The Abdominal Wall

And Hernias
Dr MUHAMMAD UMAR YOUNIS
ABDOMINAL WALL
• The structure of the abdominal wall is similar in principle to the thoracic wall.
• There are three layers, an external, internal and innermost layer.
• The vessels and nerves lie between the internal and innermost layers.
THE FASCIA
• Below the skin the superficial fascia is divided into a superficial fatty layer, Camper's
fascia, and a deeper fibrous layer, Scarpa's fascia.
• The deep fascia lies on the abdominal muscles. Inferiorly Scarpa's fascia blends with
the deep fascia of the thigh. This arrangement forms a plane between Scarpa's fascia
and the deep abdominal fascia extending from the top of the thigh to the upper
abdomen.
• Below the innermost layer of muscle, the transversus abdominis muscle, lies the
transversalis fascia. The transversalis fascia is separated from the parietal peritoneum
by a variable layer of fat.
THE MUSCLES
HERNIA - Definition
• A hernia is a protrusion of a viscus or part of a viscus through an abnormal
opening in the walls of its containing cavity .
Etiology
• Congenital defects.
• Loss of tissue strength and elasticity (from aging or repetitive stress).
• Operative Trauma.
• Increased Abdominal Pressure (heavy lifting, COPD, BPH, Ascites, Obesity).
Inguinal hernia
 History:
1. Age ( young vs. old)
2. Occupation ( nature ?? )
3. Local symptoms: Swelling, discomfort and pain
4. Systemic symptoms: if there is obstruction or strangulation
5. Precipitating factors
Clinical Types of Inguinal Hernia
 Indirect inguinal hernia:
the internal inguinal ring  the inguinal canal  external inguinal ring scrotum

Direct inguinal hernia: Hesselbach’s triangle

Pantaloon type
INGUINAL HERNIA
FEMORAL HERNIA
History
 Age ; uncommon in children , most common in old age female .
 Sex; women > men (but still commonest hernia in women the inguinal hernia )
 The patient came with local symptoms
 1- discomfort and pain
 2- swelling in the groin
 General ; femoral hernia is more likely to be strangulated than the inguinal hernia
 Multiplicity ; often bilateral
• In a femoral hernia the hernia sac is pushed into the femoral canal, below the inguinal
ligament and between the lacunar ligament and the femoral vein.
• The hernia sac thus lies inferior and lateral to the pubic tubercle and anterior to the
superior pubic ramus periosteum (COOPER’S LIGAMENT)
VENTRAL HERNIAS
UMBILICAL HERNIA
• Signs and symptoms
• Age : doesn’t appear until the umbilical cord has separated and healed .
• No specific symptoms
• Have wide neck and reduce easily , rarely give intestinal obstruction.
• Nature history ; 90 % disappear spontaneously during the first year.
Acquired umbilical hernia

 Hernia through the umbilical scar , so it is a true umbilical hernia.

 Not common and is usually secondary to increase intra abdominal pressure.
 The most common causes:
 1- pregnancy
 2- ascites
 3- ovarian cyst
 4- fibroids
 5- bowel distention
 Epigastric Hernia

 Occurring between the navel and the lower part of the rib cage in the midline of the
abdomen, these hernias are composed usually of fatty tissue and rarely contain intestine.
 Men > Women
 these hernias are often painless and unable to be pushed back into the abdomen when
first discovered.
 Spigelian Hernia
 Rare
Hernia through subumbilical portion of semi-lunar
line
Difficult to diagnose –Abdominal pain or mass
noted in abdominal wall. Frequently tender over
area
 Clinical suspicion (location)
 CT scan

 Repair primarily or with mesh

MANAGEMENT
• Most pt are treated surgically
• Increase IAP abnormalities (Chronic cough, Constipation, Bladder outlet obstruction)
should be evaluated and remedied to extent possible before elective herniorrhaphy.
• In case of intestinal obstruction and possible strangulation, Broad spectrum AB,NG
suction may be indicated, correction of volume status& elctroyles.
Primary tissue repair

• Bassini repair: inferior arch of transversalis fascia (TF) or conjoint tendon is

approximated to shelving portion of inguinal ligament.

• McVay: TF is sutured to cooper ligament.

• Shouldice: TF is incised and reapproximated.

Laproscopic &
preperitoneal repairs

• TAPP (transabdominal prepeitoneal procedure): peritoneal space entered by

conventional lap at umbilicus and peritoneum overlaying inguinal floor is
dissected away as flap.

• TEP (Total extraperitoneal repair): preperitoneal space is developed with a

balloon inserted between posterior rectus sheath and peritoneum  balloon
inflated to dissect the peritoneal flaps awau from posterior abdomianl wall and
the direct and indirect spaces, other ports inserted into this preperitoneal space
without entering peritoneal cavity.

• After lap. Dissection and reduction of hernia sac , a large piece of mesh is
placed over inguinal floor
Open tension free
repair
• Lichtenstein repair &Patch and Plug technique: Mesh is used to reconstruct inguinal
floor

• Mesh plug technique : place mesh in the hernial defect

Femoral Hernia Repair
Three approaches have been described for open surgery :
1. Infra-inguinal approach (Lockwood)
2. Inguinal approach ( Lotheissen)
3. High approach ( McEvedy)
 Incisional Hernia

 an abnormal protrusion of a viscus through the musculoaponeurotic layers of a

surgical scar.
 Swelling and mass in the incision
 Rarely incarcerate
 Etiology
Operative factors:
- types of incision: vertical incision, transrectus incision, midline incision,
standard paramedian incision
- technique of closure
- suture material
Postoperative factors:
- increased intra-abdominal pressure
- Obesity
- Malnutrition
- Smoking
-Immune dificiency
 Repair
• Bring together fresh fascial edges after trimming sac
• Clean off fascial edges at least 1 cm back
• Close with interrupted or continuous sutures
• Even with careful technique recurrence rates as high as 50% have been reported
Thank You