Abdominal hernia .

1. MODS
Surgery 3

2. 72 year old female, known case of
k/c/o HTN and T2DM presented with
c/c of multiple swelling in the lower abdomen
since 6 years
Pain in the swelling region since 5 days

3. HOPI
• The patient was apparently well 6 years back when she
developed a Swelling in lower abdomen at the site of
hysterectomy scar,
• Non compliant to abdominal binder 1 year post surgery.
• Swelling first appeared on left side and then on right. Initially
asymptomatic but since last 5 days the size of the swelling
increased in size and becomes prominent on standing and
walking and doesn’t reduce automatically She feels a dragging
pain over the swelling which is insidious,intermittent,
progressive, non radiating.
• The pain is aggravated on climbing stairs and doing strenuous
work and partially relieved on lying down

4. • H/o chronic constipation
H/o decreased appetite since 2 weeks
H/o disturbed sleep I/v/o pain from the swelling
• H/o abdominal distension present since 5 days
• No vomiting, loose stools, fever, orthopnoea,
PND,chronic cough,ascitis

5. • The postoperative period after hysterectomy
was eventful.The surgical wound was infected
,it took long time to heal

6. PAST HISTORY
• Total abdominal hysterectomy done in 2019
for endometrial cancer
• HTN since 7 years

7. PERSONAL HISTORY
• Mixed diet
• Altered sleep
• No substance abuse
• Bowel and bladder habits normal
• Family history :
• Medication history : antihypertensive(amlodipine
5 mg+ metoprolol 25 mg) since 7 years
• Allergy history: NAD

8. General physical examination
• The patient is conscious, coherent and well oriented to
time, place and person
Moderately built and nourished
• Afebrile
• PR- 80 bpm
• BP- 130/80 mm hg measured in right arm supine
position
• RR- 18/ min
• Sp02- 96% on room air
• No pallor, icterus, cyanosis , clubbing , edema or
generalised lymphadenopathy

9. • Per abdomen-Soft, slightly distended
Tenderness on the right quadrant(right hypochondrium
region)
Guarding present,no rigidity
• On percussion – dull note over the swelling
On auscultation: decreased bowel sounds present
• soft ,multiple swelling noted:
• Swelling 6x7cm on right hypochondriac region, irreducible,
irregular shape, No skin changes, cough impulse negative.
Swelling 3x3 cm on left hypochondriac region, reducible,
irregular, no skin changes, cough impulse present.
Hysterectomy Scar around 10cm long.

10. P/A examination-
• Inspection
– Abdomen- soft ,moderately distended horizontal
healed hysterectomy scar about 10cms in the
suprapubic region ,multiple swelling as described :
• Swelling 6*7 cms in the right hypochondrium
irreducible in size,irregular borders,no skin
changes,visible cough impulse negative
• Swelling 3*3.5 cms on left hypochondrium,irreducible
in size, irregular in borders, ovoid shaped,no skin
changes,visible cough impulse present.

11. – On palpation
• The local temperature not raised and tenderness noted over
the swelling
• The swellings are of same dimension as noted on
inspection.margins are diffused for the left side swelling and
regular for right sided swelling
• Expansive cough impulse is felt
• Left sided swelling is irreducible with negative cough impulse
test ,while right sided swelling is partially reducible with
positive cough impulse
• Divarication of recti is also noticed
• On percussion – dull note over the swelling
On auscultation: decreased bowel sounds present

12. Other systems
• CVS– s1,s2 present,no added sounds
• CNS-
– All higher mental function intact
– No focal neurological deficit
• RS-
– B/L NVBS present
– No adventitious sound heard

13. DIFFERENTIAL DIAGNOSIS
• This is a case of incisional hernia with multiple
defects through lower abdominal pfannenstiel
incision,partially
reducible,uncomplicated,containing bowel
most probably Swiss cheese defect

14. Investigations on admissions

15. 02/09/2022 - Bact:24.10 /hpf;Hy. Cast:0.00 /hpf;Mucus:0.02 ;Path. Cast:0.00 /hpf;URINE
SUGAR:4+ (2000 mg/dl) ;URINE PROTEIN:TRACE (15 mg/dl) ;URINE KETONES:Negative
mg/dl;URINE NITRITE:NEGATIVE ;URINE BILE PIGMENT:NEGATIVE ;URINE
BLOOD:Negative ;CAST:0.00 /hpf;COLOUR:STRAW ;CRYSTALS:0.00 /hpf;Ep.Cells:1.00
/hpf;URINE LEUCOCYTE:Negative ;URINE pH:5.5 ;RBC:1.70 /hpf;URINE SPECIFIC
GRAVITY:1.023 ;URINE UROBILINOGEN:Negative ;WBC:2.30 /hpf;YEAST CELL:0.00 /hpf;
02/09/2022 –
ABSOLUTE EOSINOPHIL COUNT:0.09 x 10³/µL
ABSOLUTE LYMPHOCYTE COUNT:2.89 x 10³/µL ;
ABSOLUTE NEUTROPHIL COUNT:5.86 x 10³/µL
BASOPHIL:0.5 %
EOSINOPHIL:0.9 %
HAEMOGLOBIN:13.4 g/dL
HAEMATOCRIT:40.2 %
LYMPHOCYTE:30.4 %
MCH:25.2 pg
MCHC:33.4 g/dL
MCV:75.5 fl
MONOCYTE:6.5 %
MPV:7.0 fL
NEUTROPHIL:61.7 %
PCT:0.204 %
PDW:16.3 %
PLATELET COUNT :292.0 x 10³/µL
RBC COUNT:5.33 x 10^6/µL
RDW:13.8 %
TOTAL WBC:9.5 x 10³/µL;
02/09/2022 - Hepatitis B Surface Antigen:Non-Reactive ;Antibodies to Hepatitis C Virus:Non-
Reactive ;Antibodies to HIV :Non-Reactive ;
03/09/2022 - CHLORIDE (Serum):101.0 mmol/L;GLUCOSE FASTING (Plasma):187
mg/dL;POTASSIUM (Serum):4.3 mmol/L;SODIUM (Serum):136.0 mmol/L;

16. 02/09/2022 –
ALANINE TRANSAMINASE (ALT) (Serum):28.7 IU/L;
ALBUMIN (Serum):4.54 g/dL;
ALKALINE PHOSPHATASE (ALP)(Serum):126 U/L;
ASPARTATE TRANSAMINASE (AST) (Serum):40 IU/L;
DIRECT BILIRUBIN (Serum):0.14mg/dL;
TOTALBILIRUBIN(Serum):0.38mg/dL
;CREATININE (Serum):0.85 mg/dL;
GLOBULIN:3.30 g/dL;
GLUCOSE RANDOM (Plasma):249 mg/dL;
POTASSIUM (Serum):4.7 mmol/L
;TOTAL PROTEIN (Serum):7.87 g/dL;
SODIUM (Serum):135.4 mmol/L;
UREA (Serum):31 mg/dL;
HbA1C (Whole Blood):13.40 %;

17. CECT Abdomen and pelvis

21. Surgery
• The patient was planned for incisional hernia
repair i/v/o impending obstruction 4/9/2022

22. Intraop findings
• Multiple defects identified transversely
– Largest with 7cm on anterolateral side with
caecum as content,another on left anterolateral
side with small bowel as content
– 4 small defects with omentum as content of
anterior abdominal wall
• 30 * 15 cms polypropylene mesh placed onlay
with 4 drains placed in situ 2 on either side

24. • Post op status POD -0
– NPO
– IVF DNS/RL @100ml/hr
– INJ VIATRAN 1.5 gm q12h
– RT insitu
– AG-88 cms
– Right DT –20 ml
– Left DT-100ml

25. POD 0 POD 1 POD 2 POD 3 PO
Stable
98% on RA
Stable
98% on RA
Stable
97% on RA
Stable
97% on RA
Sta
97%
PUT
PUT
RIGHT SIDE-100ML
LEFT SIDE -20 ML
1565/1150 ML
LEFT DT-50 ML
RIGHT DT-63 ML
CATHETER OUT
153 ML
RT OUT
1950/1600ML
LEFT DT-30 ML
RIGHT DT-70 ML
800/1900ML
RIGHT DT- 8ML
LEFT DT-70 ML
RIGH
LEFT
NPO NPO ORAL SIPS
-> LIQUID
DIET
SOFT DIET
->DIABETIC
LOW SALT
DIET
DIA
LOW
DIE
ATION Confined Confined Restricted
mobility
Dependent
mobility
Dep
mo
OTICS AND
MEDICATIONS
IV VIATRAN
IV
ANALGESICS
IV CLEXANE
IV VIATRAN
INCENTIVE SPIRO Q2h
IV ANALGESICS
IV CLEXANE
IV VIATRAN
IV
ANALGESICS
IV CLEXANE
IV VIATRAN
IV
ANALGESICS
IV CLEXANE
IV V
OR
AN
IV C

26. POD 5 POD 6 POD 7 POD 8
VITALS
SPO2
Stable
97% on RA
Stable
98% on RA
Stable
97% on RA
I/O
DT OUTPUT
Left DT-34 ml
Right DT- 10 ml
Left DT-20ml
Right DT-15 ml
Left DT OUT
Right DT-32 ml
Feeds Diabetic
Diet
Diabetic
Diet
Diabetic
diet
Discharged
AMBULATION Dependent
Mobility
Dependent
Mobility
Independent
Mobility

27. Follow up visit
• Suture site healthy.
• Right DT was removed on 12.9.2022
• sutures removed at local hospital on
17.9.2022

28. • An incisional hernia is defined as any abdominal
gap with or without a bulge in the area of post
operative scar perceptible or palpable by clinical
examination or imaging
• Incisional hernia develop in early post op period
but can present as late as 10 years after surgery.
• Incisional hernia occurs in 10-15% of the patient
with prior abdominal wall incision.
• Delayed presentation may be due to expansion of
one or more previously undetected small hernia.

29. • It can develop from any type of incision
including midline, Paramedian, subcoastal,
mcburny, pfannensteil and flank incisions.
• Midline incisions have highest incidence of
incisional hernias (3-20)%
• Vertical incisions have higher risk for hernia
than transverse ,oblique or
• upper abdominal incision are more
susceptible than lower abdominal incision

30. • The incidence of incisional hernias after
gynecological surgery is not as well studied as
that for gynecological surgery.
• Since gynaecologists rarely operate incisional
hernia and they may develop several years
after primary procedure there is little
awareness of this problem

31. Etiology
• Incisional hernia may result from breakdown
of fascial closure.Multifactorial mechanisms
with contributions from patients and technical
factors:
– Patient factors: old
age,obesity,malnutrition,connective tissue
disorder,immunosuppressive therapy
– Technical factors- wound infections,suboptimal
wound closure,fascial dehiscence,types of abd. Sx

32. Diagnosis
• Clinical examination
– The abdominal wall should be examined along the
length of all incisions since multiple adjacent
hernias separated by narrow bands of intact
fascia(Swiss cheese pattern) type of hernias can
be present.
– Large /complex hernia can contain a significant
amount of small/ large bowel outside of
abdominal cavity which is called loss of domain

33. • Preoperative CT is recommended for complex
ventral hernia defined by a large size (>10 cm
in width) and/or significant loss of domain (>
20 to 30% of the viscera residing outside the
abdominal cavity in the hernia sac .
• Pre op CT SCAN define hernia morphology
contents ,the quality of abdominal
musculature and any associated conditions
that could complicate the repair(e.g fistula)

34. • By knowing the precise location and size of the
hernia ,surgeons can better asses the potential
scale of the repair operations I.e
– Simple repair
– Component separation
– Abdominal wall reconstruction
• The radiographic relationship between the hernia
sac and the residual abdominopelvic cavity
volume is a good indication of the degree of loss
of domain

35. Surgical repairs for incisional hernia
• Open approach
– Mayo’s techniques
– Muscle pedicle flap repair
– Lattice or darning
– Keel operation
• Component separation techniques
• TAR procedure