Umbilical & other abdominal wall Hernia

1. Dr. Shirish Silwal
Paediatric Surgery
Phase B year-1

2. 
Content
 Hernia
 Umbilical Hernia
 Para umbilical hernia
 Incisional Hernia
 Epigastric Hernia
 Spigelian Hernia
 Lumbar Hernia

3. 
Hernia
 Abnormal Protrusion of whole or part of
a viscous through an abnormal opening in the wall of
the cavity in which it is contain .

4. 
 The term ‘HERNIA’ derived from the Greek word
meaning an offshoot or a bulge.
 In Latin the word ‘HERNIA’ means to tear or to
rupture.
 Egyptians (1500 BC), Phoenicians (900 BC) and
Ancient Greeks (400 BC) all describe the diagnosis of
hernia and various methods of treatment.
History

5. 
 In 1987 Dr Irving Lichtenstein published the results
of 6,321 patients followed for 2-14 years after
inguinal hernias repair with Marlex (polypropylene)
mesh.
 Lichtenstein reported a recurrence rate of 0.7 %.
 The technique bearing his name called for a
“tensionless” repair and over time this has become a
pillar of hernia surgery.

6. 
 In 1914, Sir Francis Darwin (the son o f Charles
Darwin) had made the statement that
“In science, the credit goes to the man who convinces
the world, not to the man
to whom the idea first occurs”

7. 
 By the 1960s, Dr Richard Newman had
performed over 1600 inguinal hernia repairs
using polypropylene.
Mayo recommended transverse fascial closure in
1901 and his technique remains most frequently
utilized today.

8. 
Anatomy
Components
Sac
Coverings
Contents

9. 
Different parts of
Hernial sac.
Mouth
Neck
Body
Fundus

10. 
Common
Inguinal
Incisional
Femoral
Umbilical
Epigastric
Rare
Obturator
Spigelian
Gluetal
lumbar
Diaphragmatic

11. 
Umbilical Hernia
 Common disorder in children.
 Most undergo spontaneous closure during the first 3
years of life.
 Umbilical hernias are commonly found in low-birth-
weight infants (75% of infants weighing < 1500 g),
most will resolve.

12. 
 Various theories has been kept forward regarding
the surgical intervention.
 Some theories conclude that even large defects will
spontaneously resolve without operation.
 Typical umbilical hernias should be observed at least
until age 2 yrs. If there is no improvement in the size
of the umbilical fascial ring, consider repair.

13. 
 PRESENTATION:
 May be symptomless.
 It may increase in size during crying which may
cause pain & thus more crying.
 Small hernias are Spherical; Large hernias are
Conical.

14. 
 COMPLICATION:
 Cosmetic disfigurement.
 Intermittent obstruction.
 Strangulation.

15. 

16. 
Operative Procedure
Mayo Repair

17. 

18. 
 Large defect >4cm
 Multiple defect
 Lax abdominal wall
 Recurrent cases
Indication Of Mesh Repair

19. 
PARAUMBILICAL HERNIA
 It is a protrusion through the linea alba just above or
just below umbilicus.
 Local dragging pain by its weight if large.
 Gastrointestinal symptoms due to traction on
stomach and transverse colon.
 Obstruction.
 Strangulation

20. 
MANAGEMENT:
 Reduce weight.
 Mayo technique may be
 used like Umbilical hernia

21. 
UMBLICAL HERNIA PARA-UMBLICAL HERNIA
1 The abdominal contents bulge
out through weak umbilical scar
Herniation through linea alba above
or below the umblicus
2 Umblicus is everted Umblicus becomes cresent shaped
3 The entire fundus of the sac is
covered by the umblicus
Only half of the fundus is covered by
umblicus and the reminder by
adjacent skin
4 May be congenital/acquired Always acquired
5 Ascitis is an important
precipitating factor
Obesity and lax abdominal wall are
factors
6 Neck of the sac is wide Neck of the sac is narrow
7 Congenital type can wait upto 4
years for spontaneous closure
Always needs surgery

22. 
 Incisional hernia as a diffuse extrusion of
peritoneum and abdominal contents through a weak
scar of an operation or accidental wound.
 Common complication following abdominal
surgeries. 11% of laparotomies and rises to 26%
complicated with wound infection.
Incisional Hernia

23. 
Incisional Hernia
Why it happens?
• Peritonitis
• Visceral Cancer/ascites
• Colostomy
•Incision
•Low midline/
Subcostal
•Drain/Stoma
•Wound Protection
•Suturing Technique
• Obesity
• Diabetes
• Renal Failure
• Anaemia and
Hypoproteinemia
• Post Operative
Chest Infection
Patient
Factor
Surgeon’s
Factor
Disease
Factor

24. 
 PRESENTATION
 Asymptomatic bulge noticed by the patient
 Feeling of heaviness , pain or discomfort in the
abdomen
 Constipation

25. 
 Open procedure (with Abdominoplasty)
 Anatomical Repair
 Component Separation technique
 Mesh repair
 Laparoscopic repair
 Mesh repair
MESH IS MUST
How to manage Incisional hernia?

26. 
 Low recurrence rate
 Inguinal hernia repair
 Lichtenstein’s Mesh repair: <1%
 Ventral hernia
 Suture Vs Mesh: 50% Vs 10%
 Tension free & Pain free
 Quick recovery
 Quick to learn and easy to do!
Why Mesh ?

27. 
Where to place the
Mesh?On Lay In Lay
SubLay IPOM

28. 

29. 
Epigastric hernia
 It is the fatty herniation
through linea alba
between the
xiphisternum and
umbilicus.

30. 
 Epigastric hernias were initially labeled as such in
1812 by Leveille .
 They occur through the opening for the para-midline
nerves and vessels
 It usually sacless, with only the pre-peritoneal fat content.
 The mouth of the hernia is rarely large to permit a
portion of hollow viscus to enter it

31. 
Management
 Epigastric hernias are repaired when they are prom-
inent or when they are symptomatic.
 It is important to mark the location of the defect
before anaesthesia, because in the recumbent
position they are often impossible to palpate along
the widened linea alba

32. 

33. 
 It is a rare variety of hernia occurring at the level of
arcuate line.
 Spigelian hernia (SH) is a ventral hernia that occurs
through slit-like defects in the anterior abdominal
wall adjacent to the semilunar line.
Spigelian hernia

34. 
 Adriaan van der Spieghel, he only described the
semilunar line (linea Spigeli) in 1645.
 Josef Klinkosch in 1764 first defined the spigelian
hernia as a defect in the semilunar line.
 Pain in the area with a feeling of fullness or an actual
mass are the most common symptoms.

35. 
 Defects in the aponeurosis of transverse abdominal
muscle (mainly under the arcuate line and more
often in obese individuals) have been considered as
the principal etiologic factor.
 It easily gets strangulated.

36. 
 Medially by rectus abdominus
 Laterally by internal and
External oblique
 Superiorly by linea semilunaris
spigelian triangle

37. 

38. 
 Repair consists of a transverse incision over the
defect with excision of the sac and closure of the
defect.
 Frequently, the sac is found below the external
oblique muscle and may require mesh if the defect is
large.
 A tension-free closure is important to prevent
recurrence.
Management

39. 
 The first case was reported by Garangoet in 1731.
 Petit and Grynfelt delineated the boundaries of the
superior and the inferior triangles, named after them
respectively, in 1783 and 1866
Lumbar Hernia

40. 
 Rare type of hernia. Over the last four centuries
about 300 cases of primary lumbar hernias have been
reported making it the rarest form of abdominal wall
hernias.
 Content is usually properitoneal fat .

41. 
 PRESENTATION
 Common in males
 Low back ache or a specific point of pain over the
region of the hernia.
 A palpatory finding of a swelling with cough
impulse that reduces in prone position clinches the
diagnosis.

42. 
Types of lumbar hernia

43. 
 Absorbable mesh is Prefered in the growing child
that will not cause scoliosis later.

44. 
 ASHCRAFT’S PEDIATRIC SURGERY
 Paediatric surgery Arnold G. Coran, MD
 Paediatric surgery P. Puri · M. E. Höllwarth (Eds.)
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2699222/
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3992605/
 http://shodhganga.inflibnet.ac.in/bitstream/10603/48842/6/06_chapter
%201.pdf
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4818285/
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4336063/
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3066721/
 http://www.ijsurgery.com/index.php/isj/article/viewFile/112/112
 http://case.edu/medicine/uhsurgery/media/school-of-medicine/uh-
surgery/documents/pdfs/journal-club-articles/2015/october/Holihan-
2015.-Mesh-location-in-open-VHR_-systematic-review-and-network-meta-
analysis.pdf
Reference

45. 
Thank You