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Ventral Hernia
Ventral Hernia
CLINICAL FEATURES:
It is usually Symptomless.
Increases in size on crying.
It has Classical conical shape.
Obstruction/strangulation are extremely uncommon in <3
years of age.
TREATMENT:
Conservative: Most of the hernia close
spontaneously without any treatment within two
years of age. So the methods are:
masterly inactivity, reassure parents and strapping
over a coin.
ON EXAMINATION:
Less likely to be reducible.
Maybe locally tender.
Cough impulse may or may not be felt.
It may be more than one at a time.
TREATMENT:
Conservative treatment – if very small hernia
or symptomless
If sufficiently symptomatic – Open surgery.
Anatomic repair.
Mesh repair.
• Recurrence: May be due to failure to identify a
second defect at the time of original repair.
INCISIONAL HERNIA
It is diffuse extension of peritoneum and abdominal contents
through a weak abdominal scar (scar of previous surgery).
CAUSES:
Obesity
Advanced age
Coughing, vomiting, straining
Steroids and chemotherapy
Multiparity.
Poor metabolic state of patient.
Causes that increase intraabdominal pressure.
Inapropriate suture material
Poor closure technique
Incision
Emergency procedures.
CLINICAL FEATURES:
Pain and swelling in the vicinity of previous scar
Obstruction of contents is common but
strangulation is rare
Attacks of subacute intestinal obstruction. –
abdominal colic, vomiting, constipation and
distension of abdomen
On Examiation:
Often multiple defects within same scar
Reducibility may be complete or partial
Expansile impulse on cough
Skin over the hernia is thin and atrophic
TREATMENT:
Preventive measures:
Reduction of weight in obese before elective procedures
Treat any respiratory diseases
Very careful closure of abdomen
Prevent Post op wound infection
Conservative approach:
Symptomless hernia with no signs of pain or obstruction.
Operative Treatment:
The indications are:
Symptomatic hernia which is showing signs of increasing in size
Large hernia with a small defect
Subacute intestinal obstruction
Irreducibility and
Strangulation
Mesh repair: is always better and ideal
choice of treatment with less chances of
recurrence.
Sublay or Intraperitoneal onlay mesh
IPOM aare preferable
Anatomical repair and Keel’s operation
are not usually used
SPIGELIAN HERNIA
Herniation through the defect
in spigelian fascia.
Spigelian fascia is the
aponeurosis of transversus
abdominis muscle
Its almost above the arcuate
line
Most common site is below
the level of umblicus, near the
edge of rectus sheath, at the
junction of spigelian line (linea
semilunaris) and arcuate line
(linea semicircularis)
CLINICAL FEATURES:
Soft, reducible mass lateral to the rectus muscle
and below the umbilicus
Cough impulse present.
Strangulation is common
Common in females after 50 years of age.
TREATMENT:
High risk of complications due to narrow neck
Primary Repair or Mesh repair
LUMBER HERNIA
It refers to the herniation through the Lumber triangle.
Three types of lumber hernia :
Incisional Lumber Hernia - Most common cause
Superior Lumber Hernia – From superior lumber triangle
bounded by:
12th rib superiorly
Post border of internal oblique laterally
Sacrospinalis muscle medially
Inferior Lumber Hernia – from inferior lumber triangle
bounded by:
Iliac crest inferiorly
Laterally external oblique
Latissimus dorsi medially
MC site for primary lumber hernia
DIFFERENTIAL DIAGNOSIS:
Lipoma
Paravertebral cold abscess
Phantom hernia
CLINICAL FEATURES:
Focal pain associated with movement over the site
of the defect
Vague dullness in the flank or lower back
Hernia tends to increase in size over time
ON EXAMINATION:
Swelling in the lower posterior abdomen
Reducible without much difficulty
TREATMENT:
Small defects – primary repair
Large defects – prosthetic mesh repair
Retromuscular sublay mesh repair is the
preferred procedure for lumber hernia.