Ventral hernia by Dr Teo

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  • 1. Hernia-Ventral hernia By Dr.Teo Zue Hiong
  • 2. Contents Definition Classification Incisional hernia management Spigelian hernia management
  • 3. Hernia• Definition – An abnormal protrusion of an organ or tissue outside its normal body cavity or restraining sheath
  • 4. Anatomical structure FundusCovering ofhernia sac Contents of sac (usually bowel) Neck/Mouth
  • 5. Causes of Hernia• May exploit natural openings(inguinal,femoral and obturator canals, umbilicus and oesophageal hiatus) or weak areas caused by stretching, surgical incision or laparotomy• Any condition that increases the pressure of the abdominal cavity may contribute to the formation or worsening of a hernia. – Obesity – Heavy lifting – Coughing – Straining during a bowel movement or urination – Chronic ling disease – Fluid in the abdominal cavity – Hereditary
  • 6. Classification of abdominal hernia Inguinal hernia/Groin hernia Direct inguinal hernia Indirect inguinal hernia Femoral hernia Ventral hernia Epigastric hernia Umbilical hernia Para-umbilical hernia Spigelian hernia Incisional hernia Other rare and specific interparietal hernia
  • 7. Sign and symptoms• The signs and symptoms of a hernia can range from noticing a painless lump to the painful, tender, swollen protrusion of tissue that you are unable to push back into the abdomen—possibly a strangulated hernia. – Reducible hernia – Irreducible hernia – Obstructed hernia – Strangulated hernia – Inflammed hernia
  • 8. Reducible hernia– Asymptomatic reducible hernia • New lump and the groin or other abdominal wall area • May ache but is not tender when touched. • Sometimes pain precedes the discovery of the lump. • Lump increases in size when standing or when abdominal pressure is increased (such as coughing) • May be reduced (pushed back into the abdomen) unless very large
  • 9. Irreducible hernia– Irreducible hernia • Usually painful enlargement of a previous hernia that cannot be returned into the abdominal cavity on its own or when you push it • Some may be long term without pain • Can lead to strangulation • Signs and symptoms of bowel obstruction may occur, such as nausea and vomiting
  • 10. Strangulated hernia– Strangulated hernia • Irreducible hernia where the entrapped intestine has its blood supply cut off • Pain always present followed quickly by tenderness and sometimes symptoms of bowel obstruction (nausea and vomiting) • You may appear ill with or without fever • Surgical emergency • All strangulated hernias are irreducible (but all irreducible hernias are not strangulated)
  • 11. Ventral hernia
  • 12. Ventral hernia
  • 13. Incisional hernia• One that occurs through the wound of a previous operation• Same features as a hernia that is caused by non-surgical injury to the abdominal wall• 1% of transparietal abdominal incisions are followed by a hernia
  • 14. Aetiology• A postoperative complication,can be considered in terms of three factor – Preoperative factors – Operative factors – Postoperative factors
  • 15. Preoperative factors• Age: older usually need more time to heal• Malnutrition• Sepsis: worsen• Uraemia: inhibit fibroblast division• Jaundice: impedes collagen maturation• Obesity• Diabetes mellitus• Steroids• Peritonitis
  • 16. Operative factors Type of incisions vertical are more prone to hernia than transverse Technique and materials Tension in the closure decrease the blood supply in wound Loosen knots Closure using rapidly absorbable suture materials Type of operation Operations involve bowel or urinary tract are more likely to develop wound infection Drain tube
  • 17. Postoperative factors• Wound infection: – Same important with the wrong choice of suture material – Enzyme destruction of healing tissues – Inflammatory swelling raises tissue tension and impedes blood supply – 5-20% of wound infections result in a hernia• Abdominal distension – Postoperative ileus increase the tension on a wound – Stitches may cut out• Coughing:generates wound tension
  • 18. Signs and symptoms• A bulge in the scar• As the hernia enlarges and loculates, symptoms of subacute I/O are common• Overlying skin:thin and atrophic,eventually ulcer and rupture• Strangulation is a surgical emergency• P/E: – Usually reducible – Hernia with a cough impulse at the site of an old scar – When the patient lies flat, hernias deceptively small,any manoeuvre that raise intra-abdominal pressure produces the hernia in all its glory
  • 19. Management Even small symptomatic hernias should be repaired early Prolonged observation simply increase the difficulties of subsequent repair and hazardous Surgical technique:same as for para-umbilical hernia  Exicision of the sac after reduction of its contents  Insertion of overlapping sutures into the rectus sheath
  • 20. Spigelian hernia• Rare but clinically important, less than 1% of total• An interparietal hernia in the line of the linea semilunaris(the lateral margin of the rectus sheath)• Usually at the level of the arcuate line:due to all aponeurotic layers are reflected anterior to the rectus muscle• The hernial sac emerges and enlarges like a mushroom deep to the external oblique
  • 21. S&SSymptoms Local pain that is worse on straining Lumps Non-specific lower quadrant discomfort which needs to be investigated Features of obstruction or strangulationSigns: Tenderness at the site of the hernial orifice Lump which may be difficult or even impossible to feel
  • 22. Management• Abdominal USG/CT:useful in the demonstration of these hernias• Repair:A simple matter of excising the sac and closing the defect/Laparoscopic repairs
  • 23. References1. Clincal surgery 2nd edition2. Principle and practice of surgery 5th edition
  • 24. Thank you