Q: A 40 year old man presented with a history of gradually increasing lump

over the lower abdomen, he has had previous laparotomy incision for
perforated peptic ulcer in the past.

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 Incisional H. (Postoperative H.)
• Arise through a defect in the abdominal wall in the region
of a postoperative scar.

• 10–50% of laparotomy incisions

1–5% of laparoscopic port-site incisions

• Mostly in obese pt.

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 Increase in size with time and the skin
overlying large hernias ……..

 Attacks of partial intestinal obstruction

 Strangulation is less frequent.

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 Burst abd. (Abd. Dehiscence )
In 1 – 2 %.
Between 6th – 8th postop. day.
A discharge (pink) ….. in
50% of cases.
Patient felt something given a
way.
If skin suture have been
removed ….
Pain & shock are often absent.

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 Risk factors (Burst Abdomen & Incisional H.)

Surgical factors:
1. Technique of wound closure:
a. choice of suture material: …….
b. method of closure
= interrupted suturing…..
= one layer closure …….
= using short length of suture ( golden rule: …. )
2. Drainage: …..
3. Factors relating to the incision: vertical incisions > transverse.
4. Reasons for initial operation: …..
Wound factors:
Poor quality tissues, wound infection
Patient factors:
Obesity, jaundice, malignant dis.,……
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Rx: Burst Abdomen
v Reassure the patient & cover the
wound with sterile towel.
v N/G & IVF.

v Emergency operation…..
v Peritonitis rarely occur & skin
healing is satisfactory

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 Incisional H.:Rx
= Palliative: Abd. Belt ( esp. H. through upper abd. incision)
= Operation

Principles of surgery
1) Approximation of the layers with minimal tension
2) Mesh should be used ….. recurrence.

Surgery:
= Open:
= Laparoscopic:

Reducing the risk of incisional hernia:

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 Complications of Hernias
operation
• Early – pain, heamatoma, , injury to other structures
seroma, wound infection
• Late – chronic pain,
- Ischemic orchitis :
q develops 2-3 days postop.
q Testicles & spermatic cord = hard, tender & swollen.
q Last 6-12 wks., may resolved or end with testicular atrophy.

Recurrence:
– 0.2 – 15% depending on the technique employed (with mesh <2%).
– “False recurrence”: another type of H.

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 Divercation of the recti
– There is gap between the recti.
– In elderly multipara pt.
– No risk of strangulation.
– Rx by abd. Belt.

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 Umbilical conditions in the adult:
Chronic infection:
§ Patients with poor hygiene.
§ Obese pt.
§ When a PUH is present.

Chronic fistula: May be due to

1) Superficial infection
2) A fistulous connection to deeper structures.
3) A complication of umbilical hernia repair …..

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Patent urachus:
v It open at the apex of the bladder.
v It close temporarily during micturition..
v It reveals itself later
v Rx:
Surgery

Umbilical calculus:
v Desquamated epithelium.
v Black in color.
v Rx by extraction,
or …excision of the umbilicus.

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 Neoplasm of the umbilicus:
Benign:
1. Umbilical adenoma or raspberry tumor:
v Infants.
v Partially obliterated vetillo-int. duct.
v Prolapsing of the mucosa (moist, tend to bleed)
v Rx: if pedunculated … Ligation.
If recurred …….. umbilictomy.

• Malignant:
secondary carcinoma (Sister Joseph nodules)
from neoplasm in the stomach, colon,….
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Desmiod tumor:
v Encapsulated fibroma.
v High incidence of recurrence …
v 80% in women.
v Rx: wide excision ( 2.5 cm free margin ) + mesh

Fibrosarcoma:
v Highly malignant
v Respond poorly to both radio- and chemotherapy.
v Wide excision + plastic surgical reconstruction.

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 Questions
1. A 26 year old builder / A lump over his left groin / Last 3 years.
O/E: Cough impulse +ve
Reducible lump over the left groin extending to the scrotum .
Deep ring occlusion test is positive.
Answer:

2. A 60 year old obese woman / A history of painfull lump around her umbilicus.
O/E: An irreducible lump just above the umbilicus.
Answer:

3. A 78 year old woman / A 6 week history of suspected enlarged left groin lymph node.
O/E: A 2 cm firm and irreducible lump over the medial aspect of the left groin.
Cough impulse -ve.
Answer:

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4. A 40 year old woman / A history of gradually increasing lump over the lower
abdomen / She has had three caesarean sections in the past.
O/E: A suprapubic scar / A reducible lump over the right lateral aspect of this scar .
Cough impulse +ve.

Answer :

5. A 70 year old man / A 2 year history of lump over both his groin.
O/E: Reducible lumps over both his groin
Deep ring occlusion test -ve

Answer:

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6. A 50 year old man presents with a lump below the umbilicus and lateral to the rectus. A
cough impulse is felt over the area and the lump reduce with difficulty.
Answer:

7. A 70 year old multi-para female presented with an epigastric bulge. This become
prominent while exercising in the gym. It is otherwise asymptomatic.
Examination reveals a midline gutter in the upper abdomen
Answer:

8. A 30 year old female presents with a localized sharp pain in the upper abdomen.
Examination reveals a button-like soft swelling equidistant between the xiphisternum
and the umbilicus. There is no cough impulse and the lump is not reducible.
Answer:

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