Anatomical and Physiological
Substantiations of Operative
Interventions on Ventral
Abdominal Wall
Ventral Abdominal Wall Regions
Organs Projection
Muscles of the Trunk
4 Levels of Rectus Abdominis Muscle
Sheath Structures
Layer Structure of the Ventral
Abdominal Wall
Abdominal Incisions
 Must be located nearest to the organ.
 Must have sufficient length for surgeon’s
activities.
 Must be atraumatic.
Skin Incisions of the Ventral Abdominal Wall
Superficial Inguinal Ring
Ventral Abdominal Wall (lower
internal view)
Internal Inguinal Ring
The Walls Of The Inguinal Canal
ANTERIOR WALL
 laterally - muscles fibers of the external oblique
 medially - aponeurosis of the external oblique
 most medially there is not wall but there is a deficiency
called the superficial inguinal ring.
SUPERIOR - arching fibers of the internal oblique and
sometimes transverse abdominis. These fibers start
anterior and lateral, pass over the spermatic cord and
the medially forms part of the posterior wall of the
canal.
POSTERIOR – laterally - deep inguinal ring. Medially the
posterior wall is made up of the aponeuroses of the
internal oblique and transverse abdominis.
INFERIOR - inguinal ligament.
Male Inguinal Canal
Female Inguinal Canal
HERNIA
Hernia of the abdominal wall or
external hernia is such surgical disease,
which is characterized by outlet of the
visceral organs from the place of their
physiological placement through the
natural canals or defects of the
abdominal and pelvic wall. In such case all
visceral organs covered by parietal
peritoneum and skin are not damaged.
HERNIA
Internal hernia is such disease, visceral
organs hit the peritoneum pouch. It
formed in the place of natural peritoneum
fold or recess and generally kept in the
abdominal cavity.
Anatomy of an Inguinal Hernia
Elements of a Hernia:
1. Hernial gate;
2. Hernial sac;
3. Hernial contents;
Elements of hernial sac:
а) neck;
б) body;
в) fundus.
Weak Places of the Ventral Abdominal Wall
Hernial Gates for Hernias of
Ventral Abdominal Wall
1. Umbilical hernia – umbilical ring;
2. Midline hernia – artificial hole or alba
line holes, through which intercostals
nerves pass;
3. Indirect inguinal hernia – deep ring of
inguinal canal;
4. Direct inguinal hernia – inguinal space.
Differences Between Inguinal Hernias
Indirect Hernia
Gate – internal inguinal ring
Sac - is laterally to spermatic
cord and is laterally to
inferior epigastric artery
Form is oval
It can be acquired or
congenital
Direct Hernia
Gate – inguinal space
Sac - is medially to spermatic
cord and is medially to inferior
epigastric artery
Form is round
It can be only acquired
Levelling Factors of the Inguinal Canal
Weakness
 Except in the newborn infant, the canal is an oblique
passage with the weakest areas, namely, the
superficial and deep rings, lying some distance apart.
 The anterior wall of the canal is reinforced by the
fibers of internal oblique muscle immediately in front
of the deep ring.
 The posterior wall of the canal is reinforced by the
strong conjoint tendon of the internal oblique and
transversus muscles immediately behind the
superficial ring.
 In case of sharp temporary increasing of intraabdominal pressure the muscles of superior wall
contract and bring superior wall nearer to the inferior
wall (so that the canal is virtually closed).
Steps of Surgery:
1. access
2. extraction of
hernial sac:
а) incision of hernial sac;
b) reposition of hernial
contents inside of
abdominal cavity;
c) stitching of neck of
hernial sac;
d) cutting of hernial sac;
3. grafting.
А) Lexer’s Grafting
(umbilical hernia)
B) Lexer’s grafting
(umbilical hernia, final view)
Treatment of an Umbilical
Hernia (Mayo's Method)
The defect of
ventral abdominal
wall in umbilical
ring region is
stitched by Hshaped suture in
transversal
direction.
Treatment of an Umbilical
Hernia (Sapezhko’s Method)
Forming of
abdominal
midline
duplication by
stitching in
longitudinal
direction.
Martynov’s Grafting of Anterior Wall of
Inguinal Canal
Inguinal Repair with Mesh
Liechtenstein's Grafting
Mesh patch fixation
Liechtenstein's Grafting
View of interrupted suture
Sliding Hernia
Putting in the Purse-string Suture in Case
of Sliding Hernia
Richter’s (Parietal)
Strangulation of Intestine
Retrograde Strangulation
Thank You for Attention!