Abdominal

Abdominal Wall & Hernia

Wall and
` Hernia
Based from the lecture and slides of Dr. Nolan E. Pecho, Sept. 2021

OUTLINE
I. ANATOMY of the ABDOMINAL WALL
II. ABDOMINAL WALL HERNIA
III. INGUINAL HERNIA
IV. DIAGNOSIS
V. THINGS to CONSIDER in HERNIA PATIENTS
VI. OTHER ABDOMINAL WALL HERNIAS
VII. CONGENITAL ABNORMALITIES of the ABDOMINAL
WALL
VIII. DIFFERENTIAL DIAGNOSES
IX. TREATMENT
X. COMPLICATIONS of HERNIA REPAIR
XI. OUTCOMES

ANATOMY of the ABDOMINAL WALL

ANTERIOR ABDOMINAL WALL

- Consists of 9 distinct layers: skin, subcutaneous tissue,
superficial fascia, external oblique, internal oblique, transversus
abdominis, transversalis fascia, preperitoneal adipose tissue,
peritoneum
THINNER AREAS NATURAL OPENINGS
Formed due to the fascial layer - Umbilicus Obturator
devoid of muscle tissue - Deep inguinal ring foramen
Linea alba: midline of the Superficial inguinal ring
abdomen =Spigelian point: where the
Lateral border of the rectus arcuate line intersects with the
sheath lateral border of the rectus
sheath
-Femoral canal

*In red: openings created by the neurovascular bundles passing through

the fascial covering of the abdominal wall - ARCUATE LINE: at the level of ASIS (S2)
ABOVE the arcuate line (ASIS) BELOW the arcuate line (ASIS)
- FASCIA: contiguous with the superficial adipose Aponeurosis of internal oblique Aponeurosis of the three
splits to enclose the rectus muscles form the anterior wall
tissue muscle - (-) Posterior wall rectus
- : fibrous matrix of tissue fuses with anterior - External oblique directed in muscle is in contact with the
layer of fascia at the flank and back front fascia transversalis
- Transversus directed
behind the muscle
The posterior wall formed above the arcuate line will pass in front of
the rectus at the level of the ASIS, making it a free, curved lower
border called the Arcuate Line.

- NEUROVASCULAR STRUCTURES:
Superficial blood
supply
(skin & subcutaneous
tissues)
Deep blood supply
Venous drainage
(Variable; typically follows
the arteries mentioned)
Lymphatic drainage
Above the umbilicus
Below the umbilicus
Near the umbilicus
Innervation
Branches of the:
Superficial epigastric artery
Superficial external pudendal artery
Superficial circumflex artery
Femoral artery
Superior epigastric artery
Inferior epigastric artery
ABOVE: lateral thoracic vein
BELOW: superficial epigastric &
saphenous vein
Superficial axillary nodes
Inguinal nodes
Along the falciform ligament towards
the hepatic nodes
Afferent branches of T4-T1: provide
sensation to the abdominal wall
Efferent branches of T6-T12: supply
muscles of the abdominal wall

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 Abdominal Wall & Hernia

HERNIA On LATERAL
SPIGELIAN HERNIA - protruding at the junction of the
- Protrusion of a visceral organ or part of a arcuate line and the semilunar line
RECTUS
- At or slightly above the level of arcuate line
visceral organ through an abnormal SHEATH
Interparietal hernia
opening in the walls of its containing cavity Direct/Indirect inguinal hernia
On GROIN
- Visceral organ projecting out of its normal
AREA
Femoral hernia
superior to iliac west
location towards a different cavity/space Obturator hernia ,

passing through a natural orifice, weak INFERIOR LUMBAR or PETIT HERNIA

- : bounded by iliac crest, latissimus
abdominal wall, or a congenital defect On LATERAL
dorsi, and external oblique
create a natural orifice by which a visceral - In this triangle, there is only a fascial condensation
organ may protrude or strangulate Superior lumbar hernia
On
- COMPOSITION: Gluteal hernia
POSTERIOR
Sciatic hernia
o SAC: diverticulum of the peritoneum *In blue green: rare hernias (GSIS)
consisting of: mouth, neck, body,
- ETIOLOGY: having the natural openings and thin areas on the
fundus
o COVERING: derived from the layers of the abdominal wall
external hernia
thru which the sac passes o Abdominal wall has its own protective mechanism, but if
o CONTENTS: either a portion of an organ or fluid like:
these protective mechanisms are overwhelmed by the
Omentum, Intestine, Peritoneal fluid predisposing factors, then hernia may develop

EXTERNAL Abdominal Hernia INTERNAL Abdominal Hernia

Seen by inspection bulged out Bulged out of its position but still
of the abdomen within the cavity
Examples: Examples:
Inguinal Groin hernia Diaphragmatic hernia:
}
1 Femoral
Umbilical
Other abdominal hernia {
protrusion from the abdominal
cavity to the pleural cavity
Hiatal hernia
Congenital or acquired
mesenteric defect

- TYPES of HERNIA
- Contents can be returned to abdomen
Reducible - Patient in supine or Trendelenburg position,
protrusion is reduced to its place
- Contents cannot be returned but no other
complication noted
Irreducible or
- Still persists even after manual reduction and patient
incarcerated
put in supine position
- COMPLICATIONS: incarceration and strangulation
- Bowel in hernia has good blood supply but contents
are prevented from aboral flow
Obstructed
- (+) crampy abdominal pain with distention, nausea,
vomiting, hyperactive bowel sounds initially
- Blood supply of bowel is compromised - FACTORS PREDISPOSING to hernia formation:
Strangulated - Herniated organ could lead to necrosis making it a Presence of a congenital Patent processus vaginalis

;
surgical emergency defect along the abdominal Omphalocele
wall Gastroschisis
- EMERGENCY HERNIA REPAIR indication is impending Acquired defect of the Surgical incisions
compromise of intestinal contents (strangulation): abdominal wall Stretching of the abdominal wall
o Erythematous overlying skin Coughing

{
o Tender & warm to touch
o Fever, leukocytosis, hemodynamic instability
Increase intraabdominal
pressure
Straining
Intraabdominal malignancy
COPD
BPH
ABDOMINAL WALL HERNIA
EPIGASTRIC HERNIA defect in the anterior INGUINAL HERNIA
abdominal wall between the umbilicus and xiphoid /- FACTS about inguinal hernia:
process
o INDIRECT INGUINAL HERNIAS
UMBILICAL HERNIA - common in premature infants
- Close spontaneously by 5 years of age and can be Most common for both sexes
monitored as they will spontaneously resolve o INGUINAL HERNIAS
On MIDLINE - Also seen in adults with high abdominal pressure 5x more common than femoral hernia
due to pregnancy, obesity, or ascites
DIASTASIS RECTI - abnormal separation of rectus
90% of inguinal repair in males
muscles and a laxity at the line alba MALES: 27% lifetime risk of developing inguinal
- NOT a true hernia as the midline fascia is intact (2 hernia
cm on midline abdomen above umbilicus is FEMALES: 3% lifetime risk of developing inguinal
considered abnormal)
hernia

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 Abdominal Wall & Hernia

~o FEMORAL HERNIA SPERMATIC CORD

More commonly diagnosed in LI women due to the - Traverses the inguinal canal and contains the following (all are
peculiarity of the pelvic structure enveloped with three layers of spermatic fascia):
More likely to present with CstrangulationS early than o 3 arteries

E
inguinal hernia o 3 veins
o 2 nerves *
NOTE: o Pampiniform venous plexus: ↳ischemic orchitisC
- Most common inguinal hernia in women? Indirect Inguinal hernia o Vas deferens
- Inguinal hernia more common in women than in men? Femoral
hernia FEMORAL RING
- Inguinal hernia common to be strangulated early in the course? - BOUNDARIES:
Femoral hernia Ant Iliopubic tract, inguinal ligament I I
Post
Med Lacunar ligament Acuna
ANATOMY of the INGUINAL REGION ↑

Lat Femoral vein

Doc Pecho: In the inguinal area, the muscular investment of the
internal oblique & transversus abdominis disappears and becomes
one of the investments of the spermatic cord. Literally, upon
opening of the external oblique aponeurosis at this area and deep
in spermatic cord, it is already the transversalis fascia that constitute
the posterior wall of the inguinal canal. As you may recall, the
descent of the testicle to the scrotal sac passing through the deep
& superficial inguinal ring produces a defect between the layer of
external oblique aponeurosis & transversalis fascia. It is through this
opening that an indirect inguinal hernia is produced. On the other
hand, with the transversalis fascia being the posterior wall of
ILIOPUBIC TRACT
- Aponeurotic band that begins at the ASIS and inserts into
Cooper's ligament from above
- Forms on the deep inferior margin of the transversalis abdominis
and transversalis fascia
- Helps form the inferior margin of the internal inguinal ring as it
courses medially, where it continues as the anteromedial border
of the femoral canal
LACUNAR LIGAMENT (Ligament of Gimbernat)
- STriangular fanningIof the inguinal ligament as it joins theX
-

pubic
inguinal canal, weakening of this layer consequently will produce a tubercle
direct inguinal hernia. Enlargement of the femoral canal, could
eventually develop femoral hernia. (Pectineal ligament)
- ELateral portion of the lacunar ligamentI that is fused to the
INGUINAL CANAL periosteum of the pubic tubercle
- 4-6 cm long cone-shaped region situated in the anterior portion
of the pelvic basin CONJOINT TENDON
- BEGINNING: deep or internal inguinal ring on the posterior - Fusion of the inferior fibers of the internal oblique and
abdominal wall, where the spermatic cord passes through the transversus abdominis aponeurosis at the point where they
hiatus in theCtransversalis fasciaC insert on the pubic tubercle
- END: superficial or external inguinal ring medially at the
point at which the spermatic cord crosses a defect in the external or PREPERITONEAL SPACE between the
Coblique aponeurosisI peritoneum and the posterior lamina of the transversalis fascia
⑨- TRANSVERSALIS FASCIA: Emost important part S of the
abdominal wall in preventing inguinal hernia
containing preperitoneal fat & areolar tissue

s
- BOUNDARIES: *AA SPACE of RETZIUS most medial aspect of preperitoneal space
Ant 0
External oblique aponeurosis which lies superior to the bladder

↳
Lat Internal oblique
Post Transversalis fascia, transversus abdominis muscle
Sup Internal oblique, transversus abdominis muscle VASCULAR SPACE Between the posterior and anterior laminae
Inf of transversalis fascia and houses the inferior epigastric vessels

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 Abdominal Wall & Hernia
NERVES of INTEREST in the INGUINAL REGION
- Emerges from the lateral border of the psoas major
and passes obliquely across the quadratus
lumborum
Ilioinguinal
- Supplies somatic sensation to the skin of the upper
nerve
& medial thigh
- MALES: base of penis & upper scrotum
- FEMALES:Cmons pubis)( & labium majus)☆☆☆
Iliohypogastric - Pierces the deep abdominal wall and it supplies the
nerve (T12-L1) internal oblique and transversus abdominis
NOTE:
- Ilioinguinal & iliohypogastric nerve arises together from the first
lumbar nerve
- A common variant is for the iliohypogastric & ilioinguinal nerves to exit
around the superficial inguinal rings as a single entity
- Courses along the retroperitoneum, emerges on the
anterior aspect of psoas
- Divides into genital & femoral branches
- GENITAL BRANCH: enter inguinal canal lateral to
inferior epigastric vessels
o Courses ventral to the iliac vessels and iliopubic
Genitofemoral tract
nerve (L1-L2) o MALES: travels through superficial inguinal ring
and supplies the ipsilateral scrotum and
cremaster muscle
o FEMALES: supplies the ipsilateral mons
pubis and labium majus
- FEMORAL BRANCH: courses long femoral sheath,
supplying the skin of upper anterior thigh
- Emerges lateral to the psoas muscle at the level of
Lateral
L4, and crosses the iliacus muscle obliquely toward
femoral
the ASIS
cutaneous
- Then passes interior to the inguinal ligament where
nerve (L2-L3)
it divides to supply the lateral thigh
TYPES of INGUINAL HERNIA
Passes through the(deep inguinal ring)
- BULBONOCELE: limited to the inguinal canal
INDIRECT
- FUNICULAR (partial): just above the epididymis
- SCROTAL (complete): extends to the testis
DIRECT Bulging at the posterior wall of inguinal canal
PANTALOON Combined direct and indirect (same side)
Passes through the femoral ring (medial to the
FEMORAL inferior epigastric vessels)
Appreciated below the inguinal ligament
Scrotal Bubonocele
INGUINAL HERNIA PATHOPHYSIOLOGY
- May be congenital or acquired
- ACQUIRED DEFECTS: in most ADULT inguinal hernias
- CONGENITAL: makes up the majority of PEDIATRIC hernias
- BEST CHARACTERIZED RISK FACTOR: weakness in the
abdominal wall musculature
- RISK FACTORS:
o Tissue weakness
o Family history: 8x lifetime incidence
o Strenuous activity: risk factor for acquired inguinal hernia
o COPD: accompanied by repeated episodes of high
intraabdominal pressure
o Decreased ratios of Type I to Type III collagen
o Collagen disorders (Ehlers-Danlos syndrome)
- DEVELOPMENT:
o In a normal course of development: testes descend from
the intraabdominal space into the scrotum in the 3rd
trimester
o Descent is guided by gubernaculum through an
evagination of the peritoneum, which protrudes through
the inguinal canal and becomes the processus vaginalis
o Between 36-40 weeks gestation: processus vaginalis
closes and eliminates the peritoneal opening at the internal
inguinal ring.
o PATENT PROCESSUS VAGINALIS (PPV) failure of the
peritoneum to close
Predisposes a patient to the development of an
inguinal hernia
Children with a congenital indirect inguinal hernia will
present with a PPV
DIAGNOSIS
HISTORY
- Most common symptom: groin mass that protrudes while
standing, coughing, or straining
- Patients who present with a symptomatic groin hernia will
frequently report groin pain
- Inguinal hernias may compress adjacent nerves leading to:
o Generalized pressure
o Localized sharp pain
o Neurogenic pain referred to the scrotum, testicle, or inner
thigh
- Sharp pain tends to indicate an impinged nerve
o May not be related to the extent of physical activity
performed by the patient
- Pressure or heaviness in the groin
- Patient will often reduce the hernia by pushing the contents back
into the abdomen providing temporary relief
o As the defect size increases & more intra-abdominal
contents fill the hernia sac, the hernia may become harder
to reduce and incarcerate, prompting urgent surgical
intervention
- If there is chronic constipation, cough, urinary retention: perform
a thorough work-up to rule out any underlying malignancy
PRESENTATION
- ASYMPTOMATIC HERNIAS: usually diagnosed incidentally on
PE or may be brought to the patient's attention as an abdominal
bulge
- A bulging mass in the inguinal area when intra-abdominal
pressure increases and may or may not reduce spontaneously
- May or may not be accompanied by pain
o If (+) pain: there could be obstruction or strangulation
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 Abdominal Wall & Hernia

PHYSICAL EXAMINATION INGUINAL vs FEMORAL HERNIA

INGUINAL HERNIA FEMORAL HERNIA - Whether you are dealing with inguinal or femoral hernia, it is
- Inspection palpation - Should be palpable below the necessary to perform hernia repair as early as possible
(to inguinal ligament, lateral to the
protrude hernia contents) pubic tubercle o Femoral hernia tends to obstruct early in the natural course
- Inguinal Occlusion Test: to - OBESE PATIENTS: femoral of the illness
know if it is indirect or direct by
blocking the internal inguinal ring
hernia may be misdiagnosed as
hernia of the inguinal canal
⑧- Inguinal canal lies with the
o BOUNDARIES: MR LE 11
with a finger as the patient is - THIN PATIENTS: prominent
instructed to cough inguinal fat pad may manifest as Med Lateral border of rectus sheath
o Indirect hernia: impulse on femoral pseudohernia may Lat Deep epigastric vessels
the tip of the finger prompt an erroneous diagnosis Inf Inguinal ligament
(controlled impulse) of femoral hernia o Take note that the deep inguinal ring lies lateral to the deep
o Direct hernia: impulse at the epigastric vessels a protrusion proceeding above the
dorsum of the finger
(persistent herniation)
inguinal ligament would be the inguinal hernia
ABOVE the inguinal ligament BELOW the inguinal ligament o Inguinal hernia ABOVE the inguinal ligament
o Femoral hernia BELOW the inguinal ligament
DIFFERENTIAL DIAGNOSIS
Lymphoma NOTE:
Retroperitoneal sarcoma - INSIDE epigastric
Malignancy
Metastasis
vessels: Direct hernia
Testicular tumor
Variocele - OUTSIDE epigastric vessels:
Epididymitis Indirect hernia
Testicular torsion - BELOW Femoral hernia
Primary testicular
Hydrocele - IN AND OUT OF THE TRIANGLE (can be felt it on both sides:
Ectopic testicle
Undescended testicle
Pantaloon hernia
Femoral artery aneurysm
Lymph node INDIRECT vs DIRECT INGUINAL HERNIA
Sebaceous cyst INDIRECT HERNIA DIRECT HERNIA
Hidradenitis - Persistent processus vaginalis - Weakening of the posterior
Cyst of the canal of Nuck (female) congenital (recognized at inguinal wall acquired
Saphenous vein any age of the patient) - Most common in older age group
Hematoma - Arises lateral to the deep - Hernia is at the He
Ascites epigastric vessel following the triangle
course of the inguinal canal
- Hernia may reach up to the
THINGS to CONSIDER in HERNIA PATIENTS scrotal area
1. Is the hernia right, left, or bilateral? - Hernia repair is warranted AS EARLY AS POSSIBLE since
2. Is it an inguinal or femoral hernia? indirect inguinal hernia tends to be irreducible/incarcerated as
3. Is it a direct or an indirect hernia? compared to direct inguinal hernia.
4. Is it reducible or irreducible?
5. Is the inguinal hernia complete or incomplete? REDUCIBLE VS IRREDUCIBLE
6. What is the content? - REDUCIBLE: if hernia is reduced when patient is in supine or
7. Is the content obstructed or strangulated? Trendelenburg position to assist the hernial reduction with the
gravitational pull
IS THE HERNIA RIGHT, LEFT, OR BILATERAL? - MANUAL REDUCTION: done in asymptomatic patients
- Usually, the left processus vaginalis testis closes later than - In symptomatic patients: depending on the severity of the
the right symptoms, manual reduction can be performed as long as there
o If the patient has a right-side inguinal hernia due to a patent are no signs of strangulation of the hernial content
processus vaginalis, it is more likely that the left processus
vaginalis is also patent. COMPLETE vs INCOMPLETE
o Bilateral hernia repair is warranted in this case SCROTAL FUNICULAR
(Complete) (Partial/Incomplete)
- Extends to the testis/scrotal sac - Just above the epididymis
-
well during palpation
- Tends to become irreducible or
incarcerated

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 Abdominal Wall & Hernia

CONTENTS PARAUMBILICAL HERNIA

Content Auscultation Palpation
Transillumination - Protrusion through the linea alba just
test
Omentum or Doughy with
above or below the umbilicus due to
other visceral No sounds no peristaltic the weakening of the linea alba
structure movement - WOMEN: more commonly seen
Negative
May feel especially if multiparous
May hear
Intestines peristaltic
bowel sounds - May cause intestinal obstruction
movement
Peritoneal fluid No sounds Soft, rubbery Positive - SKIN: may produce intertrigo and ulcers
- IMAGING: - PRESENTATION:
o ULTRASOUND: least invasive technique and DOES NOT 0 o Pain: from traction of visceral organ by the hernia
impart any radiation to the patient o In due time, becomes round or oval in shape
Anatomic structures can be more easily identified by o Has a tendency to sag downwards so intertrigo and ulcers
the presence of bony landmarks may form on the skin
o CT & MRI: provide static images that are able to: o Neck of the sac is narrow
Delineate groin anatomy - TREATMENT: surgery
Detect groin hernias
Exclude potentially confounding diagnoses EPIGASTRIC HERNIA
- Small and multiple, occur through
linea alba located in the midline
between the (xiphoid process) and
(umbilicus)
- May be a direct result of tearing of
fibers of linea alba
- May be CONGENITAL: due to defective midline fusion of
developing lateral abdominal wall elements
- Seen among manual laborers between 30-45 y/o
- PRESENTATION:
STRANGULATED vs OBSTRUCTED o More than 1 defect may be present
Signs of STRANGULATION Signs of BOWEL OBSTRUCTION o Usually asymptomatic: defect is situated higher on the
Tenderness over the bulging Crampy abdominal pain abdominal wall and seldom would a visceral organ
mass Abdominal distention
herniate through the defect in a patient in erect or supine
Fever Nausea, Vomiting
Leukocytes Obstipation position
Hemodynamic instability Collapse rectal vault o If visceral organs do herniate, it may easily incarcerate or
Hernia bulge is warm Hyperactive bowl sounds (initial) strangulate especially if the opening is small making it
Erythematous or discolored High pitched metabolic bowel symptomatic
overlying skin sounds
- TREATMENT:
o Surgery if symptomatic
OTHER ABDOMINAL HERNIAS
o At elective repair: usually found to contain omentum or a
UMBILICAL HERNIA portion of the falciform ligament
- Produce due to a weak
umbilicus or enlarged INTERPARIETAL HERNIA
umbilical ring - Sac passes between the layers of the
- Occurs at the umbilical anterior abdominal wall
ring and may be - Produced by a tear in the aponeurosis that
present at birth or comprises the lateral border of the rectus
develop later in life sheath
- Seen in all age groups: o Visceral organs can herniate through
10% in newborns and the flat muscles of the abdomen
premature infants (more common) - MALES: commonly affected
- Obstruction of strangulation below 3 y/o UNCOMMON - TYPES:
Sac takes the form of a diverticulum
- Close spontaneously by 5 years PREPERITONEAL
from a femoral or inguinal hernia
- PRESENTATION: Usually between the external and
INTERMUSCULAR

f
o Usually asymptomatic' unless internal oblique

{ incarcerated Sac expands between the superficial

INGUINO-SUPERFICIAL
fascia of the abdominal wall or the thigh
o ,Conical in shape
- TREATMENT: surgery
o Becomes prominent
- TREATMENT:
o Conservative under 2 y/o
o Surgery persist after 2 y/o
strangulation less indirect inguinal
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 Abdominal Wall & Hernia

SPIGELIAN HERNIA CONGENITAL ABNORMALITIES

- Interparietal hernia at level of of the ABDOMINAL WALL
arcuate line (Intermuscular type)
**not discussed in lecture**
at the junction of arcuate line &
- In early embryonic development, there is a large central defect
lateral border of rectus sheath
though which passes the vitelline (omphalomesenteric) duct and
- Can occur anywhere along the
allantois
length of the Spigelian line/zone
- Omphalocele or gastroschisis: defects in abdominal wall
(linea semilunares)
closure
o Aponeurotic band of variable width at the lateral border of OMPHALOCELE GASTROSCHISIS
the rectus abdominis - Umbilical defect - Separation in the abdominal wall
- MOST COMMON LOCATION: at or slightly above the level of

:
- Failure of all or part of the midgut - Intestines not covered by
the arcuate line to return to coelomic cavity peritoneum
during fetal life - Open usually at right side of
- Not always clinically evident as a bulge and may come to - Intestine covered by peritoneum umbilicus
medical attention because of pain or incarceration and amniotic membrane - Bridge of skin separates
- >50 y/o common - Viscera protrude in the open abdominal defect
umbilical ring and are covered by - Viscera protrude through a
- NO sex predilection a sac derived from the amnion defect lateral to the umbilicus
- Risk of incarceration is as high as 17% at the time of diagnosis and NO sac is present
- PRESENTATION: TREATMENT: TREATMENT:
o Soft reducible mass palpable lateral to rectus muscle and - SMALL DEFECT: may be closed - Carefully wrap it in pads soaked
primarily in saline (salt solution) so the
below umbilicus (Spigelian point) - LARGE DEFECT: herniated intestines do not dry
o May strangulate content rigid fascia surrounding the o Non-operative therapy out
neck of sac o Skin flap closure - Insert a nasogastric tube to
o Staged closure remove air and decompress the
- DIAGNOSIS: ultrasound & CT scan o Primary closure intestines
- TREATMENT: Repair (open or laparoscopic procedure) - Do an abdominal ultrasound to
identify the nature of herniated
LUMBAR HERNIA viscera
- Surgically repair the
- Rare hernia gastroschisis by returning the
- Inferior lumbar hernia ( ) more herniated intestines to the
common than superior lumbar hernia abdomen and then closing the
abdominal wall
- Protrusion on the flank above the iliac crest
- Weakening of the fascia is due to previous
surgery done on the flank (renal surgical
procedures)

:
- Occurs secondary to renal operations
- DIAGNOSIS & TREATMENT:
o Ultrasound & CT scan
o Surgery
VITELLINE DUCT ABNORMALITIES
Persistence of a vitelline duct remnant
INCISIONAL HERNIA MECKEL S DIVERTICULUM
on the ileal border
- Occurs as a symptomless partial disruption of the deeper Complete failure of the vitelline duct to
abdominal incision regress associated with drainage of
VITELLINE DUCT FISTULA
- May see normal peristalsis if skin is atrophic/thin mall intestinal contents from the
umbilicus
- Diffuse bulging of the whole or partial portion of incision If both the intestine and umbilical ends
- Increases in size if not repaired early CENTRAL VITELLINE DUCT
of vitelline duct regress into fibrous
(Omphalomesenteric cyst)
- 10-20% of patients may eventually develop hernias at incision cords
sites following open abdominal surgery Persistent vitelline duct
Associated with small intestinal
remnants between the GIT
- Rarely strangulate (broad-necked sac) volvulus
and anterior abdominal wall
- CAUSES (multiple factors): - TREATMENT: excision along with any accompanying fibrous
o Obesity cord
o Primary wound healing defects
o Multiple prior procedures URACHAL ABNORMALITIES
o Prior incisional hernia - Urachus: a fibromuscular tubular extension of the allantois that
o Technical errors during repair develops with the descent of the bladder to its pelvic rotation
o Additional: postoperative wound infection, prostate - Persistence of urachal remnants can result in cysts as well as
problems, surgery for abdominal aortic aneurysm fistulas to the urinary bladder with drainage of urine from the
- TREATMENT: umbilicus
o Open repair - TREATMENT: urachal excision and closure of any bladder
o Laparoscopic repair defect that may be present

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 Abdominal Wall & Hernia

DIFFERENTIAL DIAGNOSES - TREATMENT:

o Rest or Ligation of artery and evacuation of clot
**not discussed in lecture**
o Observation w/o hospitalization: small, unilateral, and
Rectus Sheath Hematoma
Epidermal Inclusion Cyst stable hematomas
Lipoma o Hospitalization with resuscitation: bilateral or large
Lymphangioma o OPERATIVE GOALS: evacuation of hematoma & ligation
Neurofibroma
Neoplastic Benign of any bleeding vessel identified
Hemangioma
Fibroma o SURGICAL INTERVENTION: treatment for rectus sheath
Desmoid tumors hematomas (samplex)
Endometrioma
Skin cancer DESMOID TUMORS
Neoplastic Malignancy Sarcoma
Metastases
- Fibrous neoplasm originating from the musculoaponeurotic
structures of the anterior abdomen
RECTUS ABDOMINIS DIASTASIS - Unencapsulated fibroma
- Separation of the two rectus abdominis muscle pillars - Aggressive fibrosis: aggressive and infiltrative local behavior
ACQUIRED Diastasis Recti CONGENITAL Diastasis Recti - Do NOT have metastatic potential but only marked cellularity in
Due to: - In newborn/premature biopsy specimens
- Advancing age - More lateral insertion of the - 80% occurs in women
- Obesity rectus muscles to the ribs and
- Following pregnancy costochondral junctions
- Occurs in old wound
(postpartum setting, - RISK FACTORS:
advanced maternal age, after o Slight female predominance
multiple or twin pregnancies, o : greatest risk
high birthweight infants)
NO treatment required TX: plication of the broad o Familial adenomatous polyposis (FAP) patients (10-
- As the infant develops, the midline aponeurosis 15%): develop desmoid tumors of the abdominal wall,
rectus abdominis muscles - For cosmetic indications or abdomen, or retroperitoneum
continue to grow and the disability of abdominal wall
diastasis recti gradually muscular function
o Non-FAP patients: abdominal wall desmoids occur most
disappears - Introduce risk of acute ventral frequently in postpartum women or in surgical scars
hernia - TREATMENT:
- PRESENTATION: o Wide excision
o Characterized by bulging of the abdominal wall in the o Radical resection with frozen section margins and
epigastrium that is sometimes mistaken for a ventral hernia immediate mesh reconstruction: most commonly
- DIAGNOSIS: recommended
o Physical examination o Doxorubicin, Dacarabizine, or Carboplatin: can produce
o CT scan remission for variable period in up to 50% of patients

RECTUS SHEATH HEMATOMA ENDOMETRIOMA

- Hemorrhage from the network of collateralizing vessels within - Seen in women 20-45 yrs
the rectus sheath and muscles (inferior epigastric vessel tear) - Bleeds during menstruation
- Commonly affects thin and feeble elderly women, athletic - Umbilical pain
muscular men, multiparous women late in pregnancy - TREATMENT: UMBILECTOMY
- OTHER CAUSES:
o History of significant blunt abdominal trauma TREATMENT
o Sudden contraction of the rectus muscles with coughing
o Sneezing For INGUINAL HERNIA
o Any vigorous physical activity - SURGERY: treatment of choice
- Spontaneous rectus sheath hematomas occur most frequently o NO conservative managements that could cure hernias
in the elderly and in those on anticoagulation therapy like the use of pessary or abdominal binder only
- PRESENTATION: temporary measures to alleviate the hernial protrusion and
o Sudden onset of unilateral abdominal pain may be complications but do not address the true cause of the
confused with lateralized peritoneal disorders such as hernia.
appendicitis o Includes:
o Site of hematoma: arcuate line Open tissue or mesh repair
- DIAGNOSIS: Laparoscopic mesh repair
o History and physical examination alone may be diagnostic Robotic assisted
o Pain increases with contraction of the rectus muscles, and - Any hernia can strangulate or cause bowel obstruction
a tender mass may be palpated emergency hernia repair
o : palpable abdominal mass that
remains unchanged with contraction of the rectus
o Ultrasound & CT scan: can confirm diagnosis and rule out
other disorders

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 Abdominal Wall & Hernia

PRINCIPLES of INGUINAL HERNIA REPAIR - Elective surgery

- Excision of the hernia sac remove the pouch of the hernia confers an unacceptable level of operative risk
which is protruding part o Despite optimal management of comorbidities, patient
- Repair of the stretched deep inguinal ring and transversalis remains high-risk
fascia: tightening it so no visceral organ can protrude through it o Open repair with local anesthesia can be safely performed
- Reinforcement of the posterior wall of the inguinal canal can be - PAIN: most common reason for elective repair
done by: - Any hernia can strangulate or cause bowel obstruction
o Approximating the conjoint tendon on the internal oblique emergency hernia repair
aponeurosis to the shelving edge of the inguinal or - Reinforcement of the posterior wall overlaying of
ligament tissues/prosthesis anterior to the transversalis fascia
o Putting an overlay mesh anterior to the transversalis fasci
Adding another layer of tissue on the posterior wall of NON-OPERATIVE
the inguinal canal - Targets pain, pressure, and protrusion of abdominal contents in
- Repair must be tension-free: to avoid dehiscence or recurrence the symptomatic patient population
of the hernia - Recumbent position: aids in hernia reduction via the effects of
gravity and relaxed abdominal wall
NOTE: - Femoral & symptomatic inguinal hernias carry higher
Do you need to perform all the principles in performing hernia complication risks surgical repair is performed EARLIER for
repair? No. these patients
- Hernia repair would depend on the type of inguinal hernia
presented by the patient TENSION or TISSUE REPAIRS TENSION-FREE or MESH
- But ALL hernia repair should include: excision of the sac and (Non-prosthetic) REPAIRS (Prosthetics)
Apposition of 1 tissue plane to With mesh, not for infected hernias
must be tensions-free another internal oblique & (strangulated hernias)
transversus abdominis muscle to Mesh effect on vas deferens
NYHUS CLASSIFICATION SYSTEM * inguinal ligament may cause azoospermia
Type Characteristic Treatment Approximation of tissues NO approximation of tissues
Indirect hernia: Stronger and recurrence rate is
-v NORMAL internal low
abdominal ring Bassini Repair A Lichtenstein Repair
Type I - Weakness of the *
Herniotomy: excision of Shouldice Repair Mesh Plug & Patch
hernial sac only H Desarda Repair Stoppa Technique
transversalis fascia
& - Seen in newborn and
children (PPV)
McVay Repair (femoral hernia)
Lytle Repair
Prolene Hernia System (PHS)

Indirect hernia Marcy Repair

-v Internal ring Andrew-Ferguson

It
ENLARGED without
impingement of the floor Herniotomy; TENSION or TISSUE REPAIRS (Non-prosthetic)
Type II of the inguinal canal Tightening on the deep
- DOES NOT extend to inguinal ring - Tissue-based herniorrhaphy suitable alternative when
the scrotum prosthetic material cannot be used safely
- Seen among teenagers - INDICATIONS: operative field contamination, emergency
and early adults
Direct hernia
surgery, and the viability of the hernia contents is uncertain
Herniotomy;
- Weakness of the
Type IIIA Reinforcement of the HR
transversalis fascia in - Most popular open tissue hernia repair procedure
posterior inguinal wall
older age group before
Indirect hernia direct sindirect on same side - Other surgeons develop their modification of the
- Enlarged enough to Bassini technique due to the tension produced by the
ENROACH upon the Herniotomy; conjoint tendon to the inguinal ligament (dehiscence
posterior inguinal wall Repair of stretched deep BASSINI of repair)
Type IIIB - Seen at any age, inguinal ring; REPAIR - Triple Layer Repair: the internal oblique,
commonly at the older Reinforcement of posterior transversus abdominis and transversalis fascia are
age group inguinal wall fixed to the shelving edge of the internal inguinal
Sliding & scrotal hernias HRR ligament & pubic periosteum with interrupted sutures
(direct & indirect) o Lateral aspect of the repair reinforces the medial
Herniotomy; border of the internal inguinal ring
Femoral hernia Tightening of the femoral - Very low recurrence rate and is now more popular
Type IIIC - Bulge BELOW the ring; HtR than the Bassini repair
inguinal ligament Reinforcement of posterior - Before you approximate the conjoint tendon to the
inguinal wall inguinal ligament, procedure is performed first with
Recurrent hernia Herniotomy; the transversalis fascia layer before closing all the
- Occur on the same side Tightening of the defect; I tR other layers of the abdominal wall
Type IV SHOULDICE
of the previously Reinforcement of posterior - Multiple Layer Continuous: its distribution of
REPAIR
repaired hernia inguinal wall tension over several layers results in lower
recurrence rates
- Genital branch of genitofemoral nerve: routinely
OPERATIVE
divided resulting in ipsilateral loss of sensation to the
- Surgical repair: definitive treatment of inguinal hernia scrotum in men or mons pubis and labium major in
women

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 Abdominal Wall & Hernia

- Modification for hernia repair by Dr. Desarda (2001)

claimed to have low recurrence rate
*
MYOPECTINEAL ORIFICE of FRUCHAUD
- Weak portion of the abdominal wall that is divided by the inguinal
DESARDA - TECHNIQUE: double-breasted repair of the external
REPAIR oblique aponeurosis to reinforce the posterior wall ligament
- Still waiting for the result whether the recurrence rate &
Inf Superior ramus of pubis

-
is really low or not.
:
Lat
= of
Iliopsoas muscle 1
Med Rectus sheath
ligament inferior to the femoral canal at the superior Sup Internal oblique, transversus abdominis
ramus of the pubis to approximate the open
MCVAY
transversalis fascia to reinforce the femoral canal
REPAIR
o With the tension produced in this repair,
recurrence rate is high
- Addresses both the inguinal and femoral ring defects
- Involves only the tightening of the deep inguinal ring
MARCY
after excision of the sac
REPAIR
- Good alternative for a type 2 hernia repair

*
TENSION-FREE or MESH REPAIRS (Non-prosthetic)
- Invention of the PROLENE MESH: a thin, strong, lightweight,
o Placed at tissues tissues adhere to it and will gain the
strength of the mesh
- MESH-BASED HENIOPLASTY: most commonly performed

and improved outcomes

- Other surgeons were not satisfied of the recurrence
rate of hernia after tissue repair, that Dr. Lichtenstein
developed a prosthetic mesh
- Propylene material is used as an overlay anterior to
the transversalis fascia so that no tissue is
approximated
LICHTENSTEIN
REPAIR
- No tension hernia repair
- Granulation tissue formation surrounding the
mesh would be reinforcement of the posterior
inguinal wall <1% recurrence
- Expands the domain of the inguinal canal by
reinforcing the inguinal floor with prosthetic mesh
minimize tension in the repair
- Modification of Lichtenstein repair
- Prior to placing the prosthetic mesh patch over the
inguinal floor, a three-dimensional prosthetic plug
is placed in the space previously occupied by the
MESH PLUG
hernia sac
& PATCH
- INDIRECT HERNIA: plug placed alongside the
TECHNIQUE
spermatic cord
- DIRECT HERNIA: sac is reduced, and then the plug
is sutured
oblique aponeurosis
- Giant Prosthetic Reconstruction of the Visceral
Space (GPRVS)
STOPPA
- A broad prosthetic mesh is placed in the
TECHNIQUE
preperitoneal space from the anterior approach
- Used in recurrent & bilateral hernias
PROLENE - Provides reinforcement to the anterior and posterior
HERNIA aspects of the abdominal wall
SYSTEM
NOTE:
- With the appearance of hernia recurrence, surgeons now
approach the repair for recurrent hernia via the POSTERIOR
APPROACH
o Use the preperitoneal space (space between the
transversalis fascia & peritoneum) to access the hernia site
o From the space behind the abdominal wall. Dr. Fruchaud
introduced his concept of myopectineal orifice
o Can be reinforced during hernia repair no recurrence
should be expected
*
LAPAROSCOPIC MESH HERNIA REPAIR
- Reinforce the abdominal wall via a posterior approach
- Indications are similar to those of open repair
o Most surgeons agree that laparoscopic approach to
bilateral or recurrent inguinal hernias is SUPERIOR to the
open approach
- Concurrent inguinal hernia repair: should be considered if a
hernia patient is scheduled to undergo another clean
laparoscopic procedure (ex. prostatectomy)
- Patient is place on a Trendelenburg position
o Video screens are placed at the foot of the bed
o Surgeon stands contralateral to the hernia
o Assistant stands opposite the surgeon
- From the peritoneal cavity, the surgeons open the
preperitoneal space incise peritoneum exposing
the myopectineal orifice
TAPP - Perform the hernia repair then place the prosthetic
(Trans- mesh to cover the myopectineal orifice as described
abdominal by Dr. Fuchaud and re-suture the peritoneum
Prepritoneal) - Enter the intraabdominal cavity confers
advantage of intraperitoneal perspective
- For bilateral hernias, large hernia defects, and
scarring from previous lower abdominal surgery
- Same procedure as TAPP but done extraperitoneally
TEPP - ADVANTAGE: access to the preperitoneal space
(Totally
Extraperitoneal)
without intraperitoneal infiltration
- Minimizes the risk of injury to intraabdominal organs
- First technique developed
IPOM - Mesh is placed over the myopectineal orifice but right
(Intraperitoneal in the peritoneum
Onlay Mesh) - Posterior approach without retroperitoneal
dissection
ANATOMICAL AREAS of CONSIDERATION Laparoscopic &
Preperitoneal Hernia Repair
- With the popularity of the laparoscopic hernia repair, new
complications arise from the surgical procedure some
patients develop persistent pain on the groin & genital area after
surgery
o Some patients develop hypovolemia and even death

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 Abdominal Wall & Hernia

o Reviewing the anatomy, surgeons were able to identify COMPLICATIONS of HERNIA REPAIR
areas where there are presence of nerves and blood - Complications common to all operations:
vessels: o Bleeding
Triangle of Pain o Wound infection
Triangle of Doom o Seroma formation
Circle of Death o Hematoma formation
o Urinary retention
o Ileus
o Injury to adjacent structure

HERNIA RECURRENCE
- Patient develops pain, bulging, or a mass at the site of an
inguinal hernia repair clinical entities such as seroma, persistent
cord lipoma, and hernia recurrence

⑧
- RISK FACTORS:
Prolongs wound healing Surgical issues
Malnutrition Improper surgical technique
Immunosuppression Improper mesh use
TRIANGLE of DOOM either patient dies or you get sued for malpractice
Diabetes Compromise of blood supply
DUG Medial Ductus adherens 1Vasde¥cns
CONTENTS:
- External iliac vessels
Steroid use
Smoking
Tension present in the tissue
repair
- Deep circumflex iliac vein Infection
Vessels of spermatic - Femoral nerve
Lateral
cord / Gonadal vessels - Genitofemoral nerve
Peritoneal edge/ genital branch PAIN
Posterior
reflected peritoneum Trauma to tissue structures and inflammation
NOCICEPTIVE
Resolves spontaneously
Direct nerve damage or entrapment
Localized, sharp or tearing sensation
NEUROPATHIC Pain medication
May give local steroid or anesthetic injections
if severely symptomatic
Conveyed through autonomic nerve fibers
Poorly localized
VISCERAL
MALES: ejaculation may precipitate the pain
due to sympathetic nerve injury

CORD and TESTIS INJURY

⑧ ISCHEMIC
ORCHITIS
Due to injury to the pampiniform plexus
Indurated, enlarged, painful testis
Self-limited

⑧
Due to injury to the testicular artery
TESTICULAR
Presence of collateral circulation avoids
ATROPHY
testicular necrosis
TRIANGLE of PAIN PGI INFERTILITY Due to injury to the vas deferens
CONTENTS :
Superomedial Gonadal vessels - Lateral femoral LAPAROSCOPIC COMPLICATIONS
cutaneous nerve
Inferolateral Iliopubic tract - Femoral nerve
- Genitofemoral nerve
URINARY RETENTION
femoral branch - General anesthesia: most common cause of urinary retention
Lateral Reflected peritoneum
after hernia repair
- INITIAL TREATMENT: decompression of the bladder with short-
☆ CIRCLE of DEATH term catheterization
- Vascular continuation formed by the following vessels: - To minimize the risk for this complication: ensure voiding prior to
o Common iliac vessels surgery & minimize perioperative fluid administration

:
o Internal iliac vessels
o Inferior epigastric ILEUS
vessels - Occurs with TAPP technique
o External iliac vessels - Self-limited but necessitates:
o Obturator vessels o Sustained inpatient observation
- Injury to any of these o Intravenous fluid maintenance
vessels causes profuse o Nasogastric decompression
bleeding hypovolemic
shock death if not
properly controlled

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 Abdominal Wall & Hernia

BOWEL OBSTRUCTION - ADHESION: when placed extraperitoneally, cause dense

- Prolonged absence of bowel function, in conjunction with a adhesion to a visceral organ that could lead to fistula formation
suspicious abdominal series and infection
- Most commonly secondary to herniation of bowel loops through - FISTULA FORMATION
peritoneal defects or large trocar insertion sites - INFECTION
- SURGERY: for unrelieved obstruction
OUTCOMES
VISCERAL INJURY - PARAMETERS FOR EVALUATING HERNIA REPAIR
- Small bowel, colon, and bladder: at risk for injury in PROCEDURES:
laparoscopic hernia repair o Recurrence Rate: best surgical procedure should be the
- DIRECT BOWEL INJURIES: from trocar placement one with the lowest recurrence rate whether it be by open
- Bowel injury may also occur secondary to: or MIS
o Electrocautery o Complication Rate: should be low or none
o Instrument trauma outside of the camera field o Post-Operative Pain: should be very minimal
- SUSPECTED BOWEL INJURY: conversion to open repair o Operative Duration: should be short or less than a 2-hour
- BLADDER INJURIES: LESS COMMON than visceral injuries procedure
associated with perioperative bladder distention or extensive o Hospital Stay: should be short (not more than 4 days)
dissection of perivesicular adhesions o Quality Of Life: should be optimal after surgery
- SHOULDICE OPERATION: most commonly performed
VASCULAR INJURY technique among tissue repairs
- ILIAC or FEMORAL VESSELS: most severely vascular injured o Most frequently executed at specialized centers
- COMMON CAUSES: o Significantly lower rates of hernia recurrence compared
o Misplaced sutures in anterior repairs with other open tissue-based methods (2012 meta-
o Trocar injury analysis from the Cochrane Database)
o Direct dissection in laparoscopic repairs - LICHTENSTEIN TENSION-FREE REPAIR: hernia recurrence
- Most commonly injured vessels in laparoscopic hernia repair is drastically reduced compared with open elective tissue-based
include the inferior epigastric and external iliac repairs
o Remains the most commonly performed procedure
HEMATOMAS worldwide among other tension-free repairs
- May present as localized collections or as diffuse brushing over o Mesh repair is associated with fewer recurrences and with
the operative site shorter hospital stay and faster return to usual activities
- SCROTAL HEMATOMA: injury to spermatic cord vessels - STOPPA TECHNIQUE: longer operative duration than the
o Self-limited, characteristic dark blue discoloration of the Lichtenstein technique
entire scrotum o Postoperative acute pain, chronic pain, and recurrence
o Intermittent warm and cold compression aids for rates are similar between the two methods
resolution - Because laparoscopic surgery requires specialized instruments
More frequently associated with and longer operative times, its cost is higher than conventional
May also develop in the:
laparoscopic repairs: open repair; however, the potential financial benefit of shorter
- Incision - Retroperitoneum hematoma
- Retroperitoneum - Rectus sheath hematoma
recovery and decreased pain may offset these costs in the long
- Rectus sheath (inf. epigastric - Peritoneal cavity hematoma term
vessels)
- Peritoneal cavity SUMMARY:
1. Hernia protrusion of a viscus or part of a viscus through an
SEROMAS abnormal opening in the wall of its containing cavity
- Loculated fluid collections 2. Factors that increase intra-abdominal pressure can cause
o Large hernia sac remnants may fill with physiologic fluid hernia
and mimic seromas 3. Can occur in any weakened area of the abdominal wall
o Often mistaken for early recurrence of hernia 4. Hernia consists of three parts: sac, covering, contents
5. Hernia content can either be reducible or irreducible
- Most commonly develop within 1 week of synthetic mesh repairs
6. Irreducible hernia has a risk of strangulation at any time
- TO ACCELERATE RESOLUTIONS: reassurance and warm 7. All hernia can strangulate
compression 8. Strangulated hernia common in hernia sac with narrow neck
o Seromas should not be aspirated due to possibility of 9. Strangulated hernia gangrene can occur within 6 hours
secondary infection 10. Indirect inguinal hernia result of patent processus vaginalis
o Can be aspirated if it causes discomfort and restricts 11. Indirect inguinal hernia most common for both sexes
activity for a long time 12. Direct hernia acquired defect, more common in elderly
13. Femoral hernia more common in women
14. Surgery is the treatment of choice
PROSTHETICS (MESH) REPAIR COMPLICATIONS
- MIGRATION: common when mesh was not anchored to the
Other References:
surrounding tissues Schwartz
KZN 2020 Trans

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 Abdominal Wall & Hernia

OPTIONAL PAGE

Congenital Abnormalities of the Abdominal Wall (Table form)

VITELLINE DUCT
OMPHALOCELE GASTROSCHISIS URACHAL ABNORMALITIES
ABNORMALITIES
- Umbilical defect - Separation in the abdominal wall - : - Urachus: a fibromuscular tubular
- Failure of all or part of the midgut - Intestines not covered by persistence of a vitelline duct extension of the allantois that
to return to coelomic cavity during peritoneum remnant on the ileal border develops with the descent of the
fetal life - Open usually at right side of - Vitelline Duct Fistula: complete bladder to its pelvic rotation
- Intestine covered by peritoneum umbilicus failure of the vitelline duct to - Persistence of urachal remnants
and amniotic membrane - Bridge of skin separates regress associated with drainage can result in cysts as well as
Characteristics

- Viscera protrude in the open
umbilical ring and are covered by a
sac derived from the amnion
- SMALL DEFECT: may be closed
primarily
- LARGE DEFECT:
o Non-operative therapy
o Skin flap closure
Treatment
abdominal defect\
- Viscera protrude through a defect
lateral to the umbilicus and NO sac
is present
- Carefully wrap it in pads soaked in
saline (salt solution) so the
herniated intestines do not dry out
- Insert a nasogastric tube to
remove air and decompress the
of small intestinal contents from fistulas to the urinary bladder with
the umbilicus drainage of urine from the
- Central Vitelline Duct umbilicus
(omphalomesenteric cyst): if both
the intestine and umbilical ends of
vitelline duct regress into fibrous
cords
- Persistent vitelline duct remnants
between the GIT and anterior
abdominal wall: associated with
small intestinal volvulus
Excision along with any Urachal excision and closure of
accompanying fibrous cord any bladder defect that may be
present

o Staged closure intestines

o Primary closure - Do an abdominal ultrasound to
identify the nature of herniated
viscera
- Surgically repair the gastroschisis
by returning the herniated
intestines to the abdomen and
then closing the abdominal wall

Page 13 of 13