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The Abdominal WallThe Abdominal Wall And Hernias And Hernias
Stanley Kurek, DO, FACSStanley Kurek, DO, FACS
Associate Professor of SurgeryAssociate Professor of SurgeryUTMCKUTMCK
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The Abdominal WallThe Abdominal Wall
The structure of the abdominal wall is similar inThe structure of the abdominal wall is similar inprinciple to the thoracic wall.principle to the thoracic wall.
There are three layers, an external, internal andThere are three layers, an external, internal andinnermost layer.innermost layer.
The vessels and nerves lie between the internalThe vessels and nerves lie between the internaland innermost layers.and innermost layers.
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Surface anatomySurface anatomy
The abdomen can be divided intoThe abdomen can be divided intoquadrants or nine abdominal regions.quadrants or nine abdominal regions.
Pain felt in these regions may bePain felt in these regions may beconsidered to be direct or referred.considered to be direct or referred.
The midline in theThe midline in the sagittalsagittal plane is theplane is thelinealinea alba.alba.
The lateral edge of the rectus sheath isThe lateral edge of the rectus sheath isthethe linealinea semilunarissemilunaris..
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1:Right Hypochondriac Region; 2:Right Lumbar Region; 3:R. Iliac (Inguinal) Region
4:Epigastric Region; 5:Unbilical Region; 6:Hypogastric (Pubic) Region;
7:Left Hypochondriac Region; 8:Left Lumbar Region; 9:Left Iliac (Inguinal) Region
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The FasciaThe Fascia
Below the skin the superficial fascia is divided into aBelow the skin the superficial fascia is divided into asuperficial fatty layer, Camper's fascia, and a deepersuperficial fatty layer, Camper's fascia, and a deeperfibrous layer,fibrous layer, Scarpa'sScarpa's fascia.fascia.
The deep fascia lies on the abdominal muscles. InferiorlyThe deep fascia lies on the abdominal muscles. InferiorlyScarpa'sScarpa's fascia blends with the deep fascia of the thigh.fascia blends with the deep fascia of the thigh.This arrangement forms a plane betweenThis arrangement forms a plane between Scarpa'sScarpa's fasciafascia
and the deep abdominal fascia extending from the top ofand the deep abdominal fascia extending from the top ofthe thigh to the upper abdomen.the thigh to the upper abdomen.
Below the innermost layer of muscle, theBelow the innermost layer of muscle, the transversustransversus
abdominisabdominis muscle, lies themuscle, lies the transversalistransversalis fascia. Thefascia. Thetransversalistransversalis fascia is separated from the parietalfascia is separated from the parietalperitoneum by a variable layer of fat.peritoneum by a variable layer of fat.
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The RectusThe Rectus Abdominis Abdominis andand
Rectus sheathRectus sheath TheThe r e c t u s m u s c l e r e c t u s m u s c l e extends from theextends from the xiphoidxiphoid process ofprocess of
the sternum and 5,6,7th costal cartilages to the pubicthe sternum and 5,6,7th costal cartilages to the pubicsymphysissymphysis and pubic crest.and pubic crest.
The muscle is enclosed within theThe muscle is enclosed within the rectus sheathrectus sheath formedformedby theby the aponeurosesaponeuroses of the lateral abdominal muscles.of the lateral abdominal muscles.
Along the length of this strap muscle there are three fibrousAlong the length of this strap muscle there are three fibrousintersections separating the muscle into four segments.intersections separating the muscle into four segments.
The fibrous intersections are attached to the anteriorThe fibrous intersections are attached to the anteriorsurface of the rectus sheath, but not to the posteriorsurface of the rectus sheath, but not to the posteriorsurface. This allows the superior and inferiorsurface. This allows the superior and inferior epigastricepigastricvessels to pass along the posterior surface of the musclevessels to pass along the posterior surface of the musclewithout encountering a barrier.without encountering a barrier.
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RectusRectus Abdominis Abdominis
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External Abdominal Oblique MuscleExternal Abdominal Oblique Muscle
TheThe e x t e r n a l o b l i q u e m u s c l e e x t e r n a l o b l i q u e m u s c l e arises from the lower eightarises from the lower eightribs.ribs.
The fibers run downwards and forwards to form anThe fibers run downwards and forwards to form anaponeurosisaponeurosis anteriorlyanteriorly..
TheThe aponeurosisaponeurosis passespasses anteriorlyanteriorly to the rectus muscle toto the rectus muscle toinsert into theinsert into the aponeurosisaponeurosis from the other side at thefrom the other side at the linealineaalba.alba.
Inferiorly theInferiorly the aponeurosisaponeurosis inserts into the anterior superiorinserts into the anterior superioriliac spine and stretches over to the pubic tubercle, formingiliac spine and stretches over to the pubic tubercle, formingthethe inguinal ligamentinguinal ligament..
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External Abdominal ObliqueExternal Abdominal Oblique
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Internal Oblique MuscleInternal Oblique Muscle
TheThe i n t e r n a l o b l i q u e m u s c l e i n t e r n a l o b l i q u e m u sc l e arises from the lumbararises from the lumbarfascia, the iliac crest and the lateral twofascia, the iliac crest and the lateral two--thirds of thethirds of theinguinal ligament and runs upwards and forwards to forminguinal ligament and runs upwards and forwards to formanan aponeurosisaponeurosis..
Above theAbove the arcuatearcuate line theline the aponeurosisaponeurosis splits to enclose thesplits to enclose therectus muscle.rectus muscle.
Below theBelow the arcuatearcuate line theline the aponeurosisaponeurosis passes anterior topasses anterior to
the rectus muscle.the rectus muscle. The inferior part of theThe inferior part of the aponeurosisaponeurosis inserts into theinserts into the
symphysissymphysis pubis.pubis.
At this insertion theAt this insertion the aponeurosisaponeurosis is fused with theis fused with theaponeurosisaponeurosis of theof the transversustransversus abdominisabdominis muscle to formmuscle to formthethe conjoint tendon.conjoint tendon.
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Internal Abdominal ObliqueInternal Abdominal Oblique
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TransversusTransversus Abdominis Abdominis
TheThe transversustransversus abdominisabdominis musclemuscle
arises from the lower six costalarises from the lower six costalcartilages, the lumbar fascia and thecartilages, the lumbar fascia and the
iliac crest.iliac crest.
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TranversusTranversus Abdominis Abdominis
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Inguinal LigamentInguinal Ligament
The inguinal ligament is formed by theThe inguinal ligament is formed by theaponeuroticaponeurotic fibers of the external obliquefibers of the external obliquemuscle.muscle.
The ligament stretches from the anteriorThe ligament stretches from the anterior
superior iliac spine (ASIS) to the pubicsuperior iliac spine (ASIS) to the pubictubercle.tubercle.
At the medial end of the inguinal ligament,At the medial end of the inguinal ligament,
fibers are reflected backwards to insertfibers are reflected backwards to insertinto the superiorinto the superior ramusramus of the pubis,of the pubis,forming theforming the lacunarlacunar ligament.ligament.
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The Inguinal CanalThe Inguinal Canal
The inguinal canal transmits the vas deferens in the maleThe inguinal canal transmits the vas deferens in the maleand the round ligament in the female.and the round ligament in the female.
The deep ring is the entrance to the inguinal canal on theThe deep ring is the entrance to the inguinal canal on theinside of the abdominal wall.inside of the abdominal wall.
The deep ring is formed in theThe deep ring is formed in the transversalistransversalis fascia. As thefascia. As thecanal passes through the abdominal wall it receives a layercanal passes through the abdominal wall it receives a layerof muscle from the internal oblique, theof muscle from the internal oblique, the cremastercremaster muscle.muscle.
At the superficial ring the inguinal canal passes through theAt the superficial ring the inguinal canal passes through the
external obliqueexternal oblique aponeurosisaponeurosis and receives a layer from theand receives a layer from theaponeurosisaponeurosis, the external spermatic fascia in the male., the external spermatic fascia in the male.
The deep inguinal ring lies lateral to the inferiorThe deep inguinal ring lies lateral to the inferior epigastricepigastricvessels. The superficial ring lies above and medial to thevessels. The superficial ring lies above and medial to thepubic tubercle.pubic tubercle.
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BOUNDARIES OF THE INGUINALBOUNDARIES OF THE INGUINAL
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BOUNDARIES OF THE INGUINALBOUNDARIES OF THE INGUINAL
CANALCANAL The inguinal canal is theThe inguinal canal is the
communication between the deepcommunication between the deepand superficial ringand superficial ring
Anterior wall: EAOAnterior wall: EAO
Inferior wall: Inguinal LigamentInferior wall: Inguinal Ligament
Superior wall: IAO and TA (conjoinedSuperior wall: IAO and TA (conjoined
tendon)tendon) Posterior wall (floor):Posterior wall (floor): TransversalisTransversalis
FasciaFascia
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The Spermatic CordThe Spermatic Cord The spermatic cord passes through the inguinal canal to theThe spermatic cord passes through the inguinal canal to the
testis.testis.
THE SPERMATIC CORD CONTAINSTHE SPERMATIC CORD CONTAINSvas deferensvas deferens
testicular artery and veinstesticular artery and veins
lymph vesselslymph vessels
autonomic nervesautonomic nervescremastericcremasteric arteryartery
artery of the vasartery of the vas
genital branch of the femoral nervegenital branch of the femoral nerve
TheThe fascialfascial covering of the spermatic cord is formed by thecovering of the spermatic cord is formed by theexternal spermatic fasciaexternal spermatic fascia dervedderved from thefrom the aponeurosisaponeurosis ofofthe external oblique, thethe external oblique, the cremastericcremasteric fascia derived fromfascia derived fromthe internal oblique and the internal spermatic fasciathe internal oblique and the internal spermatic fasciaderived from thederived from the transversalistransversalis fascia.fascia.
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The Femoral CanalThe Femoral Canal
The femoral canal lies below the inguinalThe femoral canal lies below the inguinalligament medially and lies medial to theligament medially and lies medial to thefemoral vessels.femoral vessels.
The femoral sheath is formed by theThe femoral sheath is formed by the
transversalistransversalis fascia and encloses thefascia and encloses thefemoral vessels and the femoral canal.femoral vessels and the femoral canal.
TheThe lacunarlacunar ligament forms the medialligament forms the medial
border of the femoral canal. The femoralborder of the femoral canal. The femoralvein lies lateral to the femoral canal.vein lies lateral to the femoral canal.
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HERNIASHERNIAS
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HerniasHernias
What is a Hernia?What is a Hernia?
Abnormal protrusion of intraAbnormal protrusion of intra--abdominal contentsabdominal contents throuhthrouh a defecta defect
in the abdominal wallin the abdominal wall
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OVERVIEW OF HERNIASOVERVIEW OF HERNIAS
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OVERVIEW OF HERNIASOVERVIEW OF HERNIAS
Hernias occur:Hernias occur:
7575 –– 80 % in Inguinal Region80 % in Inguinal Region 88 –– 10 %10 % IncisionalIncisional (ventral hernia)(ventral hernia)
33 –– 8 % Umbilical Hernias8 % Umbilical Hernias
DONDON’ ’ T FORGET INTERNAL HERNIAS!T FORGET INTERNAL HERNIAS!
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ETIOLOGY OF HERNIASETIOLOGY OF HERNIAS
Congenital defectsCongenital defects
Loss of tissue strength and elasticityLoss of tissue strength and elasticity(from aging or repetitive stress)(from aging or repetitive stress)
Operative TraumaOperative Trauma Increased Abdominal PressureIncreased Abdominal Pressure
(heavy lifting, COPD, BPH,(heavy lifting, COPD, BPH, AscitiesAscities,,
Obesity)Obesity)
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Complications of HerniaComplications of Hernia
PAINPAIN
OBSTRUCTIONOBSTRUCTION
BOWEL NECROSISBOWEL NECROSIS
PERFORATIONPERFORATION
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DESCRIPTIVE TERMSDESCRIPTIVE TERMS
ReducibleReducible-- can be pushed back into thecan be pushed back into theabdomenabdomen
IncarceratedIncarcerated-- cannot becannot be “ “reducedreduced” ” StrangulatedStrangulated-- the tissue in the hernia isthe tissue in the hernia is
ischemic and willischemic and will necrosenecrose due todue to
compromise of its blood supplycompromise of its blood supply SlidingSliding-- the wall of the hernia sac is partthe wall of the hernia sac is part
formed by a retroperitoneal structureformed by a retroperitoneal structure
RichterRichter’’s hernias hernia-- only one side of theonly one side of thebowel wall involved in the hernia canbowel wall involved in the hernia cannecrosenecrose without signs of obstructionwithout signs of obstruction
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Inguinal herniasInguinal hernias
Inguinal hernias are classifiedInguinal hernias are classified
as:as:1) Indirect1) Indirect
2) Direct2) Direct
3) Femoral3) Femoral
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Indirect HerniaIndirect Hernia An indirect hernia occurs when a herniaAn indirect hernia occurs when a hernia
sac enters the deep inguinal ring lateral tosac enters the deep inguinal ring lateral tothe inferiorthe inferior epigastricepigastric artery and passesartery and passes
indirectly to the superficial ring throughindirectly to the superficial ring throughthe inguinal canal.the inguinal canal.
Indirect hernias are the most commonIndirect hernias are the most commontype of hernia in both men and womentype of hernia in both men and women
CAUSE: Persistence of all or part of theCAUSE: Persistence of all or part of theembryonicembryonic processusprocessus vaginalisvaginalis results inresults invarious inguinal anomalies.various inguinal anomalies.
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INDIRECT HERNIASINDIRECT HERNIAS
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INDIRECT HERNIASINDIRECT HERNIAS
INCIDENCE:INCIDENCE:
In children, varies with gestational ageIn children, varies with gestational age
and ranges from 9 to 11% in pretermand ranges from 9 to 11% in preterminfants to 3.5 to 5% in fullinfants to 3.5 to 5% in full--term babies.term babies.
5 to 10 times more common in men than5 to 10 times more common in men than
womenwomen more frequently on the right side as amore frequently on the right side as a
result of later descent of the right testisresult of later descent of the right testis
and delayed obliteration of theand delayed obliteration of the processusprocessusvaginalisvaginalis..
Approximately 5% of men develop anApproximately 5% of men develop aninguinal hernia in their lifetimeinguinal hernia in their lifetime
CLINICAL PRESENTATIONCLINICAL PRESENTATION
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CLINICAL PRESENTATIONCLINICAL PRESENTATION
can vary from vague pain to large bulgecan vary from vague pain to large bulge
right side in 60% of casesright side in 60% of cases left side in 30%left side in 30%
bilateral in 10%.bilateral in 10%.
Bilateral inguinal hernias are moreBilateral inguinal hernias are morecommon in preterm infants.common in preterm infants.
The major risk factor in cases ofThe major risk factor in cases of inguinalinguinalherniahernia is the occurrence of bowelis the occurrence of bowelincarceration and possible strangulation.incarceration and possible strangulation.
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SURGICAL REPAIR INCLUDESSURGICAL REPAIR INCLUDES
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SURGICAL REPAIR INCLUDES
HIGH LIGATION OF HERNIA SACHIGH LIGATION OF HERNIA SAC
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Direct Inguinal HerniaDirect Inguinal Hernia
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Direct Inguinal HerniaDirect Inguinal Hernia
A direct hernia occurs when aA direct hernia occurs when a hernialhernial
sac is pushed through the conjointsac is pushed through the conjointtendon directly towards thetendon directly towards the
superficial ring.superficial ring.
Direct hernias occur medial to theDirect hernias occur medial to the
inferiorinferior epigastricepigastric vessels invessels in
HasselbachHasselbach’ ’ ss Triangle through theTriangle through thefloor of the inguinal canalfloor of the inguinal canal
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Boundaries ofBoundaries of Hasselbach'sHasselbach'sTriangleTriangle
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TriangleTriangle
Medial boundary: RectusMedial boundary: Rectus abdominisabdominis
Lateral boundary: InferiorLateral boundary: Inferior epigastricepigastricvesselsvessels
Inferior boundary: Inguinal ligamentInferior boundary: Inguinal ligament
MARKS THE AREA FOR DIRECTMARKS THE AREA FOR DIRECTHERNIASHERNIAS
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SURGICAL REPAIR INCLUDES RESURGICAL REPAIR INCLUDES RE--
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SURGICAL REPAIR INCLUDES RESURGICAL REPAIR INCLUDES RE
ENFORCEMENT OF FLOOR WITH MESHENFORCEMENT OF FLOOR WITH MESH““LICHTENSTEIN REPAIRLICHTENSTEIN REPAIR””
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Open Lichtenstein RepairOpen Lichtenstein Repair
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Open Lichtenstein Repair Open Lichtenstein Repair
Laparoscopic repairLaparoscopic repair
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Laparoscopic repair Laparoscopic repair
NONOPERATIVE MANAGEMENTNONOPERATIVE MANAGEMENT
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NONOPERATIVE MANAGEMENTNONOPERATIVE MANAGEMENT
Femoral HerniaFemoral Hernia
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Femoral HerniaFemoral Hernia
In a femoral hernia the hernia sac isIn a femoral hernia the hernia sac ispushed into the femoral canal, below thepushed into the femoral canal, below the
inguinal ligament and between theinguinal ligament and between the lacunarlacunar
ligament and the femoral vein.ligament and the femoral vein. The hernia sac thus lies inferior and lateralThe hernia sac thus lies inferior and lateral
to the pubic tubercle and anterior to theto the pubic tubercle and anterior to the
superiorsuperior pubicramuspubicramus periosteumperiosteum(COOPER(COOPER’ ’ S LIGAMENT)S LIGAMENT)
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FEMORAL HERNIAFEMORAL HERNIA
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FEMORAL HERNIAFEMORAL HERNIA
3030 –– 40% of femoral hernias become40% of femoral hernias become
incarcerated or strangulatedincarcerated or strangulated Femoral hernias are more common inFemoral hernias are more common in
women than menwomen than men…………
McVayMcVay RepairRepair –– TF and ConjoinedTF and Conjoined
tendon to Coopertendon to Cooper’ ’ s Ligaments Ligament
Umbilical HerniaUmbilical Hernia
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Umbilical HerniaUmbilical Hernia
At the umbilicus hernias can developAt the umbilicus hernias can developdue to developmental deficiencies,due to developmental deficiencies,congenital umbilical hernia, or maycongenital umbilical hernia, or may
occur due to a weakness in theoccur due to a weakness in the linealineaalba in the area of the umbilicus, analba in the area of the umbilicus, anacquired umbilical hernia.acquired umbilical hernia.
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UMBILICAL HERNIAUMBILICAL HERNIA
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UMBILICAL HERNIAUMBILICAL HERNIA
10 times more common in women10 times more common in women
Common in children but usuallyCommon in children but usuallycloses by age 2, fix at age 5closes by age 2, fix at age 5
Fewer than 5% of umbilical herniasFewer than 5% of umbilical hernias
persist into later childhood and adultpersist into later childhood and adult
lifelife
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VENTRAL HERNIAVENTRAL HERNIA
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VENTRAL HERNIA
Ventral HerniaVentral Hernia-- generic term given togeneric term given tohernias in areas other than the inguinalhernias in areas other than the inguinal
regionregion
IncisionalIncisional HerniaHernia –– most common typemost common typeof ventral hernia, results from poor woundof ventral hernia, results from poor woundhealing in a previous surgical incisionhealing in a previous surgical incision
(infection, tension,(infection, tension,
malnutrition,intramalnutrition,intra
--
abdominal pressure, etc) and occurs inabdominal pressure, etc) and occurs in55 –– 10 % of abdominal incisions10 % of abdominal incisions
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Problems and PresentationProblems and Presentation
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Bowel obstruction (N/V, pain,Bowel obstruction (N/V, pain,
Distention,Distention, ObstipationObstipation)) PERFORATION after strangulationPERFORATION after strangulation
HOW TO FIXHOW TO FIX
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LaparotomyLaparotomy :primary:primary vsvs meshmesh
closureclosure
Laparoscopy with meshLaparoscopy with mesh
Abdominal binderAbdominal binder