Abdominalwallhernias

generalconsideration

inguinalherniasfemoralhernia

incisionalhernia

umbilialherniaherniaoflineaalba

generalconsiderationDefinitionHerniameansasprout,andprotrusion.Externalabdominalwallherniaisanabnormalprotrusionofintra-abdominaltissueorthewholeorpartofaviscerathroughanopeningorfascialdefectintheabdominalwall.mostoccurinthegrionEtiology

1.intensityofabdominalwalldecreased

commonfactors:1)sitethatsometissuespassthroughtheabdominalwall,eg.Spermaticcord,roundligamentofuterus2)baddevelopmentofabdominalwhiteline3)incision,trauma,infectionetal.defectincollagensynthesisorturnover

2.anyconditionwhichincreasesintra-abdominalpressurechroniccough,chronicconstipation,dysuria,ascites,pregnancy,cry

Pathologicalanatomycomposedof:

coveringtissue:skin,subcutanoustissue

hernialsac:protrusionofperitonum,neckofthesac:isnarrowwherethesacemergesfromtheabdomenbodyofthesac

hernialcontents:smallintestine,majoromentum

Clinicaltypes

1.reducibleherniaisoneinwhichthecontentsofthesacreturntotheabdomenspontaneouslyorwithmanualpressurewhenthepatientisrecumbent.

2.irreducibleherniaisonewhosecontentsorpartofcontentscannotbereturnedtotheabdomen,withoutserioussymptoms.herniasaretrappedbythenarrowneckSlidingherniaisoneinwhichthewallofaviscusformsaportionofthewalloftheherniasac.Itismaybecolon(ontheleft),caccum(ontheright)orbladder(oneitherside).Belongstoirreduciblehernia

3.incarceratedhernia:isonewhosecontentscannotbereturnedtotheabdomen,withseveresymptoms.4.strangulatedhernia:denotescompromisetothebloodsupplyofthecontentsofthesac.incarceratedherniaandstrangulatedherniaarethetwostagesofapathologiccourseRichter’shernia(intestinalwallhernia)aherniathathasstrangulatedorincarceratedapartoftheintestinalwallwithoutcompromisingthelumen.Littrehernia:aherniathathasincarceratedtheintestinaldiverticulum(usuallyMeckeldiverticulum).Reductiveincarceratedhernia:reductionofthehernialcontents(intestine)intoabdominalcavity.Inguinalherniasinguinalhernia:aprotrusionofpartofthecontentsoftheabdomenthroughtheinguinalregionoftheabdominalwall.indirectinguinalhernia:theinternalinguinalringtheinguinalcanalexternalinguinalringscrotumdirectinguinalhernia:Hesselbach’striangleAnatomy1.Anatomiclayers1)skin,subcutaneoustissue2)externalobliquemuscle,aponeurosisSubcutaneous(external)inguinalring:Triangularopening,intheaponeurosisoftheexternalobliquejustsuperiorandlateraltothepubictubercle.Inguinalligament:itisformedasthelateraledgeoftheaponeurosisofexternalobliquerollsuponitselfandthickensintoacord,extendingfromtheanteriorsuperioriliacspinetothepubictubercle.LacunarligamentCooper’sligament(pectinealligament)Sensorynerves:iliohypogastricnerve,ilioinguinalnerve3)internalobliquemuscleandtranverseabdominalmuscleConjoinedtendon(flaxinguinalis):thelowerfibersoftheinternalobliquemusclefusewiththelowermostarchingfibersofthetransversemuscleoftheabdomenandinsertwiththemintothepubictubercle,formingtheconjoinedtendon.4)TransversalisfasciaInternalinguinalring:isthepointatwhichthespermaticcordorroundligamentpassesthroughthetransversalisfasciatoentertheinguinalcanal.surfacemarking:2cmsuperiortothepointmidwaybetweentheanteriorsuperioriliacspineandthepubictubercle.Iliopubictract:itisthethickestportionofthetransversalisfasciaintheinguinalregion.Itparallelsandliesjustmedialtotheinguinalligament.5)extraperitonealfatandperitoneum2.AnatomyofinguinalcanalContents:spermaticcord,roundligament,ilioinguinalnerveWalls:anterior:skin,superficialfascia,andexternalabliqueaponeurosisposterior:transversalisfasciasuperior:conjoinedtendeninferior:inguinalligament3Hesselbach’striangleBoundedbytheinguinalligament,theinferiorepigastricvessels,andthelateraledgeofrectusmuscle.

Causesofindirectinguinalhernia

1.congenitalabnormalityofanatomyduetofailureoffusionoftheprocessusvaginalisperitoneiafterthetestishasdescendedintothescrotum.2.acquiredweaknessordefectofabdominalwallClinicalmanifestationanddiagnosisSymptoms:pain,discomfort,draggingsensationSign:reducibleorirreduciblelump,expansilecoughimpulse

Reducingtheherniafully,compresstheinternalring:becontrolled–indirectnotcontrolled--direct

Differencesbetweenindirectanddirectherniafeatureindirectdirectagechildren,youngpeopleagedpeoplepathwayofprotrusioncomingdowntheinguinalcanal,mayenterthescrotumpassthroughHesselbach’striangle,rarelyenterthescrotumcontoursofsacelliptic,pear-shapedsemispheric,widebasecompresstheinternalringafterreducedcontrolledcontrolledRelationshipofspermaticcordwithsacPosteriortothesacAnteriorandlateraltothesacRelationshipofsacneckwithinferiorepigastricarterySacneckislateraltoitSacneckismedialtoitIncarceratedincidencehighlowDifferentialdiagnosis1dydroceleoftestistranslucenttest(+)2communicatedhydrocele3hydroceleofcord:notreducible4undescendedtestis5acuteintestinalobstructionTreatment

1.nonoperativetherapyIndications:<1yearoldelderlypatientsorwithseveresystemicdisease--truss2.operationsforinguinalhernia

conventionalrepairsPrinciples:excisionorreductionofthehernialsac,highligationofthesac,andrepairthewallsoftheinguinalcanalA:highligationofherniasacUsedininfants,andpatientswithseverelocalinfectionB:repairofwallsoftheinguinalcancalIrepairoftheanteriorwalloftheinguinalcanalFergusonrepairIIRepairoftheposteriorwall

Bassinirepair

Halstedrepair:placingthelatterinasubcutanouspositionMcVayrepair:loweredgeofinternalobliquemuscleandtheconjoinedtendonareapproximatedtoCooper’sligamentontheiliopectineallineofthepubis.

Shouldicerepair:theposteriorwalloftheinguinalcanalisrepairedbydividingthetransversalisfasciafromthepubistoadjacenttotheinferiorepigastricvessel,thenimbricatesutures.Internalring:passafingertip2)tension-freehernioplastyinsertionofaprostheticmesh3)laparoscopicrepairofinguinalhernia3.managementruleofincarceratedandstrangulatedherniaIndicationsformanualreduction:1)duration<3-4hours,nolocaltenderness,noabdominaltenderness,norigidityofabdominalmuscle2)elderlypatientsorwithotherseverediseases,andtheintestinalloopisstillaliveUsuallyrequiresemergencyoperation4.Managementruleofrecurrentinguinalhernia1)truerecurrenthernia2)concomitanthernia3)newoccurringherniaFemoralherniaintroductionFemoralherniaisaprotrusionofperitoneumthroughthefemoralcanal.Usuallyinwomen>40yearsCauses:laxityofgrointissueelevatedintra-abdominalcanalAnatomyoffemoralcanalFemoralring–fossaovalisAnterior:inguinalligamentPosterior:pectinealligamentMedial:lacunarligamentLateral:femoralvein

Pathologicanatomyfemoralringfemoralcanalfossaovalis

subcutaneoustessueofthethigh

HighincidenceofstrangulationClinicalfindingsanddiagnosisReduciblefemoralhernia:asymptomaticlump,localizedintermittentdiscomfortIrreduciblefemoralhernia:constantlumpandlocalizeddiscomfortStrangulatedfemoralherniaDifferentialdiagnosis

1.indirectinguinalhernia2.lipoma

3.groinlymphnodes4.longsaphenousvarix

5.iliolumbartuberculousabscessTreatmentNotbetreatedconservativelyRuleoperation:excisionorreductionofthehernialsac,andnarrowingofthestretchedfemoralopeningmethods:McVayrepairtension-freehernioplastylaparoscopicrepairofinguinalhernia

OtherabdominalexternalherniaIncisionalherniaIncisionalhernia:anabnormalprotrusionofaviscusthroughthemusculoaponeuroticlayersofasurgicalscar.WounddehiscenceEtiologyPreoperativefactorsOperativefactors:typesofincision:verticalincision,transrectusincision,midlineincision,standardparmedianincision