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Chapter 20: Anatomic Defects of the Abdominal Wall and Pelvic Floor: Abdominal Hernias, Inguinal Hernias, and Pelvic Or…

Abdominal Wall Hernias

p. 443 The abdominal wall is made up of the following structures beginning
externally: skin; subcutaneous connective tissue; external oblique, internal
oblique, and transversus abdominis muscles with their investing fascia; and
parietal peritoneum. The rectus abdominis muscles run longitudinally in
the midline from the xiphoid to the pubic symphysis. The investing fasciae
of the external oblique, internal oblique, and transversus abdominis
muscles completely encase the rectus abdominis muscles cephalad to the
semilunar line. Caudally from the semilunar line the muscle is completely
behind the aponeurosis of the fasciae of these muscles and lies directly on
the peritoneum (Fig. 20.1 ). Normally the investing fasciae join in the
midline after surrounding the rectus abdominis muscles.

F I G U R E 20. 1 Layers of the abdominal wall. A, Above semilunar line. B, B…

In the male, the descent of the testes from their original retroperitoneal site
to the scrotum necessitates passing through the abdominal wall to the
inguinal region. At the level of the transversalis fascia where the descent
begins, the internal inguinal ring is formed. The inferior epigastric artery
defines the medial margin of this ring as it courses from the external iliac
artery medially and superiorly into the rectus sheath. The inguinal canal
runs from the internal inguinal ring obliquely downward, emerging through
the external inguinal ring and opening in the external oblique aponeurosis
just above the pubic spine, and then continuing into the scrotum. This
allows for passage of the testes and for the presence of part of the spermatic
cord.

In the female, the round ligament courses in the same direction but ends
short of the labia.

An inguinal hernia—that is, a bulge of peritoneum through the internal

inguinal ring and into the inguinal canal—is less common in the female than
in the male and is frequently identified after stretching of the abdominal
wall during or after pregnancy. It may be related to a congenital weakness of
this area. Occasionally a femoral-type groin hernia may develop. In this
case, the defect in the transversalis fascia occurs in the Hesselbach triangle,
which is an area bounded laterally by the inferior epigastric artery,
inferiorly by the inguinal ligament, and medially by the lateral margin of the
rectus sheath (Fig. 20.2 ). The hernia sac passes under the inguinal
ligament into the femoral triangle rather than coursing through the inguinal
canal. Femoral hernias are more common in females than in males and
have higher risk of strangulation (Fitzgibbons, 2015 ).

F I G U R E 20. 2 Right femoral (A) and right inguinal (B) hernias in the female.

With a reducible hernia, the contents can be returned to the abdominal

cavity. If the contents cannot be reduced, the hernia is said to be
incarcerated. An incarcerated hernia may be acute, accompanied by pain,
or long-standing and asymptomatic. If the blood supply to the incarcerated
structure is compromised, the hernia is said to be strangulated. Because the
hernia sac is primarily prolapsed peritoneum, the hernia itself is not
strangulated but only its contents. On rare occasions, a portion of the wall
of the hernia sac is composed of an organ such as the sigmoid colon or the
cecum. In these instances, the hernia is called a sliding hernia.

A ventral hernia occurs in the abdominal wall away from the groin.
Examples include umbilical hernias, which are caused by congenital
relaxation of the umbilical ring, and incisional hernias, which are
herniations through separation of fascial planes after operative incision.
Incisional hernias generally involve the separation of the fascia of the
abdominal wall with the hernia sac palpated beneath the skin and
subcutaneous tissue. The sac wall is composed of peritoneum. Because the
umbilicus consists of a fusion of skin, fascia, and peritoneum, an umbilical
hernia generally occurs because the fascial ring is grossly separated,
allowing the hernia sac to protrude. This occurs most frequently in obese
women. The hernia sac itself is made up of peritoneum and subcutaneous
tissue beneath the skin (Fig. 20.3 ). Two special ventral hernias include
the epigastric hernia, which occurs in a defect of the linea alba above the
umbilicus, and the rare spigelian hernia, which is a herniation at a point
where the vertical linea semilunaris joins the lateral border of the rectus
muscle. Spigelian hernias are rare and result from congenital or acquired
defects. These are rather rare hernias (1% to 2% of all hernias).

F I G U R E 20. 3 Umbilical hernia.

p. 444 Rectus diastasis is an acquired abdominal wall defect in which the rectus
muscles on either side of the midline separate. This is not a true hernia, as
there is no fascial defect, but it is mentioned here for differential diagnosis
purposes. Pregnancy is a common risk factor for rectus diastasis.

Etiology
Hernias may be the result of a congenital malformation. The umbilical
hernia is the best example. Before 10 weeks’ gestation, the abdominal
contents are partially herniated through the umbilicus into the extra
embryonic coelomic cavity. However, after 10 weeks the viscera normally
return to the abdominal cavity, and the defect in the abdominal wall closes
during subsequent fetal growth. Generally at birth only the space occupied
by the umbilical cord remains patent. After the cutting of the cord, the area
heals so that the skin in the area of the umbilicus fuses above the closed
fascial layer. Some infants at birth will show a small umbilical hernia, but in
most instances the fascial defect closes during the first 3 years of life. If it
does not close, an umbilical hernia will form. Black infants have umbilical
hernias more often than do white infants. Occasionally, umbilical hernias
occur in adults after the distention of the abdominal cavity with pregnancy
or with ascites.

p. 445 In rare cases the abdominal wall closure process is less complete during
gestation, leading to an omphalocele, which is a hernia sac at the umbilicus
covered only by peritoneum and including bowel and other abdominal
contents. Omphaloceles are usually seen in infants with other
malformations and possibly chromosome anomalies, such as trisomy 13.

Hernias that occur in adults are often associated with trauma or injury. In
many instances, the hernia bulge develops slowly after years of heavy labor.
It is likely that a congenital anatomic defect was always present but became
exaggerated over time, leading to the development of a hernia. Zimmerman
and Anson suggested that inguinal lesions resulted from inadequate muscle
support at the lower area of the inguinal canal, primarily caused by a defect
in the internal oblique muscle. Stretching of this area in pregnancy may
initiate a hernia, but other factors, such as chronic cough caused by
smoking or chronic respiratory disease, may be responsible.

Incisional hernias generally occur because of poor healing of the fascia after
surgery. This may be secondary to poor nutrition, infection, obesity, or
necrosis of the fascia secondary to suturing. It may also occur because
absorbable suture loses its tensile strength before healing is complete or
excessive wound tension. Stress and strain secondary to chronic cough or
vomiting in the postoperative period may contribute to the process.
Emergency surgery increases the risk of incisional hernia. Other conditions
that inhibit wound healing include obesity, smoking, connective tissue
disorders, and immunosuppressant medications. Incisional hernias may
develop in 10% to 15% of patients after abdominal laparotomy incisions.

Symptoms, Signs, and Diagnosis

Bulges in the abdominal wall lead to the discovery of most ventral or groin
hernias in women, either by a physician at the time of physical examination
or by the patient. Occasionally, excessive straining or trauma will be
implicated, and the patient may experience a feeling of tearing of tissue.
Frequently the bulges are noted during an increase in intraabdominal
pressure such as with coughing, pregnancy, or ascites. Most hernias are
asymptomatic, but in some cases, particularly with larger ones, there may
be aching or discomfort. Should intraabdominal organs move into the sac,
the patient may experience some discomfort. Organs that strangulate
within the sac cause acute pain and discomfort. Incarcerated organs may
give nonspecific visceral pain, which is most likely the result of mesenteric
stretching. An incisional hernia with incarceration may present with a
bowel obstruction.

In cases in which a hernia exists but no contents are within the sac, physical
examination reveals a weakening at the site of the hernia. It is often
possible to feel the “ring” of the hernia as one palpates the defect through
the skin and subcutaneous tissue. The patient’s straining will generally
accentuate the hernia, making it more palpable and visible. In the case of
inguinal and femoral hernias, it may be necessary for the patient to be
standing for one to palpate the hernia.

When there are intraabdominal contents within the hernia sac, the hernia is
more easily palpated. The physician should then decide, based on his or her
attempts to gently milk the contents from the sac back through the defect
ring, whether the contents are reducible. For a hernia that does not reduce
easily but in which there is no evidence of vascular compromise, it is
sometimes useful to apply ice packs to the abdomen in the area of the
incarcerated hernia before additional attempts are made to reduce it. In
cases of strangulated hernia, evidence of devitalization of an organ, such as
fever, leukocytosis, and evidence for an acute abdomen, may be noted.

With classic presentation of strangulated hernia on history and physical

exam, surgical management should be pursued without imaging
confirmation. If symptoms are present, but the exam cannot confirm a
hernia, ultrasonography can be ordered. Computed tomography (CT) and
magnetic resonance imaging (MRI) provide more anatomic detail and
accuracy, but at increased cost and radiation exposure with CT.

Management
Nonoperative management of ventral wall and incisional hernias in women
is often feasible. Umbilical hernias in little girls will generally close by age 3
or 4 years and rarely become incarcerated. Unincarcerated groin hernias are
often small and become uncomfortable only with an increase in
intraabdominal pressure, such as occurs with pregnancy. Many authors
advocate repair, however, because the small neck of these hernias may
make incarceration more likely. With pregnancy, the opportunity for
incarceration is reduced because the increasing size of the uterus pushes
bowel contents away from the area of the herniation. Trusses and other
supports are generally difficult to fit and are of little value in women.

Larger hernias, hernias that continuously contain intraabdominal contents,

hernias that cause continuing discomfort, and those that have been
incarcerated should be repaired. Most incisional hernias should be repaired,
but asymptomatic groin hernias can be safely managed conservatively.
Some general principles of operative repair can be stated. The first principle
involves the anatomy of the hernia. The hernia almost always consists of a
sac of peritoneum with a narrow neck and a fascial defect of some sort. In
rare instances, if a peritoneal sac is broad based, it may be possible to
simply reduce the sac through the fascial defect without opening it and
then to repair the fascial defect. However, if a narrow-necked sac exists, it
must be dissected free of the fascial defect, emptied of its contents, and
then excised and sutured at the neck (base). The fascial defect is then
mobilized completely to remove stress and scarring, and it is closed with
permanent suture. In many cases the fascial defect may be large, and the
degree of mobilization that is required may be impossible. In such
instances, patching with inert material, such as polypropylene mesh, may
be necessary. Mesh repairs have become the preferred technique for
incisional hernias because the recurrence rate is lowered. Studies are
conclusive regarding lower recurrence risk for hernia using permanent
mesh. However, the infection risk is higher. Sutured repair without mesh is
still acceptable for small hernias (<2 to 3 cm).

The second principle involves management of the contents of the hernia

sac. Usually the hernia sac reduces with ease, but if intraabdominal
contents are fixed to the sac wall by adhesions, the sac must be opened and
the adhesions carefully separated. Care must be taken not to damage the
organs or their blood supply. When these organs are reduced from the sac,
the sac may be handled in the usual fashion. When incarceration has
occurred, the organs must be inspected for viability before replacement.

Umbilical Hernia Repair

To surgically repair an umbilical hernia, a curved incision is made at the
inferior margin of the umbilicus (Fig. 20.4 ). The umbilicus is dissected
free of the sac and reflected upward. The sac is then dissected free of the
fascial defect and either reduced or excised, depending on the
circumstances. The fascial edges are freshened and either closed by direct
approximation anterior to posterior using nonabsorbable sutures or
mobilized and closed in a “vest over pants” manner, suturing the anterior
edge to the posterior edge in an overlapping fashion. Studies have not
shown that neither of these closures is superior to the other, and the
approach taken generally is the one that best fits the circumstances. The
umbilicus is then tacked to the fascial defect and the skin margin
approximated. Large defects may require mesh placement to avoid tension
on the closure (Aslani, 2010 ). Laparoscopic repair is also possible.

SLIDESHOW

F I G U R E 20. 4 Repair of umbilical hernia. A, Site of incision. B, Umbilicus …

Incisional Hernia
p. 447 Repair of an incisional hernia can be accomplished by incising the skin
through the old scar or via a parallel incision and dissecting through the
subcutaneous tissue to identify both margins of the separated fascial
defect. The peritoneum of the hernia sac is then isolated, dissected free of
the margins, and reduced in the most appropriate fashion, with the surgeon
exercising care not to damage any organs that may be fixed in the sac by
adhesions. The fascial edges are then mobilized completely and closed with
a mass suture technique. Outcome studies show a sutured repair is more
likely to result in a recurrence than a mesh repair, although sutured repair
may be adequate for small hernias (<2 or 3 cm) and when the risk of using a
mesh prosthesis is unacceptable. Laparoscopic repairs are increasingly
common. In a meta-analysis of five randomized controlled trials involving
611 patients, the recurrence risk and length of hospital stay were similar, but
laparoscopic repairs had reduced risk of wound infection compared to open
repairs (Al Chalabi, 2015 ).

Prevention of incisional hernias bears mention because 10% to 15% of

abdominal incisions will develop a hernia. Preventing wound infection with
appropriate antibiotic prophylaxis if indicated and careful surgical
technique is worthwhile because the hernia rate increases to 23% with
postoperative wound infection. A meta-analysis of abdominal fascial
closure concluded that a continuous nonabsorbable suture closure resulted
in the lowest rates of incisional hernia. Weight loss and smoking cessation
should be recommended, as these are risk factors for hernia development.

Pelvic Organ Prolapse