Hernia-Ventral hernia

By Dr.Teo Zue Hiong

ContentsDefinitionClassificationIncisional hernia

managementSpigelian hernia

management

Hernia

• Definition– An abnormal protrusion of an organ or tissue

outside its normal body cavity or restraining sheath

Neck/MouthNeck/Mouth

Contents of sac(usually bowel)

FundusFundusCovering of Covering of hernia sachernia sac

Anatomical structure

Causes of Hernia• May exploit natural openings(inguinal,femoral and

obturator canals, umbilicus and oesophageal hiatus) or weak areas caused by stretching, surgical incision or laparotomy

• Any condition that increases the pressure of the abdominal cavity may contribute to the formation or worsening of a hernia.– Obesity– Heavy lifting– Coughing– Straining during a bowel movement or urination– Chronic ling disease– Fluid in the abdominal cavity– Hereditary

Classification of abdominal herniaInguinal hernia/Groin hernia

Direct inguinal herniaIndirect inguinal herniaFemoral hernia

Ventral herniaEpigastric herniaUmbilical herniaPara-umbilical herniaSpigelian herniaIncisional hernia

Other rare and specific interparietal hernia

Sign and symptoms

• The signs and symptoms of a hernia can range from noticing a painless lump to the painful, tender, swollen protrusion of tissue that you are unable to push back into the abdomen—possibly a strangulated hernia. – Reducible hernia– Irreducible hernia– Obstructed hernia– Strangulated hernia– Inflammed hernia

Reducible hernia

– Asymptomatic reducible hernia• New lump and the groin or other abdominal wall area• May ache but is not tender when touched.• Sometimes pain precedes the discovery of the lump.• Lump increases in size when standing or when abdominal pressure

is increased (such as coughing) • May be reduced (pushed back into the abdomen) unless very large

Irreducible hernia

– Irreducible hernia• Usually painful enlargement of a previous hernia that

cannot be returned into the abdominal cavity on its own or when you push it • Some may be long term without pain • Can lead to strangulation • Signs and symptoms of bowel obstruction may occur,

such as nausea and vomiting

Strangulated hernia

– Strangulated hernia• Irreducible hernia where the entrapped intestine has

its blood supply cut off • Pain always present followed quickly by tenderness and

sometimes symptoms of bowel obstruction (nausea and vomiting) • You may appear ill with or without fever • Surgical emergency • All strangulated hernias are irreducible (but all

irreducible hernias are not strangulated)

Ventral hernia

Ventral hernia

Incisional hernia

• One that occurs through the wound of a previous operation

• Same features as a hernia that is caused by non-surgical injury to the abdominal wall

• 1% of transparietal abdominal incisions are followed by a hernia

Aetiology• A postoperative complication,can be

considered in terms of three factor– Preoperative factors– Operative factors– Postoperative factors

Preoperative factors• Age: older usually need more time to heal• Malnutrition• Sepsis: worsen• Uraemia: inhibit fibroblast division• Jaundice: impedes collagen maturation• Obesity• Diabetes mellitus• Steroids• Peritonitis

Operative factorsType of incisions

vertical are more prone to hernia than transverseTechnique and materials

Tension in the closure decrease the blood supply in woundLoosen knotsClosure using rapidly absorbable suture materials

Type of operationOperations involve bowel or urinary tract are more likely to

develop wound infectionDrain tube

Postoperative factors• Wound infection:– Same important with the wrong choice of suture material– Enzyme destruction of healing tissues– Inflammatory swelling raises tissue tension and impedes

blood supply– 5-20% of wound infections result in a hernia

• Abdominal distension– Postoperative ileus increase the tension on a wound– Stitches may cut out

• Coughing:generates wound tension

Signs and symptoms• A bulge in the scar• As the hernia enlarges and loculates, symptoms of subacute I/O

are common• Overlying skin:thin and atrophic,eventually ulcer and rupture• Strangulation is a surgical emergency

• P/E:– Usually reducible– Hernia with a cough impulse at the site of an old scar– When the patient lies flat, hernias deceptively small,any

manoeuvre that raise intra-abdominal pressure produces the hernia in all its glory

Management Even small symptomatic hernias should be repaired early

Prolonged observation simply increase the difficulties of subsequent repair and hazardous

Surgical technique:same as for para-umbilical herniaExicision of the sac after reduction of its contents Insertion of overlapping sutures into the rectus sheath

Spigelian hernia

• Rare but clinically important, less than 1% of total• An interparietal hernia in the line of the linea

semilunaris(the lateral margin of the rectus sheath)

• Usually at the level of the arcuate line:due to all aponeurotic layers are reflected anterior to the rectus muscle

• The hernial sac emerges and enlarges like a mushroom deep to the external oblique

S&S

Symptoms Local pain that is worse on straining Lumps Non-specific lower quadrant discomfort which needs to be

investigated Features of obstruction or strangulation

Signs: Tenderness at the site of the hernial orifice Lump which may be difficult or even impossible to feel

Management

• Abdominal USG/CT:useful in the demonstration of these hernias

• Repair:A simple matter of excising the sac and closing the defect/Laparoscopic repairs

References

1. Clincal surgery 2nd edition2. Principle and practice of surgery 5th edition

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