abdomen wall defects and hernias,exomphalos

1. ABDOMINAL WALL DEFECTS
IN NEONATE
By
Dr Muhammad Afzal ch
AP SURGERY

2. TYPES OF ABDOMEN DEFECTS
Cong inguinal hernias
Diaphramatic hernia
Exomphalos.
gastroschisis

3. GASTROSHISIS
It is a defect of the abdominal wall due to that
gut lies outside the belly.,

5. EXOMPHALOS
herniation of abdominal organs through
navel covered by thin membrane.

7. DIAPHRAGMATIC HERNIA
It a is a birth defect where there is a hole in
the diaphragm and abdominal protrude in
chest through it.

10. CONGENITAL INGUINAL
HERNIA

11. DEFINITION
 It is herniation of part of the
abdominal viscera outside the
abdominal cavity through a
preformed sac “Patent processus
vaginalis”, which occurs in pediatric
age group.

12. Incidence
 Inguinal hernitomy is the most common
general surgical operation in Pediatrics.
 Occurs in 0.8% up to 4.4%.
 Higher in infants than children.
 Higher in prematures.
 Male : Female = 7:1.
 Right side 60%, Left: 32%, Bilateral: 8%.

13. Pathogenesis:
 The processus vaginalis (P.V.) develops
during the third month of Gestation as an
outpouching of the peritoneal cavity
through the deep ring.
 During testicular descent at the 7th month, it
becomes covered with the P.V., that extends
to the scrotum.

14.  During the 9th month, the testicular descent
triggers obliteration of PV, although the
mechanism of obliteration is not fully
understood.
 Abnormalities of obliteration results in eith
hernia or hydrocele according to the caliber
of unobliterated PV.

15. Abnormalities of processus vaginalis

16. CLINICAL FEATURES
 painless swelling that appears on crying, and
disappear spontaneously.
 Contents: mainly small bowel.
 maldescended testis.
 Commonly presented with incarceration.

17.  Diagnosis:
- History of swelling:
Associated with crying and irritability.
- On examination:
• Swelling on straining.
thickening of the cord.
-Hypertrophy of cremasteric ms.

18. In Female
canal is not well developed,
Indirect inguinal hernia may occur, called
“Ing. Hernia of canal of Nuck”.
The content here is mainly the ovary and fallopian
tube.

19. Complications
 Irreducibility,
 Obstruction,
 strangulation.

24. Isolation of the vas and
tesicular vessels
Hernial sac with its
contents
Testicle

25. Incarcerated
Cecum
Hernial sac
Testicle

28. Surgical management

29.  Elective cases: herniotomy.
 Emergency cases: irreducible.
- Manual reduction.
• Contraindications of manual reduction:
- Fever
- tender abdomen
- Intestinal obstruction.
- X ray: air-fluid levels
+Ve local signs of strangulation.

31. The distal part of the sac
may be left alone if the
hernia is complete.

32. Hernia of canal of
Nuck

33. Postoperative complications
 Scrotal hematoma.
 Scrotal edema, which resolves
spontaneously within days.
 Testicular atrophy: if dissection affects the
vasculature.
 Iatrogenic ascending undescended testicles.
 Injury to the vas.
 Recurrence.

34. Incision
Immediate recurrence

44. CONGENITAL HYDROCELE

45. Congenital Hydrocele
 DEFINITION
Accumulation of fluid in pr. vaginalis.
When the caliber of the patent P.V is small to
admit abdominal viscera but can admit
peritoneal fluid.

46. PRESENTATION
 Neonatal presentation.
 Late presentation.
 acute inguinoscrotal swelling.

47. TYPES
 Congenital hydrocele “Primary”.
 Acquired hydrocele “ Secondary”.

48. Complete hydrocele
- Communicating
- non-communicating:
• Tense: testis cannot be palpated
• Soft: Testis is palpable through hydrocele sac.

49. Hydrocele of the cord:
- Communicating
- non-communicating (encysted):
* Tense: Non-fluctuant.
* Soft : Fluctuant.
Infantile hydrocele (Funicular):
- Communicating
- non-communicating:
*Tense * Soft.

50.  Combined hydrocele
- Hydrocele of the cord + complete
Hydrocele of the hernial sac.

53. Clinical Picture
 painless cystic swelling, that shows diurnal &
nocturnal variations in size.
 Commonly soft cystic, but sometimes tense.
 In hydrocele of the cord, a cystic supratesticular
mass may be felt, with positive testicular traction
test.
 +Ve translucency.

57. Congenital hydrocele
* Transillumination

59. Management
1) Neonatal presentation:
- tense: operative.
- Soft : follow-up, many possibilities might
occur
2) Late presentation.
Less than one year: as above.
More than one year: Operative.
Acute hydrocele: Operative to exclude acute
scrotum.

60.  I follow-up strategy
1) Turn into tense.
2) Becomes softer.
3) Completely disappears .
4) Hydrocele of hernial sac.

61. SURGERY
. Disconnection of the PV.
transfixion of the proximal end.

62. MALDESCENDED
TESTIS

63. Maldescended testis
1) Arrested: in the superficial inguinal pouch
- At the neck of scrotum.
- Associated with inguinal hernia.
- Acute swelling if torsion occurred.
2) Retractile, ascending, ectopic: presented
with inguinal swelling

64. VARICOCELE

65. DEFINITION
Dilatation, elongation and
tortuousity of the pampiniform
plexus of veins.

66. incidence
 Very rare under the age of 10 year-old.
 Above this age, the incidence rises to
become near the adult onset (5-12%)
 Left side: 80% - 90%.

67. pathophysiology
 Venous dilatation, with reversal of blood
flow causes disturbance of the
countercurrent heat exchange mechanism of
the spermatic cord.
 Local increase in temperature due to blood
stagnation

68. Varicocele in Pediatrics
pathophysiology
 Local increase in temperature due to blood
stagnation leads to : -
1) Dartos muscle relaxation: loss of scrotal
wrinkles.
2) Cremasteric muscle relaxation: low-lying
testis.

69. Etiology
 Primary varicocele:
The left side is commoner due to : -
1} Right angle fusion of the left testicular vein to the
left renal vein.
2} Longer course left Test. vein,.
3} Pressure effect of the loaded sigmoid
4} Nut-cracker mechanism of the aorta with the
superior mesenteric artery.

70. 5} Vascular spasm at the origin of the vein by
adrenaline coming from the adrenal gland.
6} Higher incidence of congenital absence of
valves on the left side “40% left, 23% right”.

71.  Secondary varicocele:
Secondary to:
A) Renal enlargement: Wilms’ tumour,
neuroblastoma, hydronephrosis.
B) Retroperitoneal malignancies.

72. Clinical picture
 Young boy with mainly affection of the left
side .
 Mild dragging pain on the affected side.
 Loss of scrotal wrinkles on the affected
side.
 The left side is hanging down more than the
right.

73.  Varicocele may be classified by size into: -
Grade I: evident only by Valsalva maneuver.
Grade II: evident without Valsalva.
Grade III: Visible as a scrotal space-
occupying lesion

74. Complications
Thrombophlebitis.
Testicular dysfunction.
Psychological troubles.

75. TREATMENT
 Indications for surgery:
 Chronic pain and discomfort
 demonstrable testicular atrophy in
adolescence.
 Infertility in adults.

76. Surgery
 Three approaches:
1) Low inguinal approach
2) High ing. Approach
3) Retroperitoneal approach
Open Laparoscopic

78. Other causes
* Testicular tumours
* Epidydimo-orchitis
* Testicular torsion
* Hematocele
* Scrotal haematoma
* Idiopathic scrotal oedema