Hernias, Umblicus and Abdominal Wall

DR Javed swati
Presentation
By Dr. Javed Swati
FCPS Associate Professor of Surgery Department Peshawar medical college
javedswati
HERNIAS, UMBLICUS AND ABDOMINAL WALL

Introduction? Definition:G.F Common to all hernias Aetiological factors
I.
a)
Raised intra abdominal pressure

Power full mascular effort examples are whooping cough, chronic cough, straining on micturtion, straining on defecation intra abdominal malignancy
Dr. JavedswatiAfter Correction/Elective 000
II.
Muscular weakness like excessive smoking, obesity, old age, multipara woman a) b) Congenital P.P.V Acquired P.P.V eg peritoneal dialysis
III.
Dr. Javedswati
000
External Hernias
-
Epigastric Para umblical Umblical Spigelian Divarication Inguinal Femoral Incisional Obturator Superior lumber Inferior lumber Gluteal Sciatic
Dr. Javedswat iAfter Correction/Elective
Internal Hernias in abdomen

-
Hiatus hernias Hernia around ilioceal area
Hernias around D.J junction
Dr. JavedswatiAfter Correction/Elective
000
Composition of Hernias Main three parts are:

Sac
Coverings of Sac
Contents of Sac
000
Possible contents could he

Omentum Intestinal Portion of circumfernce of Gut Portion of Bladder Ovary + fallopian tube
Meckels diverticulum Appendix Fluid

8 Dr. JavedswatiAfter Correction/Elective 000
Classifications I. Site
a) External b) Internal
II. Reducible?
III. Irreducible? Obstructed? Strangulator? Inflamed?
Reducible Hernia.? Irreducible Hernia? Obstructed Hernia? Incarcerated Hernia? Strangulated Hernia?
10
000
Strangulated Hernias
Pathology? Clinical Feature
-
Pain:Nausea Vomiting Increase in size of Hernia
O/E Hernia is Tense, Tender, Irreducible, no expancile impulse.

11
If not treated may lead to ischemia
perforation, Peritonitis.
Richters Hernia?
Strangulated Richters Hernia? Strangulated omentocoele? Inflamed Hernia?
Inguinal Hernia
Surgical anatomy
a) Superficial inguinal ring? b) Deep inguinal ring? c) Inguinal cannal?

Types
I. Indirect inguinal Hernia II. Direct inguinal Hernia
13
000
Indirect (Oblique) Inguinal Hernia

G.F ? Types
1.
Bubonocele
2.
3.
Funicular
Complete (Scrotal) C.F?
14
000
Points to be cleared on Examination

Is the hernia right, left or bilateral
Is it inguinal or Femoral
Is it direct or indirect
15
Is it reducible or irreducible
Is the inguinal hernia incomplete or complete What are the contents?
D/D in male 1. Vaginal hydrocoele
2. Encysted hydrocoele of the cord

3. Spermotocoele 4. Femoral hernia 5. Incomplete disended testis 6. Lipoma of the cord
D/D in female
1.
Hydrocoele of cannal of nuck
2.
Femoral hernia
Treatment
Herniotomy Herniotomy + Herniorrphy with or without mesh Trus

17
Direct Inguinal Hernia

Introduction? G.F? C.F?
Funicular direct inguinal hernia (Prevesical hernia)? Dual (Saddle bag. Pantaloon hernia)
Operation for direct hernia?

Laparoscopic herniorraphy? Strangulated Inguinal hernia
C.F? Pathology? Treatment
a) General b) Operation
19
000
Treatment of Strangulated Inguinal Hernia

Pre-operative: Avoid unnecessary delay and treat it as emergency Vigrous resucitation with I/V fluid Nasogastric aspiration Antibiotics Catheterisation
20
000
Operation: Inguinal herniotomy for strangulation? Conservation measure in children and infants? Taxis? NB it is condemned Dangers of taxis i. Contusion or rapture of the intestinal wall ii. Reduction en mass iii. Reduction into the loculus of the sac iv. Rapture of the sac at neck
21
000
Non operative treatment of hernia 1. Only indicated in children 2. Forcible. Reduction must never be attempted. Maydls Hernia (Hernia en W)? Results of operation for inguinal hernia Sliding hernia (Hernia englissade)?
22
000
Femoral Hernia
G.F - More common in woman - Can not be controlled with truss - Have a high incidence of strangulation - Should be operated as soon as possible
23
000
Surgical Anatomy of Femoral Hernia? Boundaries of femoral ring

Inguinal ligament Posterior Astley coopers (ilio pectineal ligament) Medially Knife like edge of Gimbernets (Larcunar ligament) Laterally Thin septum of femoral sheet separating it from femoral vein.
Anterior
24
000
Sex incidence? Pathology? C.F Rare before puberty Common between 20-40yrs and increasing age Twice common on Rt side 20% bilateral Less symptomatic than inguinal Dragging pain due to Omentum
25
000
D.D of femoral hernia 1. An inguinal hernia 2. A sephana varix 3. An enlarged femoral lymphnode 4. Lipoma 5. A femoral aneurysm 6. A psoas abscess 7. A distended psoas bursa 8. Repture of the adductor longus with haematoma formation
26
000
Hydrocoele of femoral hernial Sac

Laugiers femoral hernia?
Narathas femoral hernia?

Cloquets hernia?
27
000
Umblical Hernia
I Exomphlos (omphalocoele) Types Small A) Primary closure B) Large?
Treatment 1. Non operative thrapy 2. Skin flap closure 3. Staged closure 4. Primary closure
II.
Congenital umblical hernia
III.
Umblical Hernia of Infants and children
Treatment after 2 years Operation Herniorraphy
29
000
Para Umblical hernia?

(Supra umblical hernia, infra umblical hernia)
C.F
- Female to male ration is 5:1
- Patient is usually over weight between 35 and 50years
Increasing obesity and flabiness of abdominal musculature and repeated pregnancies are important itiological factors - Usually irreducible
30
000
- Dragging pain
- G.I symptoms - Intestinal colic
- Intertrigo of the adjacent surface of skin and trophic
ulcer are trouble some complication
31
000
Treatment Advised in all cases If no emergency advise weight loss Umblical herniorraphy i. Primary closure if defect is small ii. Myos repair iii. Prosthetic buttressing if defect is large or hernia is recurred Additional laptectomy Strangulation? Operation of strangulation?
Epigastric hernia (Fatty hernia of the linea alba) Introduction
33
000
C.F
Common in manual workers between 30 to 45 years Symptoms - Small hernia better felt than seen - May be symptomless - Painful - Referred pain
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000
Treatment
-
Treated if gives symptoms Operations
Rare external hernias

1. 2. 3. a. b.
Inter parital hernia (Interstitial hernia)? Other verities Spigelian hernia Lumber hernia Inferior Superior
35
D/D of lumber hernia

1. 2.
Lipoma Cold abscess
3.
Phantom hernia (Poliomyelitis)
36
000
Parineal Hernia?
Types - Post operative hernia
- Median sliding perineal hernia
- Antero-lateral perineal hernia - Postero lateral perineal hernia
Obturator hernia? Gluteal and sciatic hernia?

D/D
i. ii. iii.
Lipoma Cold abscess Gluteal anurysm
38
000
INFLAMMATION OF UMBLICUS:
INFECTION OF UMBLICAL CORD:
OMPHALITIS?
39
000
COMPLICATION:
Abscess of abdominal wall Extensive ulceration of abdominal wall Septicaemia Jaundice in new born Portal vein thrombosis and subsequent portal
hypertension Peritonitis Umblical hernia
40
000
UMBLICAL GRANULOMA???
DERMATITIS OF AND AROUND THE UMBLICUS?? PILONIDAL SINUS???
(UMBLICAL CALCULUS UMBOLITH) ?

UMBLICAL FISTULAE???
41
000
THE VITELLOINTESTINAL DUCT???
POSSIBLE PRESENTATION OF VITELLOINTESTINAL DUCT:

INTRA ABDOMINAL CYST?
INTRAPERITONEAL BAND MECKELS DIVERTICULUM PULLED IN UMBLICAL HERNIA. BAND ATTACHED WITH ANOTHER LOOP LEADING TO
INTESTINAL OBSTRUCTION BAND ATTACHED WITH MESENTRY NEAR DISTAL ILLEUM.
TREATMENT:
42
000
PATENT URACHUS????
TREATMENT:
TREAT DISTAL OBSTRUCTION UMBLECTOMY+EXCISION OF THE URACHUS
43
000
NEOPLASMS OF THE UMBLICUS:

BENIGN: UMBLICAL ADENOMA ,
ENDOMETRIOMA MALIGNANT: SECONDARY CARCINOMA OF UMBLICUS(SISTER JOSEFS NODULE) FROM STOMACH ,COLON ,OVARY, BREAST
44
000
ABDOMINAL WALL
Burst Abdomen and Incision Hernia
Introduction?
Factor related to the incidence of Burst abdomen and Incisional Hernia
45
000
1.
Technique of wound closure

a) Choice of suture material
b) Methods of Closure
c) Drainage
2.
Factor related to incision?
46
000
3.
Resons for initial of operation (Infection, Pancratitis, Obstruction) Coughing, Vomiting, Distention
General condition of the patient (Obesity, Jaundice, Malignant disease, Hypoproteinemia, Anemia, Pregnancy steroid)
4.
5.
47
000
Burst Abdomen
(Abdominal Dehiscence)
C.F
- Serosangitinous (Pink) discharge from the wound - Feeling something giving way - Viscera lie on skin - Pain and shock are often absent - There may be sign and symptoms of intestinal
obstruction
48
000
Treatment
- Emergency closure of wound
- N.G tube - I/V fluids - Antibiotics
49
000
Incisional Hernia?
Precursors are
- Obesity - Post operative persistent cough - Post operative abdominal distension - Peritonitis - Placement of drain through wound
50
000
C.F
- Size varies - May be irreducible and strangulation
- May be asymptomatic
- All the features of any hernia
51
000
Treatment
- Paliative (Abdominal belt) - Operation?
Simple opposition Complex opposition Plastic fiber mesh net closures
Divarication of rectus abdominus?
52
000
Tearing of the inferior epigastric artery? Common In

- Elderly women - Thin and feeble atheletic - Muscular man usually below middle age - Pregnant woman mainly multipara late in
pregnancy
C.F? D/D
- Twisted ovarian cyst in woman - On right side appendicular lump - Strangutor spigelian hernia
Treatment
- Evacultion of clot and ligation of vessel
54
000
Infection of Abdominal Wall

Cellutlitis
a.Saperficial
b.Deep
Progressive postoperative bacterial syngistic gangrene? Amoebic cutis?
55
000
Neoplasma of Abdominal Wall

- Desmoid tumor? - Fibrosarcoma of abdominal wall? - Adenocarcinoma?
56
000
57
000

Hernias, Umblicus and Abdominal Wall

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DR Javed swati

HERNIAS, UMBLICUS AND ABDOMINAL WALL

Raised intra abdominal pressure

Internal Hernias in abdomen

Hiatus hernias Hernia around ilioceal area

Hernias around D.J junction

Dr. JavedswatiAfter Correction/Elective

Composition of Hernias Main three parts are:

Dr. JavedswatiAfter Correction/Elective

Possible contents could he

Meckels diverticulum Appendix Fluid

Dr. JavedswatiAfter Correction/Elective

Pain:Nausea Vomiting Increase in size of Hernia

O/E Hernia is Tense, Tender, Irreducible, no expancile impulse.

If not treated may lead to ischemia

a) Superficial inguinal ring? b) Deep inguinal ring? c) Inguinal cannal?

I. Indirect inguinal Hernia II. Direct inguinal Hernia

Dr. JavedswatiAfter Correction/Elective

Indirect (Oblique) Inguinal Hernia

Dr. JavedswatiAfter Correction/Elective

Points to be cleared on Examination

D/D in male 1. Vaginal hydrocoele

2. Encysted hydrocoele of the cord

Hydrocoele of cannal of nuck

Herniotomy Herniotomy + Herniorrphy with or without mesh Trus

Direct Inguinal Hernia

Operation for direct hernia?

Dr. JavedswatiAfter Correction/Elective

Treatment of Strangulated Inguinal Hernia

Dr. JavedswatiAfter Correction/Elective

Dr. JavedswatiAfter Correction/Elective

Dr. JavedswatiAfter Correction/Elective

Dr. JavedswatiAfter Correction/Elective

Surgical Anatomy of Femoral Hernia? Boundaries of femoral ring

Dr. JavedswatiAfter Correction/Elective

Dr. JavedswatiAfter Correction/Elective

Dr. JavedswatiAfter Correction/Elective

Hydrocoele of femoral hernial Sac

Narathas femoral hernia?

Dr. JavedswatiAfter Correction/Elective

Congenital umblical hernia

Umblical Hernia of Infants and children

Treatment after 2 years Operation Herniorraphy

Dr. JavedswatiAfter Correction/Elective

Para Umblical hernia?

Dr. JavedswatiAfter Correction/Elective

- Intertrigo of the adjacent surface of skin and trophic

ulcer are trouble some complication

Dr. JavedswatiAfter Correction/Elective

Epigastric hernia (Fatty hernia of the linea alba) Introduction

Dr. JavedswatiAfter Correction/Elective

Dr. JavedswatiAfter Correction/Elective

Treated if gives symptoms Operations

Rare external hernias

D/D of lumber hernia

Lipoma Cold abscess

Phantom hernia (Poliomyelitis)

Dr. JavedswatiAfter Correction/Elective

Obturator hernia? Gluteal and sciatic hernia?

Lipoma Cold abscess Gluteal anurysm

Dr. JavedswatiAfter Correction/Elective

INFECTION OF UMBLICAL CORD:

Dr. JavedswatiAfter Correction/Elective