia 3. Sciatic Hernia3. Sciatic Hernia
GENERAL CONSIDERATIONSGENERAL CONSIDERATIONS
Other Abdominal Wall HerniaOther Abdominal Wall Hernia
4. Parastomal Hernia4. Parastomal Hernia
5. Internal hernia 5. Internal hernia
(a) Normal Orifice(a) Normal Orifice
(b) Abnormal Orifice(b) Abnormal Orifice
(c) Iatrogenic ( post-operative)(c) Iatrogenic ( post-operative)
GENERAL CONSIDERATIONSGENERAL CONSIDERATIONS
Other Abdominal Wall HerniaOther Abdominal Wall Hernia
6. Co6. Congenital Abdominalngenital Abdominal Wall defect Wall defect
(a) Gastroschisis(a) Gastroschisis
(b) Omphalocele(b) Omphalocele
7. C7. Congenitalongenital Diaphragmatic Hernia Diaphragmatic Hernia
(a) Bochdalek(a) Bochdalek
(b) Morgagni(b) Morgagni
Abdominal Wall DefectsAbdominal Wall Defects Ventral HerniaVentral Hernia
Defect in the abdominal wall with Defect in the abdominal wall with intestines intestines or preperitoneal fat thru fascial or preperitoneal fat thru fascial defectdefect
On PE fascial defect usually palpable in On PE fascial defect usually palpable in obese patients obese patients
Ultrasound or CT scan for the diagnosisUltrasound or CT scan for the diagnosis Same principle of management as Same principle of management as groingroin herniahernia
Ventral HERNIAVentral HERNIA Umbilical HerniaUmbilical Hernia Occur more frequently in females; 10-30% Occur more frequently in females; 10-30% live birthlive birth Obesity and repeated pregnancies precludes Obesity and repeated pregnancies precludes this problemthis problem In infants aponeurotic defect of 1.5 cm or less In infants aponeurotic defect of 1.5 cm or less would close spontaneouslywould close spontaneously Repair for children present by the age of Repair for children present by the age of three or four & infants whose defect is 2 cmthree or four & infants whose defect is 2 cm
Ventral HERNIAVentral HERNIA Umbilical HerniaUmbilical Hernia
MAYO HERNIOPLASTYMAYO HERNIOPLASTY
Vest over pants imbrication of the superior Vest over pants imbrication of the superior
& inferior aponeurotic fascia layer& inferior aponeurotic fascia layer
EPIGASTRIC HERNIAEPIGASTRIC HERNIA
Protrusion of properitoneal fat & peritoneum Protrusion of properitoneal fat & peritoneum
through the dicussating fibers of the through the dicussating fibers of the rectus rectus
sheath in the midline (linea alba) between sheath in the midline (linea alba) between
the xiphoid.the xiphoid.
Ventral HERNIAVentral HERNIA Epigastric HerniaEpigastric Hernia Diastasis RectiDiastasis Recti Wide gap between the medial borders Wide gap between the medial borders
of theof the rectus sheath rectus sheath Diffuse bulge at upper midline of Diffuse bulge at upper midline of
abdomenabdomen Not a fascial defect, hence repaired forNot a fascial defect, hence repaired for cosmetic purposescosmetic purposes Incisional HerniaIncisional Hernia
Patient Rogelia TacubanPatient Rogelia Tacuban
INCISIONAL HERNIOPLASTYINCISIONAL HERNIOPLASTY
Anatomic reconstruction of the abdominal Anatomic reconstruction of the abdominal
wall and Includes;wall and Includes;
Closure of the parietal defectClosure of the parietal defect Restoration of normal intra-abdominal Restoration of normal intra-abdominal
pressurepressure Tendinous reinforcement of the lateralTendinous reinforcement of the lateral
abdominal muscles.abdominal muscles.
Clear View of External O AponeurosisClear View of External O Aponeurosis
Separation of the SacSeparation of the Sac
CATTELL REPAIR
Ventral HERNIAVentral HERNIA
Incisional HerniaIncisional Hernia 2-11% of abdominal wall closure2-11% of abdominal wall closure 56% in the first year postoperative56% in the first year postoperative 17% incarcerate17% incarcerate 20-46% repeat recurrence20-46% repeat recurrence Causes:Causes: 1. Obesity1. Obesity 2. post-op pulmonary complications2. post-op pulmonary complications 3. Wound infection3. Wound infection
Visceral HERNIAVisceral HERNIA
Incisional HerniaIncisional Hernia
4. Jaundice4. Jaundice
5. Advanced age5. Advanced age
6. Abdominal Distention6. Abdominal Distention
7. Re-use of previous incision7. Re-use of previous incision
8. Emergency operation8. Emergency operation
9. Pregnancy9. Pregnancy
10. Chemotherapy post-op10. Chemotherapy post-op
Ventral HERNIAVentral HERNIA Incisional HerniaIncisional Hernia
11. Steroids11. Steroids
12. Malnutrition12. Malnutrition
13. Ascites13. Ascites
14. Peritoneal dialysis14. Peritoneal dialysis
Trocar HerniasTrocar Hernias
< 1% after laparoscopic procedure< 1% after laparoscopic procedure
Fascial defects > 5mm should be closedFascial defects > 5mm should be closed
Ventral HERNIAVentral HERNIA Repair TechniquesRepair Techniques
1. P1. Primary repair w/rimary repair w/ non-absorbablenon-absorbable monofilamentmonofilament
sutures; 49-58% failure ratesutures; 49-58% failure rate
Mayo repair (fascial imbrication) 54% Mayo repair (fascial imbrication) 54% recurrecur
in 5-7 years follow upin 5-7 years follow up
“ “Far and Near” suturing by Shukla= 0%Far and Near” suturing by Shukla= 0%
Internal retention suturing-2% recur forInternal retention suturing-2% recur for
large ventral hernialarge ventral hernia
Ventral HERNIAVentral HERNIA Repair TechniquesRepair Techniques
2. Mesh onlay- 6% recur2. Mesh onlay- 6% recur
3. Mesh onlay and patch repair= Mesh placed3. Mesh onlay and patch repair= Mesh placed
deep to the rectus sheathdeep to the rectus sheath
4. Sandwich and cuffed mesh repair 4. Sandwich and cuffed mesh repair combinedcombined
onlay + inlayonlay + inlay
5. Stoppa- Giant mesh prosthesis for large 5. Stoppa- Giant mesh prosthesis for large >10>10
cm incisional herniacm incisional hernia
6. Laparoscopic repair6. Laparoscopic repair
Emergency Abdominal Wall Emergency Abdominal Wall DefectDefect
Difficult abdominal wall closure in:Difficult abdominal wall closure in:
Massive bowel edemaMassive bowel edema
Tissue loss due to TraumaTissue loss due to Trauma
Debridement for necrotizing lesionsDebridement for necrotizing lesions
Resection of tumorsResection of tumors
Repair with prosthetics w/ absorbable Repair with prosthetics w/ absorbable meshmesh
followed by skin grafting then followed by skin grafting then plannedplanned
ventral hernia repairventral hernia repair
Other Abdominal Wall Other Abdominal Wall HerniaHernia
SPIGELIAN HERNIASPIGELIAN HERNIA Ventral Ventral hernia occurringhernia occurring along the subumbilical along the subumbilical
portion of the Spieghel’s Semilunar line & portion of the Spieghel’s Semilunar line &
through Spieghel’s Fascia.through Spieghel’s Fascia.
Vague pain, mass usually not palpableVague pain, mass usually not palpable, , intraintra
mural mural mass located 0-6 cranialmass located 0-6 cranial to interspinous to interspinous
line (horizontal line between 2 ASIS)line (horizontal line between 2 ASIS)
Usual location- just below semicircular line ofUsual location- just below semicircular line of
Douglas; Defect in Transversus AbdominisDouglas; Defect in Transversus Abdominis
Other Abdominal Wall HerniaOther Abdominal Wall Hernia
LUMBAR HERNIALUMBAR HERNIA CongenitalCongenital spontaneous spontaneous & traumatic herniation & traumatic herniation
occur through Grynfelts superior & petits occur through Grynfelts superior & petits
inferior lumbar triangleinferior lumbar triangle..
Defect in transversalis fascia & TranversusDefect in transversalis fascia & Tranversus
Abdominis AponeurosisAbdominis Aponeurosis
Contains retroperitoneal sac or peritoneumContains retroperitoneal sac or peritoneum
lined saclined sac
Lumbar HerniaLumbar Hernia
PETIT’S TRIANGLE PETIT’S TRIANGLE is bounded by:is bounded by:
Medial= Latissimus dorsi muscleMedial= Latissimus dorsi muscle
Lateral= External oblique muscleLateral= External oblique muscle
Inferior= Iliac crestInferior= Iliac crest
Covered by superficial fasciaCovered by superficial fascia
GRYNFELT’S TRIANGLE GRYNFELT’S TRIANGLE is bounded by:is bounded by:
Superior= 12Superior= 12thth rib rib
Lateral= Internal oblique abdominal muscleLateral= Internal oblique abdominal muscle
Medial=Sacrospinalis muscleMedial=Sacrospinalis muscle
Covered by latissimus dorsiCovered by latissimus dorsi
PELVIC HERNIA- PELVIC HERNIA- occurs in cachetic, elderlyoccurs in cachetic, elderly
patients in the, Obturator fossa, Perineum &patients in the, Obturator fossa, Perineum &
Greater and lesser sciatic foraminaGreater and lesser sciatic foramina
1. Obturator Hernia1. Obturator Hernia
50% with Howship-Romberg Sign50% with Howship-Romberg Sign
Pain in the region of the hip, and of the knee Pain in the region of the hip, and of the knee
and on the inner aspect of the thigh because and on the inner aspect of the thigh because
of pressure on the obturator nerve by an of pressure on the obturator nerve by an
obturator hernia.obturator hernia.
Other Abdominal Wall HerniaOther Abdominal Wall Hernia
Usually in emaciated females in late 70’s onUsually in emaciated females in late 70’s on
the right sidethe right side
Often with either large or small bowel Often with either large or small bowel
incarceration or strangulationincarceration or strangulation
Rarely with a mass at the anteromedial thighRarely with a mass at the anteromedial thigh
or a bulge on rectal or pelvic examinationor a bulge on rectal or pelvic examination
Diagnosis by CT scanDiagnosis by CT scan
Repair by midline approach to take care ofRepair by midline approach to take care of
bowel problem too.bowel problem too.
Other Abdominal Wall HerniaOther Abdominal Wall Hernia
2. Perineal Hernia2. Perineal Hernia
Occur spontaneously or after APR orOccur spontaneously or after APR or
pelvic exenterationpelvic exenteration
1. Anterior- defect in urogenital 1. Anterior- defect in urogenital diaphragm;diaphragm;
mass in labia majoramass in labia majora
2. Po2. Posterior-sterior- defect in the levatordefect in the levator ani between ani between
the urinary bladder and rectumthe urinary bladder and rectum
Repair= Transperineal or transabdominal Repair= Transperineal or transabdominal
primary repair or with meshprimary repair or with mesh
Other Abdominal Wall HerniaOther Abdominal Wall Hernia
3. Sciatic Hernia3. Sciatic Hernia
Rarest of all hernias; Rarest of all hernias;
Occurs in the greater or lesser sciatic Occurs in the greater or lesser sciatic
foramen or thru a defect in the foramen or thru a defect in the pyriformispyriformis
musclemuscle
Presents as sciatic nerve palsy and a Presents as sciatic nerve palsy and a massmass
or simply intestinal obstructionor simply intestinal obstruction
Repair= GRepair= Glutealluteal or Transabdominalor Transabdominal approachapproach
Other Abdominal Wall HerniaOther Abdominal Wall Hernia
PARASTOMAL HERNIAPARASTOMAL HERNIA Occurs thru defects adjacent to ostomy Occurs thru defects adjacent to ostomy
sitesite Incidence: 12-32% paracolostomyIncidence: 12-32% paracolostomy < 10% paraileostomy< 10% paraileostomy Prevention: Small fascial incision, avoidPrevention: Small fascial incision, avoid maturing thru the abdominal incisionmaturing thru the abdominal incision Complications: Complications: 1. Obstruction;1. Obstruction; 2. Incarceration2. Incarceration 3. Poor Appliance fit3. Poor Appliance fit 4. Local pain4. Local pain
Other Abdominal Wall HerniaOther Abdominal Wall Hernia
PARASTOMAL HERNIAPARASTOMAL HERNIA
Repair: Primary fascial or prosthetic Repair: Primary fascial or prosthetic repairrepair
or relocation of stomaor relocation of stoma
Symptoms generally well toleratedSymptoms generally well tolerated
All repairs associatedAll repairs associated with: with:
1. 1. significant morbiditysignificant morbidity
2. high recurrence 2. high recurrence
Other Abdominal Wall HerniaOther Abdominal Wall Hernia
INTERNAL HERNIAINTERNAL HERNIA Abdominal contents protrude thru Abdominal contents protrude thru normal or abnormal intra-abdominal normal or abnormal intra-abdominal orificeorifice 3. Iatrogenic (Post operative)3. Iatrogenic (Post operative) (a) Defect in Mesentery or Omentum(a) Defect in Mesentery or Omentum Peterson Hernia=thru Roux limbPeterson Hernia=thru Roux limb CONGENITAL ABDOMINAL WALL DEFECTSCONGENITAL ABDOMINAL WALL DEFECTS GastroschisisGastroschisis 1. Herniation of abdominal viscera without 1. Herniation of abdominal viscera without
aa sac, intact umbilical cordsac, intact umbilical cord
Other Abdominal Wall HerniaOther Abdominal Wall Hernia
CONGENITAL ABDOMINAL WALL DEFECTSCONGENITAL ABDOMINAL WALL DEFECTS OmphaloceleOmphalocele 1. Herniation of abdominal viscera into 1. Herniation of abdominal viscera into
thethe umbilical cord, hence lined by umbilical cord, hence lined by
internallyinternally by peritoneal sac and externally byby peritoneal sac and externally by amnionamnion 2. Associated anomalies:2. Associated anomalies: (a) Cloacal exstrophy(a) Cloacal exstrophy (b) Chromosomal abnormality in 50%(b) Chromosomal abnormality in 50%
Other Abdominal Wall HerniaOther Abdominal Wall Hernia
CONGENITAL ABDOMINAL WALL DEFECTSCONGENITAL ABDOMINAL WALL DEFECTS GastroschisisGastroschisis 2. Two times (2X) more common than2. Two times (2X) more common than omphaloceleomphalocele 3. Associated anomalies: Intestinal 3. Associated anomalies: Intestinal
Atresia Atresia 10%10% 4. Eviscerated Bowels are:4. Eviscerated Bowels are: (a) Edematous(a) Edematous (b) Shortened with fibrinous adhesions(b) Shortened with fibrinous adhesions 5. < 10% mortality5. < 10% mortality
Other Abdominal Wall HerniaOther Abdominal Wall Hernia
CONGENITAL DIAPHRAGMATIC HERNIACONGENITAL DIAPHRAGMATIC HERNIA Bochdalek HerniaBochdalek Hernia (a) Postero-lateral, most common at costal(a) Postero-lateral, most common at costal and spinal diaphragmatic attachmentand spinal diaphragmatic attachment (b) Associated with malrotation, pulmonary(b) Associated with malrotation, pulmonary hypoplasiahypoplasia (c) 4 x more common in the left side(c) 4 x more common in the left side (d) Only 10-20% have a sac; 80% mortality(d) Only 10-20% have a sac; 80% mortality by the first year of lifeby the first year of life
Other Abdominal Wall HerniaOther Abdominal Wall Hernia
CONGENITAL DIAPHRAGMATIC HERNIACONGENITAL DIAPHRAGMATIC HERNIA
Bochdalek HerniaBochdalek Hernia
(e) Better repaired after a few days to(e) Better repaired after a few days to
weeks when the child stabilizes;weeks when the child stabilizes;
higher mortality if repaired at birthhigher mortality if repaired at birth
(f) Repair: Transabdominal with the Ladd(f) Repair: Transabdominal with the Ladd
procedure for the malrotationprocedure for the malrotation
Morgagni Morgagni
(a) Between sternal & costal (a) Between sternal & costal diaphragmaticdiaphragmatic
mmargin either retrosternalargin either retrosternal or parasternal or parasternal
Other Abdominal Wall HerniaOther Abdominal Wall Hernia
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