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    abdominal wall abdominal wall Presentation Transcript

    • ABDOMINAL WALL DEFECTS Celso M. Fidel, MD, FPCS,FPSGS Diplomate Philippine Board of Surgery
    • Introduction ABDOMINAL WALL  Complex musculo-aponeurotic structure  Attached to the :  Vertebral column posteriorly  Ribs superiorly  Bones of the pelvis inferiorly  Derived embryonically in a segmental, metameric manner, and is reflected in blood supply and innervation.
    • Introduction
      • ABDOMINAL WALL
      •  Protects and restrains the abdominal viscera,
      • and its musculature
      •  Acts indirectly to flex the vertebral column.
      •  Integrity is essential to the prevention of
      • hernias, whether they be:
      •  Congenital
      •  Acquired
      •  Iatrogenic
    • Introduction ABDOMINAL WALL It is the repository of the panniculus adiposus May reach considerable proportions in some members of the species afflicted with morbid obesity .
    • Introduction ABDOMINAL WALL Variety of pathology difficult to assess on physical examination. Computed tomography (CT) often delineates these abnormalities
    • GENERAL CONSIDERATIONS  VENTRAL HERNIA  UMBILICAL HERNIAS  EPIGASTRIC HERNIA  INCISIONAL HERNIA  TROCAR HERNIA  Emergency Abdominal wall Defects  Difficult Abdominal Wall Closure
    • ABDOMINAL WALL HERNIAS
    • UMBILICAL HERNIAS
    • UMBILICAL HERNIA
    •  
    • GENERAL CONSIDERATIONS  Other Abdominal Wall Hernia  Spigelian Hernia  Lumbar Hernia 1. Petit’s or inferior triangle hernia 2. Grynfelt’s or sup. Triangle hernia  Pelvic Floor Hernia 1. Obturator Hernia 2. Perineal Hernia 3. Sciatic Hernia
    • GENERAL CONSIDERATIONS  Other Abdominal Wall Hernia 4. Parastomal Hernia 5. Internal hernia (a) Normal Orifice (b) Abnormal Orifice (c) Iatrogenic ( post-operative)
    • GENERAL CONSIDERATIONS  Other Abdominal Wall Hernia 6. Co ngenital Abdominal Wall defect (a) Gastroschisis (b) Omphalocele 7. C ongenital Diaphragmatic Hernia (a) Bochdalek (b) Morgagni
    • Abdominal Wall Defects
      •  Ventral Hernia
        • Defect in the abdominal wall with intestines
        • or preperitoneal fat thru fascial defect
        • On PE fascial defect usually palpable in
        • obese patients
        • Ultrasound or CT scan for the diagnosis
        • Same principle of management as groin
        • hernia
    • Ventral HERNIA
      •  Umbilical Hernia
      •  Occur more frequently in females; 10-30%
      • live birth
      •  Obesity and repeated pregnancies precludes
      • this problem
      •  In infants aponeurotic defect of 1.5 cm or less
      • would close spontaneously
      •  Repair for children present by the age of
      • three or four & infants whose defect is 2 cm
    • Ventral HERNIA
      •  Umbilical Hernia
      •  MAYO HERNIOPLASTY
      •  Vest over pants imbrication of the superior
      • & inferior aponeurotic fascia layer
      •  EPIGASTRIC HERNIA
      •  Protrusion of properitoneal fat & peritoneum
      • through the dicussating fibers of the rectus
      • sheath in the midline (linea alba) between
      • the xiphoid.
    • Ventral HERNIA
      •  Epigastric Hernia
      •  Diastasis Recti
      •  Wide gap between the medial borders of the
      • rectus sheath
      •  Diffuse bulge at upper midline of abdomen
      •  Not a fascial defect, hence repaired for
      • cosmetic purposes
      •  Incisional Hernia
    • Patient Rogelia Tacuban
    • INCISIONAL HERNIOPLASTY
      •  Anatomic reconstruction of the abdominal
      • wall and Includes;
        •  Closure of the parietal defect
        • Restoration of normal intra-abdominal
        • pressure
        • Tendinous reinforcement of the lateral
        • abdominal muscles.
    • Clear View of External O Aponeurosis
    • Separation of the Sac
    • CATTELL REPAIR
    • Ventral HERNIA
      •  Incisional Hernia
      •  2-11% of abdominal wall closure
      •  56% in the first year postoperative
      •  17% incarcerate
      •  20-46% repeat recurrence
      •  Causes:
      • 1. Obesity
      • 2. post-op pulmonary complications
      • 3. Wound infection
    • Visceral HERNIA
      • Incisional Hernia
      • 4. Jaundice
      • 5. Advanced age
      • 6. Abdominal Distention
      • 7. Re-use of previous incision
      • 8. Emergency operation
      • 9. Pregnancy
      • 10. Chemotherapy post-op
    • Ventral HERNIA
      •  Incisional Hernia
      • 11. Steroids
      • 12. Malnutrition
      • 13. Ascites
      • 14. Peritoneal dialysis
      •  Trocar Hernias
      •  < 1% after laparoscopic procedure
      •  Fascial defects > 5mm should be closed
    • Ventral HERNIA
      •  Repair Techniques
      • 1. P rimary repair w/ non-absorbable monofilament
      • sutures; 49-58% failure rate
      •  Mayo repair (fascial imbrication) 54% recur
      • in 5-7 years follow up
      •  “ Far and Near” suturing by Shukla= 0%
      •  Internal retention suturing-2% recur for
      • large ventral hernia
    • Ventral HERNIA
      •  Repair Techniques
      • 2. Mesh onlay- 6% recur
      • 3. Mesh onlay and patch repair= Mesh placed
      • deep to the rectus sheath
      • 4. Sandwich and cuffed mesh repair combined
      • onlay + inlay
      • 5. Stoppa- Giant mesh prosthesis for large >10
      • cm incisional hernia
      • 6. Laparoscopic repair
    • Emergency Abdominal Wall Defect
      •  Difficult abdominal wall closure in:
      •  Massive bowel edema
      •  Tissue loss due to Trauma
      •  Debridement for necrotizing lesions
      •  Resection of tumors
      •  Repair with prosthetics w/ absorbable mesh
      • followed by skin grafting then planned
      • ventral hernia repair
    • Other Abdominal Wall Hernia
      •  SPIGELIAN HERNIA
      •  Ventral hernia occurring along the subumbilical
      • portion of the Spieghel’s Semilunar line &
      • through Spieghel’s Fascia.
      •  Vague pain, mass usually not palpable , intra
      • mural mass located 0-6 cranial to interspinous
      • line (horizontal line between 2 ASIS)
      •  Usual location- just below semicircular line of
      • Douglas; Defect in Transversus Abdominis
    • Other Abdominal Wall Hernia
      •  LUMBAR HERNIA
      •  Congenital spontaneous & traumatic herniation
      • occur through Grynfelts superior & petits
      • inferior lumbar triangle .
      •  Defect in transversalis fascia & Tranversus
      • Abdominis Aponeurosis
      •  Contains retroperitoneal sac or peritoneum
      • lined sac
    • Lumbar Hernia
      •  PETIT’S TRIANGLE is bounded by:
      •  Medial= Latissimus dorsi muscle
      •  Lateral= External oblique muscle
      •  Inferior= Iliac crest
      •  Covered by superficial fascia
      •  GRYNFELT’S TRIANGLE is bounded by:
      •  Superior= 12 th rib
      •  Lateral= Internal oblique abdominal muscle
      •  Medial=Sacrospinalis muscle
      •  Covered by latissimus dorsi
      •  PELVIC HERNIA- occurs in cachetic, elderly
      • patients in the, Obturator fossa, Perineum &
      • Greater and lesser sciatic foramina
      • 1. Obturator Hernia
      •  50% with Howship-Romberg Sign
      • Pain in the region of the hip, and of the knee
      • and on the inner aspect of the thigh because
      • of pressure on the obturator nerve by an
      • obturator hernia.
      Other Abdominal Wall Hernia
      •  Usually in emaciated females in late 70’s on
      • the right side
      •  Often with either large or small bowel
      • incarceration or strangulation
      •  Rarely with a mass at the anteromedial thigh
      • or a bulge on rectal or pelvic examination
      •  Diagnosis by CT scan
      •  Repair by midline approach to take care of
      • bowel problem too.
      Other Abdominal Wall Hernia
      • 2. Perineal Hernia
      •  Occur spontaneously or after APR or
      • pelvic exenteration
      • 1. Anterior- defect in urogenital diaphragm;
      • mass in labia majora
      • 2. Po sterior- defect in the levator ani between
      • the urinary bladder and rectum
      •  Repair= Transperineal or transabdominal
      • primary repair or with mesh
      Other Abdominal Wall Hernia
      • 3. Sciatic Hernia
      •  Rarest of all hernias;
      •  Occurs in the greater or lesser sciatic
      • foramen or thru a defect in the pyriformis
      • muscle
      •  Presents as sciatic nerve palsy and a mass
      • or simply intestinal obstruction
      •  Repair= G luteal or Transabdominal approach
      Other Abdominal Wall Hernia
      •  PARASTOMAL HERNIA
      •  Occurs thru defects adjacent to ostomy site
      •  Incidence: 12-32% paracolostomy
      • < 10% paraileostomy
      •  Prevention: Small fascial incision, avoid
      • maturing thru the abdominal incision
      •  Complications:
      • 1. Obstruction;
      • 2. Incarceration
      • 3. Poor Appliance fit
      • 4. Local pain
      Other Abdominal Wall Hernia
      •  PARASTOMAL HERNIA
      •  Repair: Primary fascial or prosthetic repair
      • or relocation of stoma
      •  Symptoms generally well tolerated
      •  All repairs associated with:
      • 1. significant morbidity
      • 2. high recurrence
      Other Abdominal Wall Hernia
      •  INTERNAL HERNIA
      •  Abdominal contents protrude thru
      • normal or abnormal intra-abdominal
      • orifice
      • 3. Iatrogenic (Post operative)
      • (a) Defect in Mesentery or Omentum
      • Peterson Hernia=thru Roux limb
      •  CONGENITAL ABDOMINAL WALL DEFECTS
      •  Gastroschisis
      • 1. Herniation of abdominal viscera without a
      • sac, intact umbilical cord
      Other Abdominal Wall Hernia
      •  CONGENITAL ABDOMINAL WALL DEFECTS
      •  Omphalocele
      • 1. Herniation of abdominal viscera into the
      • umbilical cord, hence lined by internally
      • by peritoneal sac and externally by
      • amnion
      • 2. Associated anomalies:
      • (a) Cloacal exstrophy
      • (b) Chromosomal abnormality in 50%
      Other Abdominal Wall Hernia
      •  CONGENITAL ABDOMINAL WALL DEFECTS
      •  Gastroschisis
      • 2. Two times (2X) more common than
      • omphalocele
      • 3. Associated anomalies: Intestinal Atresia
      • 10%
      • 4. Eviscerated Bowels are:
      • (a) Edematous
      • (b) Shortened with fibrinous adhesions
      • 5. < 10% mortality
      Other Abdominal Wall Hernia
      •  CONGENITAL DIAPHRAGMATIC HERNIA
      •  Bochdalek Hernia
      • (a) Postero-lateral, most common at costal
      • and spinal diaphragmatic attachment
      • (b) Associated with malrotation, pulmonary
      • hypoplasia
      • (c) 4 x more common in the left side
      • (d) Only 10-20% have a sac; 80% mortality
      • by the first year of life
      Other Abdominal Wall Hernia
      •  CONGENITAL DIAPHRAGMATIC HERNIA
      •  Bochdalek Hernia
      • (e) Better repaired after a few days to
      • weeks when the child stabilizes;
      • higher mortality if repaired at birth
      • (f) Repair: Transabdominal with the Ladd
      • procedure for the malrotation
      •  Morgagni
      • (a) Between sternal & costal diaphragmatic
      • m argin either retrosternal or parasternal
      Other Abdominal Wall Hernia
    • THANK YOU!!!