Abdominal wall Hernia

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forth stage

Surgery

Lec-3

.

د

ﺳﻣﯾر اﻟﺻﻔﺎر

26/10/2015

Abdominal wall hernia

Richter’s hernia

 Frequent complication of femoral hernia
 Only part of circumference of bowel enclosed in the hernia sac which may become 

gangrenous

 Clinically; abdominal symptoms of IO but with no constipation.

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Diagnosis:

 High index of suspicion
 Urgent surgical interference
 Almost always the diagnosis made at surgery

Umbilical hernia

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In neonates

 Exomphalos 
 1/6000 of births
 Failure of all or part of midgut to return to the coelom 

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In infants and children

 Defect in the umbilical cicatrix
 Equal sex incidence
 Black infants 8 times more

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Clinical features

 Symptomless
 More prominent during crying
 Obstruction or strangulation is rare below 3 years of age 
 Most of cases resolve by itself within 2 years

Diagnosis

 Swelling with umbilical cicatric at fundus of swelling
 Reducible
 ECI +ve  -----Crying

Treatment

 Conservative below the age of 2 years – reassurance of parents
 After 2 years needs surgical repair

Paraumbilical Hernia

 Adults
 Women> men
 Risk factors :Obesity ,Pregnancy
 Repair primarily or with mesh

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Pathogenesis

 Weak point in the linea alba just above or just below the umbilical cicatrix
 Round or oval in shape
 May sag downwards
 May become a large size
 The neck of sac is often remarkably small in size
 Contents; mostly small intestine or omentum or both(Sometimes part of transverse 

colon)

Clinical features

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Classical patient:

 Adult Female (F:M ; 5:1)
 Aged between 35 and 50 years
 Overweight
 multipara 

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Symptoms

 Abdominal swelling
 Dragging pain
 Intestinal colics—obstruction
 Epigastric pain (stomachache)

Complications

1. Irreducibility with possibility of IO
2. Ulceration of skin over fundus of sac
3. Intertrigo 

Diagnosis -------> clinical :

 Swelling just above or below the umbilicus
 Prominent on standing
 Disappear on lying
 Expensile cough impulse

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Treatment

Operation is advised in nearly  all patients.

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Indications:

1. Liable for complication
2. Cosmetic

The operation is "Herniotomy and Repair" ,Either Myo’s repair or Mesh repair.
Mesh repair is indicated for

1. Large defect > 4 cm
2. Recurrent hernia 

Postoperative complications

Local and specific

1. Collection(Hematoma,Seroma )
2. Infection (Wound infection,Pus collection)
3. Recurrence 

Epigastric Hernia(Fatty hernia of linea alba)

 Incidence 1-5%
 Men> women
 Between xiphoid and umbilicus
 20% multiple
 Repair primarily

Pathogenesis

 Extraperitoneal fat protrusion through decussating fibers at linea alba
 At sites of blood vessels 

Clinical features

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Symptomless:

 Accidental finding
 The size of a Pea 
 Felt not seen
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Painful ---local pain and tenderness

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Referred pain----DU like symptoms

Treatment: operation

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Spieghelian Hernia

 Rare
 Hernia through subumbilical portion of semi-lunar line
 Difficult to diagnose
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Clinical suspicion (location)

–

CT scan

 Repair primarily or with mesh

Incisional Hernia

 This occurs after 2-10% of all abdominal surgeries, although some people are more at 

risk. 

 After surgical repair, these hernias have a high rate of returning (20-45%). 
 Risk factors
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Technical

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Wound infection

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Smoking

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Hypoxia/ ischemia

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Tension

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Obesity

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Malnutrition

 Laparoscopic vs. open repair

Lumbar Hernia

 Congenital, spontaneous or traumatic
 Grynfeltt’s  triangle:
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12th rib, internal oblique and sacrospinalis muscle

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Covered by latissimus dorsi 

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 Petit’s triangle:
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Latissimus dorsi, external oblique and iliac crest

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Covered by superficial fascia

Pelvic Hernia

1) Obturator hernia

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Most commonly in women

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Howship-Romberg sign

2) Sciatic hernia
3) Perineal hernia

Parastomal Hernia

 Variant of incisional hernia
 Paracolostomy > paraileostomy 
 Low rate if through rectus muscle
 Traditionally relocate stoma, repair defect
 Concern for mesh erosion
 Laparoscopic repair

Abdominal Wall Hernia

1) Richter’s hernia
2) Littre’s hernia
3) Hernia in W 
4) Pantallon 

Umbilical Hernia

 Common in infants
 Close spontaneously if <1.5 cm
 Repair if > 2 cm or if persists at age 3-4 years
 Repair primarily or with mesh