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ventral hernias
This document discusses various types of ventral hernias. It defines ventral hernias as hernias that occur in the abdominal wall. It then provides details on the anatomy of the abdominal wall and the pathophysiology of hernia formation. Several specific types of ventral hernias are described including epigastric, umbilical, incisional, lumbar, and parastomal hernias. For each type, the document outlines characteristics, clinical presentation, complications, and treatment approaches. Surgical repair is generally recommended, and mesh placement is often used to reinforce repairs.
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ventral hernias
- 2. VENTRAL HERNIASVENTRAL HERNIAS BYBY DR’ARSHAD TMO SURGICAL B WARDDR’ ARSHAD TMO SURGICAL B WARD SAIDU GROUP OF TEACHING HOSPITAlSAIDU GROUP OF TEACHING HOSPITAl SWATSWAT
- 3. Anatomy of Abdominalwall The abdominal wall is made up of skin, superficial fascia, deep fascia, muscles, extra peritoneal fascia, and parietal peritoneum.
- 4. Hernia “Abnormal Protrusionof whole or part of a viscous through an abnormal opening in the wall of the cavity in which it is contain”.
- 5. Pathophysiology of hernia formation A normal abdominal wall has sufficient strength to resist high abdominal pressure and prevent hernia formation Causes are: 1. Basic design weakness 2. Weakness due to structure entering and leaving the abdomen 3. Develpmental failure 4. Genetic weakness of the collagen 5. Truma/surgery 6. Weakness due to ageing and pregnancy 7. Neurological and muscle diseases 8. Excessive intra-abdominal pressure 9. smoking
- 6. Pathophysiology of hernia formation Currentviews: Histological evidence and relationships between hernia and other diseases related to collagen proves that it is a “collagen disease”. It has been shown that hernia is no more common in Olympic weight lifters than the general population, suggesting that high pressure is not a major factor in causing hernia. A recent Studies shows that hernia risk is being negatively related to body mass index (BMI), contrary to widespread belief.
- 7. Clinical history inhernia case Patient are usually aware of a lump Self diagnosis is common Usually painless, sometime itching and heavy feeling Sharp intermittent pain suggest pinching of tissue Severe pain should alert the surgeon It is important to know whether it is primary or recurrent, recurrent are more difficult to treat Ask about respiratory symptoms, urinary and bowel habits.
- 8. Check for: Reducibility Cough impulse tenderness, temperature Overlying skin colour changes Multiple defects/ contralateral side Signs of previous repair Associated pathology in respiratory, urinary, GIT, muscular and nevous systems
- 9. Investigations for hernia ØFor most hernia no specific investigation is required, diagnosis made clinically Ø Chest X-ray (hiatus and diaphragmatic hernia) Ø Ultrasound (where the nature of the content in doubt and post operatively to differentiate between early recurrence and collection) Ø CT (In complex incisional hernia to look for number, size of defects , contents, adhesions and excluding other intra-abdominal pathology. Ø CT angiogram (for occult sac) Ø MRI (sportsman groin, whether pain is due to occult hernia or orthopaedic injury)
- 10. Not allhernias require surgical repair The surgeon should recommend repair when complications are likely the most worrying being , strangulation with bowel obstruction and bowel infarction Any case of irreducible hernia especially when there is pain and tenderness should be offered repair unless coexisting medical factors place the patient at very high risk from surgery or anaesthesia Increasing difficulty in reduction and increase in size are indication for surgery Surgery should be offered to younger adult patient as symptoms and complication are likely over time. In elderly if the hernia is asymptomatic, small in size, can be reduced easily and is not causing anxiety then observation alone should be sufficient. Truss can be used to control a hernia but few surgeons would recommend this approach. Management principles of hernia
- 11. Operative approaches tohernia Reduction of content into abdominal cavity with the removal of any nonviable tissue and bowel repair if necessary Excision and closure of a peritoneal sac if present or replacing it deep to the muscle Re-approximation of the walls of the neck of the hernia if possible Permanent reinforcement of the abdominal wall defect with suture or mesh
- 12. Types of ventralhernias: 1) Epigastric hernia 2) Umblical hernia 3) Paraumblical hernia 4) Spigelian hernia 5) Incisional hernia 6) Parastomal hernia 7) Lumbar hernia 8) Traumatic hernia 9) 10)
- 13. Epigastric hernia Anywherebetween the xiphoid process and the umbilicus, usually midway. Usually less than 1cm
- 14. Ø Protrusion ofextraperitoneal fat through the linea alba- site where small blood vessels pierced the linea alba. Ø More likely that the defect occurs as a result of a weakened linea alba due to abnormal decussation of the fibres of the aponeurosis. Ø A swelling the size of a pea(<1cm) -protrusion of extraperitoneal fat only Ø Ø Ø
- 15. Enlarges, itdrags a pouch of peritoneum after it The mouth of the hernia is rarely large to permit a portion of hollow viscus to enter it. It is likely that an epigastric hernia is the direct result of a sudden strain, tearing the interlacing fibres of the linea alba.
- 16. Clinical presentation Oftenin fit, healthy male between 25 and 40 years of age. May be very painful even if pea size due to narrow neck Can be felt easily than it can be seen. Cough impulse may or may not be positive. Mainly clinically Diagnosis
- 17. Treatment q conservative: Verysmall – disappear(infarction) Small to moderate - If the hernia is giving rise to symptoms, operation should be undertaken. Ø
- 18. Operation (open orlap) Ø Ø The protruding extraperitoneal fat is cleared from the hernial orifice by gauze dissection. Ø After ligating the pedicle, the small opening in the linea alba is closed with non-absorbable sutures in adults and with absorbable sutures in children. Ø Ø
- 19. Ø When ahernial sac is present, it is opened and any contents reduced, after which the sac neck is transfixed and the sac excised before repairing the linea alba. Ø If the hernia is large (defect greater than 4 cm diameter), the repair should be reinforced with polypropylene mesh positioned in the retro-muscular plane. TYPES OF MESH 1) synthetic mesh 2) biological mesh 3) absorbable mesh 4) tissue separating mesh Ø
- 20. Umbilical hernia Commondisorder 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.
- 21. Presentation Ø May besymptomless. Ø Bulge typically slightly to one side of the umbilicus. Ø In children It may increase in size during crying which may cause pain & thus more crying. Ø Skin changes may be seen in larger hernias. Ø Small hernias are Spherical, Large hernias are Conical. Ø Obstruction and strangulation is uncommon below the age of three years.
- 22. COMPLICATIONS: ü Cosmeticdisfigurement ü Intermittent obstruction. ü Strangulation. ü Related to skin ü ü
- 23. TREATMENT Principles 1. Tension freerepair 2. Studies have shown that although primary repair remains a popular choice, but mesh is superior in terms of reduce recurrence 3. Primary repair only for only <3cm defects Ø Conservative treatment is indicated under the age of two years when the hernia is symptomless. Ø 95% will resolve spontaneously. Ø Spontaneous closure after 2 years is unlikely.
- 24. Surgical treatment Lessthan 1cm, closed with simple figure of eight or darn with non-absorbable suture. Up to 2cm, then mayo repair (double breasted). Crdiff repair Larger than 2cm, then mesh repair is recommended which can be placed in different planes in the abdominal wall. 1)
- 25. Para umbilical hernia ØIn adults most hernias in the umbilical region occurs above (common) or below the umbilicus, result from weakness in the linea alba, rather than directly through the umbilicus. Ø Are more common in women than in men by a factor of five fold. Ø They rarely occur in children and are most common in adults between 35 and 50 years. Ø Often, the hernial sac has multiple loculations containing omentum and occasionally small and large bowel.
- 26. The hernialneck is narrow compared to the size of the fundus predisposing to incarceration and strangulation. Treatment Strangulated hernia should be repaired as an emergency Long standing hernia is repaired electively If small can be repaired quite easily Repairing a large PUH Difficult because: 1) The viscera in the sac stick to its wall and when freeing them you may damage gut 2) Usually there are several loculi, divided by fibrous septa
- 27. 3) The sacoften extend to the skin 4) You have to rise flaps under which blood and exudate can collect and become infected postoperatively. Mayo repair is commonly used Ø In this technique the contents are freed from its wall and reduced, then sac is reduced, the fascial defect is closed with upper flap overlying the lower, thereby doubling the strength of its repair.
- 28. Ø Ø If thedefect is to large you may have to extend it longitudinally, making relaxing incisions in the rectus sheath on either side, and then overlap the aponeurosis laterally. Ø Ø Cardiff (double breasted) repair Ø Mesh repair
- 29. Incisional Hernia “Defectin the musculofascial layer of the abdominal wall in the region of post operative scar”. 10-50% of laparotomy scars. 1-5% of laparoscopic port size incision.
- 31. Predisposing factors: Patient related: ØObesity Ø Malnutrition Ø immunosuppression/ steroid therapy Ø Chronic cough Ø Anemia Ø cancer
- 32. wound related: Ø Poorquality tissue Ø Wound infection Surgical factors: Ø In appropriate suture material Ø Incorrect suture placement
- 33. Clinical features Ø Localizedbulge Ø Multiple swellings along the length of scar Ø Atrophy and thinning of the overlying skin Ø Peristalsis can be observed Ø obstruction
- 34. Treatment Asymptomatic: Ø Abdominal binderand belt is sufficient Symptomatic: Ø Surgical repair Principles of surgery: Ø Repair should cover the whole length of the previous incision Ø Approximation with minimal tension Ø Prosthetic mesh should be placed to reduce the risk of recurrence Ø Appropriate systemic antibiotics
- 35. Open/laparoscopic: Ø Open closurewithout mesh is not recommended even with layered closure because of high recurrence. Ø Only recommended in gross contamination. Ø Mesh can be placed in different planes as mentioned for umbilical henia. Management of very large incisional hernia: Ø If volume of sac is more 25% (calculated from CT images) of the volume of abdominal cavity, then repair will cause loss of abdominal domain. Ø Even if domain is not a concern, closure is still difficult and special technique are required. Ø
- 36. Techniques to overcome thesedifficulties: 1) Progressive pre-operative pneumoperitoneum over several weeks. 2) Resection of the omentum or resection of the colon at the time of repair. 3) Prosthetic mesh to span the uncloseable gap in the musculofascial layer. 4) Musculofascial advancement or transposition flaps to achieve closure. 5) “Ramirez component separation technique”, giving relaxing incisions in external oblique aponeurosis or posterior sheath.
- 37. Reducing the riskof incisional hernia: Improving the patient’s general condition Closing wound with Non-absorbable suture or very slowly absorbable suture Smaller and closure bites Suture length to the wound length should be 4:1 (Jenkin’s rule) Drain should be brought out through separate incision Prophylactic mesh placement
- 38. Spigelian haernia “Arisethrough spigelian fascia (aponeurosis of the transversus abdominus muscle)” Uncommon. Common in elderly. Common below the umbilicus. In young, contents are usually extraperitonial fats while in older patients there is often a peritoneal sac.
- 42. Clinical presentation Intermittentpain due to pinching of fats. Bulge In older patients usually reducible swelling with intermittent obstruction. Diagnosis confirmed by CT scan.
- 43. Treatment Surgery isrecommended as the narrow neck may predispose to strangulation. No abnormality will be seen until external oblique is opened. Spigelian fascia can be repaired with suture or mesh can be placed.
- 44. Lumber hernia Lumberhernia occurs either through superior lumber triangle or inferior lumber triangle of petit. Superior lumber triangle is bounded above 12th rib, quadratus lumborum medially and posterior border of internal oblique laterally. Inferior lumber triangle is bounded below by iliac crest, external oblique laterally and latissimus dori medially. Most primary hernias occur through inferior lumber triangle.
- 48. Differential diagnosis Lipoma Tuberculous abscess Pseudo hernia due to muscular paralysis (most common cause is injury to subcostal nerve during a renal surgery)
- 49. Treatment Natural historyis increase in size and surgery is recommended Can be approached by open laparocopic surgery A TAPP laparoscopic approach is common nowadays In this surgery patient is positioned in semi-lateral position, ports inserted far away from the defect, peritoneum incised above the hernia, dissected back, defect exposed, mesh placed, peritoneum re-sutured over the mesh.
- 50. Parastomal hernia Themuscle defect created during stoma formation tend to increase in size, ultimately leads to massive herniation around the stoma. Occurs in over 50% cases Once occurs causes ill fitting of stoma bag leading to leakage and subsequent complications
- 54. Treatment Ideal treatmentis to rejoin the bowel and remove the stoma Both suture and mesh repair have high chances of failure Current recommendations: Ø Prophylactic mesh should be placed in the retro-muscular space at the time of stoma formation so that the bowel passes through a whole in the centre of the mesh
- 55. Traumatic hernia “Hernias through non-anatomic defects caused by injury’’ Types: 1. Through stab wound sites (incisional hernias) 2. Through splits or tears in the abdominal muscles following blunt trauma 3. Abdominal bulging secondary to muscle atrophy which occurs as a result of nerve injury
- 56. Clinical features Bulge Intermittent pain Signs of obstruction Non-anatomical location Treatment Ø If asymptomatic, conservatively Ø If symptomatic or narrow neck hence chances of obstruction or strangulation then surgery is indicated Ø If there is diffuse bulge then some form of plication of the stretched musculofascial layer with mesh reinforcement is required.