5. It refers to the herniation of abdominal
contents through the umblical defect.
The umbilical defect is present at birth
but closes as the stump of the
umbilical cord heals, usually within a
week of birth.
This process may be delayed, leading
to the development of herniation in the
neonatal period.
The umbilical ring may also stretch
and reopen in adult life.
6. IN CHILDREN
INCIDENCE:
Boys = Girls
Black infants (8x) > White
10% of infants, having higher incidence in premature
babies.
Hernia appears within a few weeks of birth.
CLINICAL FEATURES:
It is usually Symptomless.
Increases in size on crying.
It has Classical conical shape.
Obstruction/strangulation are extremely uncommon in
<3 years of age.
7. TREATMENT:
Conservative: Most of the hernia close
spontaneously without any treatment within
two years of age. So the methods are:
masterly inactivity, reassure parents and
strapping over a coin.
Operative: Herniorrhaphy is indicated when
the hernia is still present after 2 years of age.
8. IN ADULTS
In adults it is called Paraumblical Hernia as
the defect is not through the true umblicus.
Reopening of umbilical defect caused by
conditions that cause thinning and
stretching of midline raphe (linea alba)
Repeated pregnancies weaken the
abdominal wall
Obesity causes flabby abdominal muscle
Ascites, especially in cirrhotic patients
9. ON EXAMINATION:
Round swelling with well defined fibrous
margin.
Contents:
Small umbilical hernia often contain
extraperitoneal fat or omentum.
Larger hernia contain small or large bowel.
Very large hernia have narrow neck of the
sac and prone to become irreducible,
obstructed and strangulated (unlike
children).
10. Clinical features:
Swelling in the umbilical region - increase
on coughing/straining
Expensile cough impulse is present
Patient may also have inguinal hernia
Reducibility can be present
Crescent-shaped appearance of the
umbilicus
Patient complaint of pain due to tissue
tension, and symptom of intermittent bowel
obstruction.
Dermatitis in case of large hernia (due to
thinned & stretched of overlying skin)
11. TREATMENT:
• Reduce weight of the patient
• Treat the underlying cause.
• Surgical treatment Open or Laproscopic.
12. SURGICAL PROCEDURES:
Very small defects < 1 cm
Closed with a simple figure-of-eight suture.
OR
Repaired by darn technique
Defects up to 2 cm
Sutured primarily with minimal tension.
(Herniorrhaphy)
OR
Classical repair by Mayo
Defects > 2 cm
Mesh repair is the treatment of choice
13. Mesh is placed in one of the several anatomical
planes
(A) Onlay - mesh is placed anterior to the anterior
rectus sheath.
(B) Sublay - mesh is placed immediately above the
posterior rectus sheath.
(C) Intraperitoneal - mesh is placed directly beneath
the peritoneum as the final layer of the abdominal
wall.
Hernia Repair can also be done Laproscopically
15. It occurs in the linea alba anywhere
between the xiphoid process and the
umbilicus.
Its called “Fatty hernia of linea alba” as it
usually contains extra peritoneal fat.
When enlarges drags a pouch of
peritoneum and becomes a true
epigasric hernia.
Etiology: Sudden strain leading to tearing
of interlacing fibres of the linea alba.
Usually occurs in Males of age 25 to 40
years.
16. CLINICAL FEATURES:
Symptomless in most of the cases.
Painful- if partial strangulation of fat occurs.
It may mimic pain of PUD.
ON EXAMINATION:
Less likely to be reducible.
Maybe locally tender.
Cough impulse may or may not be felt.
It may be more than one at a time.
17. TREATMENT:
Conservative treatment – if very small
hernia or symptomless
If sufficiently symptomatic – Open surgery.
Anatomic repair.
Mesh repair.
• Recurrence: May be due to failure to
identify a second defect at the time of
original repair.
19. It is diffuse extension of peritoneum and abdominal
contents through a weak abdominal scar (scar of
previous surgery).
CAUSES:
Obesity
Advanced age
Coughing, vomiting, straining
Steroids and chemotherapy
Multiparity.
Poor metabolic state of patient.
Causes that increase intraabdominal pressure.
Inapropriate suture material
Poor closure technique
Incision
Emergency procedures.
20. CLINICAL FEATURES:
Pain and swelling in the vicinity of previous
scar
Obstruction of contents is common but
strangulation is rare
Attacks of subacute intestinal obstruction. –
abdominal colic, vomiting, constipation and
distension of abdomen
On Examiation:
Often multiple defects within same scar
Reducibility may be complete or partial
Expansile impulse on cough
Skin over the hernia is thin and atrophic
21. TREATMENT:
Preventive measures:
Reduction of weight in obese before elective procedures
Treat any respiratory diseases
Very careful closure of abdomen
Prevent Post op wound infection
Conservative approach:
Symptomless hernia with no signs of pain or obstruction.
Operative Treatment:
The indications are:
Symptomatic hernia which is showing signs of increasing in
size
Large hernia with a small defect
Subacute intestinal obstruction
Irreducibility and
Strangulation
22. Mesh repair: is always better and ideal
choice of treatment with less chances
of recurrence.
Sublay or Intraperitoneal onlay mesh
IPOM aare preferable
Anatomical repair and Keel’s
operation are not usually used
23. SPIGELIAN HERNIA
Herniation through the
defect in spigelian fascia.
Spigelian fascia is the
aponeurosis of transversus
abdominis muscle
Its almost above the
arcuate line
Most common site is below
the level of umblicus, near
the edge of rectus sheath,
at the junction of spigelian
line (linea semilunaris) and
arcuate line (linea
semicircularis)
24. CLINICAL FEATURES:
Soft, reducible mass lateral to the rectus
muscle and below the umbilicus
Cough impulse present.
Strangulation is common
Common in females after 50 years of age.
TREATMENT:
High risk of complications due to narrow
neck
Primary Repair or Mesh repair
25. LUMBER HERNIA
It refers to the herniation through the Lumber triangle.
Three types of lumber hernia :
Incisional Lumber Hernia - Most common cause
Superior Lumber Hernia – From superior lumber triangle
bounded by:
12th rib superiorly
Post border of internal oblique laterally
Sacrospinalis muscle medially
Inferior Lumber Hernia – from inferior lumber triangle
bounded by:
Iliac crest inferiorly
Laterally external oblique
Latissimus dorsi medially
MC site for primary lumber hernia
26.
27. DIFFERENTIAL DIAGNOSIS:
Lipoma
Paravertebral cold abscess
Phantom hernia
CLINICAL FEATURES:
Focal pain associated with movement over the
site of the defect
Vague dullness in the flank or lower back
Hernia tends to increase in size over time
ON EXAMINATION:
Swelling in the lower posterior abdomen
Reducible without much difficulty
28. TREATMENT:
Small defects – primary repair
Large defects – prosthetic mesh repair
Retromuscular sublay mesh repair is the
preferred procedure for lumber hernia.
