Ventral HerniaeBYPROF/ GOUDA ELLABBAN

Ventral HerniaeHernia : The protrusion of an abdominal viscera through

weakness of the wall covering.

There are 5 types :1- Incisional hernia 2- Epigastric hernia3- Umblical hernia4- Paraumblical hernia5- Spigelian hernia

Ventral Herniae1- Incisional herniaThis is a hernia that occurs at the site of a surgical incision.

2- Epigastric herniaOccurs in the middle portion of the abdomen, above the umbilicus

Ventral Herniae3- Umbilical hernia :swelling protrudes through a weakness in the abdominal wall at the Umbilicus. (mostly in children)

4- Paraumbilical hernia :occur above or below the umbilicus, through a weak

place in linea alba, rather than directly through the umbilicus itself.

Rare in children and are most common in adults between 35 and 50 years.

Ventral Herniae

5- Spigelian hernia :occurring through the spigelian fascia along the

Spiegel's semilunar line and lie under the external oblique aponeurosis just outside the lateral border of the Rectus muscles & above the level of the inferior epigastric vessels.

Symptoms & Signs

1- Incisional hernia :- Often, painless

1- discomfort & bulging. (Most common)

2- pain (sharp or dull ache)

3- nausea and vomiting.

4- strangulation. (silent)

Symptoms & Signs

2- Epigastric hernia :(may be asymptomatic)

1- pain 2- vomiting & nausea. 3- aggravated by eating 4- relieved by reclining

5- strangulation

Symptoms & Signs

3- Umbilical hernia :(Mostly no symptoms)1- pain

2- incarceration3- strangulation

4- Paraumbilical hernia :1- pain2- intestinal obstruction 3- skin changes with large hernias(five times more common in women than in men)(strangulation is common in adults but not children)

Symptoms & Signs

5- Spigelian hernia :1- pain (Later, more dull, constant, and diffuse)

2- incarceration.

3- stragulation.

Differential Diagnoses

1- Incisional hernia : 1- tumor 2- Endometriosis 3- Hematoma 4- T.B

2- Epigastric hernia :1- peptic ulcer 2- G.B disease

3- hiatus hernia 4- pancreatitis

5- upper small bowel obstruction

6- subcutaneous lipoma

7- neurofibroma

Differential Diagnoses

3- Umbilical hernia :1- Umbilical pyogenic granuloma2- Omphalitis3- Patent urachus4- Exomphalos5- Paraumbilical hernia

4- Paraumbilical hernia :1- Umbilical hernia 2- Lipoma 3- tumor

Differential Diagnoses

5- Spigelian hernia : 1- rectus sheath hematoma

2- seroma

3- peritoneal tumor

4- pseudocyst at the end of a ventriculo-peritoneal shunt.

Investigations• The hernia’s are diagnosed most of the time clinically by

the doctor on physical examination.

• Ultrasound.

• CT scan. To confirm diagnosis, where doubt exists.

Treatment of Ventral Hernias.

Initial Treatment• A truss which is a belt with a large pad on it that applies pressure to

the site of the hernia with the aim of keeping the bulge from popping out.

• The Truss just minimizes symptoms by preventing significant herniation through the defect in the abdominal wall.

• It should only be used as a short term measure until surgery can be performed.

• Sedation and Trendelenburg’s positioning may be helpful in an obstructed hernia.

• Trendelenburg’s position: Sitting the patient in a supine position, inclined 45 degrees, his head at the lower end, his legs flexed over the upper end.

Pre-Operative Care

• No Solid food after mid night, the night before surgery.

• Medications which may thin the blood should be stopped 7 days prior to surgery. Aspirin

• Fluid, electrolyte correction, and antibiotics administration. If the hernia was strangulated or obstructed.

Definitions1.Herniotomy: Surgical removal of the hernial sac and closure of the neck.

2.Herniorrhaphy: Surgical repair of the hernia, and reconstruction of the abdominal wall.

3.Hernioplasty: Surgical repair of a hernia, using a mesh patch for reinforcement.

Mesh: Which is a synthetic material (prolene, teflon, marlex).Used to reinforce the abdominal wall and therefore decrease recurrence of hernia.

Operation Principles:

Umbilical and paraumbilical Hernias• Treatment of umbilical hernia in children is by observation.

• More than 95% of these hernias will close by the age of 5 yrs.

• Large hernias greater than 2.5cm or if the child is over 4-5 yrs old may be fixed surgically.

• If the hernia is strangulated, the patient requires urgent surgery.

• General anesthesia is used in most children.

• Local anesthesia can be used in older children or adults.

• A semicircular incision in a skin crease exposes the umbilical sac, Then it is dissected or repaired.

• If the defect is very large, mesh is needed to decrease the tension on the weakened area in the abdominal wall after repair of the hernia.

• In Paraumbilical hernias, the sac is excised and the edges of the rectus sheath are overlapped above and below the hernia.

This procedure is Called Mayo’s Operation.

Epigastric hernias• Strangulated and obstructed hernias need immediate

surgical repair.

• After anesthetic induction, a small transverse incision directly overlying the defect is carried to the linea alba.

• Most of the time a Mesh is used.

• Local anesthesia is performed In adults,having small to moderate sized Epigastric Hernia.

• Recurrence is rare, although a second epigastric hernia may develop elsewhere in another defect.

Spigelian hernias

• Despite their rarity and difficulty in diagnosis, spigelian hernias have an easy approach.

• A transverse incision to the sac with dissection to the neck and clean approximation of the internal oblique and transversus abdominis is all that is necessary.

• The risk of recurrence is small.

Incisional Hernia • Large or complex incisional hernias often require general

anesthesia.

• If the general condition of the patient is good, the hernia is repaired by dissecting out and suturing the individual layers of the abdominal wall.

• Large hernias are repaired with a sheet of nylon or polypropylene mesh.

• In patient with concurrent abdominal wall infections, drainage, or open wounds, are not advised to do the surgery.

• Abdominal belt is prescribed.

Summary Of Surgical Treatment:

The options for repair are:1. Open sutured repair. 2. Open mesh repair.3. Laparoscopic mesh repair. A modern technique.

• The open suture repair has higher recurrence rate ( 41%-50%)

• Prosthetic mesh repair has lower recurrence rate (12%-24%) And it is preferred in smaller hernias.

• Laparoscopic mesh repair is preferred in larger hernias.The recovery is shorter and the recurrence rate is decreased to

(5%).

Postoperative Orders

• Pain Will be controlled with Medicine. Paracetamol.

• Patient should rest for 2 weeks with no hard activity, and take a vacation from work.

• All other normal activities can be done but without increased straining activities for 6 weeks.

• The patient can support his/her abdomen by wearing a girdle or similar garment.

Postoperative Complications

1. Bleeding.2. Infection of the incision.3. Injury to the intestine or other intra-abdominal organ.4. Urine retention.5. Recurrence.6. Numbness.7. Chronic Incisional Pain.

The last two complications are generally mild, non-debilitating, and resolves over time.

Preventive Measures There is no sure way of preventing a hernia from developing, particularly

if it results from an inherited weakness in the abdominal wall.

However, avoiding certain risk factors may be helpful:

1. Stop smoking chronic cough which causes increased straining.

2. If you have violent sneezing attacks due to Hayfever, try to get some effective allergy treatment.

3. High-fiber diet or laxatives in treatment of Chronic constipation is necessary to prevent straining and increased intra-abdominal pressure.

4. If your job requires heavy lifting, learn the proper way to lift and wear a support garment.

THANK YOU

FINITO