ventral hernia management

1. Ventral Hernia Management
DR MANJIL MALLA
1ST YEAR RESIDENT.,GENERAL SURGERY
PAHS

2. Anatomy of anterior abdominal wall

4. Ventral Hernia
 Any protrusion of viscera through anterior abdominal
wall
 Categorized as spontaneous and acquired
 Spontaneous hernia:
 Umbilical and paraumbilical-71 %
 Epigatric-25%
 Others-4%

5.  Acquired Hernia
 Incisional
o Laparotomy 89%
o Laparoscopy 5%
 Parastomal 6%

6. Classification
European hernia society

7. Incisional Hernia

9. Umbilical Hernia:
 Umbilical hernia occurs when the umbilical
scar closes incompletely in the child or fails
and stretches in later years in the adult
patient
 In infants
 Congenital and common
 Closes spontaneously by 2 years of age
 If persist after 5 years –surgical repair

10.  In adults
 Largely acquired
 Female>male
 hernia does not protrude through umbilical cicatrix
 protrusion through the linea alba just above the
the umbilicus -supraumbilical
 occasionally below the umbilicus (infraumbilical) –
so called as paraumbilical hernia

11. Etiology
 multifactorial, commonly found in association with
processes that increase intraabdominal pressure
 pregnancy
 obesity
 ascites
 persistent or repetitive abdominal distention in
bowel obstruction or peritoneal dialysis

12. Clinical Features
 Pain and swelling are the main symptoms
 Pain increases on prolonged standing or heavy
exercise
 Content: mostly omentum

13. Treatment
 Reduce weight of the patient
 Treat the cause of ascites
 Mayo’s operation – vest over pants repair :
imbrication of superior and inferior fascial edges
 For smaller defects – open umbilical hernia repair
 For larger defects - >2 cm – mesh repair – open
or laparoscopic

14. Epigastric Hernia :
 Hernia protruding through interlacing fibres of the linea
alba anywhere between umbilicus and xiphisternum
 protrusion of extraperitoneal fat - fatty hernia of linea alba
 Multiple in up to 20% of patients and approximately 80%
are in midline

15. Etiology:
Sudden strain leading to tearing of interlacing
fibers of linea alba
Clinical Features:
 Symptomless
 Painful- in partial strangulation of fat
 Referred dyspepsia
 On palpation – feels firm, no cough impulse and
cannot be reduced

16. Treatment:
 Midline defect is usually elliptical in nature with the
long axis oriented transversely
 Hernia will often not be seen on laparoscopy owing
to the lack of peritoneal involvement through the
hernia defect
 Open repair – excision of incarcerated preperitoneal
tissue and simple closure of defect

17. Incisional Hernia
 It is herniation through a weak abdominal scar (scar of
previous surgery)
 Etiology:
 Factors related to patients:
1. Obesity – due to fat encroaching in between the muscle layers
2. Advanced age
3. Multiparity,malnutrition,peritoneal
dialysis,jaundice,hypoproteinemia,anaemia, malignant diseases
4. Coughing,vomting and overzealous ventilation in early postoperative
period
5. Steroids and chemotherapy

18. 6.Smoking in postoperative period.
7.Causes which increases the intra-abdominal pressure(BPH, straining,
stricture urethra or rectum, ascites)
 Factors related to procedure:
o Vertical incision higher chances of incisional hernia than horizontal
incision
o Layered closure of the abdomen has got higher chance than single
layer
o Continuous closure has got higher chances than interrupted closure

19. o Using absorbable suture material
o Emergency surgical wound has higher chances than elective
surgical wound
o Laparotomy wound

20. Clinical Features:
 Pain and swelling in the vicinity of previous scar
 Bulging more prominent on standing and coughing,reduces
spontaneously on lying down
 Attacks of subacute intestinal obstruction
 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- chr.bronchitis
 Very careful closure of abdomen
 Single layer closure 5-8mm
 5mm apart
 2-0 suture
 4:1 suture length
 All precautions to prevent immediate postoperative wound
infection should be taken

22. Operative treatment:
 Primary repair
 Defect small <2cm
 Viable surrounding tissue
 As a result of technical error in initial operation
 Prosthetic repair
 Larger defect >2 to 3cm

23. Mesh placement options:
 Onlay technique: after primary
closure of the fascial defect
mesh is placed over the
anterior fascia
 Advantages: no direct contact
with viscera
 Disadvantages:
 More chances of seroma
formation
 superficial location of mesh-
more prone for infection

24.  Inlay technique: interposition of prosthetic mesh
between the fascial edges.
 Very high recurrence rates
 Sublay/ underlay technique:prosthetic mesh placed
below the fascial components

25.  Retromuscular technique:
 also called as Rives-Stoppa-Wantz Retrorectus Repair
 placement of mesh under the rectus muscle & above the
posterior rectus sheath
 Advantage
 intraabdominal forces hold the prosthesis against the muscles.
 Forces that created the hernia now are used to prevent its
recurrence

26. Component separation technique
skin and subcutaneous fat dissected
free
from the anterior sheath of the
rectus abdominis muscle and the
aponeurosis of the external oblique
muscle.
external abdominal oblique is
incised 1 to 2 cm lateral to the
rectus abdominis muscle.

27. • external oblique separated
from the internal oblique
Dissection carried to posterior
axillary wall
Additional length can be achieved by incising post rectus sheath
above the arcuate line

28. Laproscopic surgical repair
 IPOM(intraperitoneal onlay mesh)
 IPOM plus:
 defect >2cm
 6 to 10 cm difficult to close
 >10 cm: laproscopic TAR or Robotic TAR

29. Lap vs open
 Whenever feasible laproscopic repair is preferred.

30. Advantages of LAP
 Lower rate of wound infection
 Shorter hospital stay
 Quicker return to work
 Presence of swiss cheese defect can be seen

31. Disadvantages
 Higher operating cost
 Expertise needed
 More serious complication

32. Parastomal hernia
 Common complication after stoma creation
 Incidence highest in colostomies-50%
 Usually asymptomatic
 Complications like bowel obstruction and
strangulation rare
Treatment :
 Primary fascial repair-recurrence
 Stoma relocation
 Prosthetic repair

33. Spigelian hernia
 Unusual hernia
 Occurs through the
Spigelian fascia –composed
of aponeurotic layer
between rectus muscle
medially and semilunar line
laterally
 Often interparietal

34. Clinical features:
 more common in 4th to 7th decade
 small swelling lateral to rectus muscle- above level of
umbilicus(10%),below umbilicus(90%)
 sharp pain or tenderness at this site
 ultrasound abdomen and CT scan are useful to
establish the diagnosis
 Complications: high risk of incarceration due to
narrow neck
 Treatment: Primary Repair or Mesh repair

35.  References:
 sabiston textbook of surgery,south asia edition
 Schwartz’s principles of surgery,10th edition

36. THANK YOU