Hernias 1

Dr. Muslim Kandel2019-20

Hernias
Lecture one General features to all types of hernias
Definition
Hernia is a protrusion of the contents of a patient's abdomen (some abdominal organ, part
of his omentum , or his abdominal fat) through an abnormal opening or weak area in the
abdominal walls .
May be external ( through abdominal wall )or intraabdominal ( like hiatus hernia or
through band )The external abdominal hernia is the commonest
Review of Surgical Anatomy
Anatomy of anterior &lateral abdominal wall
Its composed from following layers
1-skin & superfecial facia
2-Abd. Muscles
Tow paramedian
-Rectus abdominus .m
-Pyramidalis m
Three anterolateral flat m
-ext . Abd. Oblique m
- int. Abd. Oblique m
-transversus abd. m
3- facia transversalis ( strong layer )
4- pariatal layer of peritoneum ( form
sac of hernia)

There are weak points at abd wall that’s more liable to form hernias are:-
1- umbilicus
- scar of umbilical cord in embryo , lies in middle of abd. wall
2- inguinal canal
Its oblique intramuscular passage in the lower part of ant. Abd. Wall transmit (
spermatic cord in male or round leg. In female ), lies just above med1\2 if ing.
Ligament about 4 cm length , start from

Deep inguinal ring – is a U-shaped condensation of the

transversalis fascia and it lies 1.25 cm above the inguinal
(Poupart ’ s) ligament, midway between the symphysis
pubis and the anterior superior iliac spine.
Superficial inguinal ring - is a triangular aperture in the
aponeurosis of the external oblique and lies 1.25 cm above
the pubic tubercle
Boundaries of canal:-
Ant. wall of canal→ext. oblique & fleshy int. oblique
Post.wall of canal→ facia transversalis
Roof → lower arched fiber of int. oblique
Floor→ inguinal leg
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Dr. Muslim Kandel2019-20

3- The femoral canal & sheath

is formed by a prolongation downward, of the abd.
fascia, behind the inguinal ligament transmit the
structures pass from abd. to L.Limbs
Its divided by two vertical partitions→ 3 compartments
--lateral contains the femoral artery
--the intermediate the femoral vein,
--the medial and smallest one is named the femoral
canal, and contains some lymphatic vessels
and a lymph gland embedded in a small amount of
areolar tissue

Other weak points in abd. wall

--Hiatus of esophagus. Foramen of Winslow → they cause internal hernia .
--Between layers of abd. Wall (arcuate line)
--Iatrogenic :- Surgical incision –Colostomy→ incisional hernia
General features of Hernias
Aetiology of hernias
a- congenital
undescending testis usually associated with inguinal hernia , An indirect hernia
may occur in a congenital preformed sac — the remains of the processus vaginalis.
b- aquired
1- raises intra-abdominal pressure (ie. Whooping cough is a predisposing cause in
childhood , amongst smokers …)
2- Acquired collagen deficiency increasing an individual ’ s susceptibility to the
development of hernias
3—obesity and pregnancy due to :-
-- Stretching of the abdominal musculature because of an increase in contents,
-- Fat acts to separate muscle bundles and layers, weakens aponeurosis and favours the
appearance of paraumbilical, direct inguinal and hiatus hernias.
--A femoral hernia is rare in nulliparous women and men, but more common in
multiparous women owing to stretching of the pelvic ligaments.
4-after surgical operation(incisional hernia) wound is weakest area in abdominal
wall
Composition of a hernia .
1- The sac
The sac is a diverticulum of peritoneum consisting of mouth, neck, body and fundus.
The body of the sac varies greatly in size and thickness in childhood the sac is very thin.
In long-standing cases the wall of the sac may be comparatively thick.

2- The covering s are derived from the layers of the abdominal wall through which the sac
passes. In long-standing cases they become atrophied from stretching and so amalgamated
that they are indistinguishable from each other.
3- Contents
Commonly either omentum = omentocele (epiplocele);
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Dr. Muslim Kandel2019-20

Or intestine = enterocele. More commonly small bowel, but may be large intestine or
appendix; Sometimes a portion of the circumference of the intestine Richter ’ s hernia;
But other structures like ur. bladder, fallopian tube ….may be but rare
What's happen inside hernia?
Usually hernia is reducible either spontenously during supine position or reduce by
patent himself , but sometimes may become
1- Irreducible hernia ( especially when omentum ) .
2- Obstructed hernia (especially when bowel )
3-Strangulated hernia
especially when blood vessels that supply contents are blocked)
4-inflamed hernia
when the contents superadded by infection either from
- from inflammation of the contents of the sac (e.g. acute appendicitis or salpingitis)
-or from external causes (e.g. the trophic ulcers which develop in the dependent areas of
large umbilical or incisional hernias).
Pathology.
--In reducible hernia the content not adherent sac so reduce easy to abdominal cavity
-- The irreducible hernia due to adhesion of omentum inside sac or over crowded
of he contents so that difficult to reduce contant
-- Obstructed and strangulated hernia
if bowel inter sac may cause intestinal obstruction
Initially, only the venous return is impeded so the wall of the intestine becoming
congested and bright red with the transudation of serous fluid into the sac ,with time
congestion will increases The intestinal pressure increases distending the intestinal loop
gradually the arterial supply becomes more and more impaired.-, part of blood is
extravasated ( The fluid in the sac becomes blood stained, that sign of impaired blood
supply and beginning of gangrene ), Bacterial transudation occurs secondary to the
lowered intestine viability and the sac fluid becomes infected
-Richter ’ s hernia--
is a hernia in which the sac contains only
a portion of the circumference of the
intestine (usually small intestine). It
usually complicates femoral and, rarely,
obturator hernias

Clinical features.
--in non obstructed
--cough impulse.
-- In large hernias there is a sensation of weight, and dragging on the mesentery may
produce epigastric pain.
-- In infants the swelling appears when the child cries.
--in obstructed
--signs of intestinal obstruction ,Sudden pain at first situated over the hernia is followed
by generalised abdominal pain, colicky in character and often located mainly at the
umbilicus. Nausea and subsequently vomiting ensue. The patient may complain of an
increase in hernia size.
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--On examination, the hernia is tense, extremely tender and irreducible, and there is no
expansile cough impulse.
-- Spontaneous cessation of pain must be viewed with caution as this may be a sign of
perforation
common hernias 75% inguinal region 5 –20% incisional 10% umbilical and epigastric 5%femoral
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Dr. Muslim Kandel2019-20

Hernias
Lecture two types of abdominal wall hernias
Groin hernias (inguinal, femoral)
1-Inguinal hernia
The indirect inguinal hernia, the most common form of groin hernia across all ages and
both genders, etiology behind the indirect inguinal hernia is believed to be a patent
processus vaginalis,
A- Indirect (oblique) inguinal hernia
It is most common in the young, whereas a direct hernia is most common in the old. In
the first decade of life inguinal hernia is more common on the right side in the male. males
are 20 times more commonly affected than females This is no doubt associated with the
later descent of the right testis and a higher incidence of failure of closure of the processus
vaginalis. In adult males, 65 per cent of inguinal hernias are indirect and 55 per cent are
right-sided. The hernia is bilateral in 12 per cent of cases .

Three types of indirect inguinal hernia occur

1- Bubonocele
When the hernias limited to the inguinal canal
2- Funicular the processus vaginalis is closed just
above the epididymis the content of the sac can be
felt separately from the testis, which lies below the
hernia
3- Complete (scrotal) — a complete inguinal hernia
is rarely present at birth but is commonly
encountered in infancy
Differential diagnosis
The presentation of inguinal hernia either groin mass or scrotal swelling
Groin mass
• an encysted hydrocele of the cord;
(move with pulling down of testis )
• a femoral hernia; ( 3 finger test Zeimen test
• an incompletely descended testis; ( empty testis )
• a lipoma of the cord
• LN.
Scrotal swelling
• hydrocele -- (can get above it. , trnslumination )
• spermatocele;
Treatment of indirect inguinal hernia
1) Operative treatment. Which is treatment of choice
A- Open technique which is traditional treatment . done under local, epidural or spinal,
as well as general, anesthesia
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- in children until age 16years use herniotomy only . This is dissecting out and opening
the hernial sac, reducing any contents, and then transfixing the neck of the sac and
removing the remainder.
- in in adult Herniotomy and repair (herniorrhaphy).
◼ suturing between inguinal lig & conjoin tendon by many methodes(Bassini, Darning , Shouldice
◼ mesh inserted between inguinal lig & conjoin tendon (tension free)
B -laparoscopic repair
In the laparoscopic approach uses mesh to repair the hernia defect in a plane posterior to the defect
1- Totally Extraperitoneal(TEP)
an inflatable balloon is placed in the preperitoneal space, and the repair is done preperitoneal. More skill
.required
2- Trans-abdominal Preperitoneal(TAPP)
*** whereas the open approaches repair the hernia anterior to the defect.
Complication of operation:-
1- recurrence it is often secondary to deep infection, undue tension on the repair, or tissue ischemia.
2-infection , stitch abscess &sinus
3 Postoperative groin pain, or neuralgia due to (nerve injury)
4- urine retention
5 Testicular swelling and atrophy (ischemic orchitis )thrombosiss of pampiniform plexus
6- Injury to the vas is a rare complication
7-secondary hydrocele
2- non operative
may be used when operation is contraindicated or when operation is refused
1-A truss. provides support for the herniated area, using a
pad and belt ,Used in old age or who unfit for operation.

2-gallow ’ s traction
only indicated in infants. The child is given analgesia and
placed in gallow ’ s traction In 75 % of cases reduction is
effected and there appears to be no danger of gangrenous
intestine being reduced
B-Direct inguinal hernia
In adult males, 35 % of inguinal hernias are direct. At presentation, 12 % of patients will
have a contralateral hernia , there is a four-fold increased risk of future development of
contralateral hernia.
--The sac passes through a weakness or defect of the transversalis fascia in the posterior
wall of the inguinal canal
-- Predisposing factors are :-
1-smoking,chr. Chest inf , prostate hypertrophy causes increase intraabd. pressure
2-occupations that involve straining and heavy lifting.
3-Damage to the ilioinguinal nerve (previous appendicectomy) due to resulting
weakness of the conjoined tendon.
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Diffrentiate from indirect inguinal hernia

-- A direct inguinal hernia is always acquired.
-- Direct hernias do not often attain a large size or descend into the scrotum).
-- lies behind the spermatic cord.
--the neck of the sac is wide, direct inguinal hernias do not often strangulate.
-- 3 finger test (Zeimman test)

Treatment same as indirect hernia

manual reduction of hernial content :
should be done softly with sedation , the vigorous manipulation (taxis) has no place in
modern surgery Its dangers include:
• contusion or rupture of the intestinal wall;
→bowel contents go into peritoneum cause peritonitis
→the sac may rupture at its neck and the contents are reduced, not into the peritoneal
cavity but extraperitoneally
• reduction-en-masse: ‘ The sac together with its contents is pushed forcibly back into the
abdomen; as the bowel will still be strangulated by the neck of the sac, the symptoms are in

Special forms of inguinal hernia

1- prevesical hernia.
The prevesical fat and a portion of the bladder that protrudes through a small oval defect
in the medial part of the conjoined muscle just above the pubic tubercle. It occurs
principally in elderly males and occasionally becomes strangulated.
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2-Dual (saddle bag; pantaloon) hernia. This type of hernia

consists of two sacs which straddle the inferior epigastric
artery, one sac being medial and the other lateral to this vessel.
The condition is not rare and is a cause of recurrence, one of the
sacs having been overlooked at the time of operation.

3- Maydl ’ s hernia (syn. hernia-in-W).

Maydl ’ s hernia is rare. The strangulated loop of the W lies
within the abdomen, thus local tenderness over the herniais not
marked

4-Sliding hernia
As a result of slipping of the posterior parietal peritoneum on
the underlying retroperitoneal structures, the sigmoid colon, the
caecum , portion of the bladder

Strangulated inguinal hernia

occurs at any time during life and in both sexes. Sometimes a hernia strangulates on the
first occasion that it descends; but commonly occur in:-
--Indirect inguinal hernias, the direct variety is less due to the wide neck of the sac.
-- in patients who have use a truss for a long time,
-- in those with a partially reducible or irreducible hernia.
Usually, the small intestine is involved in the strangulation; the next most frequent is the
omentum; sometimes both are involved. It is rare for the large intestine to become
strangulated in an inguinal hernia, even when the hernia is of the sliding variety.

Treatment of strangulated inguinal hernia

(The danger is in the delay not in the operation)
*preoperation = Vigorous resuscitation with intravenous fluids, nasogastric aspiration ,
antibiotics , catheterisation.
* operation= An incision is made over the most prominent part of the swelling.
→- Devitalised omentum is excised after being securely ligated.
- gangrenous intestine is excised by localised resection with end to end anastomosis
- Viable intestine is returned to the peritoneal cavity.
- Doubtfully viable bowel , use warm moist back with 100% O2 for 5 min then re
check viability of bowel →if viable bowel returned back if devitelized excise .
-prosthetic mesh is best avoided
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Dr. Muslim Kandel2019-20

2- Femoral hernia
Femoral hernia is the third most common type of primary
hernia. It accounts for about 20 per cent of hernias in
women and 5 per cent in men.

Clinical features.
Femoral hernia is rare before puberty. Between 20 and 40 years of age the prevalence rises
and continues to old age. The right side is affected twice as often as the left, and in 20 per
cent of cases the condition is bilateral.
The femoral hernia often presents as a small bulge just below the medial groin crease. It is
often difficult to reduce on initial presentation
The symptoms to which a femoral hernia gives rise are less pronounced than those of an
inguinal hernia; may be unnoticed by the patient for years, perhaps until the day it
strangulates. Adherence of the greater omentum sometimes causes a dragging pain. Rarely,
a large sac is present.

Differential diagnosis.
1-An inguinal hernia ( 3 finger test Zeimman )
2-A saphena varix. (Associate with varicosity of long saphenous vein)
3- An enlarged femoral lymph node .(other enlarged lymph nodes to aid the diagnosis. )
4-Lipoma.
5-A femoral aneurysm ( pulsatile )
6-. A psoas abscess ( TB lumber vertebrate )
7-A distended psoas bursa. (The swelling diminishes when the hip is flexed and
osteoarthritis of the hip is present. )
Strangulated femoral hernia
A femoral hernia strangulates frequently and gangrene rapidly develops. This is
explained by the narrow, unyielding femoral ring. In 40 % of cases the obstructing
agent is not the lacunar ligament but the neck of the femoral sac itself.
A Richter ’ s hernia is a frequent occurrence
Treatment of a femoral hernia.
A truss is contraindicated , only open surgery. There are many approaches
-- the low operation below the inguinal ligament via a groin-crease incision,
-- the high operation vertical incision to deal with both femoral& inguinal hernias
In all cases the open sac reduce healthy contents to abdomen (herniotomy) then
herniorrhaphy by suturing inguinal ligament with iliopectenial fascia . or
insertion polypropylene mesh.
Lecture three Umbilical hernias
1- Exomphalos (omphalocele and gastroschisis)
occurs once in every 6000 births; it is due to failure of all or part of the midgut to
return to the coelom during early foetal life.
gastroschisis :-when the sac ruptuered
during labour or after lead to appearance o
f bowel out of abdomen
Omphalocele When the sac remains
unruptured, it is semitranslucent and, although
very thin, it consists of two layers — an outer
layer of amniotic membrane and an inner layer
of peritoneum.,

Omphaloceles may be divided into

Omphaloceles minor those with a fascial defect of less than 4cm
Omphaloceles major those with a fascial defect of greater than 4 cm.
In large defects the liver, spleen, stomach, pancreas, colon or bladder may be seen
through the membrane. The intestine lies freely mobile within the intact sac without
evidence of adhesions or inflammation.

Omphaloceles minor Omphaloceles major

Treatment
-- Small defects may be closed primarily soon after birth
-- Large defects, the difficulty is disproportion between the size of the abdominal
cavity and the volume of the sac contents.
a- Operative therapy many operatios :- skin flap closure, staged closure ( silo), and
primary closure
b-Nonoperative therapy:- is appropriate for premature infants with a gigantic intact
sac or associated anomalies make survival of a major operation unlikely. The intact
sac is painted daily with a desiccating antiseptic solution and, if successful, an eschar
forms over the sac. Eventually granulisation grows in from the periphery and the
subsequent ventral hernia can be repaired later.

2- Congenital umbilical hernias

a- Umbilical hernia of infants and children
This is a hernia through a weak umbilicus which may partially result from failure of
the round ligament (obliterated umbilical vein) to cross the umbilical ring and
partially from absence of the Richet fascia.
-- Both sexes seem to be equally affected, although
--the incidence in black infants eight times higher than in white infants.
--The hernia is often symptomless but increases in size on crying
Obstruction or strangulation below the age of 3 years is extremely uncommon
Treatment.
Conservative treatment is indicated under the age of 2 years. 95 per cent of hernias
will disappear spontaneously. herniorrhaphy is indicate If the hernia persists at 2
years of age
b- Paraumbilical hernia (supraumbilical or infraumbilical hernia)
In adults the hernia does not occur through the umbilical scar. It is a protrusion
through the linea alba just above or sometimes just below the umbilicus
-- Paraumbilical hernias can become very large..
-- Women are affected five times more frequently than men.
-- common in overweight women specially after pregnency, of 35 and 50 years.
Treatment.
1-- If the defect is small, a primary herniorrhaphy can be performed.
2 - If the defect is large, the repair
is:-The classic primary repair is (
Mayo s operation). The
aponeurosis on both sides overlap
of 5 or 7.5 cm. Interrupted
mattress sutures are then inserted
into the aponeurosis,
3- In the case of very large
primary paraumbilical hernias
(fascial defect > 4 cm) or for
recurrent paraumbilical hernias,
the use of prosthetic material
(polypropylene mesh) is
recommended.
- Additional lipectomy
if large fatty abdomen.
Epigastric hernia (fatty hernia of the linea alba)
An epigastric hernia occurs through the linea alba anywhere between the xiphoid
process and the umbilicus, usually midway between these structures. Such a hernia
commences as a protrusion of extraperitoneal fat through the linea alba
. More than one hernia may be present and
the commonest cause of ‘ recurrence ’ is
failure to identify a second defect at the time
of original repair. A swelling the size of a pea
consists of a protrusion of extraperitoneal fat
only (fatty hernia of the linea alba).
The mouth of the hernia is rarely large
enough to permit a portion of hollow viscus
to enter it;
The patients are often manual workers
between 30 and45 years of age. Usually
Symptomless
Treatment
legating the pedicle, the small opening in the
linea alba is closed by nonabsorbable sutures
in adults and with absorbable sutures in
children.

Burst abdomen (wound dehiscence)

The disruption of the all layers of wound, mostly between the 6th and 8th day after operation In
1—2 per cent of cases
Factors
1- surgeon causes ( Technique of wound closure).
• inappropriate suture material —catgut leads to a higher incidence of bursts than
the use of nonabsorbable, so should never be used;
• method of closure —interrupted suturing has a low incidence. than contenous
• tight sutures , may act as cutter when the patient is conscious and coughing.
• drainage directly through a wound leads to a higher incidence of ‘ bursts ’ than
employing drainage through a separate (stab) incision.
• Midline and vertical incisions have a tendency to burst which is higher than those
which are transverse.
2- operation causes .
• Infected case; causes wound infection
• Operations on the pancreas, with leakage of enzymes,
• Coughing; vomiting;. At the completion of an operation any violent coughing set
off by the removal of an endotracheal tube and suction of the laryngopharynx strains
the sutures;
• vomiting and distension (e.g. due to ileus) in the early postoperative period.
• Over-vigorous postoperative ventilation in sedated patients can lead to wound
disruption.
3- patient causes .
Obesity, jaundice, malignant disease, hypoproteinaemia and anaemia are all factors
conducive to disruption of a laparotomy wound; abdominal wounds in pregnancy are
notorious for a high risk of disruption; steroids delay wound healing.
Clinical features
• A serosanguinous (pink) discharge from the wound before fully disruption in
50 % of cases. It is the most pathognomonic sign of impending wound disruption.
Patients often ‘ felt something give way ’ .
• If skin sutures have been removed,
omentum or coils of intestine may be
forced through the wound and will be
found lying on the skin.
• Pain and shock are often absent
• there may be symptoms and signs of
intestinal obstruction.

Treatment
An emergency operation is required to replace the bowel, relieve any obstruction then resuture the
wound.
--While awaiting operation, reassure the patient and cover the wound with a sterile towel.
-- nasogastric tube and intravenous fluid therapy commenced.
operation.
--Each protruding coil of intestine is washed
gently with saline solution and returned to the
abdominal cavity.
--close of The abdominal wall by
(tension suture ) all layers are approximated by
through and through sutures of monofilament
nylon, each passed through a soft rubber or
plastic tuber collar.

--The abdominal wall may be supported by strips of adhesive plaster encircling the anterior two-
thirds of the circumference of the trunk.
-- Antibiotic therapy should be started., peritonitis rarely supervenes
A second dehiscence rarely occurs.
Incisional hernia (postoperative hernia)
Incisional hernia occurs due to disruption of deep layers of abdominal wall with intact skin
and subcutaneous tissues most often in :-
-obese individuals,
-a persistent postoperative cough
-postoperative abdominal distension
Causes : same as wound dehiscence , due to patients , operation and surgeon causes
Clinical features
An incisional hernia usually starts as a symptomless , may occur through a small portion of the
scar, often the lower end. More frequently there is a diffuse bulging of the whole length of the
incision. usually increases in size more and more of its become irreducible.
- Sometimes the skin overlying it is so thin and atrophic that normal peristalsis can be seen in the
underlying intestine.
- Attacks of partial intestinal obstruction are common and strangulation is liable to occur at the
neck of a small sac or in a loculus of a large one.
Treatment
Palliative. An abdominal belt is sometimes satisfactory, especially in cases of a hernia through an
upper abdominal incision.
Operative
1- Simple clossuer .
The layers are repaired usually with nonabsorbable sutures, sometime need tension-relaxing
incisions
2-Complex apposition .
These consist of various procedures (Mayo, ‘ Keel ’ , Kattel , da Silva)
3-Plastic mesh ..
these techniques are now the method of choice for all
-- if above the umbilicus, A mesh is then inserted between the posterior rectus sheath and the
muscle
--If below the umbilicus, the mesh is placed in the preperitoneal space.
Careful haemostasis and meticulous asepsis are essential , then put suction drainage (. Redivac).
Postoperative treatment.
NG and intravenous fluids are employed, and nothing by mouth allowed until the bowels have
functioned( bowel sound +ve)
 Early ambulation and gentle physical exercise are to be encouraged. The patient should not resume
strenuous exercise for several weeks.

High recurrence rate of the hernia in between 30 and 50% except where mesh techniques have
been employed in specialist centers, where recurrence rates may be as low as 10 %

Rare external hernias

1- Divarication of the recti abdominis
Divarication of the recti abdominis is seen principally in elderly multiparous patients. When the patient
strains, a gap can be seen between the recti abdominis through which the abdominal contents bulge
2- Tearing of the inferior epigastric artery
occurs in elderly women, athletic, muscular men, or pregnant women, causes haematoma is usually at the
level of the arcuate line,
3- Interparietal hernia ( interstitial hernia).
An interparietal hernia has a hernial sac which passes between the layers of the anterior abdominal
wall Preperitoneal (20 %) Intermuscular (60 %) Inguinosuperficial (20 %)
4 - Lumbar hernia. 5 -Obturator hernia.6 -Gluteal and sciatic hernias.

Lecture four other abdominal wall problems

Umbilicus
Diseases of the umbilicus
• Inflammation
Infection of the stump of the umbilical cord
(omphalitis)
Umbilical granuloma ( Chronic infection of the umbilical stump)
Pilonidal sinus (a sinus containing a sheath of hairs)
• Fistula
Faecal Patent vitellointestinal duct
Neoplastic ulceration from the transverse colon
Tuberculous peritonitis
Urinary= Patent urachus

• Neoplasms
Benign Adenoma (raspberry tumour) , Endometrioma
Malignant
Primary
Secondary ( Stomach, Colon, including the rectum , Ovary and
uterus Breast)
• Hernia
• Umbilical calculus
Inflammation of the umbilicus
A) Acute infection of the umbilical cord (Omphalitis).
Usually occur at the third or fourth day post delivery the stump in over 50 per cent
of babies born in maternity hospitals. The chief prophylaxis is strict asepsis during
cutting of the cord and the use of 0.1 per cent chlorhexidine, locally, for a few days
management
-- antibiotic therapy usually localises the inflammation.
--warm moist dressings, the crusts separate, giving exit to pus.
complications
1-- Abscess of the abdominal wall. the infection is liable to spread along the
hypogastric arteries or umbilical vein , If gentle pressure is exerted above or below
the umbilicus , and a bead of pus exudes,
2- Extensive ulceration of the abdominal wall
. Extensive ulceration of the abdominal wall due to synergistic infection is treated in
the same way as postoperative subcutaneous gangrene
3- Septicaemia .
Septicaemia can occur from organisms entering the bloodstream via the umbilical
vein.
4- Jaundice in neoborn baby this grave complication.
Infection reaching the liver via the umbilical vein may cause a stenosing intrahepatic
cholangiolitis, appearing some 3—6 weeks after birth.
5- Portal vein thrombosis .
Portal vein thrombosis and subsequent portal hypertension.
B) umbilical granuloma
is the most common umbilical abnormality in neonates, causing inflammation and
drainage. Most fail to epithelialize and persist for more than 2 months some
time with discharge An umbilical granuloma its look as small piece of bright red,
moist flesh that remains in the umbilicus after cord separation It contains no nerves
and has no feeling.
The cause of umbilical granuloma is delay healing during the drying up process, but
the exact cause is unknown.
Management :-the most common treatment is the topical application of
concentrated silver nitrate solution or double ligutuer
Umbilical fistulae
The umbilical cord contains blood vessels that carry blood to and from the fetus to
the mother
its also has fine connections with the urinary bladder and the intestines of the fetus.
At birth, the umbilical cord falls off, outside. At around the same time, the internal
communications of blood vessels and with the intestines called (vitellointestinal
duct) and bladder called (urachus) both also are shrivel off.
A ) patent vitellointestinal duct.
The vitellointestinal duct occasionally persists and gives rise to one of the following
conditions
1•If all duct is patent  umbilical fistula discharges mucus and, rarely, faeces.
2• If a small portion only of the duct near the umbilicus remains un obliterated.
sinus that discharges mucus
3• Sometimes both the umbilical and the intestinal ends of the duct close,  intra-
abdominal cyst develops
4• With its lumen obliterated intraperitoneal band (there is danger, for intestinal
obstruction )
5•Such a band may contract and pull a Meckel ’ s diverticulum into a congenital
umbilical hernia

Treatment
. A patent vitellointestinal duct should be excised together with a Meckel ’ s
diverticulum, if one is present, preferably when the child is about 6 months old.
When a vitellointestinal band gives rise to acute intestinal obstruction, after
removing the obstruction by dividing the band,

B )Patent urachus.
A patent urachus seldom reveals itself until maturity or even old age. This is because
the contractions of the bladder commence at the apex of the organ and pass towards
the base. A patent urachus, because it opens into the apex of the bladder, is closed
temporarily during micturition and so the potential urinary stream to the bladder is
cut off. Therefore the fistula remains unobtrusive until a time when the organ is
overfull, usually due to some form of obstruction.
Treatment .
Treatment is directed to removing the obstruction to the lower urinary tract.
If, after this has been remedied, the leak continues or a cyst develops in connection
with the urachus, umbilectomy and excision of the urachus down to its insertion into
the apex of the bladder, with closure of the latter, is indicated
Infections of the abdominal wall
Cellulitis
can occur in any of the planes of the abdominal wall.
1- Superficial cellulitis
2- Deep cellulitis
Antibiotic therapy is the mainstay of treatment. When tenderness persists, an
anatomical incision dividing the muscles carefully, layer by layer, until pus or
purulent fluid is encountered is often advisable.
3-Progressive postoperative bacterial synergistic gangrene. This is, fortunately, a
rare complication after laparotomy, usually for a perforated viscus (notably
perforated appendicitis
The gangrenous skin liquefies exposing underlying granulation tissue. If the
condition persists, overwhelming septicaemia and associated multiorgan failure
supervene.

Treatment
.Identification of the organisms and a report on their sensitivity to antibiotics is
essential. Metronidazole should be given together with a powerful broad-spectrum
antibiotic. Without vigorous and effective treatment the gangrene spreads to the
flanks and the patient may die of toxaemia
. If the infection has become established, surgical debridement of all the necrotic
and infected tissue should be performed. Hyperbaric oxygen, if available, can be
life-saving. Cellulitis due to bacteroides may give no bacterial growth by
conventional techniques and may be missed.

Neoplasms of the abdominal wall

Desmoid tumour
A desmoid tumour is a tumour arising in the musculoaponeurotic structures of the
abdominal wall, especially below the level of the umbilicus. It is a completely
unencapsulated fibroma.
80%of cases occur in women, many of whom have borne children, and the neoplasm
occurs occasionally in scars of old hernial or other abdominal operation wounds..
They can occur in cases of familial polyposis coli (Gardner ’ s syndrome).
The tumour is composed of fibrous tissue usually of very slow growth, it tends to
infiltrate muscle in the immediate neighbourhood. Eventually it undergoes a
myxomatous change; it then increases in size more rapidly. Metastasis does not
occur. Unlike fibroma elsewhere, no sarcomatous change occurs.

Treatment.
the tumour is excised widely at least 2.5 cm of healthy tissue, recurrence commonly
takes place.
These tumours are moderately radiosensitive. (Intraperitoneal desmoids are best left
alone when possible.)

Fibrosarcoma of the abdominal wall

is rare. It is resistant to radiotherapy and only in some cases can a wide excision,
with nylon mesh repair, offer hope of a cure.