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Hernia-Ventral hernia
By Dr.Teo Zue Hiong
ContentsDefinitionClassificationIncisional hernia
managementSpigelian hernia
management
Hernia
• Definition– An abnormal protrusion of an organ or tissue
outside its normal body cavity or restraining sheath
Neck/MouthNeck/Mouth
Contents of sac(usually bowel)
FundusFundusCovering of Covering of hernia sachernia sac
Anatomical structure
Causes of Hernia• May exploit natural openings(inguinal,femoral and
obturator canals, umbilicus and oesophageal hiatus) or weak areas caused by stretching, surgical incision or laparotomy
• Any condition that increases the pressure of the abdominal cavity may contribute to the formation or worsening of a hernia.– Obesity– Heavy lifting– Coughing– Straining during a bowel movement or urination– Chronic ling disease– Fluid in the abdominal cavity– Hereditary
Classification of abdominal herniaInguinal hernia/Groin hernia
Direct inguinal herniaIndirect inguinal herniaFemoral hernia
Ventral herniaEpigastric herniaUmbilical herniaPara-umbilical herniaSpigelian herniaIncisional hernia
Other rare and specific interparietal hernia
Sign and symptoms
• The signs and symptoms of a hernia can range from noticing a painless lump to the painful, tender, swollen protrusion of tissue that you are unable to push back into the abdomen—possibly a strangulated hernia. – Reducible hernia– Irreducible hernia– Obstructed hernia– Strangulated hernia– Inflammed hernia
Reducible hernia
– Asymptomatic reducible hernia• New lump and the groin or other abdominal wall area• May ache but is not tender when touched.• Sometimes pain precedes the discovery of the lump.• Lump increases in size when standing or when abdominal pressure
is increased (such as coughing) • May be reduced (pushed back into the abdomen) unless very large
Irreducible hernia
– Irreducible hernia• Usually painful enlargement of a previous hernia that
cannot be returned into the abdominal cavity on its own or when you push it • Some may be long term without pain • Can lead to strangulation • Signs and symptoms of bowel obstruction may occur,
such as nausea and vomiting
Strangulated hernia
– Strangulated hernia• Irreducible hernia where the entrapped intestine has
its blood supply cut off • Pain always present followed quickly by tenderness and
sometimes symptoms of bowel obstruction (nausea and vomiting) • You may appear ill with or without fever • Surgical emergency • All strangulated hernias are irreducible (but all
irreducible hernias are not strangulated)
Ventral hernia
Ventral hernia
Incisional hernia
• One that occurs through the wound of a previous operation
• Same features as a hernia that is caused by non-surgical injury to the abdominal wall
• 1% of transparietal abdominal incisions are followed by a hernia
Aetiology• A postoperative complication,can be
considered in terms of three factor– Preoperative factors– Operative factors– Postoperative factors
Preoperative factors• Age: older usually need more time to heal• Malnutrition• Sepsis: worsen• Uraemia: inhibit fibroblast division• Jaundice: impedes collagen maturation• Obesity• Diabetes mellitus• Steroids• Peritonitis
Operative factorsType of incisions
vertical are more prone to hernia than transverseTechnique and materials
Tension in the closure decrease the blood supply in woundLoosen knotsClosure using rapidly absorbable suture materials
Type of operationOperations involve bowel or urinary tract are more likely to
develop wound infectionDrain tube
Postoperative factors• Wound infection:– Same important with the wrong choice of suture material– Enzyme destruction of healing tissues– Inflammatory swelling raises tissue tension and impedes
blood supply– 5-20% of wound infections result in a hernia
• Abdominal distension– Postoperative ileus increase the tension on a wound– Stitches may cut out
• Coughing:generates wound tension
Signs and symptoms• A bulge in the scar• As the hernia enlarges and loculates, symptoms of subacute I/O
are common• Overlying skin:thin and atrophic,eventually ulcer and rupture• Strangulation is a surgical emergency
• P/E:– Usually reducible– Hernia with a cough impulse at the site of an old scar– When the patient lies flat, hernias deceptively small,any
manoeuvre that raise intra-abdominal pressure produces the hernia in all its glory
Management Even small symptomatic hernias should be repaired early
Prolonged observation simply increase the difficulties of subsequent repair and hazardous
Surgical technique:same as for para-umbilical herniaExicision of the sac after reduction of its contents Insertion of overlapping sutures into the rectus sheath
Spigelian hernia
• Rare but clinically important, less than 1% of total• An interparietal hernia in the line of the linea
semilunaris(the lateral margin of the rectus sheath)
• Usually at the level of the arcuate line:due to all aponeurotic layers are reflected anterior to the rectus muscle
• The hernial sac emerges and enlarges like a mushroom deep to the external oblique
S&S
Symptoms Local pain that is worse on straining Lumps Non-specific lower quadrant discomfort which needs to be
investigated Features of obstruction or strangulation
Signs: Tenderness at the site of the hernial orifice Lump which may be difficult or even impossible to feel
Management
• Abdominal USG/CT:useful in the demonstration of these hernias
• Repair:A simple matter of excising the sac and closing the defect/Laparoscopic repairs
References
1. Clincal surgery 2nd edition2. Principle and practice of surgery 5th edition
Thank you
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