1. Anatomical and Physiological Substantiations of Operative Interventions on Ventral Abdominal Wall Associate-professor Slabyy O.B.

2. Ventral Abdominal Wall Regions

3. Organs Projection

4. Muscles of the Trunk

5. 4 Levels of Rectus Abdominis Muscle Sheath Structures

6. Weak Places of the Ventral Abdominal Wall

7. Layer Structure of the Ventral Abdominal Wall

8. Abdominal Incisions Must locate nearest to the organ.
Must have sufficient length for surgeon activities.
Must be atraumatic.

9. Skin Incisions of the Ventral Abdominal Wall

10. Male Inguinal Canal

11. Female Inguinal Canal

12. Superficial Inguinal Ring

13. Ventral Abdominal Wall (lower internal view)

14. Internal Inguinal Ring

15. HERNIA
Hernia of the abdominal wall or external hernia is such surgical disease, which is characterized by outlet of the visceral organs from the place of their physiological placement through the natural canals or defects of the abdominal and pelvic wall. In such case all visceral organs covered by parietal peritoneum and skin are not damaged.

16. HERNIA
Internal hernia is such disease, visceral organs hit the peritoneum pouch. It formed in the place of natural peritoneum fold or recess and generally kept in the abdominal cavity.

17. Anatomy of an Inguinal Hernia
Elements of a Hernia:
1. Hernial gate;
2. Hernial sac;
3. Hernial contents;
Elements of hernial sac:
а) neck;
б) body;
в) fundus.

18. The Walls Of The Inguinal Canal
ANTERIOR WALL
laterally - muscles fibers of the external oblique
medially - aponeurosis of the external oblique
most medially there is not wall but there is a deficiency called the superficial inguinal ring.
SUPERIOR - arching fibers of the internal oblique and sometimes transverse abdominis. These fibers start anterior and lateral, pass over the spermatic cord and the medially forms part of the posterior wall of the canal.
POSTERIOR – laterally - deep inguinal ring. Medially the posterior wall is made up of the aponeuroses of the internal oblique and transverse abdominis.
INFERIOR - inguinal ligament.

19. Hernial Gates for Hernias of Ventral Abdominal Wall
1. Umbilical hernia – umbilical ring;
2. Midline hernia – artificial hole or alba line holes, through which intercostals nerves pass;
3. Indirect inguinal hernia – deep ring of inguinal canal;
4. Direct inguinal hernia – inguinal space.

20. Differences Between Inguinal Hernias
Indirect Hernia
Gate – internal inguinal ring
Sac - is laterally to spermatic cord and is laterally to inferior epigastric artery
Form is oval
It can be acquired or congenital
Direct Hernia
Gate – inguinal space
Sac - is medially to spermatic
cord and is medially to inferior epigastric artery
Form is round
It can be only acquired

21. Levelling Factors of the Inguinal Canal Weakness
Except in the newborn infant, the canal is an oblique passage with the weakest areas, namely, the superficial and deep rings, lying some distance apart.
The anterior wall of the canal is reinforced by the fibers of internal oblique muscle immediately in front of the deep ring.
The posterior wall of the canal is reinforced by the strong conjoint tendon of the internal oblique and transverses muscles immediately behind the superficial ring.
In case of sharp temporary increasing of intra-abdominal pressure the muscles of superior wall contract and bring superior wall nearer to the inferior wall.

22. Steps of Operative Intervention: а) incision of hernial sac; b) reposition of hernial contents inside of abdominal cavity; c) stitching of neck of hernial sac; d) cutting of hernial sac; e) grafting.

23. А) Lexer’s Grafting (umbilical hernia)

24. B) Lexer’s grafting (umbilical hernia, final view)

25. Treatment of an Umbilical Hernia (Mayo's Method)
The defect of ventral abdominal wall in umbilical ring region is stitched by H-shaped suture in transversal direction.

26. Treatment of an Umbilical Hernia (Sapezhko’s Method)
Forming of abdominal midline duplication by stitching in longitudinal direction.

27. Martynov’s Grafting of Anterior Wall of Inguinal Canal

28. Inguinal Repair with Patch

29. Liechtenstein's Grafting
Mesh patch fixation

30. Liechtenstein's Grafting
View of interrupted suture

31. Sliding Hernia

32. Putting in the Purse-string Suture in Case of Sliding Hernia

33. Richter’s (Parietal) Strangulation of Intestine

34. Retrograde Strangulation

35. Thank You for Attention!