2 ILOs At the end of this presentation students will be able to: Describe the aetiology, presentation of rectus sheath hematoma.Describe the aetiology, presentation of desmoid tumor.State the anatomy of inguinal canal, femoral canal and umbilicus.Describe the aetiology, risk factors, presentation, complications and management of groin hernias.Differentiate between different types of groin hernia.Describe the presentation and management of other abdominal wall hernias.
3 Diseases of UmbilicusPersistent vitello-intestinal duct: Persistent part- Meckel’s diverticulum. Whole patent duct forms fistula between ileum & umbilicus. Foul discharge. Treated by excision.Persistent urachus: Cyst or urinary fistula.Tumours: Primary- SCC, Melanoma Secondary: Tumour tracking along ligamentum teres.Hernia
4 Rectus sheath haematoma Aetiology: Spontaneous (anticoagulation) Traumatic (excessive physical activity) Bleeding from inferior epigastric artery Present as painful, tender swelling Diagnosis-U/S Treatment: Spontaneous resolution or surgical evacuation.
5 Desmoid tumourFibromatosis from fibroaponeurotic part of rectus abdominis.More common in young female of child bearing age, OC use.Other sites- extremity, intra-abdominal.Asymptomatic slow growing mass.Diagnosis: CT or MRI for delineation, core needle biopsy.Treatment: Wide local excision Local recurrence high if margins are involved Recurrence treated by radiotherapy, anti-oestrogen or NSAID (Sulindac, indomethacin) Rapid growing- chemotherapy
6 Abdominal wall herniaDefinition: Abnormal protrusion through weakness in the wall of the cavity It carries with a peritoneal sac.Contributing factors: Chronic cough, obesity, straining (constipation), repeated pregnancy, family history, ascites, defective collagen synthesis, heavy lifting, RLQ incision.Inguinal, femoral, PUH, epigastric & incisionalReducible & irreducibleObstructed & strangulated hernia
10 Indirect Inguinal hernia Enters through deep ring within a sac.Dragging discomfortLumpCough impulse, reducibilityDeep ring occlusion testIrreducible with features intestinal obstruction (obstructed hernia)Above features with severe pain in hernia, skin redness and very tender- strangulated hernia
12 Direct inguinal hernia Bulges through weakness of Hasselbach’s triangleWide neck so rarely obstructs or strangulatesAppears as wide bulgeOften spontaneously reduces after cough or lyingDeep ring occlusion does not control
13 ManagementAll IH in children and most IH in adult ( if fit for surgery) recommended repair.Preoperative investigations for fitness.Done mostly as a day caseLocal, regional or general anaesthesiaLaparoscopic or open surgical repairOpen repair IH: Herniotomy + mesh repairDH: No sac excision, sac reduced, weakness/ defect of fascia transversalis repaired, then mesh applied to posterior inguinal wall as in IH
16 Femoral herniaProjects through femoral ring and passes down the femoral canal (1.25 cm)Bound laterally by a thin septum separating it from Femoral vein, anteriorly- inguinal ligament, medially- lacunar ligament and posteriorly- superior ramus of pubis & pectineal ligament of Cooper.Appears through the saphenous opening in deep fascia, appear to lie in front of inguinal ligament
21 Clinical features Groin swelling (often small), groin pain on exercise Sometimes difficult to distinguish with IHExamination: Put a finger tip over pubic tubercle (How to find it?).IH- above & medial, FH- below & lateralOften irreducible due to its curved course.Obstruction, strangulation rate high (40%)D/D: LN, saphenous varix (thrill on cough, disappears on lying down), ectopic testis, psoas abscess
22 Treatment Advise Surgery to all Surgery under local/ GA Open surgery: Sac is dissected, contents reduced & femoral ring obliterated by suturing inguinal ligament to pectineal ligament.Laparoscopic approach.
23 Epigastric hernia Protrusion through a defect in linea alba Firm midline lump.Often contains preperitoneal fat.Sometimes peritoneal sac with omentum.Open surgical repair by non-absorbable suture or meshLaparoscopic repair- if large
24 Umbilical, Para-umbilical hernia UH: Protrusion through umbilicus. Seen infants when they cry. Most- spontaneous resolution by age 3, If not- surgical repairPUH: Protrusion through tissue around umbilicusHernia gradually enlarges, stretching overlying skinDefect multilocular, irreducible due to adhesionMore common in femaleSurgery advised- high risk of obstruction/ strangulation
26 Surgery for PUHOpen Surgery: Transverse skin incision. Sac dissected, contents reduced, sac excised and defect repaired by simple suture, Mayo’s repair or mesh repair if large defect (>3cm)Laparoscopic repair
27 Incisional herniaHernia bulging through poorly healed abdominal incisionsMore common with midline vertical incisionsPredisposing factors: Poor surgical technique, infection, obesity, chest infection and collagen disorders.Defects may be multiloculatedCough impulse, defects felt on reducing herniaRisk of obstruction/ starngulation
29 Surgical repair Open surgery: Prolene mesh repair Laparoscopic mesh repair: Less postoperative pain, shorter hospital stayMesh repair complications: Seroma, infectionLaparoscopic repair: Less hernia recurrence
30 Rare external herniasSpigelian hernia: through linea semilunaris at the lateral border of rectus abdominis. Surgical repairLumber hernia bulges above iliac crest between posterior border of ext. oblique & latissimus dorsi.Obturator hernia through obturator canal. Common in female. Diagnosis usually made at laparotomy for intestinal obstruction due to strangulated hernia.
31 Complications of hernia Incarcerated: Hernia contents are irreducible but not obstructed or strangulated.Obstructed: Irreducible hernia presenting with intestinal obstruction.Strangulated: When blood supply to the contents is jeopardized in an irreducible hernia.