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LECTURE  2 ABDOMINAL WALL HERNIAS National O. Bogomolets  Medical  University  Faculty  Surgery Department N1 Kyiv 2007 Prof. Kucher M.
A  h ernia is a hole in the abdominal wall. This hole allows the protrusion of a structure that is supposed to be within the abdomen. The structure that protrudes can be some fat, a loop of intestine, the appendix, an ovary, or part of the bladder.  You can think of a hernia like an inner tube of a tire that is protruding out of the outer tread which is worn out. Hernias can occur in men and women of all ages and in children. Some hernias are present at birth. Others develop slowly over a period of months or years.
 
INCIDENCE No  peritoneum sac  - no hernia:
Abdominal wall (ventral)   hernias Inguinal hernias are in the groin area. They are most common in men,  primarily because of the unsupported space left in the groin after the testicles  descend into the scrotum
Abdominal wall (ventral)   hernias femoral hernias occur at the top of the thigh in the space through  which the femoral artery, vein, and nerve pass into the thigh.  These hernias occur most often in women
Abdominal wall (ventral)   hernias Umbilical hernias occur in the umbilicus (belly button). They are usually congenital hernias (present since birth)
Abdominal wall (ventral)   hernias Incisional hernias occur at the site of previous abdominal surgery
Inferior lumbar hernia of Petit Superior lumbar  hernia  of Grynfellt-Lesshaft
The anterior perspecrive
The posterior perspecrive
TESTIS DESCENDING
Congenital inguinal hernia Inguinal hernia: the processus vaginalis has remained open allowing abdominal contents (fluid and loops of bowel) to enter into the scrotum Noncommunicating hydrocele Normal scrotum
Can I get above it? hydrocele Congenital hernia
the hernia sac exits through the internal  inguinal ring and takes an oblique path the hernia sac exits through the external  inguinal ring directly Inguinal hernias can be indirect or direct:
A sliding hernia is an indirect hernia where the posterior wall of the sac is formed by large bowel (ascending colon on the right, sigmoid/descending colon on the left)  or bladder
Why do hernias develop? Familial predisposition:  connective tissue disorders  (altering collagen formation) Hernias commonly develop in an  area of weakness  including natural spaces and thin tissue, such as the internal inguinal ring and the floor of the inguinal canal.  Hernias may develop at these sites or other areas due to aging, injury, an old incision, or a weakness present at birth.  Another important factor in the development of hernias is an  increase in the intra-abdominal pressure . This could be secondary to chronic constipation and prolonged straining, chronic persistent coughing, lifting heavy objects, pregnancy, obesity, or chronic liver disease.
Symptoms & signs Protruding bulge  Pain  Discomfort  Weakness symptoms of Inguinal hernia: Groin lump  Groin pain  Intestinal blockage reducible swelling ritual of patient cough
Physical examination
DIFFERENTIALS ,[object Object],[object Object],[object Object],[object Object],[object Object],Groin abscess Hematoma Lipoma Lymphadenitis Pseudoaneurysm Spermatocele Tumor Undescended or retracted testes Varicocele
US & Radiology
[object Object]
Inguinal hernia  repairs ,[object Object],[object Object],[object Object]
Open Nonprosthetic:  Bassini
Open Nonprosthetic:  Shouldice
Open Prosthetic :  Lichtenstein
М. Кучер Laparoscopic ТАРР
М. Кучер ТАРР
М. Кучер ТАРР
М. Кучер ТАРР
М. Кучер ТАРР :   m esh fixation (tacking)
М. Кучер ТАРР : peritoneum closure
Prognosis : hernia recurrence  ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Long term randomized clinical trial of non mesh versus mesh repair of primary inguinal hernia ,[object Object],[object Object],[object Object],[object Object]
Two meta-analyses  (Memon 2003 & McCormack 2003)   Laparoscopic vs Open hernia repair ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
М. Кучер Hernia complications ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
М. Кучер if those organs cannot slide easily back into the abdomen,the hernia is said to be irreducible. Irreducible hernias are often painful and can lead to complications Hernia complications
М. Кучер if the intestine becomes trapped in the hernia sack it is said to be incarcerated
М. Кучер if the neck of the hernia sack actually pinches off the supply of blood to those organs which have become trapped inside, the hernia is said to be strangulated Severe pain  Fever  Vomiting  Gangrene
М. Кучер strangulation of antimesenteric portion of the bowel (Richter’s hernia) No signs of obstruction!!! Stragulated  hernia Maydl’s  hernia
М. Кучер strangulated hernia is a medical emergency  that requires immediate surgery
Intraoperative options ,[object Object],[object Object]
Mayo umbilical hernia repair
Incision hernia
Incision hernia repair ,[object Object],[object Object],[object Object]
Onlay placement ,[object Object],[object Object]
sublay/inlay  placement ,[object Object],[object Object]
PROLENE MESH: major comlication ,[object Object]
Ideal hernia mesh ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Incision hernia repair ,[object Object]
[object Object]
New biological mesh ,[object Object],[object Object],[object Object]

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Bohomolets Surgery 4th year Lecture #2

  • 1. LECTURE 2 ABDOMINAL WALL HERNIAS National O. Bogomolets Medical University Faculty Surgery Department N1 Kyiv 2007 Prof. Kucher M.
  • 2. A h ernia is a hole in the abdominal wall. This hole allows the protrusion of a structure that is supposed to be within the abdomen. The structure that protrudes can be some fat, a loop of intestine, the appendix, an ovary, or part of the bladder. You can think of a hernia like an inner tube of a tire that is protruding out of the outer tread which is worn out. Hernias can occur in men and women of all ages and in children. Some hernias are present at birth. Others develop slowly over a period of months or years.
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  • 4. INCIDENCE No peritoneum sac - no hernia:
  • 5. Abdominal wall (ventral) hernias Inguinal hernias are in the groin area. They are most common in men, primarily because of the unsupported space left in the groin after the testicles descend into the scrotum
  • 6. Abdominal wall (ventral) hernias femoral hernias occur at the top of the thigh in the space through which the femoral artery, vein, and nerve pass into the thigh. These hernias occur most often in women
  • 7. Abdominal wall (ventral) hernias Umbilical hernias occur in the umbilicus (belly button). They are usually congenital hernias (present since birth)
  • 8. Abdominal wall (ventral) hernias Incisional hernias occur at the site of previous abdominal surgery
  • 9. Inferior lumbar hernia of Petit Superior lumbar hernia of Grynfellt-Lesshaft
  • 13. Congenital inguinal hernia Inguinal hernia: the processus vaginalis has remained open allowing abdominal contents (fluid and loops of bowel) to enter into the scrotum Noncommunicating hydrocele Normal scrotum
  • 14. Can I get above it? hydrocele Congenital hernia
  • 15. the hernia sac exits through the internal inguinal ring and takes an oblique path the hernia sac exits through the external inguinal ring directly Inguinal hernias can be indirect or direct:
  • 16. A sliding hernia is an indirect hernia where the posterior wall of the sac is formed by large bowel (ascending colon on the right, sigmoid/descending colon on the left) or bladder
  • 17. Why do hernias develop? Familial predisposition: connective tissue disorders (altering collagen formation) Hernias commonly develop in an area of weakness including natural spaces and thin tissue, such as the internal inguinal ring and the floor of the inguinal canal. Hernias may develop at these sites or other areas due to aging, injury, an old incision, or a weakness present at birth. Another important factor in the development of hernias is an increase in the intra-abdominal pressure . This could be secondary to chronic constipation and prolonged straining, chronic persistent coughing, lifting heavy objects, pregnancy, obesity, or chronic liver disease.
  • 18. Symptoms & signs Protruding bulge Pain Discomfort Weakness symptoms of Inguinal hernia: Groin lump Groin pain Intestinal blockage reducible swelling ritual of patient cough
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  • 25. Open Nonprosthetic: Shouldice
  • 26. Open Prosthetic : Lichtenstein
  • 31. М. Кучер ТАРР : m esh fixation (tacking)
  • 32. М. Кучер ТАРР : peritoneum closure
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  • 37. М. Кучер if those organs cannot slide easily back into the abdomen,the hernia is said to be irreducible. Irreducible hernias are often painful and can lead to complications Hernia complications
  • 38. М. Кучер if the intestine becomes trapped in the hernia sack it is said to be incarcerated
  • 39. М. Кучер if the neck of the hernia sack actually pinches off the supply of blood to those organs which have become trapped inside, the hernia is said to be strangulated Severe pain Fever Vomiting Gangrene
  • 40. М. Кучер strangulation of antimesenteric portion of the bowel (Richter’s hernia) No signs of obstruction!!! Stragulated hernia Maydl’s hernia
  • 41. М. Кучер strangulated hernia is a medical emergency that requires immediate surgery
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