hernia (femoral & umbilical)
TRANSCRIPT
FEMORAL & UMBILICAL
HERNIANUR HANISAH BINTI ZAINOREN
CONTENTS
Anatomy
Introduction
Causes
Clinical features
Diagnosis
Treatment
SHEATH . CANAL . RINGFEMORAL
FEMORAL SHEATH
FEMORAL SHEATH
FEMORAL SHEATH
FEMORAL SHEATH
FEMORAL SHEATH
FEMORAL SHEATH
FEMORAL SHEATH
FEMORAL SHEATH
FEMORAL CANAL
FEMORAL CANAL
FEMORAL RING
FEMORAL RING BOUNDARIES
ANTERIORLY
FEMORAL RING BOUNDARIES
POSTERIORLY
FEMORAL RING BOUNDARIES
MEDIALLY
FEMORAL RING BOUNDARIES
LATERALLY
FEMORAL RING
FEMORAL RING
Lymphatics
Areolar tissue
Boundaries of femoral ring :
•Superoanteriorly inguinal lig.
•Inferoposteriorly iliopectineal lig.
•Medially lacunar ligament (Gimbernat’s ligament)
•Laterally thin septum which separates femoral canal & femoral vein(silver fascia)
INTRODUCTION
Protrusion of extra peritoneal tissue, peritoneum & sometimes abdominal content through the femoral canal
Female: Male = 2:1
Commonly unilateral, right side are more affected
Bilateral, in 15-20 %
RISK FACTORS
1. Female
2. Old ages
3. Low weight, elderly females
4. Previous h/o sutured inguinal hernia
repair
CLINICAL FEATURES
•Gaur sign : dilatation of superficial epigastric/ circumflex iliac veins due to compression
•Right side is more commonly affected
•Small swelling below the inguinal lig. very often unnoticed
•Expansile impulse is often not present due to narrow canal
•Swelling is below and lateral to pubic tubercle
•Strangulation 30-80%
INGUINAL VS FEMORAL HERNIA
INGUINAL FEMORALAbove and medial to
the pubic tubercleBelow and lateral to the
pubic tubercle
Above the crease of the groin
Below the crease of the groin
Can be reduced completely
Cannot be reduced completely
Cough impulse usually present
Many do not have cough impulse
INVESTIGATION
•No specific investigations are required•Ultrasound & CT scan•Emergency patient , small bowel obstruction usually occurs plain X-ray
TREATMENT
3 classical approach :
i. Low approach (Lockwood)
below the inguinal ligament
ii. Inguinal approach
(Lotheissen) through inguinal
canal
iii. High approach (McEvedy)
mainly above the inguinal canal
*some cases can be managed laparoscopically
TREATMENT
1. Low approach (Lockwood)
•An incision is made over 1cm below and parallel to the inguinal lig.
•The sac is opened and the contents are reduced
•Non-absorbable sutures are placed between inguinal ligament & iliopectineal ligament
TREATMENT
2. Inguinal approach (Lotheissen)•Transversalis fascia is opened from deep inguinal ring to pubic tubercle.
•Hernia is reduced by combination of pulling from above and pushing from below.
•Once reduced, neck of hernia is closed with sutures/ mesh plugs
TREATMENT
3. High Approach (McEvedy)
•Horizontal incision is made in lower abdominal
centered at lateral edge of rectus muscle.
•Ant. Rectus sheath is incised and rectus muscle
displaced medially.
•Hernia is reduced and sac is opened for careful
inspection of bowel.
•Femoral defect then is closed with sutures/ mesh
TREATMENT
4. Laparoscopic approach
•TEP and TAPP approach can be used
•A standard mesh is inserted
•Ideal for reducible femoral hernias, not
in emergency cases nor for irreducible
hernia
DIFFERENTIAL DIAGNOSIS
•Direct inguinal hernia
•Lymph node
•Saphena varix
•Lipoma
•Femoral artery aneurysm
•Psoas abscess
•Rupture of adductor longus with haematoma
UMBILICAL HERNIA
UMBILICAL HERNIA
The umbilical defect is present at birth but closes as the stump of the umbilical cord heals, usually within a week of birth
This process may be delayed, leading to the development of herniation in the neonatal period
The umbilical ring may also stretch and reopen in adult life
UMBILICAL HERNIA IN CHILDREN•10% of infants, higher incidence in premature babies•Hernia appears within a few weeks of birth•Symptomless •Increases in size on crying•Classical conical shape
Incidence:•Boys = Girls•Black infants (8x) > White
Obstruction/strangulation are extremely uncommon in
<3 years of age
TREATMENT• Conservative treatment : < 2 years, symptomless,
parental reassurance
• 95% will resolve spontaneously
• Surgical repair : if the hernia persists > 2 years (unlikely to
resolve)
OPERATION• Small curved incision is made immediately below the
umbilicus
• Neck of the sac is defined, opened and any contents are
returned to the peritoneal cavity
• Sac is closed and redundant sac is excised
• The defect in linea alba is closed
with interrupted sutures.
UMBILICAL HERNIA IN ADULTReopening of umbilical defect caused by conditions that cause thinning and stretching of midline raphe (linea alba)Repeated pregnancies weaken abdominal wall
Obesity flabby abdominal muscle
Ascites, especially in cirrhotic patients
Defect in median raphe is immediately adjacent to
true umbilicus (usually above) PARAUMBILICAL
HERNIA
UMBILICAL HERNIA IN ADULT
•Round with well defined fibrous margin.
•ContentsSmall umbilical hernia often contain extraperitoneal fat
or omentum
Larger hernia contain small or large bowel
Very large hernia have narrow neck of the sac
prone to become irreducible, obstructed and
strangulated.
UMBILICAL HERNIA IN ADULT
Clinical features• Swelling in the umbilical region - increase on
coughing/straining
• Cough impulse expansile impulse is present
• Patient may also have inguinal hernia
• Reducibility can be present
• Crescent-shaped appearance of the umbilicus
• Patient complaint of pain due to tissue tension, and
symptom of intermittent bowel obstruction
• Dermatitis in case of large hernia (due to thinned &
stretched of overlying skin)
UMBILICAL HERNIA IN ADULT
Treatment•Operation hernia that contain bowel
(higher risk of strangulation)
•Small hernia is left alone if it is asymptomatic (but may enlarge and require surgery at a later date)
•Reduction of weight
*Surgery may be performed open or laparoscopically
OPEN UMBILICAL HERNIA REPAIRVery small defects < 1 cm
•Closed with a simple figure-of-eight suture
•Repaired by darn technique where a non-absorbable,
monofilament suture is criss-crossed across the defect
and anchored firmly to the fascia all around
OPEN UMBILICAL HERNIA REPAIR
Defects up to 2 cm• Sutured primarily with minimal tension
• Classical repair by Mayo :
• A transverse incision is made and the hernia sac is dissected, opened
and its content reduced
• Any non viable tissue is removed
• The peritoneum is closed
• The defect in the anterior rectus sheath is extended laterally on both
sides and elevated to create an upper and lower flap (double
breasted)
OPEN UMBILICAL HERNIA REPAIR
Defects > 2 cm
•Mesh repair; mesh is placed in one of the several
anatomical planes
• Within the peritoneal cavity
• In the retromuscular space
• In the extraperitoneal space
• In the subcutaneous plane
LAPAROSCOPIC UMBILICAL HERNIA REPAIR
•3 ports are placed laterally on the abdominal wall
•The contents of the hernia are reduced by traction and
external pressure
•A disc of non-adherent mesh, is introduced and positioned on
the under surface of the abdominal wall, centered on the
defect
•It is then fixed to the peritoneum and posterior rectus
sheaths using staples, tacks or sutures
REFERENCES
•Short Practice of Surgery, Bailey & Love’s, 26th Edition
•Manipal Manual of Surgery,K Rajagopal Shenoy, 4th edition
•https://www.youtube.com/watch?v=NMXdU4UIu9Y
THANK YOU