Anatomical and Physiological Anatomical and Physiological Substantiations of Operative Substantiations of Operative

Interventions on Ventral Interventions on Ventral Abdominal WallAbdominal Wall

Ventral Abdominal Wall Ventral Abdominal Wall RegionsRegions

Organs ProjectionOrgans Projection

Muscles of the TrunkMuscles of the Trunk

4 Levels of Rectus Abdominis 4 Levels of Rectus Abdominis Muscle Sheath StructuresMuscle Sheath Structures

Layer Structure of the Ventral Layer Structure of the Ventral Abdominal WallAbdominal Wall

Abdominal IncisionsAbdominal Incisions

Must be located nearest to the organMust be located nearest to the organ.. Must have sufficient length for surgeon’s Must have sufficient length for surgeon’s

activitiesactivities.. Must be atraumatic. Must be atraumatic.

Skin Incisions of the Ventral Abdominal WallSkin Incisions of the Ventral Abdominal Wall

Superficial Inguinal RingSuperficial Inguinal Ring

Ventral Abdominal Wall (lower Ventral Abdominal Wall (lower internal view)internal view)

Internal Inguinal RingInternal Inguinal Ring

TThe Walls Of The Inguinal he Walls Of The Inguinal CanalCanal

ANTERIOR WALL ANTERIOR WALL laterally - muscles fibers of the external oblique laterally - muscles fibers of the external oblique medially - aponeurosis of the external oblique medially - aponeurosis of the external oblique most medially there is not wall but there is a most medially there is not wall but there is a

deficiency called the superficial inguinal ring. deficiency called the superficial inguinal ring. SUPERIOR -SUPERIOR - arching fibers of the internal oblique and arching fibers of the internal oblique and

sometimes transverse abdominis. These fibers start sometimes transverse abdominis. These fibers start anterior and lateral, pass over the spermatic cord anterior and lateral, pass over the spermatic cord and the medially forms part of the posterior wall of and the medially forms part of the posterior wall of the canal. the canal.

POSTERIORPOSTERIOR – – laterallaterallyly -- deep inguinal ring. Medially deep inguinal ring. Medially the posterior wall is made up of the aponeuroses of the posterior wall is made up of the aponeuroses of the internal oblique and transverse abdominis. the internal oblique and transverse abdominis.

INFERIORINFERIOR - inguinal ligament. - inguinal ligament.

Male Inguinal CanalMale Inguinal Canal

Female Inguinal CanalFemale Inguinal Canal

HERNIAHERNIA

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

HERNIAHERNIA

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

Anatomy of an Inguinal Anatomy of an Inguinal HerniaHernia

Elements of a Elements of a HerniaHernia::

1. Hernial gate1. Hernial gate;;

2. 2. Hernial sacHernial sac;;

3. 3. Hernial contentsHernial contents;;

Elements of hernial Elements of hernial sacsac::а) а) neckneck;;

б) б) bodybody;;

в) в) fundusfundus..

Weak Places of the Ventral Abdominal WallWeak Places of the Ventral Abdominal Wall

Hernial Gates for Hernias of Hernial Gates for Hernias of Ventral Abdominal Wall Ventral Abdominal Wall

1. 1. Umbilical herniaUmbilical hernia – – umbilical ringumbilical ring;;

2. 2. Midline herniaMidline hernia – – artificial hole or artificial hole or alba line holes, through which alba line holes, through which intercostals nerves passintercostals nerves pass;;

3. 3. Indirect inguinal herniaIndirect inguinal hernia – – deep ring deep ring of inguinal canalof inguinal canal;;

4. 4. Direct inguinal herniaDirect inguinal hernia – – inguinal inguinal spacespace..

Differences Between Inguinal Differences Between Inguinal Hernias Hernias

Indirect HerniaIndirect HerniaGate – internal inguinal ringGate – internal inguinal ring

Sac - is laterally to spermatic Sac - is laterally to spermatic cord and is laterally to cord and is laterally to inferior epigastric arteryinferior epigastric artery

Form is ovalForm is oval

It can be acquired or It can be acquired or congenitalcongenital

Direct HerniaDirect HerniaGate –Gate – inguinal spaceinguinal space

Sac - is medially to spermaticSac - is medially to spermatic

cord and is medially to inferior cord and is medially to inferior epigastric arteryepigastric artery

Form is roundForm is round

It can be only acquiredIt can be only acquired

Levelling Factors of the Inguinal Canal Levelling Factors of the Inguinal Canal WeaknessWeakness

Except in the newborn infant, the canal is an Except in the newborn infant, the canal is an oblique passage with the weakest areas, namely, oblique passage with the weakest areas, namely, the superficial and deep rings, lying some the superficial and deep rings, lying some distance apart. distance apart.

The anterior wall of the canal is reinforced by the The anterior wall of the canal is reinforced by the fibers of internal oblique muscle immediately in fibers of internal oblique muscle immediately in front of the deep ringfront of the deep ring..

The posterior wall of the canal is reinforced by the The posterior wall of the canal is reinforced by the strong conjoint tendon of the internal oblique and strong conjoint tendon of the internal oblique and transversus muscles immediately behind the transversus muscles immediately behind the superficial ringsuperficial ring..

In case of In case of sharp temporarysharp temporary increasing of intra- increasing of intra-abdominal pressure the muscles of superior wall abdominal pressure the muscles of superior wall contract and bring superior wall nearer to the contract and bring superior wall nearer to the inferior wall (so that the canal is virtually closed)inferior wall (so that the canal is virtually closed). .

Steps of Surgery:Steps of Surgery:

1. access1. access2. extraction of 2. extraction of hernial sac: hernial sac:а) а) incision of hernial incision of hernial sacsac; ; bb) ) repositionreposition of hernial of hernial contents inside of contents inside of abdominal cavityabdominal cavity; ; cc) ) stitching of neck of stitching of neck of hernial sachernial sac; ; dd) ) cutting of hernial cutting of hernial sac;sac;3. grafting.3. grafting.

А) А) Lexer’s GraftingLexer’s Grafting ( (umbilical herniaumbilical hernia))

BB) ) Lexer’s graftingLexer’s grafting ((umbilical herniaumbilical hernia, , final viewfinal view))

Treatment of an Umbilical Treatment of an Umbilical Hernia (Mayo's Method)Hernia (Mayo's Method)

The defect of The defect of ventral abdominal ventral abdominal wall in umbilical wall in umbilical ring region is ring region is stitched by H-stitched by H-shaped suture in shaped suture in transversal transversal directiondirection..

Treatment of an Umbilical Treatment of an Umbilical Hernia (Sapezhko’s Method)Hernia (Sapezhko’s Method)

Forming of Forming of abdominal abdominal midline midline duplication by duplication by stitching in stitching in longitudinal longitudinal direction.direction.

Martynov’s Grafting of Anterior Wall Martynov’s Grafting of Anterior Wall of Inguinal Canalof Inguinal Canal

Inguinal Repair with MeshInguinal Repair with Mesh

Liechtenstein's GraftingLiechtenstein's GraftingMesh patch fixation

Liechtenstein's GraftingLiechtenstein's Grafting

View of interrupted suture

Sliding HerniaSliding Hernia

Putting in the Purse-string Suture in Putting in the Purse-string Suture in Case of Sliding HerniaCase of Sliding Hernia

Richter’sRichter’s ( (ParietalParietal))Strangulation of IntestineStrangulation of Intestine

RetrogradeRetrograde Strangulation Strangulation

Thank You for Thank You for Attention!Attention!