Abdominal wall & hernia
Prof M K Alam
ILOs
At the end of this presentation students will be able to:
 Describe the aetiology, presentation of rectus sheath hematoma.
 Describe the aetiology, presentation of desmoid tumor.
 State the anatomy of inguinal canal, femoral canal and umbilicus.
 Describe the aetiology, risk factors, presentation, complications and
management of groin hernias.
 Differentiate between different types of groin hernia.
 Describe- presentation & management of other abdominal wall
hernias.
Diseases of Umbilicus
• Persistent vitello-intestinal duct: Persistent part-
Meckel’s diverticulum. Whole patent duct forms
fistula between ileum & umbilicus. Foul discharge.
Treated by excision.
• Persistent urachus: Cyst or urinary fistula.
• Tumours: Primary- SCC, Melanoma
Secondary: Tumour tracking along ligamentum teres.
• Hernia
Rectus sheath haematoma
Aetiology: Spontaneous (anticoagulation)
Traumatic (excessive physical activity).
Bleeding from inferior epigastric artery.
Present as painful, tender swelling.
Diagnosis-U/S.
Treatment: Spontaneous resolution
or surgical evacuation.
Desmoid tumour
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Fibromatosis/ neoplasm: from fibroaponeurotic part of rectus
abdominis.
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More common in young female of child bearing age, OC use.
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Other sites- extremity, intra-abdominal.
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Asymptomatic slow growing mass.
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Diagnosis: CT or MRI for delineation, core needle biopsy.
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Treatment: Wide local excision.
Local recurrence high if margins are involved.
Recurrence treated by radiotherapy, anti-oestrogen
or NSAID (Sulindac, indomethacin)
Rapid growing- chemotherapy
Abdominal wall hernia
• Definition: Abnormal protrusion through
weakness in the wall of the cavity.
It carries with a peritoneal sac.
• Contributing factors: Chronic cough, obesity,
straining (constipation), repeated pregnancy,
family history, ascites, defective collagen
synthesis, heavy lifting, RLQ incision.
Types of hernias
• Groin hernias: Inguinal (direct/ indirect), femoral
• PUH, epigastric
• Incisional
Each type can be:
• Reducible & irreducible
• Obstructed & strangulated
Inguinal hernia
• Incidence:
• Indirect Inguinal Hernia (60%),
• Direct Inguinal Hernia(25%)
• Femoral hernia (15%)
• Anatomy of inguinal canal:
Indirect Inguinal hernia
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Enters through deep ring within a sac.
Dragging discomfort
Lump
Cough impulse, reducibility
Deep ring occlusion test
Irreducible with features intestinal obstruction
(obstructed hernia)
• Above features with severe pain in hernia, skin
redness and very tender- strangulated hernia
Direct inguinal hernia
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Bulges through weakness of Hasselbach’s triangle
Wide neck so rarely obstructs or strangulates
Appears as wide bulge
Often spontaneously reduces after cough or lying
Deep ring occlusion does not control
Management
• All IH in children and most IH in adult ( if fit for
surgery): surgical repair.
• Preoperative investigations for fitness.
• Done mostly as a day case
• Local, regional or general anaesthesia
• Laparoscopic or open surgical repair
Inguinal hernia repair
• Open repair IH: Herniotomy + mesh repair- adult
Only herniotomy-children
• DH: No sac excision, sac reduced, weakness/
defect of fascia transversalis repaired, then mesh
applied to posterior inguinal wall as in IH
Femoral hernia
• Projects through femoral ring and passes down the
femoral canal (1.25 cm)
• Bound laterally by a thin septum separating it from
Femoral vein, anteriorly- inguinal ligament, medially-
lacunar ligament and posteriorly- superior ramus of
pubis & pectineal ligament of Cooper.
• Appears through the saphenous opening in deep
fascia, appear to lie in front of inguinal ligament
Clinical features of Femoral hernia
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Groin swelling (often small)
Groin pain on exercise
Sometimes difficult to distinguish with IH
Examination: Put a finger tip over pubic tubercle
(How to find it?).
IH- above & medial, FH- below & lateral
Often irreducible due to its curved course.
Obstruction, strangulation rate high (40%)
D/D: LN, saphenous varix (thrill on cough,
disappears on lying down), ectopic testis, psoas
abscess
Treatment
• Advise Surgery to all
• Surgery under local/ GA
• Open surgery: Sac is dissected, contents reduced
& femoral ring obliterated by suturing inguinal
ligament to pectineal ligament.
• Laparoscopic approach.
Epigastric hernia
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Protrusion through a defect in linea alba
Firm midline lump.
Often contains preperitoneal fat.
Sometimes peritoneal sac with omentum.
Open surgical repair by non-absorbable suture or
mesh
• Laparoscopic repair- if large
Umbilical, Para-umbilical hernia
• UH: Protrusion through umbilicus. Seen infants when
they cry. Most- spontaneous resolution by age 3, If
not- surgical repair
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PUH: Protrusion through tissue around umbilicus
Hernia gradually enlarges, stretching overlying skin
Defect multilocular, irreducible due to adhesion
More common in female
Surgery advised- high risk of obstruction/ strangulation
PUH, UH
Surgery for PUH
• Open Surgery: Transverse skin incision. Sac
dissected, contents reduced, sac excised and
defect repaired by simple suture, Mayo’s
repair or mesh repair if large defect (>3cm)
• Laparoscopic repair
Incisional hernia
• Hernia bulging through poorly healed abdominal
incisions
• More common with midline vertical incisions
• Predisposing factors: Poor surgical technique,
infection, obesity, chest infection and collagen
disorders.
• Defects may be multiloculated
• Cough impulse, defects felt on reducing hernia
• Risk of obstruction/ strangulation
Surgical repair
• Open surgery: Prolene mesh repair
• Laparoscopic mesh repair: Less postoperative
pain, shorter hospital stay
• Mesh repair complications: Seroma, infection
• Laparoscopic repair: Less hernia recurrence
Rare external hernias
• Spigelian hernia: through linea semilunaris at the
lateral border of rectus abdominis. Surgical repair
• Lumber hernia bulges above iliac crest between
posterior border of ext. oblique & latissimus dorsi.
• Obturator hernia through obturator canal.
Common in female. Diagnosis usually made at
laparotomy for intestinal obstruction due to
strangulated hernia.
Complications of hernia
• Incarcerated: Hernia contents are irreducible but
not obstructed or strangulated.
• Obstructed: Irreducible hernia presenting with
intestinal obstruction.
• Strangulated: When blood supply to the contents
is jeopardized in an irreducible hernia.
Thank you!