Approach to abdominal wall

hernia
by : younis zainal khaleel
kufa college of medicine .. Medical student .. Stager

Topics of presentation
1 . All types of abdominal wall
hernia other than inguinal and
femoral (previously discussed ).
2 . Divarication of the rectus
abdominis and incisional hernia .

Those are

Incisional hernia :
at the site of previous incision

According to there incidence

Anterior abdominal wall hernia

Umbilical hernia
Many different condition represent
umbilical hernia , they differ by
each other in there
pathophysiology and age of
incidence .
1- Omphalocele & gastrochisis ( at
birth)
2- Umbilical hernia of infants and
children
3- acquired umbilical hernia (adult
and older)
*

omphalocele
1.. Omphalocele and gastrochisis.
-1: 6000 births
Gastroschisis: It is the congenital anomaly
characterized by a defect in the anterior wall through
which the abdominal contents freely fall.
Omphalocele: It is a congenital birth defect that
involves the umbilical cord itself, and the organs
remain enclosed in the visceral peritoneum.
-There is some debate as to whether gastroschisis
represents a separate entity or is simply an
Omphalocele with ruptured membranes, but the
debate of little importance because the same
principles of treatments.

Pathophysiology of omphalocele
An omphalocele is caused by error in the embryonic development

Normal development there are 3 distinct portions formed

foregut, midgut & hindgut

At early fetal life much of midgut is temporarily herniated

outside the abdomen at the umbilicus

The midgut later re-enters the abdomen and opening of

abdominal wall is closed

*Failure for the midgut to return and re-enter the abdomen

Omphalocele is formed

omphalocele
Management of omphalocele
Small defects : may be closed primarily soon after
birth
Large defect : a more substantial problem and
four
techniques have been described:
* non-operative therapy,
* skin flap closure,
*staged closure and
* primary closure.

Umbilical hernia
2.. Congenital umbilical hernia

Umbilical hernia

Pathophysiology of congenital
umbilical hernia
During development of fetus

A small opening is present in the abdominal muscles, so that the

umbilical cord can pass through, connecting mother to baby.

Usually the abdominal opening closes.

(After birth) Sometimes these muscles do not meet- creating a

small opening.

A loop of intestine can move into the opening between

abdominal muscle and cause and hernia.

Congenital umbilical hernia

age : usually at birth , but may not be noticed until umbilical
cord has separated & healed or it stay so small and not noticed
until it enlarged months later.
Symptoms : usually Symptomless, but mother anxiety is
common , intestinal obstruction is extremely rare.
Signs :
_ Have a classical conical shape or hemispherical .
_ size ( range from 0.5_10cm) .
They reduce spontaneously when the child lies down and
become tense when the child cries.
Cough impulse:expansile cough impulse is invariably present.
Composition : are soft, compressible and easy to reduce,
They usually contain bowel and so may be resonant to
percussion

Congenital umbilical hernia

Natural history :The vast majority of
congenital umbilical hernia disappear
spontaneously during the first few years of life
(up to 2 year), It is difficult to believe that a
large defect will close over in an active child,
but this is the usual
course of events.

umbilical hernia
Treatment of infantile umbilical hernia
Conservative treatment
indicated 2 years; Just reassurance of the
parents, as 95% of hernias will disappear
spontaneously and rarely strangulate .

Surgical : If persists at 2 years of age or older it

is unlikely to resolve and herniorrhaphy is
indicated.

UMBILICAL HERNIA IN ADULTS

UMBILICAL HERNIA IN ADULTS

A true umbilical hernia comes through the
umbilical scar. It is not common in adults
and usually secondary to raised intraabdominal pressure. but the common causes
of an acquired umbilical hernia are pregnancy
and ascites. The local physical signs of the
hernia are identical to those described for the
congenital variety.

Paraumbilical hernia

Paraumbilical hernia

Paraumbilical hernia
is a protrusion through the linea alba,
1. just above (supraumbilical hernia)
2. just below the umbilicus (infraumbilical)
hernia)

Paraumbilical hernia
M:F 1:5 therefore its common in woman who are
*overweight
*ages of 35 and 50
*repeated pregnancy .
Symptoms : The commonest symptoms are
discomfort and a swelling
some time they present complaining of pain or
discomfort around the umbilicus, made worse by
prolonged standing or strenuous exercise , and if its
large one cause a dragging pain because of its
weight .
Strangulation is common , but the usual contents in
this case are extraperitoneal fat or omentum, so even
strangulation occur, the bowel is not obstructed.

Paraumbilical hernia
General examination The patient is quite likely
to be obese and may have other herniae and
generalized abdominal wall laxity.
Shape :classically make the umbilicus crescent
shape if its so near the umbilicus but not in obese
pt and in large one .
Composition The lump is firm as it usually contains
omentum. If it contains bowel, it is soft and
resonant to percussion.
If the hernia can be reduced, the firm fibrous edge of
the defect in the linea alba is easy to feel. It may
vary in size from a few millimetres in diameter to a
defect big enough to admit your hand.

Paraumbilical hernia
Management
May strangulate so need surgery

Which type of hernia here ??

And what's this ??

Epigastric hernia
occurs through the linea alba anywhere between the
xiphoid process and the umbilicus, usually midway
between these structures.
Its usually as a protrusion of extraperitoneal fat that
why called (fatty hernia of the linea alba) , The
mouth of the hernia is rarely large enough to permit a
portion of hollow viscus to enter it; consequently, either
the sac is empty or it contains a small portion of
greater omentum.

Epigastric hernia
Pathophysiology
it is more likely a result of a weakened linea alba due to
abnormal decussation of the fibres of the aponeurosis
That why an epigastric hernia is the direct result of a
sudden strain tearing of the interlacing fibres of the linea
alba.
and the patients are often manual workers between 30 and
45 years of age.

Epigastric hernia
Clinical features
Symptomless
Painful (attacks of local pain, worse on physical
exertion, and tenderness to touch and light clothing)

Referred pain The pain is often associated with

eating, so the patient calls it indigestion and makes a selfdiagnosis of peptic ulceration.
A likely explanation for this is Referred pain that the fatty
hernia is nipped by the linea alba on leaning forward in the
sitting position adopted at the dining table.

Epigastric hernia
On examination
_feel firm, don't usually have a cough
impulse
_cannot be reduced.
_sometimes impossible to distinguish
them from lipoma
_ only the typical position suggesting
the correct diagnosis

Epigastric hernia
Treatment : indicated when a
considerable symptom occur .

Which type of hernia here??

Spigelian hernia
hernia occurring at the level of the arcuate line
The sac, lie beneath the internal oblique muscle, where
it is virtually impalpable it advances through that
muscle and spreads out like a mushroom between the
internal and external oblique muscles and gives rise to
a more evident swelling.

Spigelian hernia
Clinically
So rare , usually over 50 years of age, equal in M &
F.
Typically, a soft, reducible mass will be encountered
lateral to the rectus muscle and below the umbilicus
Dx : By US , CT . Treatment : need operation

Posterior wall hernia

Superior lumber hernia
Inferior lumber hernia (more common)

lumber hernia
lumbar hernias are usually occur secondary to
renal operations, when extensive incisional
sacs may be present
Treatment: operation

Pelvic hernia
These are rare types of hernia.
1. Obturator
2. Gluteal
3. Sciatic

Obturator hernia
which passes through the obturator canal,
women : men 6:1.
Most patients are over 60 years of age.
The swelling is liable to be overlooked because it is covered
by the pectineus muscle

Obturator hernia
It seldom causes a definite swelling, but if the limb is
flexed, abducted and rotated outwards, the hernia
sometimes becomes more apparent.
but can cause intestinal obstruction with nausea &
vomiting.
And the presentation usually as a strangulated hernia , In
more than 50% of cases of strangulated obturator hernia,
pain is referred along the obturator nerve by its geniculate
branch to the knee.
On vaginal or rectal examination the hernia can
sometimes be felt as a tender swelling in the region of the
obturator foramen.
Treatment
Operation is indicated

Gluteal and sciatic hernias

A gluteal hernia passes through the greater
sciatic foramen
A sciatic hernia passes through the lesser
sciatic foramen.

Gluteal and sciatic hernias

Presentation : sciatica , local pain , swelling .
Differential diagnosis must be made between these
conditions and:
a lipoma under the gluteus maximus;
a tuberculous abscess;
a gluteal aneurysm.
All doubtful swellings in this
situation should be explored by
operation.

Incisional hernia
An abdominal incisional hernia is a
hernia through an acquired scar in
the abdominal wall, caused by a
previous surgical operation or
injury.
Scar tissue stretches progressively
if subjected to constant stress.

Incisional hernia
occurs most often in
obese individuals
postoperative abdominal distension .
Postoperative infection or haematoma .
operations for peritonitis because, as a rule, the
wound becomes infected.
There may be a history of factors likely to weaken
the abdominal musculature, such as chronic
cough or steroid therapy.
Weakness Often the event passes unnoticed if the
skin wound remains intact after the stitches have
been removed.

Incisional hernia
Clinical presentation
may occur through
1. a small portion at the lower end or frequently as a diffuse
bulging
Symptoms : The commonest symptoms are a lump and pain.
Intestinal obstruction can occur, causing distension,
colic, vomiting, constipation and severe pain in the
lump.
Those through a lower abdominal scar, usually increases
steadily in size and more and more of its contents become
irreducible .
Nevertheless, most cases of incisional hernia are
asymptomatic and broad-necked and do not need
treatment Therefore they are rarely strangulate.

Incisional hernia
Examination
The common findings are a lump with
an expansile cough impulse, beneath
an old scar.
Incisional hernia are not
unusual irreducible,
the defect being plugged with
adherent omentum.

Incisional hernia
Treatment
1.Palliative : An abdominal belt is sometimes
satisfactory, especially in cases of a hernia through an
upper abdominal incision.

2.Operation
Postoperative care
* nil by mouth and intravenous fluids until bowels have functioned
*Early ambulation and gentle physical exercise to be encouraged.
*patient should not resume strenuous exercise for several weeks.

Result of operation (recurrence )

Without mesh .. 30_50%

With mesh .. 10%

Divarication of the rectus

abdominis
This is separation of the rectus abdominis muscles
with extenuation of the linea alba, from xiphisternum
to umbilicus and occasionally below.

Divarication of the rectus

abdominis
in children may be seen in the first few
years.
_The condition usually improves and eventually
disappears as the child grows.

The only clinical concern is the cosmetic

disfigurement,
as strangulation is impossible.

Divarication of the
rectus abdominis
in adults,
in women during and immediately after childbirth. There
may be a wide separation of the muscles, with stretched
overlying abdominal skin.
As abdominal tone recovers, the defect closesbut may
become permanent after multiple pregnancies.
2 way to examine :
1.. Make the recti to relax :the patient lying supine The
examiner may be able to push a hand into the abdominal
cavity .
2.. Make the recti fully tense :ask the patient to raise the
head and legs together or other way to tense the recti ,
The thinned-out linea alba then bulges, producing a
visible swelling.

Divarication of the rectus

abdominis
Treatment
An abdominal belt is all that is
required. As there is no risk of
strangulated intestinal contents.

Important messages ,
Review slide ..

Is this hernia ??

Is this hernia ??