VENTRAL HERNIA

Dr. Namerah Nasir

ABDOMINAL WALL
Abdominal wall is made of these layers:
 Skin
 Subcutaneous tissue
 Fascia:
 Camper's fascia - fatty superficial
layer.
 Scarpa's fascia - deep fibrous layer.
 Muscle:
 External oblique abdominal muscle
 Internal oblique abdominal muscle
 Rectus abdominis
 Transverse abdominal muscle
 Pyramidalis muscle
 Fascia transversalis
 Peritoneum
VENTRAL HERNIA
 It refers to hernia of the anterior abdominal
wall except groin hernias.
 It includes:
 Umblical Hernia
 Paraumblical Hernia
 Epigastric Hernia
 Incisional Hernia
 Spigelian Hernia
 Lumbar Hernia
 Traumatic
UMBLICAL HERNIA
 It refers to the herniation of abdominal
contents through the umblical defect.
 The umbilical defect is present at birth
but closes as the stump of the umbilical
cord heals, usually within a week of birth.
 This process may be delayed, leading to
the development of herniation in the
neonatal period.
 The umbilical ring may also stretch and
reopen in adult life.
IN CHILDREN
INCIDENCE:
 Boys = Girls
 Black infants (8x) > White
 10% of infants, having higher incidence in premature babies.
 Hernia appears within a few weeks of birth.

CLINICAL FEATURES:
 It is usually Symptomless.
 Increases in size on crying.
 It has Classical conical shape.
 Obstruction/strangulation are extremely uncommon in <3
years of age.
TREATMENT:
Conservative: Most of the hernia close
spontaneously without any treatment within two
years of age. So the methods are:
masterly inactivity, reassure parents and strapping
over a coin.

Operative: Herniorrhaphy is indicated when the

hernia is still present after 2 years of age.
IN ADULTS
 In adults it is called Paraumblical Hernia as the
defect is not through the true umblicus.
 Reopening of umbilical defect caused by
conditions that cause thinning and stretching of
midline raphe (linea alba)
 Repeated pregnancies weaken the abdominal
wall
 Obesity causes flabby abdominal muscle
 Ascites, especially in cirrhotic patients
ON EXAMINATION:
Round swelling with well defined fibrous
margin.
Contents:
 Small umbilical hernia often contain
extraperitoneal fat or omentum.

 Larger hernia contain small or large bowel.

 Very large hernia have narrow neck of the sac

and prone to become irreducible, obstructed
and strangulated (unlike children).
Clinical features:
 Swelling in the umbilical region - increase on
coughing/straining
 Expensile cough impulse is present
 Patient may also have inguinal hernia
 Reducibility can be present
 Crescent-shaped appearance of the umbilicus
 Patient complaint of pain due to tissue tension,
and symptom of intermittent bowel
obstruction.
 Dermatitis in case of large hernia (due to
thinned & stretched of overlying skin)
TREATMENT:
• Reduce weight of the patient
• Treat the underlying cause.
• Surgical treatment Open or Laproscopic.
SURGICAL PROCEDURES:
 Very small defects < 1 cm
Closed with a simple figure-of-eight suture.
OR
Repaired by darn technique
 Defects up to 2 cm
Sutured primarily with minimal tension.
(Herniorrhaphy)
OR
Classical repair by Mayo
 Defects > 2 cm
Mesh repair is the treatment of choice
 Mesh is placed in one of the several anatomical planes
 (A) Onlay - mesh is placed anterior to the anterior rectus
sheath.
 (B) Sublay - mesh is placed immediately above the
posterior rectus sheath.
 (C) Intraperitoneal - mesh is placed directly beneath the
peritoneum as the final layer of the abdominal wall.
 Hernia Repair can also be done Laproscopically
EPIGASTRIC HERNIA
 It occurs in the linea alba anywhere between
the xiphoid process and the umbilicus.
 Its called “Fatty hernia of linea alba” as it
usually contains extra peritoneal fat.
 When enlarges drags a pouch of peritoneum
and becomes a true epigasric hernia.
 Etiology: Sudden strain leading to tearing of
interlacing fibres of the linea alba.
 Usually occurs in Males of age 25 to 40
years.
CLINICAL FEATURES:
 Symptomless in most of the cases.
 Painful- if partial strangulation of fat occurs.
 It may mimic pain of PUD.

ON EXAMINATION:
 Less likely to be reducible.
 Maybe locally tender.
 Cough impulse may or may not be felt.
 It may be more than one at a time.
 TREATMENT:
 Conservative treatment – if very small hernia
or symptomless
 If sufficiently symptomatic – Open surgery.
 Anatomic repair.
 Mesh repair.
• Recurrence: May be due to failure to identify a
second defect at the time of original repair.
INCISIONAL HERNIA
 It is diffuse extension of peritoneum and abdominal contents
through a weak abdominal scar (scar of previous surgery).

 CAUSES:
 Obesity
 Advanced age
 Coughing, vomiting, straining
 Steroids and chemotherapy
 Multiparity.
 Poor metabolic state of patient.
 Causes that increase intraabdominal pressure.
 Inapropriate suture material
 Poor closure technique
 Incision
 Emergency procedures.
CLINICAL FEATURES:
 Pain and swelling in the vicinity of previous scar
 Obstruction of contents is common but
strangulation is rare
 Attacks of subacute intestinal obstruction. –
abdominal colic, vomiting, constipation and
distension of abdomen

On Examiation:
 Often multiple defects within same scar
 Reducibility may be complete or partial
 Expansile impulse on cough
 Skin over the hernia is thin and atrophic
TREATMENT:
Preventive measures:
 Reduction of weight in obese before elective procedures
 Treat any respiratory diseases
 Very careful closure of abdomen
 Prevent Post op wound infection

Conservative approach:
 Symptomless hernia with no signs of pain or obstruction.

Operative Treatment:
The indications are:
 Symptomatic hernia which is showing signs of increasing in size
 Large hernia with a small defect
 Subacute intestinal obstruction
 Irreducibility and
 Strangulation
 Mesh repair: is always better and ideal
choice of treatment with less chances of
recurrence.
 Sublay or Intraperitoneal onlay mesh
IPOM aare preferable
 Anatomical repair and Keel’s operation
are not usually used
SPIGELIAN HERNIA
 Herniation through the defect
in spigelian fascia.
 Spigelian fascia is the
aponeurosis of transversus
abdominis muscle
 Its almost above the arcuate
line
 Most common site is below
the level of umblicus, near the
edge of rectus sheath, at the
junction of spigelian line (linea
semilunaris) and arcuate line
(linea semicircularis)
CLINICAL FEATURES:
 Soft, reducible mass lateral to the rectus muscle
and below the umbilicus
 Cough impulse present.
 Strangulation is common
 Common in females after 50 years of age.

TREATMENT:
 High risk of complications due to narrow neck
 Primary Repair or Mesh repair
LUMBER HERNIA
 It refers to the herniation through the Lumber triangle.
 Three types of lumber hernia :
Incisional Lumber Hernia - Most common cause
Superior Lumber Hernia – From superior lumber triangle
bounded by:
 12th rib superiorly
 Post border of internal oblique laterally
 Sacrospinalis muscle medially
Inferior Lumber Hernia – from inferior lumber triangle
bounded by:
 Iliac crest inferiorly
 Laterally external oblique
 Latissimus dorsi medially
MC site for primary lumber hernia
DIFFERENTIAL DIAGNOSIS:
 Lipoma
 Paravertebral cold abscess
 Phantom hernia

CLINICAL FEATURES:
 Focal pain associated with movement over the site
of the defect
 Vague dullness in the flank or lower back
 Hernia tends to increase in size over time

ON EXAMINATION:
 Swelling in the lower posterior abdomen
 Reducible without much difficulty
TREATMENT:
 Small defects – primary repair
 Large defects – prosthetic mesh repair
 Retromuscular sublay mesh repair is the
preferred procedure for lumber hernia.