Types of Abdominal Hernia
? Epigastric
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? paraumbilical? Umbilical
? lumbar
? Spigelian
? femoral
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? inguinalThe Basic Feature Of Al Hernias
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? Occur at a weak spot .? Reduce on lying down ,or with direct pressure.
? Have an expansile cough impulse
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A hernia consist of 3 parts:
1.Sac:
consist of a diverticulum of
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peritoneum.
2.Contents:
Omentum, small or large intestine,
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urinary bladder, Omentum, ovaries
malignant nodules or ascetic fluid.
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3.Coverings:derived from the layers of abdominal
wall.
Complications Of Hernias
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? Irreducible
the hernia contents cannot be manipulated back into the abdominal
cavity.
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? Incarcerated
the contents of the sac are literally inpresiond in the sac of Hernia.
? Obstruction
the loop of the bowel become non functioning with normal blood
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supply .
? Strangulated
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cut off the blood supply to the content sac (tender).Femoral Hernia
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Femoral Canal? The major feature of the femoral canal is the femoral
sheath.
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? This sheath is a condensation of the deep fascia (fascia
lata) of the thigh and contains, from lateral to medial,
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the femoral artery, femoral vein, and femoral canal.? The femoral canal is a space medial to the vein that
al ows for venous expansion and contains a lymph
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node (node of Cloquet).
? Other features of the femoral triangle include the
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femoral nerve, which lies lateral to the sheathFemoral Hernia
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Femoral herniaAge: uncommon in children , most common in old age
female .
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Sex: women > men (but still commonest hernia in
women the inguinal hernia )
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Discomfort and painSwelling in the groin
Femoral hernia is more likely to be strangulated than
the inguinal hernia
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Narrow neck High risk for strangulation
Multiplicity: often bilateral
Femoral hernia versus inguinal hernia
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Inguinal hernia
Femoral hernia
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1- more common in male1- more common in females
2- pass through the inguinal canal
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2- pass through the femoral canal
3- neck of the sac is above and medial
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3- neck of the sac is below and lateralthe pubic tubercle
the pubic tubercle
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4- less common to be strangulated
4- more common to be strangulated
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5- can be treated without surgery5- must be treated surgical y
6- the two diagnostic signs of hernia +
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6- the two diagnostic signs of hernia -
7- the sac mainly contain ; bowel
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7- the sac mainly contains ; omentumFemoral hernia repair
Femoral hernias should be repaired very soon after
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the diagnosis has been made because of the high riskof strangulation
There is no place for a truss for a femoral hernia
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Different approaches :Open VS Laparoscopic
Open surgery
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Three approaches have been described for open
surgery :
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? Infra-inguinal approach (Lookwood)? Supra-inguinal approach ( McEvedy)
? Trans-inguinal approach ( Lotheissen)
Each technique has the principle of dissection of
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the sac with reduction of its contents, followedby ligation of the sac and closure between the
inguinal and pectineal ligaments.
Epigastric Hernia
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? It occurs through the linea alba midway between thexiphisternum & the umbilicus
? It is a protrusion of extraperitonial fat from the site of
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entry of a small blood vessel through the linea alba
(fatty Hernia of linea alba)
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? It is usually small in size, it may drag a pouch ofperitoneum to form a true hernia
? The neck is usually too small to allow a hollow
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viscous to enter it, consequently the sac is empty or
it contains small part of omentum (not true hernia )
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? It is probably as a result of sudden strain that tearsthe interlacing fibers of linea alba
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? Clinically; The patient is usually a manual worker, 30-50y in age, symptom less, incidentally discovered
during routine exam
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? Pain & tenderness is due to strangulated fat.
? Referred pain & dyspepsia
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? Treatment: Excision & repair of defect.Epigastric Hernia
Umbilical Hernia
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? True umbilical Common in children? Intestinal obstruction extremely rare
? Surgical repair if persisted after 3rd birthday
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? Site: in the center of the umbilicus
? Size and shape: size can vary from vary small to very
large. Shape is usually hemispherical.
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? Composition: contain bowel, resonant to percussion
? They reduce spontaneously when the child lies down
? Reducibility: easy
? Cough impulse: invariably present
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Acquired umbilical herniaHernia through the umbilical scar , so it is a true
umbilical hernia.
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Not common and is usually secondary to increase intra
abdominal pressure.
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The most common causespregnancy
ascites
ovarian cyst
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fibroidsbowel distension
Para-umbilical hernia
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? Para umbilical usually middle age women obese ormultiparous
? It is a protrusion through the linea alba just above or the
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umbilicus. As it enlarges it sags downward and can attain a
large dimensions
? The neck of the sac is narrow as compared with the size of
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the sac & it's contents ( omentum, small intestine or part of
the colon). Usually loculated due to adhesions.
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? Clinical y; more common in women, obese, multiparous & 35-50y of age.
? It becomes irreducible due to adhesions & strang-ulation
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may occur.
? Pain colicky or dragging.
? The skin over it becomes reddened, smooth & may become
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excoriated.
? Treated by division of adhesions. & repair of defect "Mayo's
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repair"Incisional Hernia
? Protrusion through surgical wound
? Occur after 3-5% of abdominal operation
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? Causes1. Midline ,vertical incision
2. Poor technique
3. Wound or chest infection
4. Obesity
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Strangulation is rare but repair is advisableIncisional hernia
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Prevention of Incisional Hernia? Continuous Closure with Running Suture
? Monofilament slowly absorbable suture (PDS)
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#1 or 2? Suture: Wound Length < 4:1
Summary
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? Hernias are common, morbid, and costly? Best chance of success is mesh repair : uncontaminated field
? Laparoscopic vs Open stil debated
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? What can't be cured must be endured