abdominal wall

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abdominal wall

  1. 1. ABDOMINAL WALL DEFECTS Celso M. Fidel, MD, FPCS,FPSGS Diplomate Philippine Board of Surgery
  2. 2. Introduction ABDOMINAL WALL  Complex musculo-aponeurotic structure  Attached to the :  Vertebral column posteriorly  Ribs superiorly  Bones of the pelvis inferiorly  Derived embryonically in a segmental, metameric manner, and is reflected in blood supply and innervation.
  3. 3. Introduction <ul><li>ABDOMINAL WALL </li></ul><ul><li> Protects and restrains the abdominal viscera, </li></ul><ul><li>and its musculature </li></ul><ul><li> Acts indirectly to flex the vertebral column. </li></ul><ul><li> Integrity is essential to the prevention of </li></ul><ul><li>hernias, whether they be: </li></ul><ul><li> Congenital </li></ul><ul><li> Acquired </li></ul><ul><li> Iatrogenic </li></ul>
  4. 4. Introduction ABDOMINAL WALL It is the repository of the panniculus adiposus May reach considerable proportions in some members of the species afflicted with morbid obesity .
  5. 5. Introduction ABDOMINAL WALL Variety of pathology difficult to assess on physical examination. Computed tomography (CT) often delineates these abnormalities
  6. 6. GENERAL CONSIDERATIONS  VENTRAL HERNIA  UMBILICAL HERNIAS  EPIGASTRIC HERNIA  INCISIONAL HERNIA  TROCAR HERNIA  Emergency Abdominal wall Defects  Difficult Abdominal Wall Closure
  7. 7. ABDOMINAL WALL HERNIAS
  8. 8. UMBILICAL HERNIAS
  9. 9. UMBILICAL HERNIA
  10. 11. GENERAL CONSIDERATIONS  Other Abdominal Wall Hernia  Spigelian Hernia  Lumbar Hernia 1. Petit’s or inferior triangle hernia 2. Grynfelt’s or sup. Triangle hernia  Pelvic Floor Hernia 1. Obturator Hernia 2. Perineal Hernia 3. Sciatic Hernia
  11. 12. GENERAL CONSIDERATIONS  Other Abdominal Wall Hernia 4. Parastomal Hernia 5. Internal hernia (a) Normal Orifice (b) Abnormal Orifice (c) Iatrogenic ( post-operative)
  12. 13. GENERAL CONSIDERATIONS  Other Abdominal Wall Hernia 6. Co ngenital Abdominal Wall defect (a) Gastroschisis (b) Omphalocele 7. C ongenital Diaphragmatic Hernia (a) Bochdalek (b) Morgagni
  13. 14. Abdominal Wall Defects <ul><li> Ventral Hernia </li></ul><ul><ul><li>Defect in the abdominal wall with intestines </li></ul></ul><ul><ul><li>or preperitoneal fat thru fascial defect </li></ul></ul><ul><ul><li>On PE fascial defect usually palpable in </li></ul></ul><ul><ul><li>obese patients </li></ul></ul><ul><ul><li>Ultrasound or CT scan for the diagnosis </li></ul></ul><ul><ul><li>Same principle of management as groin </li></ul></ul><ul><ul><li>hernia </li></ul></ul>
  14. 15. Ventral HERNIA <ul><li> Umbilical Hernia </li></ul><ul><li> Occur more frequently in females; 10-30% </li></ul><ul><li>live birth </li></ul><ul><li> Obesity and repeated pregnancies precludes </li></ul><ul><li>this problem </li></ul><ul><li> In infants aponeurotic defect of 1.5 cm or less </li></ul><ul><li>would close spontaneously </li></ul><ul><li> Repair for children present by the age of </li></ul><ul><li>three or four & infants whose defect is 2 cm </li></ul>
  15. 16. Ventral HERNIA <ul><li> Umbilical Hernia </li></ul><ul><li> MAYO HERNIOPLASTY </li></ul><ul><li> Vest over pants imbrication of the superior </li></ul><ul><li>& inferior aponeurotic fascia layer </li></ul><ul><li> EPIGASTRIC HERNIA </li></ul><ul><li> Protrusion of properitoneal fat & peritoneum </li></ul><ul><li>through the dicussating fibers of the rectus </li></ul><ul><li>sheath in the midline (linea alba) between </li></ul><ul><li>the xiphoid. </li></ul>
  16. 17. Ventral HERNIA <ul><li> Epigastric Hernia </li></ul><ul><li> Diastasis Recti </li></ul><ul><li> Wide gap between the medial borders of the </li></ul><ul><li>rectus sheath </li></ul><ul><li> Diffuse bulge at upper midline of abdomen </li></ul><ul><li> Not a fascial defect, hence repaired for </li></ul><ul><li>cosmetic purposes </li></ul><ul><li> Incisional Hernia </li></ul>
  17. 18. Patient Rogelia Tacuban
  18. 19. INCISIONAL HERNIOPLASTY <ul><li> Anatomic reconstruction of the abdominal </li></ul><ul><li>wall and Includes; </li></ul><ul><ul><li> Closure of the parietal defect </li></ul></ul><ul><ul><li>Restoration of normal intra-abdominal </li></ul></ul><ul><ul><li>pressure </li></ul></ul><ul><ul><li>Tendinous reinforcement of the lateral </li></ul></ul><ul><ul><li>abdominal muscles. </li></ul></ul>
  19. 20. Clear View of External O Aponeurosis
  20. 21. Separation of the Sac
  21. 22. CATTELL REPAIR
  22. 23. Ventral HERNIA <ul><li> Incisional Hernia </li></ul><ul><li> 2-11% of abdominal wall closure </li></ul><ul><li> 56% in the first year postoperative </li></ul><ul><li> 17% incarcerate </li></ul><ul><li> 20-46% repeat recurrence </li></ul><ul><li> Causes: </li></ul><ul><li>1. Obesity </li></ul><ul><li>2. post-op pulmonary complications </li></ul><ul><li>3. Wound infection </li></ul>
  23. 24. Visceral HERNIA <ul><li>Incisional Hernia </li></ul><ul><li>4. Jaundice </li></ul><ul><li>5. Advanced age </li></ul><ul><li>6. Abdominal Distention </li></ul><ul><li>7. Re-use of previous incision </li></ul><ul><li>8. Emergency operation </li></ul><ul><li>9. Pregnancy </li></ul><ul><li>10. Chemotherapy post-op </li></ul>
  24. 25. Ventral HERNIA <ul><li> Incisional Hernia </li></ul><ul><li>11. Steroids </li></ul><ul><li>12. Malnutrition </li></ul><ul><li>13. Ascites </li></ul><ul><li>14. Peritoneal dialysis </li></ul><ul><li> Trocar Hernias </li></ul><ul><li> < 1% after laparoscopic procedure </li></ul><ul><li> Fascial defects > 5mm should be closed </li></ul>
  25. 26. Ventral HERNIA <ul><li> Repair Techniques </li></ul><ul><li>1. P rimary repair w/ non-absorbable monofilament </li></ul><ul><li>sutures; 49-58% failure rate </li></ul><ul><li> Mayo repair (fascial imbrication) 54% recur </li></ul><ul><li>in 5-7 years follow up </li></ul><ul><li> “ Far and Near” suturing by Shukla= 0% </li></ul><ul><li> Internal retention suturing-2% recur for </li></ul><ul><li>large ventral hernia </li></ul>
  26. 27. Ventral HERNIA <ul><li> Repair Techniques </li></ul><ul><li>2. Mesh onlay- 6% recur </li></ul><ul><li>3. Mesh onlay and patch repair= Mesh placed </li></ul><ul><li>deep to the rectus sheath </li></ul><ul><li>4. Sandwich and cuffed mesh repair combined </li></ul><ul><li>onlay + inlay </li></ul><ul><li>5. Stoppa- Giant mesh prosthesis for large >10 </li></ul><ul><li>cm incisional hernia </li></ul><ul><li>6. Laparoscopic repair </li></ul>
  27. 28. Emergency Abdominal Wall Defect <ul><li> Difficult abdominal wall closure in: </li></ul><ul><li> Massive bowel edema </li></ul><ul><li> Tissue loss due to Trauma </li></ul><ul><li> Debridement for necrotizing lesions </li></ul><ul><li> Resection of tumors </li></ul><ul><li> Repair with prosthetics w/ absorbable mesh </li></ul><ul><li>followed by skin grafting then planned </li></ul><ul><li>ventral hernia repair </li></ul>
  28. 29. Other Abdominal Wall Hernia <ul><li> SPIGELIAN HERNIA </li></ul><ul><li> Ventral hernia occurring along the subumbilical </li></ul><ul><li>portion of the Spieghel’s Semilunar line & </li></ul><ul><li>through Spieghel’s Fascia. </li></ul><ul><li> Vague pain, mass usually not palpable , intra </li></ul><ul><li>mural mass located 0-6 cranial to interspinous </li></ul><ul><li>line (horizontal line between 2 ASIS) </li></ul><ul><li> Usual location- just below semicircular line of </li></ul><ul><li>Douglas; Defect in Transversus Abdominis </li></ul>
  29. 30. Other Abdominal Wall Hernia <ul><li> LUMBAR HERNIA </li></ul><ul><li> Congenital spontaneous & traumatic herniation </li></ul><ul><li>occur through Grynfelts superior & petits </li></ul><ul><li>inferior lumbar triangle . </li></ul><ul><li> Defect in transversalis fascia & Tranversus </li></ul><ul><li>Abdominis Aponeurosis </li></ul><ul><li> Contains retroperitoneal sac or peritoneum </li></ul><ul><li>lined sac </li></ul>
  30. 31. Lumbar Hernia <ul><li> PETIT’S TRIANGLE is bounded by: </li></ul><ul><li> Medial= Latissimus dorsi muscle </li></ul><ul><li> Lateral= External oblique muscle </li></ul><ul><li> Inferior= Iliac crest </li></ul><ul><li>  Covered by superficial fascia </li></ul><ul><li> GRYNFELT’S TRIANGLE is bounded by: </li></ul><ul><li> Superior= 12 th rib </li></ul><ul><li> Lateral= Internal oblique abdominal muscle </li></ul><ul><li> Medial=Sacrospinalis muscle </li></ul><ul><li>  Covered by latissimus dorsi </li></ul>
  31. 32. <ul><li> PELVIC HERNIA- occurs in cachetic, elderly </li></ul><ul><li>patients in the, Obturator fossa, Perineum & </li></ul><ul><li>Greater and lesser sciatic foramina </li></ul><ul><li>1. Obturator Hernia </li></ul><ul><li> 50% with Howship-Romberg Sign </li></ul><ul><li>Pain in the region of the hip, and of the knee </li></ul><ul><li>and on the inner aspect of the thigh because </li></ul><ul><li>of pressure on the obturator nerve by an </li></ul><ul><li>obturator hernia. </li></ul>Other Abdominal Wall Hernia
  32. 33. <ul><li> Usually in emaciated females in late 70’s on </li></ul><ul><li>the right side </li></ul><ul><li> Often with either large or small bowel </li></ul><ul><li>incarceration or strangulation </li></ul><ul><li> Rarely with a mass at the anteromedial thigh </li></ul><ul><li>or a bulge on rectal or pelvic examination </li></ul><ul><li> Diagnosis by CT scan </li></ul><ul><li> Repair by midline approach to take care of </li></ul><ul><li>bowel problem too. </li></ul>Other Abdominal Wall Hernia
  33. 34. <ul><li>2. Perineal Hernia </li></ul><ul><li> Occur spontaneously or after APR or </li></ul><ul><li>pelvic exenteration </li></ul><ul><li>1. Anterior- defect in urogenital diaphragm; </li></ul><ul><li>mass in labia majora </li></ul><ul><li>2. Po sterior- defect in the levator ani between </li></ul><ul><li>the urinary bladder and rectum </li></ul><ul><li> Repair= Transperineal or transabdominal </li></ul><ul><li>primary repair or with mesh </li></ul>Other Abdominal Wall Hernia
  34. 35. <ul><li>3. Sciatic Hernia </li></ul><ul><li> Rarest of all hernias; </li></ul><ul><li> Occurs in the greater or lesser sciatic </li></ul><ul><li>foramen or thru a defect in the pyriformis </li></ul><ul><li>muscle </li></ul><ul><li> Presents as sciatic nerve palsy and a mass </li></ul><ul><li>or simply intestinal obstruction </li></ul><ul><li> Repair= G luteal or Transabdominal approach </li></ul>Other Abdominal Wall Hernia
  35. 36. <ul><li> PARASTOMAL HERNIA </li></ul><ul><li> Occurs thru defects adjacent to ostomy site </li></ul><ul><li> Incidence: 12-32% paracolostomy </li></ul><ul><li>< 10% paraileostomy </li></ul><ul><li> Prevention: Small fascial incision, avoid </li></ul><ul><li>maturing thru the abdominal incision </li></ul><ul><li> Complications: </li></ul><ul><li>1. Obstruction; </li></ul><ul><li>2. Incarceration </li></ul><ul><li>3. Poor Appliance fit </li></ul><ul><li>4. Local pain </li></ul>Other Abdominal Wall Hernia
  36. 37. <ul><li> PARASTOMAL HERNIA </li></ul><ul><li> Repair: Primary fascial or prosthetic repair </li></ul><ul><li>or relocation of stoma </li></ul><ul><li> Symptoms generally well tolerated </li></ul><ul><li> All repairs associated with: </li></ul><ul><li>1. significant morbidity </li></ul><ul><li>2. high recurrence </li></ul>Other Abdominal Wall Hernia
  37. 38. <ul><li> INTERNAL HERNIA </li></ul><ul><li> Abdominal contents protrude thru </li></ul><ul><li>normal or abnormal intra-abdominal </li></ul><ul><li>orifice </li></ul><ul><li>3. Iatrogenic (Post operative) </li></ul><ul><li>(a) Defect in Mesentery or Omentum </li></ul><ul><li>Peterson Hernia=thru Roux limb </li></ul><ul><li> CONGENITAL ABDOMINAL WALL DEFECTS </li></ul><ul><li> Gastroschisis </li></ul><ul><li>1. Herniation of abdominal viscera without a </li></ul><ul><li>sac, intact umbilical cord </li></ul>Other Abdominal Wall Hernia
  38. 39. <ul><li> CONGENITAL ABDOMINAL WALL DEFECTS </li></ul><ul><li> Omphalocele </li></ul><ul><li>1. Herniation of abdominal viscera into the </li></ul><ul><li>umbilical cord, hence lined by internally </li></ul><ul><li>by peritoneal sac and externally by </li></ul><ul><li>amnion </li></ul><ul><li>2. Associated anomalies: </li></ul><ul><li>(a) Cloacal exstrophy </li></ul><ul><li>(b) Chromosomal abnormality in 50% </li></ul>Other Abdominal Wall Hernia
  39. 40. <ul><li> CONGENITAL ABDOMINAL WALL DEFECTS </li></ul><ul><li> Gastroschisis </li></ul><ul><li>2. Two times (2X) more common than </li></ul><ul><li>omphalocele </li></ul><ul><li>3. Associated anomalies: Intestinal Atresia </li></ul><ul><li>10% </li></ul><ul><li>4. Eviscerated Bowels are: </li></ul><ul><li>(a) Edematous </li></ul><ul><li>(b) Shortened with fibrinous adhesions </li></ul><ul><li>5. < 10% mortality </li></ul>Other Abdominal Wall Hernia
  40. 41. <ul><li> CONGENITAL DIAPHRAGMATIC HERNIA </li></ul><ul><li> Bochdalek Hernia </li></ul><ul><li>(a) Postero-lateral, most common at costal </li></ul><ul><li>and spinal diaphragmatic attachment </li></ul><ul><li>(b) Associated with malrotation, pulmonary </li></ul><ul><li>hypoplasia </li></ul><ul><li>(c) 4 x more common in the left side </li></ul><ul><li>(d) Only 10-20% have a sac; 80% mortality </li></ul><ul><li>by the first year of life </li></ul>Other Abdominal Wall Hernia
  41. 42. <ul><li> CONGENITAL DIAPHRAGMATIC HERNIA </li></ul><ul><li> Bochdalek Hernia </li></ul><ul><li>(e) Better repaired after a few days to </li></ul><ul><li>weeks when the child stabilizes; </li></ul><ul><li>higher mortality if repaired at birth </li></ul><ul><li>(f) Repair: Transabdominal with the Ladd </li></ul><ul><li>procedure for the malrotation </li></ul><ul><li> Morgagni </li></ul><ul><li>(a) Between sternal & costal diaphragmatic </li></ul><ul><li>m argin either retrosternal or parasternal </li></ul>Other Abdominal Wall Hernia
  42. 43. THANK YOU!!!

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