Abdominal wall, Hernia and Umblicus

M Kamil/Department of surgery/2018-2019
Learning objectives
To know and understand:
 Basic anatomy of the abdominal
wall and its weaknesses
 Causes of abdominal hernia
 Types of hernia and classifications
 Clinical history and examination
findings in hernia
 Complications of abdominal
hernia
 Non-surgical and surgical
management of hernia including
mesh
 Complications of hernia surgery
 Other abdominal wall conditions
Abdominal wall; functions and structure
Functions:
1. Protection for enclosed organs
2. Mobility
Roof: the diaphragm separating the
negative pressure intrathoracic
cavity from positive pressure intra-
abdominal cavity
Floor: bony pelvis
Anteriorly: the two recti muscles
joined by Linea Alba
Laterally: three muscles with criss-
crossing fibers separated by its own
fascia
Posteriorly: spine and paravertebral
muscles with two areas of potential
weakness (lumbar triangles)
Divarication of the recti
• A condition that follow
chronic persistent
increase in intra-
abdominal pressure
• There is stretching of
the linea alba as the
recti muscles separate
• Occur in the upper
abdomen in middle
age obese men
• In the lower abdomen;
it occurs in women
after birth trauma
• For small divarication;
simple abdominal
binder is effective. For
severe cases; surgery
is indicated
Anatomical causes of abdominal wall herniation
Basic design weakness:
 The posterior wall of
the inguinal canal ( the
Hasselbach's triangle)
 It is the site of “direct
or medial inguinal
hernia” (common)
 Lumbar triangles
 superior and inferior
lumbar triangles are
the site for superior
and inferior lumbar
hernia (rare)
Anatomical causes of abdominal wall herniation
Weakness points; where structures
entering and leaving the abdomen:
1. The internal ring of the inguinal canal
where the testis and spermatic cord
leaves down to the scrotum leading to
lateral or indirect inguinal hernia
2. Medial to the femoral vessels; causing
femoral hernia
3. Obturator nerve through the
Obturator foramen; the Obturator
hernia (rare)
4. Sciatic nerve through the sciatic
foramen leading to sciatic hernia (rare)
5. The diaphragmatic hiatus where
esophagus enter the abdomen; Hiatus
Hernia
Anatomical causes of abdominal wall herniation
Developmental failure:
The patent processus
vaginalis in infant
causing indirect inguinal
hernia of infancy
Failure at the umblical
scar ; causing umblical
hernia
Linea alba defect
causing epigastric
hernia
Clinical history and diagnosis in hernia
 Frequently self diagnosis. Lump under the skin usually
painless
 Pain is aching. Some times heavy feeling. Pinching of tissue
cause sharp intermittent pain. Severe pain indicates
strangulation.
 Reducibility assessment: spontaneous; by the patient; by
the surgeon
 Primary or recurrent? (scar?)
 Past history:
• Cardiorespiratory? anesthetic risk
• Prostatism (urinary symptoms)? need for preoperative
catheterization
• Intake of anticoagulants?
 ± cough impulse?
Clinical examination in hernia
• Examine lying down then standing
• Ask patient to cough
• Lift head (assess linea alba weakness; divarication of recti)
• Overlying skin: normal or abnormal. bruises and cellulitis;
strangulation?
• Visible and Palpable cough impulse; (? Saphena varix),
remember that a positive cough impulse is not necessarily a
hernia and a negative cough impulse can still be a hernia
• Reducibility; size and number of defects (multiple in
incisional hernia). Irreducible; urgent (obstruction-
strangulation)
• Site of defect: medial or lateral or below inguinal ligament,
through the umblicus; below or above the umblicus. In a
previous surgical scar
• Number of defects (incisional hernia)
Clinical/intraoperative classification of groin hernia
• Primary
• Recurrent
 Lateral (indirect)
 Medial (direct)
 Femoral
Defect size in finger breadths: each finger breadth
is 1.5 cm
Example: a primary indirect (lateral) inguinal hernia
with an estimate defect size of 3 cm is class PL2
Principles of management
Indications for surgery:
1. Relief of symptoms or discomfort
2. Cosmesis
3. Doubtful diagnosis
4. When Complications are likely :
 Irreducibility
 When possibility of strangulation is high like in femoral hernia
 Hx of increasing difficulty of reduction
 Hx of increasing size
 Young age group (active patient)
5. Urgent operation is indicated for:
obstruction – incarceration - strangulation
Basic principles of surgery for hernia
• Appropriate explorative incision
• Identification of the sac and dissection free
• Assessment of the neck
• Opening of the sac and examination of the
contents
• Reduction of viable content and excision of the
sac (herniotomy)
• Appropriate reinforcement/repair for the hernia
opening and the posterior wall (herniorrhaphy)
by natural tissue repair or synthetic (mesh)
Basic principles of surgery for inguinal hernia
Types of surgical repair:
Classical (natural tissue repair):
1. Bassini’s repair (conjoined tendon-inguinal ligament)
2. Shouldice repair (double breasting of transversalis
fascia)
3. The Darn “Maloney” repair
4. “Desarda” repair; a strip of external oblique
aponeurosis left attached at both ends and used in
repair
Synthetic (open mesh) “Lichtenstein” repair
Mesh in hernia repair
Mesh is used:
 To bridge a defect
 To plug a defect
 To augment a repair
Types of Mesh:
A. Synthetic non-absorbable {polypropylene, Polyester and
Polytetrafluroethylene (PTFE)} durable and Provoke fibrous tissue reaction
But: problem of mesh contraction causing pain and possibility of
recurrence
B. Absorbable Polyglycolic acid mesh. Used for temporary closure and to
buttress suture repair
C. Biological mesh: sheets of sterilized, decellularised, non-immunogenic
connective tissue of different sources used to provide a “scaffold“ to
encourage neo-vascular and neo-collagen ingrowth and deposition. It is
exposed to enzymatic degradation and remodeled with normal host
fibrous tissue.
Mesh in hernia repair
Positioning of the mesh:
Both open surgical or
laparoscopic approach is used.
Onlay: outside the muscle in the
subcutaneous tissue
Inlay: (within the defect) like
mesh plug
Sublay: between fascial layers in
the abdominal wall or
Extraperitoneally against muscle
or fascia
Intraperitoneal: it has two sides;
parietal adhesive side and a
peritoneal slippery non-adhesive
side
Complications of surgery for hernia
 Immediate:
• Bleeding; inferior epigastric or iliac vessels injury (preventable)
• Postoperative Urinary Retention (preventable)
 Later:
• seroma secondary to liquefied haematoma or serum collection secondary
to excessive inflammatory response to sutures or mesh (unpreventable)
• Surgical site infections (SSI) superficial or deep)
 Delayed:
• Recurrence (preventable)
• Chronic pain- pain 3 months after surgery secondary to nerve irritation or
entrapment or due to mesh shrinkage
• Testicular artery damage with testicular infarction and atrophy (rare and
preventable)
Femoral hernia
 Occurs in the small space just medial
to the femoral vein “femoral canal”
which contains fat and some
lymphatic tissue (nodes of Cloquet)
 Occurs more frequently in females
(larger femoral canal)
 There is a substantial risk of femoral
hernia development after sutured
inguinal hernia repair (recent)
 Clinically; appears below and lateral
to the pubic tubercle in the upper leg
rather than in the lower abdomen
 Often small and irreducible
Femoral hernia
 Possibility of strangulation is higher
than in inguinal hernia and often
occurrence of Richter type of hernia
 When increased in size; it is reflected
superiorly ( DDx from direct medial
inguinal hernia)
 For clinical uncertainty; US and/or CT
scan is indicated
Surgery for femoral hernia:
1. The low “Lockwood” approach- when
there is no risk of strangulation or
need to bowel resection
2. The inguinal “Lotheissen's” approach
3. The high “McEvedy” approach
4. Laparoscopic approach
Sportsman’s Hernia
• Severe groin pain extending to the scrotum and upper thigh
occurring in a young man Football or Rugby player
• Clinically; tenderness over the pubic bone and insertion of
adductor muscles
• Pathology of pain: adductor strain or pubic symphysis
diastasis or rarely muscle tearing (Gilmore’s Groin). Some
times it occurs secondary to stretching of posterior wall of
inguinal canal
• Hernia surgery rarely relieve the pain
• Exclude: Hip, Pelvic or lumbar spinal problems. Also bladder
problems should be excluded
• Investigations like US, CT scan and MRI may be needed to
reach diagnosis
The “Ventral” hernia
 Umblical
 Paraumblical
 Epigastric
 Incisional
 Spigelian
 Parastomal
 Lumbar
 traumatic
Umblical hernia
 Failure of closure of umblical cord defect;
usually in infants and children Equal sex
incidence but higher rate in premature infants
and black children.
 Often symptomless; appears clear on crying
and classically conical
 Obstruction/strangulation is extremely
uncommon before 3 years of age
 Majority resolve spontaneously before 2 year
age; after two years; surgery is indicated
 It may also occur in adults; it is associated
with pregnancy; obesity and liver cirrhosis
with ascitis. It occur secondary to massive
increase in intra abdominal pressure. Because
of the narrow neck; obstruction/strangulation
is possible
Paraumblical Hernia
• Weakness and defect around
the umblicus (supraumbilical
or infraumbilical) termed as
Paraumbilical hernia
• More frequent in multiparous
obese females
• Start small but may grow to a
large size
• Contents commonly omentum
thus obstruction due to
adhesions of the omentum is a
common incident
• Surgery is indicated; open
mayo’s double breasted repair
or mesh Hernioplasty ; open
or by laparoscopy
Epigastric Hernia
 A defect in the linea alba anywhere between the xiphoid
process and the umbilicus . It begins with a transverse
split in the midline raphe; thus the defect is elliptical
 Hypothesis: the defect occurs at the site where small
blood vessels pierce the linea alba or, more likely, due to
abnormal decussation of aponeurotic fibers related to
heavy physical activity
 Usually small and contain a little of extraperitoneal fat but
may enlarge with a peritoneal sac containing omentum
and/or bowel
 More than one hernia may be present. The most common
cause of ‘recurrence’ is failure to identify a second defect
at the time of original repair.
 Often affect fit, healthy men 25 and 40 years. can be very
painful (DDx peptic ulcer). A soft midline swelling felt
more easily than seen, locally tender. Usually irreducible
(narrow neck). It may resemble a lipoma. A cough impulse
may or may not be felt.
 Tx: open or laparoscopic repair
 N.B: the small hernia previously had been called “fatty
Hernia of the Linea Alba”
Incisional hernia
 Definition: a hernia that
arises through a defect in
the musculofascial layers of
the abdominal wall in the
region of a postoperative
scar
 Usually start as a disruption
of the musculofascial layers
of a wound in the early
postoperative period.
 The Appearance of a
serosangunious discharge is
the classical pathognomonic
sign of wound disruption
Incisional hernia
Factors predisposing to incisional hernia:
A. Patient factors:
Obesity; malnutrition; immunosuppression; steroid therapy; chronic
cough and malignancy
B. Wound factors:
Poor quality tissue and postoperative wound infection (SSI)
C. Surgical factors:
Inappropriate suture material and incorrect sutures placement
Treatment:
if asymptomatic, early, wide neck, no multiple defects and reducible;
can be prevented from increasing in size by wearing an abdominal
binder
Principle of repair is either by open or laparoscopic surgery
Incisional hernia
The following principles are applied for both approaches:
1. The repair should cover the whole length of the previous incision
2. Approximation of the musculofascial layers should be done with
minimal tension
3. Prosthetic mesh should be applied to reduce possibility of
recurrence
4. In clean-contaminated wounds; mesh should be applied in a
different plane
5. Simple suturing technique without use of prosthetic mesh carry a
high risk of recurrence
6. Different suture repair like Mayo’s, “Keel” and da Silva repairs are
indicated in contaminated wounds.
7. In a Large incisional hernia; a sac of more than 25% of the
abdominal cavity size, there will be loss of abdominal “domine”,
Ordinary repair may lead to compartment syndrome and wound
dehiscence
Techniques to overcome potential loss of abdominal domine
1. Preoperative abdominal expansion by
progressive “pneumoperitoneum” over
several weeks
2. Resection of omentum and/or colon at
the time of repair
3. The use of large prosthetic mesh
4. The use of musculofascial advancement
or transpositional flaps
5. Ramirez's component separation
technique
6. Wedge resection of redundant skin and
fat (Lipectomy) to improve postoperative
abdominal contour
7. Junkin’s Rule: Suture length : wound
length is 4 : 1
Spigelian (interstitial) Hernia
 Uncommon; underdiagnosed
 Equal sex incidence and more
in elderly
 Basically arises through a
defect in the spigelian fascia
(aponeurosis of the TA m.)
then advance through the IO
then deep to EO aponeurosis
and appear at the lateral
border of the rectus sheath
commonly below level of
umbilicus
 In young; usually contain
extraperitoneal fat. In elderly
big and contain a peritoneal
sac
 Dx suspected on basis of
location and presence of a
mass and usually need US, CT
scan or MRI for confirmation
Lumbar Hernia
 Rare and appear
through superior
lumbar ∆ or
inferior lumber ∆.
Commonly
through the
inferior lumbar ∆
 DDx: lipoma,
tuberculous
abscess and
pseudo-hernia (M
paralysis)
 Treatment: surgical
repair; open or by
laparoscopy
Parastomal Hernia
 A stoma is a hernia
created through the
abdominal wall
 Parastomal hernia
occurs due to muscular
weakness around the
stoma
 It causes difficulties in
bag fitting with leakage
around the stoma
 Tx : re-siting the stoma
or repair with Sublay
mesh by open or
laparoscopic surgery
 Recently: mesh is
placed at the time of
creation of high risk
stoma
Traumatic hernia
Arises through non-anatomical
defect caused by injury; types:
 Through abdominal stab
wound, in fact; an incisional
hernia
 Through splits or tears in the
abdominal muscles after
blunt trauma
 Secondary to muscular
atrophy after nerve injury Ex;
lumbar pseudohernia after
open nephrectomy
Dx: trauma history and the non-
anatomical location
Tx: open or laparoscopic repair
especially for large or tight neck
hernia
Rare external hernia
 Perineal hernia
 Obturator hernia
 Gluteal hernia
 Sciatic hernia
Characterized by:
o Rarity
o Vague signs and symptom
o Difficult clinical diagnosis
o CT or MRI is needed to verify
the defect
o High possibility of
strangulation and Richter's
hernia type
o Difficult surgical repair; the
need of mesh fixation with
glue
Umblicus and abdominal wall
Chronic Omphalitis Variety of bacteria
and fungi can be involved:
 Poor hygiene
 Obesity
 PUH
 Keratin plug
Chronic umblical fistula:
 Secondary to infection
 Infected Epidermoid cyst
 True fistula secondary to diseases of
the liver, bladder and gynecological
organs extending to the ligaments
attached to umblicus and present as
a fistula with or without a mass
 Secondary to complicated umblical
hernia repair with mesh or non-
absorbable suture
 Persistent patent Urachus or
vitellointestinal duct in infants
Umblicus and abdominal wall
Malignancy at the umblicus:
 Primary squamous cell carcinoma
 Secondary from GI malignancy
(adenocarcinoma). Present as a nodular
lesion at the umblicus (Sister Joseph’s
nodule) indicating advanced malignancy
Infections of the abdominal wall; superficial
and deep SSI
Abdominal wall Cutenous fistula:
1. Secondary to chronic intra-abdominal
abscess after occult bowel perforation,
appendicitis, diverticulitis and
cholecystitis. CT scan help in Dx and
localization. Tx by CT or US guided
aspiration
2. Advanced malignancy eroding through
the abdominal wall
3. The enterocutaneous fistula of Crohn’s
disease
Umblicus and abdominal wall
Synergistic (Melenye’s) gangrene of the
abdominal wall (Necrotizing Fasciitis)
 Occurs as a result of synergistic
action of non-haemolytic
streptococci and staphylococci
leading to rapid tissue necrosis
proceeding to gangrene and
overwhelming systemic infection
 Tx: high doses of powerful systemic
antibiotics and early and repetitive
debridement of non-viable tissue.
Hyperbaric oxygen therapy may be
indicated
 Mortality rate is high if not
controlled
 Various plastic procedures after
excision can be performed
Umblicus and abdominal wall
Neoplasms of the abdominal wall
• Soft tissue Fibrosarcoma
• Desmoid tumor
 It is a hamartoma
 More common in women
 May associate familial adenomatous
polyposis
 Histologically consist of plasmoidal
cell masses resembling giant cells
 Clinical and radiological feature of a
mass within the abdominal wall
 Surgical resection with a wide free
margin is necessary
 Characterized by high recurrence
rate
Umblicus and abdominal wall
Abdominal compartment syndrome
 Abdominal hypertension is a
result of sustained increase in
intra abdominal pressure above
20 mmHg (normal is 7-15 mmHg)
 Intra abdominal pressure can be
measured directly by intra
abdominal catheter connected to
transducer or indirectly by
measuring intravesical pressure
 Trauma, postoperative bowel
oedema and peritonitis have all
been implicated
 Intra abdominal hypertension
lead to reduced blood flow to the
organs and consequent tissue
ischemia leading to MOF
 Tx: by laparostomy then delayed
closure of the abdomen