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Ventral hernias

  2. 2. Ventral hernia • Any protrusion of viscera through anterior abdominal wall is called as Ventral hernia. • categorized as spontaneous or acquired • Spontaneous –primary defects in abdominal fascia includes- Umbilical & paraumbilical hernia Epigastric hernia Spigelian hernia • Acquired - Incisional hernia - parastomal hernia
  3. 3. Umbilical hernia . • The umbilicus is formed by the umbilical ring of the linea alba. Intra-abdominally, the round ligament (ligamentum teres) and the paraumbilical veins join into the umbilicus superiorly, and the median umbilical ligament (obliterated urachus) enters inferiorly . • Umbilical hernia occurs when the umbilical scar closes incompletely in the child or fails and stretches in later years in the adult patient.
  4. 4. • Umbilical hernias in infants are congenital and are quite common. They close spontaneously in most cases by the age of 2 years. Those that persist after the age of 5 years are frequently repaired surgically. • Operation: umbilicus should be preserved
  5. 5. • Umbilical hernias in adults are largely acquired - known to occur more commonly in adult females with a female:male ratio of 3:1 • In adults the hernia does not protrude through umbilical cicatrix. It is a protrusion through the linea alba just above the the umbilicus - (supraumbilical) or occasionally below the umbilicus (infraumbilical) – so called as paraumbilical hernia
  6. 6. Etiology - multifactorial, commonly found in association with processes that increase intra- abdominal pressure – • pregnancy, • obesity, • ascites, • persistent or repetitive abdominal distention in bowel obstruction, or peritoneal dialysis.
  7. 7. Clinical features: • Pain and swelling are the main ssymptoms • Pain increases on prolonged standing or heavy exercise • Content: mostly omentum Differential diagnosis: • Abdominal wall varices associated with advanced cirrhosis, • umbilical granulomas • metastatic tumor implants in the umbilical soft tissue (Sister Joseph's node).
  8. 8. Treatment: • Reduce weight of the patient • Treat the cause of ascites • Mayo’s operation – vest over pants repair : imbrication of superior and inferior fascial edges • For smaller defects – open umbilical hernia repair • For larger defects - >2 cm – mesh repair – open or laparoscopic
  9. 9. Epigastric hernia: • Hernia protruding through interlacing fibres of the linea alba anywhere between umbilicus and xiphisternum • protrusion of extraperitoneal fat - fatty hernia of linea alba • They are multiple in upto 20% of patients and appeoximately 80% are in midline
  10. 10. • Etiology: sudden strain leading to tearing of interlacing fibres of the linea alba • Clinical features: 1. Symptomless 2. Painful- in partial strangulation of fat 3. Referred dyspepsia On palpation – feels firm, no cough impulse and cannot be reduced Differential diagnosis : lipoma
  11. 11. Treatment • The midline defect is usually elliptical in nature, with the long axis oriented transversely • The hernia will often not be seen on laparoscopy owing to the lack of peritoneal involvement through the hernia defect • Open repair - Primary suturing
  12. 12. Incisional hernia:Postoperrative ventral hernia • It is herniation through a weak abdominal scar (scar of previous surgery). • Causes- • Factors related to patients: 1. Obesity – due to fat encroaching in between the muscle layers 2. Advanced age 3. Multiparity,malnutrition,peritoneal dialysis,jaundice,hypoproteinemia,anaemia, malignant diseases 4. Coughing,vomting and overzealous venetilation in early postoperative period 5. Steroids and chemotherapy
  13. 13. • Smoking in postoperative period. • Causes which increases the intra-abdominal pressure (BPH, straining, stricture urethra or rectum, ascites) Factors related to procedure: • 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
  14. 14. • 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 • Drainage through the main laparotomy wound may precipitate formation of incisional hernia
  15. 15. Clinical features: • Pain and swelling in the vicinity of previous scar • bulging more prominent on standing and coughing,reduces spontaneously on lying down • Attacks of subacute intestinal obstruction – abdominal colic,vomiting,constipation and distention of abdomen • reducibility may be complete or partial • expansile impulse on cough • skin over the hernia is thin and atrophic • On Palpation, the edge of the defect can be delineated - rising test,divarcation of recti H/O previous operation,stormy postoperative period, discharge through requiring prolonged dressing
  16. 16. Types: Type I: • midline hernias with large muscular defects, • spontaneously reducible • Strangulation is rare
  17. 17. Type II: • lateral part of abdomen, • defect in the musculature is relatively small and irregular • Bowel loops are usually matted with adhesions to the sac • High risk for strangulation
  18. 18. • D/D: deposit of tumor old abscess foreign body granuloma Complications: • Loss of abdominal domain • Respiratory dysfunction -paradoxical respiratory abdominal motion • bowel edema, stasis of the splanchnic venous system, urinary retention, and constipation • abdominal compartment syndrome, and acute respiratory failure- return of displaced viscera
  19. 19. Treatment : Preventive measures: • Reduction of weight in obese before elective procedures • Treat any respiratory diseases- chr.bronchitis • Very careful closure of abdomen • all precautions to prevent immediate postoperative wound infection should be taken Conservative management: In elderly – not fit for surgery due to general condition In type I incisional hernias
  20. 20. Operative treatment: Anatomical restoration : small hernias with minimal scar tissue Approximation of the rectus sheath KEEL operation - hernial sac is not opened - fundus of the sac is is pleated with non adsorbable sutures and pushed into the peritoneal cavity - the cross section of this looks like the ‘keel’ of a ship  Cattle’s operation Lattice or Darning muscle pedicle flaps – tensor fascia lata / rectus femoris
  21. 21. Components separation technique: :
  22. 22. Endoscopic component separation technique
  23. 23. Prosthetic repair: • Onlay technique: after primary closure of the fascial defect mesh is placed over the anterioe fascia • Advantages: no direct contact with viscera Disadvantages: a) large subcutaneous dissection leads – more chances of seroma formation b) superficial location of mesh- more prone for infection • Inlay technique: interposition of prosthetic mesh between the fascial edges. - Very high recurrence rates • Sublay/ underlay technique:prosthetic mesh placed below the fascial components
  24. 24. • Retromuscular technique: - also called as Rives-Stoppa-Wantz Retrorectus Repair - placement of mesh under the rectus muscle & above the posterior rectus sheath Advantage: • intraabdominal forces hold the prosthesis against the muscles. • The forces that created the hernia now are used to prevent its recurrence.
  25. 25. • Intraperitoneal mesh placement: - dual type or composite mesh can be placed in intra peritoneal position - about 4cm beyond the fascial defect and fixed to abdominal walls.
  26. 26. Laparoscopic repair: ▫  wound complications ▫  recurrence rate ▫  pain ▫ coverage of “Swiss cheese” abdomen • Placing the mesh intraperitoneally under the defect • Dual mesh or composite meshes are in use • Procedure is done under general anaesthesia • Surgeon and cameraman standing on left side of patient • Monitor is placed on right side at footend • Port placement and number- varies according to site and size of the hernia
  27. 27. Identify approximate size of defect
  28. 28. Determine sites for placement of ports
  29. 29. Sizing the mesh • 3 options: Intracorporeal with pneumoperitoneum, extracorporeal with pneumoperitoneum, extracorporeal desufflated • With extracorporeal measurement, the diameter of the outer (skin) circle is larger than the inner (peritoneal) circle. • This difference is proportional to the size of the patient.
  30. 30. Access to abdomen ▫ Blunt trocar with open technique/ visiport o Verres needle ▫ Remote from hernia site Trocar Requirements depend on hernia size ▫ 10 mm or 12 mm and 5 mm trocars
  31. 31. • Begin careful adhesiolysis • Blunt and sharp dissection • Avoid use of cautery • Full extent of defect should be identified • Beware of the presence of multiple defects
  32. 32. • Once the defect is measured a mesh is selected that provides at least 3 cm of overlap around the defect. • Some surgeons use a 4 – 6 cm overlap. • This may be particularly important in the recurrent hernia or in the morbidly obese patient. • Dual or four layered mesh with non adhesive surface facing towards abdominal contents is placed • All four corners are are sutured using transfascial fixation • Tackers (heical )are placed all around at a distance of 5mm – 1cm
  33. 33. Advantages: • Proper visualization of entire abdomen • Avoidance of unnecessary dissection • Identification of multiple/swiss cheese defects • Less recurrence rates • Short hospital stay • Less morbid surgery • Faster recovery • Better in obese patients
  34. 34. Complications • Prolonged ileus • Seroma • Suture site pain • Intestinal/bladder injury • Cellulitis of trocar site • Mesh infection • Hematoma or post-op bleeding • Respiratory distress • Trocar site herniation
  35. 35. • When an enterotomy occurs – ▫ Contamination  repair injury and delay hernia repair ▫ No spillage  repair hernia ▫ Bladder injury  repair hernia ▫ Delayed bowel injury  remove mesh and delay repair
  36. 36. • In case of Large Seroma ▫ Observation: most of them will resolve without intervention ▫ Repetitive sterile aspiration ▫ When persistent beyond 8 weeks or longer: removal of mesh and excision of hypertrophic mesothelium • Pain at transabdominal suture site > 8 weeks -Nonsteroidal anti-inflammatory agents/oral narcotics -Subfascial injection of combination lidocaine and bupivacaine
  37. 37. Parastomal hernia: • common complication of stoma creation • incidence is highest in colostomies – almost 50% • usually asymptomatic • complications like bowel obstruction and strangualtion are rare Treatment: • Primary fascial repair – high recurrences • Stoma relocation • Prosthetic repair
  38. 38. Sugarbaker repair Diasadvantage: permanent foreign body placed in apposition to the bowel will cause Erosion,obstruction
  39. 39. Spigelian hernia: • A spigelian hernia occurs along the semilunar line - represent the line of transition from the muscular fibers of the transversus abdominis muscle to the posterior aponeurosis of the rectus. • The widest portion of the spigelian fascia is the area where the semilunar line intersects the arcuate line of Douglas • most common type of interparietal hernias
  40. 40. Clinical features: • more common in 4th to 7th decade • small swelling lateral to rectus muscle- above level of umbilicus(10%),below umbilicus(90%) • sharp pain or tenderness at this site • ultrasound abdomen and CT scan are useful to establish the diagnosis • Complications: high risk of incarceration due to narrow neck • Treatment: Primary Repair or Mesh repair
  41. 41. Pelvic hernias: • Obturator hernia • Sciatic hernia • Perineal hernia Posterior hernias: • Lumbar - Superior triangle - Inferior triangle
  42. 42. Obturator hernia: • passes through the obturator canal • Weakness of obturator membrane at its superomedial portion pierced by obturator nerve and vessels resluts in formation of hernial sac • occurs six times more frequently in women than in men
  43. 43. Clinical features: • Difficult to diagnose ,as the swelling is covered by the pectineus • Hernia becomes apparent only when the hip is flexed,abducted and rotated outwards • The leg is usually kept in a semiflexed position and movement increases the pain • Compression of obturator nerve causes pain in anteromedial surface of thigh(Howship Romberg sign) – relieved by thigh flexion
  44. 44. • Small bowel is the most common content to be found in an obturator hernia, rare cases- appendix, Meckel's diverticulum, omentum, bladder, and ovary incarcerated in the hernia. • Narrow neck - > 50% present with complete or partial obstruction,incarceration or strangulation • Pain is referred to knee joint by articulate branch of obturator nerve • Only rectal/vaginal examination can detect a tender swelling in the region of obturator foramen
  45. 45. Treatment: • Three general operative approaches 1. lower midline transperitoneal approach 2. lower midline extraperitoneal approach 3. Anterior thigh exposure The lower midline transperitoneal approach: • most common method for repair of obturator hernias • dilated small bowel is runs deep into the pelvis, where it is found to enter the obturator canal alongside the obturator vessels and nerve.
  46. 46. • reduce the incarcerated bowel with gentle traction • The pelvic side of the obturator canal has a rigid opening that cannot be digitally dilated, making reduction of the hernia sac more difficult. • If traction alone does not allow reduction of the bowel, the obturator membrane can be carefully incised from anterior to posterior to facilitate exposure. • Care should be taken to avoid injury to both the incarcerated bowel and the obturator vessels • If these maneuvers are unsuccessful, a counter incision can be made in the medial groin to facilitate reduction from both sides of the canal
  47. 47. • After reducing the hernia, the intestine is assessed for viability and resected as needed • The hernia opening is then closed around the obturator vessels with a running layer of polypropylene or nylon suture applied in the thin layer of fascia that encircles the inner circumference of the canal. • In a clean case without bowel contamination, a piece of mesh can be placed over the obturator foramen and fixed to cooper’s ligament to prevent migration
  48. 48. The midline extraperitoneal approach • Used when the diagnosis of obturator hernia is made preoperatively • It allows complete exposure of the opening of the obturator canal • Incision: vertical midline incision from umbilicus to pubis • The preperitoneal plane is entered deep to the rectus muscle,and the bladder is peeled from the peritoneum • The space is opened so that the superior pubic ramus and the obturator internus muscle are exposed
  49. 49. • The hernia sac is seen as a projection of peritoneum passing inferiorly into the obturator canal • The sac is incised at the base, the contents are reduced, and the neck of the sac is transected • The internal opening to the obturator canal is closed with a continuous suture • The bites of tissue should include the periosteum of the superior pubic ramus and the fascia on the internal obturator muscle. • preperitoneal mesh can be placed to cover the defect
  50. 50. The thigh/femoral approach: • A vertical incision in the upper medial thigh placed along the adductor longus muscle • The muscle is retracted medially to expose the pectineus muscle, which is cut across its width to expose the sac • The sac is carefully incised, the contents inspected and reduced if viable, and the sac is excised • The hernial opening is closed with a continuous suture layer
  51. 51. PERINEAL HERNIAS • Protrusions of the intra-abdominal contents through a weakened pelvic floor Includes • pelvic hernias, • ischiorectal hernias, • pudendal hernias, • subpubic hernias • hernias of the pouch of Douglas
  52. 52. • Primary perineal hernias are extremely rare • Secondary,or postoperative, perineal hernias are more commonly seen and occur in patients status post abdominoperineal resection Etiology : • Common in 5th – 7th decade • 5 times more common in women • Predisposing factors to a primary perineal hernia include - deep or elongated pouch of Douglas, obesity,chronic ascites, history of pelvic infection, and obstetric trauma
  53. 53. The anterior perineal hernia: (pelvic or pudendal) • The sac enters in front of the broad ligament and lateral to the bladder, emerging anterior to the transversus perinei musculature. • The sac may pass between the ischiopubic bone and the vagina, thereby producing a swelling in the posterior portion of the labia majus. • Posterior perineal hernias(hernia of pouch of Douglas): The hernia enters between the rectum and the uterus to pass posteriorly to the broad ligament.
  54. 54. Lateral pelvic hernia – ischiorectal hernia • occur through the hiatus of Schwalbe when the levator ani muscle is not firmly attached to the internal obturator fascia • Presents posteriorly in the ischiorectal fossa Clinical features: • Complains of soft protuberance that is reduced in the recumbent position. • Anterior perineal hernia- minor urinary retention or discomfort • In posterior perineal hernias – difficulty in sitting posture,rarely constipation or the feeling of incomplete defecation
  55. 55. • Three options for repair of the perineal hernia I. Transperitoneal II. Perineal III. Combined Transperitoneal approach: • ideal for complete repair – wide exposure • Ideal for repair of secondary perineal hernias • Primary repair for small defects Mesh repair for large defects/atrophied musculature Perineal approach: • repair is more direct and avoids a laparotomy • Suitable for small hernia defect in an unhealthy patient • The risk of recurrence is high
  56. 56. Sciatic hernias: • Protrusion of peritoneum and intra-abdominal contents through the greater or lesser sciatic notch • Greater sciatic notch: suprapiriform (60%) infrapiriform (30%) • Lesser sciatic notch - subspinous hernias (10%)
  57. 57. • The hernia sac passes laterally, inferiorly, and ultimately posteriorly to lie deep to the gluteus maximus muscle – usually reducible • Pain deep in the buttocks,radiating down the leg in the sciatic nerve distribution • Rarely, ureteral obstruction occurs because the ipsilateral ureter is contained within the hernia contents. • Incarceration of the hernia can occur, and sciatic hernia has been known to present with bowel obstruction.
  58. 58. • Treatment: I. Transperitoneal II. Transgluteal III. Combined Transperitoneal approach: • Preferred in cases of incarceration, bowel obstruction • care must be taken to avoid injury to the many nerves and vessels found in this region • The defect is repaired using interrupted nonabsorbable suture or a prosthetic mesh plug or patch for larger hernia defects.
  59. 59. The posterior or transgluteal technique: • For uncomplicated, reducible sciatic hernias diagnosed preoperatively • The patient is placed in the prone position • The gluteus maximus muscle is approached through a gluteal incision starting at the posterior edge of the greater trochanter and is detached at its origin to expose the hernia defect • This exposure allows visualization of the piriformis muscle, the gluteal vessels and nerve, and the sciatic nerve
  60. 60. LUMBAR HERNIAs: • 3 types of lumbar hernias I. Superior lumbar hernia II. Inferior lumbar hernia III. Incisional lumbar hernia • Commonly seen in 5th decade • Male :female – 2:1 • Left sided hernias are more common • Congenital type are rare • Acquired hernias are commonly associated with back or flank trauma, poliomyelitis, back surgery – infected kidney,drainage of lumbar abscess, and the use of the iliac crest as a donor site for bone grafts.
  61. 61. I. Superior lumbar hernia: - Protrusion of abdominal contents through superior lumbar triangle of Grynfeltt Boundaries: Above: 12th rib medially – sacrospinalis laterally - posterior border of internal oblique muscle II.Inferior lumbar hernia: - Protrusion of abdominal contents through inferior lumbar triangle of Petit Boundaries: Below – crest of ilium medially – ant.border of lattismus dorsi laterally – posterior border of external oblique muscle
  62. 62. Clinical features: • Hernia tends to increase over time and may assume large proportions and overhang the iliac crest • vague dullness in the flank or lowerback • focal pain associated with movement over the site of the defect • On physical examination-swelling in the lower posterior abdomen – reducible without much difficulty • Ultrasound abdomen and CT abdomen will aid in diagnosis • Strangulation is rare • Differential diagnosis: lipoma,paravertebral cold abscess,phantom hernia
  63. 63. Operative repair: • Under general anesthesia • Patient kept in modified lateral decubitus position with kidney rest • oblique skin incision in the region of the hernia • Sac is identified and reduced • Small defects – primary repair • Large defects – prosthetic mesh repair • Recently - intraperitoneal laparoscopy/ retroperitoneoscopy have been reported as minimally invasive procedures
  64. 64. References: • Lee McGregor's Surgical anatomy • Skandalakis surgical anatomy • Schwartz principles of surgery 9th edition • Sabiston text book of 19th edition • Bailey and love 26th edition • Fischer mastery of surgery 6th edition • DAS manual on clinical surgery • Text book of das 8th edition • ZOLLINGER’S atlas of surgical operations