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VENTRAL HERNIA
Dr.B.Selvaraj MS;MCh;FICS Professor of Surgery Melaka Manipal Medical college Melaka Malaysia 75150 VENTRAL HERNIA
Ventral Hernia This term refers to hernias of the anterior abdominal wall except groin hernias. Ventral hernias Epigastric Umbilical & Paraumbilical Incisional Spigelian Lumbar
Epigastric Hernia It is the protrusion or herniation of extraperitoneal fat through a defect in the linea alba anywhere between the xiphoid process and the umbilicus, usually midway between these structures. The condition is always acquired, common in manual labourers between the ages of 30 and 45yrs often precipitated by sudden strain causing tearing of the interlacing fibres of the linea alba. Initially there is protrusion of extraperitoneal fat through the same opening where the linea alba is pierced by a small blood vessel. At this stage, there is no well-formed sac and it is called fatty hernia of linea alba.
Epigastric Hernia In the next stage, as the hernia grows bigger and bigger, it drags a pouch of peritoneum after it and becomes a true epigastric hernia which may contain omentum or bowel
Epigastric Hernia- Clinical Features There are three clinical types: Symptomless—At the initial stage it is symptomless and often discovered by the patient himself as a swelling during washing his body Painful swelling—Localized pain exactly at the site of hernia as the fatty content of the hernia is pressed by the tight margins of the gap in the linea alba to produce partial strangulation. Symptoms of peptic ulcer—As stated above. Pain may also be due to associated peptic ulcer or gall stones
Epigastric Hernia- Clinical Features O/E: There is a firm globular swelling, varying from a pea size to 2cm diameter, does not have cough impulse (usually) and can not be reduced. The gap in the linea alba cannot be felt clearly. For this reason epigastric hernia is difficult to distinguish from lipoma. Abdominal examination is normal.
Epigastric Hernia- Treatment If small and symptomless, the lump can be overlooked. If there are symptoms, operation is done. Before operation patient is advised for an upper GI endoscopy to exclude an underlying peptic ulcer disease.
Umbilical Hernia- In Children Umbilical hernia develops due to either absence of umbilical fascia(Richet’s fascia) or incomplete closure of umbilical defect. In children common cause is umbilical sepsis. This is common in male child (2:1), who is usually brought to the doctor with the compliant of swelling in the umbilical region, whenever the child cries. Most cases are symptomless but parents are anxious about the swelling. Strangulation is rare.
Umbilical Hernia- In Children
Umbilical Hernia- In Children Treatment Conservative—Most of the hernia close spontaneously without any treatment within two years of age. So the methods are: masterly inactivity, reassure parents and strapping over a coin Operative—Herniorrhaphy is indicated when the hernia is still present after 2 years of age
Umbilical Hernia- In Adults(Para umbilical) In adults, hernia does not protrude through the umbilical cicatrix. It is a protrusion through the linea alba just above the umbilicus (supraumbilical) or occasionally below the umbilicus (infraumbilical). That’s why it is called paraumbilical hernia. Commonly occurs in middle-aged or elderly women (M:F = 1:5) Contributing factors are obesity, multiparous women, persistent source of straining, e.g. chronic cough, constipation, bladder neck obstruction
Umbilical Hernia- In Adults(Para umbilical) The usual content is the greater omentum, often accompanied by small intestine or a portion of the transverse colon. Owing to adhesions between the contents and the sac, the sac becomes loculated in most cases and the hernia is usually irreducible. There is a swelling in the umbilical region. Initially the swelling is small but gradually it increases and attains a big size.
Umbilical Hernia- In Adults(Para umbilical) Dragging pain may be present due to adherent omentum. The swelling is firm in consistency as it contains mostly omentum. Dull on percussion. Cough impulse is present when the contents are not adherent, but absent when the hernia becomes irreducible. After reducing the swelling, the defect can be made out in the linea alba.
Umbilical Hernia- In Adults(Para umbilical) Complications Irreducibility Obstruction with colicky abdominal pain and vomiting, distension follows soon. Untreated cases develop strangulation. As the sac enlarges, it sags down resulting in friction of skin and this causes intertrigo (Dermatitis between the skin folds).
Umbilical Hernia- In Adults(Para umbilical) Treatment Mayo’s operation: After weight reduction using double breasting technique Mesh repair: For larger defects – open or Laparoscopic- Overlay or IPOM
Incisional Hernia Definition & Causes An incisional hernia is one where the peritoneal sac herniates through an acquired scar in the abdominal wall usually caused by a previous surgical operation or an accidental trauma. It is very common in females. Contents of such hernia are usually bowel and/ or omentum. Precipitating factors: Many factors singly or in combination are responsible Poor surgical technique: Non anatomic incision, Method of closure, Inappropriate suture material, Suturing technique and Drainage tube brought out through main wound.
Incisional Hernia Causes Postoperative complications: Postoperative wound infection, cough, and respiratory distress due to pneumonia or lung collapse. General factors: patients with severe anemia, hypoproteinemia, diabetes, advanced malignant disease, jaundice, chronic renal failure, steroid or immunosuppressive. Tissue failure: Late development of hernia after 5, 10 or more years after operation is usually associated with tissue failure that is abnormal collagen production and maintenance
Incisional Hernia Clinical Features History: A previous operation or trauma is noticed. There may be history of wound infection. Age: Incisional hernia may occur at any age but more commonly in elderly females. Symptoms: Swelling and pain are the commonest symptoms. Rarely features of intestinal obstruction may be present Signs: expansile impulse on coughing, reducibility, after reduction can feel the defect through the scar
Incisional Hernia Clinical Features Type1: It occurs through, the midline upper or lower abdominal incision where the muscular defect is wide with smooth and regular margins. Hence this hernia gets reduced spontaneously as soon as the patient lies down. Risk of strangulation is almost negligible. Type 2: The hernia is situated in the lateral part of abdomen. Here the risk of strangulation is more
Incisional Hernia Clinical Features
Incisional Hernia Treatment Conservative Approach: If the neck of the incisional hernia is wide shows no signs of an increase in size and the patient has no symptoms, it may be observed. Operative Treatment: The indications are: Symptomatic hernia which is showing signs of increasing in size and needs repair. Large hernia with a small defect. Such a hernia has a high chance of strangulation and needs to be repaired early. Subacute intestinal obstruction, irreducibility and strangulation are definite indications for repair of incisional hernia.
Incisional Hernia Treatment Mesh repair: is always better and ideal with less chances of recurrence. Sublay or Intraperitoneal onlay mesh IPOM Anatomical repair and Keel’s operation not in vogue
Incisional Hernia Treatment
Incisional Hernia Treatment Large defect: Ramirez component separation: 20 cms mobilization is achieved
Spigelian Hernia It is a type of inter-parietal hernia occurring at the level of arcuate line through spigelian point Spigelian hernia can occur above (10%) or below (90%) the umbilicus. Below the umbilicus it occurs at the junction of linea semilunaris and linea semicircularis
Spigelian Hernia Clinical Features Presents as a soft, reducible mass lateral to the rectus muscle and below the umbilicus, with impulse on coughing. Strangulation is common Precipitating factors are obesity, chronic cough, old age, and multiple pregnancies. Common in females after 50 years of age. D/D: abdominal wall lipoma, abdominal wall hematoma & soft tissue sarcoma
Spigelian Hernia Treatment Open or Laparoscopic Mesh Repair
Lumbar Hernia Clinical Features It is herniation either through superior or inferior lumbar triangle. Superior lumbar triangle (Grynfelt’s/Lesgaft’s triangle) is bounded by sacrospinalis, 12th rib and posterior border of internal oblique Inferior lumbar triangle is bounded by latissimus dorsi, external oblique and iliac crest (triangle of Petit). Lumbar hernia is more common through superior lumbar triangle.
Lumbar Hernia Clinical Features It can be: Primary or Secondary, which is due to previous renal surgery, more common. D/D: Lipoma, cold abscess and lumbar phantom hernia Treatment : Repair using fascial flaps or mesh.
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