This document discusses the anatomy of the abdominal wall and incisional hernias. It notes that incisional hernias occur through weak points in previous abdominal scars from surgery. Factors that can predispose to incisional hernias include vertical or midline scars, emergency surgeries, poor wound healing, increased abdominal pressure from coughing or straining, and underlying conditions like obesity, malnutrition or liver disease. Clinical features may include a swelling or bulge that increases with coughing along with pain. Treatment involves surgical repair of the hernia defect.

1. Dr. Muhammad Ayoub Jalbani
Assistant Professor
Surgical UNIT III

2. Anatomy of the Abdominal Wall

3. Anatomy of the Abdominal Wall

4. Function of Musculofascial Layers
5 paired muscles (3 flat, 2 vertical)
3 flat – int/ext oblique and transversalis
Increase abdominal pressure to facilitate
defecation, micturition, and parturition
Stabilizes trunk
2 vertical – rectus abdominus and pyramidalis
Rectus - tensor of the abdominal wall, flexor of
the vertebrae, stabilize the pelvis during walking,
protects the abdominal viscera, aids in forced
expiration

5. Anatomy

6. INCISIONAL HERNIA
It is herniation through a weak
abdominal scar (scar of previous
surgery).
It is common in old age and obese
individuals.

7. Predisposing Factors
Vertical scar, midline scar, lower
abdominal scar— may injure the nerves of
the abdominal muscles.
Scar of major surgeries (biliary,
pancreatic).
Scar of emergency surgeries (peritonitis,
acute abdomen).

8. Cont..
Faulty technique of closure.
Poor nutritional status of the patient.
Presence of cough, tuberculosis,
jaundice, anaemia, hypoproteinaemia.

9. Cont..
Malignancy, immunosuppression.
Smoking in postoperative period.
Causes which increases the intra-
abdominal pressure (BPH, straining,
stricture urethra or rectum, ascites).

10. Factors responsible for development
of Incisional hernia
Vertical incision has got higher chances of
incisional hernia than horizontal incision
Layered closure of the abdomen has got higher
chance than single layer
Continuous closure has got higher chances than
interrupted closure

11. Cont..
Using absorbable suture material has got higher
chances of hernia than non-absorbable sutures
Emergency surgical wound has higher chances
than elective surgical wound
Laparotomy for peritonitis, acute abdomen, and
trauma can commonly cause incisional hernia

12. Drainage through the main laparotomy
wound may precipitate formation of
incisional hernia
Chronic cough, smoking, obstructive
uropathy, constipation can precipitate
incisional hernia

13. Diabetes, old age, malnutrition,
malignancy, anaemia,
hypoproteinaemia, jaundice, ascites,
liver disease, uraemia, steroid therapy,
immunosuppressive diseases are other
precipitating factors

14. Clinical Features
Swelling in the scar region.
Pain.
Impulse on coughing.
Gurgling sound.
Often bowel peristalsis may be visible
under the skin.

15. Eventually features of irreducibility,
obstruction,
strangulation is seen.
Hernia is common in lower abdomen.
It may be small or large; huge or
massive (diffuse)

16. Scar, its extent and location, whether
healed primarily or secondarily, skin over
the scar and swelling is noted. Details of the
swelling with expansile impulse on
coughing and examination both in lying
down and standing are done.
Gap cannot be assessed in an irreducible
hernia.

20. Type of defects in Incisional Hernia
Small defect
Large and wide defect
Very large defect
Massive / diffuse
Multiple defects

21. Investigations:
Always the precipitating factors must be
looked for:
Chest X-ray.
U/S abdomen.
Tests relevant for causes.

22. Complications of incisional hernia
Irreducibility,
Obstruction,
Strangulation,
Incarceration.