Abdominal Wall and Abdominal Wall Hernias

8/19/2019 Abdominal Wall and Abdominal Wall Hernias

1/66

The Abdominal WallThe Abdominal Wall And Hernias And Hernias

Stanley Kurek, DO, FACSStanley Kurek, DO, FACS

Associate Professor of SurgeryAssociate Professor of SurgeryUTMCKUTMCK


2/66

The Abdominal WallThe Abdominal Wall

The structure of the abdominal wall is similar inThe structure of the abdominal wall is similar inprinciple to the thoracic wall.principle to the thoracic wall.

There are three layers, an external, internal andThere are three layers, an external, internal andinnermost layer.innermost layer.

The vessels and nerves lie between the internalThe vessels and nerves lie between the internaland innermost layers.and innermost layers.


3/66

Surface anatomySurface anatomy

The abdomen can be divided intoThe abdomen can be divided intoquadrants or nine abdominal regions.quadrants or nine abdominal regions.

Pain felt in these regions may bePain felt in these regions may beconsidered to be direct or referred.considered to be direct or referred.

The midline in theThe midline in the sagittalsagittal plane is theplane is thelinealinea alba.alba.

The lateral edge of the rectus sheath isThe lateral edge of the rectus sheath isthethe linealinea semilunarissemilunaris..


4/66

1:Right Hypochondriac Region; 2:Right Lumbar Region; 3:R. Iliac (Inguinal) Region

4:Epigastric Region; 5:Unbilical Region; 6:Hypogastric (Pubic) Region;

7:Left Hypochondriac Region; 8:Left Lumbar Region; 9:Left Iliac (Inguinal) Region


5/66


6/66


7/66

The FasciaThe Fascia

Below the skin the superficial fascia is divided into aBelow the skin the superficial fascia is divided into asuperficial fatty layer, Camper's fascia, and a deepersuperficial fatty layer, Camper's fascia, and a deeperfibrous layer,fibrous layer, Scarpa'sScarpa's fascia.fascia.

The deep fascia lies on the abdominal muscles. InferiorlyThe deep fascia lies on the abdominal muscles. InferiorlyScarpa'sScarpa's fascia blends with the deep fascia of the thigh.fascia blends with the deep fascia of the thigh.This arrangement forms a plane betweenThis arrangement forms a plane between Scarpa'sScarpa's fasciafascia

and the deep abdominal fascia extending from the top ofand the deep abdominal fascia extending from the top ofthe thigh to the upper abdomen.the thigh to the upper abdomen.

Below the innermost layer of muscle, theBelow the innermost layer of muscle, the transversustransversus

abdominisabdominis muscle, lies themuscle, lies the transversalistransversalis fascia. Thefascia. Thetransversalistransversalis fascia is separated from the parietalfascia is separated from the parietalperitoneum by a variable layer of fat.peritoneum by a variable layer of fat.


8/66


9/66

The RectusThe Rectus Abdominis Abdominis andand

Rectus sheathRectus sheath TheThe r e c t u s m u s c l e r e c t u s m u s c l e extends from theextends from the xiphoidxiphoid process ofprocess of

the sternum and 5,6,7th costal cartilages to the pubicthe sternum and 5,6,7th costal cartilages to the pubicsymphysissymphysis and pubic crest.and pubic crest.

The muscle is enclosed within theThe muscle is enclosed within the rectus sheathrectus sheath formedformedby theby the aponeurosesaponeuroses of the lateral abdominal muscles.of the lateral abdominal muscles.

Along the length of this strap muscle there are three fibrousAlong the length of this strap muscle there are three fibrousintersections separating the muscle into four segments.intersections separating the muscle into four segments.

The fibrous intersections are attached to the anteriorThe fibrous intersections are attached to the anteriorsurface of the rectus sheath, but not to the posteriorsurface of the rectus sheath, but not to the posteriorsurface. This allows the superior and inferiorsurface. This allows the superior and inferior epigastricepigastricvessels to pass along the posterior surface of the musclevessels to pass along the posterior surface of the musclewithout encountering a barrier.without encountering a barrier.


10/66

RectusRectus Abdominis Abdominis


11/66

External Abdominal Oblique MuscleExternal Abdominal Oblique Muscle

TheThe e x t e r n a l o b l i q u e m u s c l e e x t e r n a l o b l i q u e m u s c l e arises from the lower eightarises from the lower eightribs.ribs.

The fibers run downwards and forwards to form anThe fibers run downwards and forwards to form anaponeurosisaponeurosis anteriorlyanteriorly..

TheThe aponeurosisaponeurosis passespasses anteriorlyanteriorly to the rectus muscle toto the rectus muscle toinsert into theinsert into the aponeurosisaponeurosis from the other side at thefrom the other side at the linealineaalba.alba.

Inferiorly theInferiorly the aponeurosisaponeurosis inserts into the anterior superiorinserts into the anterior superioriliac spine and stretches over to the pubic tubercle, formingiliac spine and stretches over to the pubic tubercle, formingthethe inguinal ligamentinguinal ligament..


12/66

External Abdominal ObliqueExternal Abdominal Oblique


13/66

Internal Oblique MuscleInternal Oblique Muscle

TheThe i n t e r n a l o b l i q u e m u s c l e i n t e r n a l o b l i q u e m u sc l e arises from the lumbararises from the lumbarfascia, the iliac crest and the lateral twofascia, the iliac crest and the lateral two--thirds of thethirds of theinguinal ligament and runs upwards and forwards to forminguinal ligament and runs upwards and forwards to formanan aponeurosisaponeurosis..

Above theAbove the arcuatearcuate line theline the aponeurosisaponeurosis splits to enclose thesplits to enclose therectus muscle.rectus muscle.

Below theBelow the arcuatearcuate line theline the aponeurosisaponeurosis passes anterior topasses anterior to

the rectus muscle.the rectus muscle. The inferior part of theThe inferior part of the aponeurosisaponeurosis inserts into theinserts into the

symphysissymphysis pubis.pubis.

At this insertion theAt this insertion the aponeurosisaponeurosis is fused with theis fused with theaponeurosisaponeurosis of theof the transversustransversus abdominisabdominis muscle to formmuscle to formthethe conjoint tendon.conjoint tendon.


14/66

Internal Abdominal ObliqueInternal Abdominal Oblique


15/66


16/66

TransversusTransversus Abdominis Abdominis

TheThe transversustransversus abdominisabdominis musclemuscle

arises from the lower six costalarises from the lower six costalcartilages, the lumbar fascia and thecartilages, the lumbar fascia and the

iliac crest.iliac crest.


17/66

TranversusTranversus Abdominis Abdominis


18/66


19/66


20/66

Inguinal LigamentInguinal Ligament

The inguinal ligament is formed by theThe inguinal ligament is formed by theaponeuroticaponeurotic fibers of the external obliquefibers of the external obliquemuscle.muscle.

The ligament stretches from the anteriorThe ligament stretches from the anterior

superior iliac spine (ASIS) to the pubicsuperior iliac spine (ASIS) to the pubictubercle.tubercle.

At the medial end of the inguinal ligament,At the medial end of the inguinal ligament,

fibers are reflected backwards to insertfibers are reflected backwards to insertinto the superiorinto the superior ramusramus of the pubis,of the pubis,forming theforming the lacunarlacunar ligament.ligament.


21/66

The Inguinal CanalThe Inguinal Canal

The inguinal canal transmits the vas deferens in the maleThe inguinal canal transmits the vas deferens in the maleand the round ligament in the female.and the round ligament in the female.

The deep ring is the entrance to the inguinal canal on theThe deep ring is the entrance to the inguinal canal on theinside of the abdominal wall.inside of the abdominal wall.

The deep ring is formed in theThe deep ring is formed in the transversalistransversalis fascia. As thefascia. As thecanal passes through the abdominal wall it receives a layercanal passes through the abdominal wall it receives a layerof muscle from the internal oblique, theof muscle from the internal oblique, the cremastercremaster muscle.muscle.

At the superficial ring the inguinal canal passes through theAt the superficial ring the inguinal canal passes through the

external obliqueexternal oblique aponeurosisaponeurosis and receives a layer from theand receives a layer from theaponeurosisaponeurosis, the external spermatic fascia in the male., the external spermatic fascia in the male.

The deep inguinal ring lies lateral to the inferiorThe deep inguinal ring lies lateral to the inferior epigastricepigastricvessels. The superficial ring lies above and medial to thevessels. The superficial ring lies above and medial to thepubic tubercle.pubic tubercle.


22/66


23/66

BOUNDARIES OF THE INGUINALBOUNDARIES OF THE INGUINAL


24/66

BOUNDARIES OF THE INGUINALBOUNDARIES OF THE INGUINAL

CANALCANAL The inguinal canal is theThe inguinal canal is the

communication between the deepcommunication between the deepand superficial ringand superficial ring

Anterior wall: EAOAnterior wall: EAO

Inferior wall: Inguinal LigamentInferior wall: Inguinal Ligament

Superior wall: IAO and TA (conjoinedSuperior wall: IAO and TA (conjoined

tendon)tendon) Posterior wall (floor):Posterior wall (floor): TransversalisTransversalis

FasciaFascia


25/66

The Spermatic CordThe Spermatic Cord The spermatic cord passes through the inguinal canal to theThe spermatic cord passes through the inguinal canal to the

testis.testis.

THE SPERMATIC CORD CONTAINSTHE SPERMATIC CORD CONTAINSvas deferensvas deferens

testicular artery and veinstesticular artery and veins

lymph vesselslymph vessels

autonomic nervesautonomic nervescremastericcremasteric arteryartery

artery of the vasartery of the vas

genital branch of the femoral nervegenital branch of the femoral nerve

TheThe fascialfascial covering of the spermatic cord is formed by thecovering of the spermatic cord is formed by theexternal spermatic fasciaexternal spermatic fascia dervedderved from thefrom the aponeurosisaponeurosis ofofthe external oblique, thethe external oblique, the cremastericcremasteric fascia derived fromfascia derived fromthe internal oblique and the internal spermatic fasciathe internal oblique and the internal spermatic fasciaderived from thederived from the transversalistransversalis fascia.fascia.


26/66

The Femoral CanalThe Femoral Canal

The femoral canal lies below the inguinalThe femoral canal lies below the inguinalligament medially and lies medial to theligament medially and lies medial to thefemoral vessels.femoral vessels.

The femoral sheath is formed by theThe femoral sheath is formed by the

transversalistransversalis fascia and encloses thefascia and encloses thefemoral vessels and the femoral canal.femoral vessels and the femoral canal.

TheThe lacunarlacunar ligament forms the medialligament forms the medial

border of the femoral canal. The femoralborder of the femoral canal. The femoralvein lies lateral to the femoral canal.vein lies lateral to the femoral canal.


27/66


28/66

HERNIASHERNIAS


29/66


30/66

HerniasHernias

What is a Hernia?What is a Hernia?

Abnormal protrusion of intraAbnormal protrusion of intra--abdominal contentsabdominal contents throuhthrouh a defecta defect

in the abdominal wallin the abdominal wall


31/66

OVERVIEW OF HERNIASOVERVIEW OF HERNIAS


32/66

OVERVIEW OF HERNIASOVERVIEW OF HERNIAS

Hernias occur:Hernias occur:

7575 –– 80 % in Inguinal Region80 % in Inguinal Region 88 –– 10 %10 % IncisionalIncisional (ventral hernia)(ventral hernia)

33 –– 8 % Umbilical Hernias8 % Umbilical Hernias

DONDON’ ’ T FORGET INTERNAL HERNIAS!T FORGET INTERNAL HERNIAS!


33/66

ETIOLOGY OF HERNIASETIOLOGY OF HERNIAS

Congenital defectsCongenital defects

Loss of tissue strength and elasticityLoss of tissue strength and elasticity(from aging or repetitive stress)(from aging or repetitive stress)

Operative TraumaOperative Trauma Increased Abdominal PressureIncreased Abdominal Pressure

(heavy lifting, COPD, BPH,(heavy lifting, COPD, BPH, AscitiesAscities,,

Obesity)Obesity)


34/66

Complications of HerniaComplications of Hernia

PAINPAIN

OBSTRUCTIONOBSTRUCTION

BOWEL NECROSISBOWEL NECROSIS

PERFORATIONPERFORATION


35/66

DESCRIPTIVE TERMSDESCRIPTIVE TERMS

ReducibleReducible-- can be pushed back into thecan be pushed back into theabdomenabdomen

IncarceratedIncarcerated-- cannot becannot be “ “reducedreduced” ” StrangulatedStrangulated-- the tissue in the hernia isthe tissue in the hernia is

ischemic and willischemic and will necrosenecrose due todue to

compromise of its blood supplycompromise of its blood supply SlidingSliding-- the wall of the hernia sac is partthe wall of the hernia sac is part

formed by a retroperitoneal structureformed by a retroperitoneal structure

RichterRichter’’s hernias hernia-- only one side of theonly one side of thebowel wall involved in the hernia canbowel wall involved in the hernia cannecrosenecrose without signs of obstructionwithout signs of obstruction


36/66


37/66

Inguinal herniasInguinal hernias

Inguinal hernias are classifiedInguinal hernias are classified

as:as:1) Indirect1) Indirect

2) Direct2) Direct

3) Femoral3) Femoral


38/66

Indirect HerniaIndirect Hernia An indirect hernia occurs when a herniaAn indirect hernia occurs when a hernia

sac enters the deep inguinal ring lateral tosac enters the deep inguinal ring lateral tothe inferiorthe inferior epigastricepigastric artery and passesartery and passes

indirectly to the superficial ring throughindirectly to the superficial ring throughthe inguinal canal.the inguinal canal.

Indirect hernias are the most commonIndirect hernias are the most commontype of hernia in both men and womentype of hernia in both men and women

CAUSE: Persistence of all or part of theCAUSE: Persistence of all or part of theembryonicembryonic processusprocessus vaginalisvaginalis results inresults invarious inguinal anomalies.various inguinal anomalies.


39/66


40/66

INDIRECT HERNIASINDIRECT HERNIAS


41/66

INDIRECT HERNIASINDIRECT HERNIAS

INCIDENCE:INCIDENCE:

In children, varies with gestational ageIn children, varies with gestational age

and ranges from 9 to 11% in pretermand ranges from 9 to 11% in preterminfants to 3.5 to 5% in fullinfants to 3.5 to 5% in full--term babies.term babies.

5 to 10 times more common in men than5 to 10 times more common in men than

womenwomen more frequently on the right side as amore frequently on the right side as a

result of later descent of the right testisresult of later descent of the right testis

and delayed obliteration of theand delayed obliteration of the processusprocessusvaginalisvaginalis..

Approximately 5% of men develop anApproximately 5% of men develop aninguinal hernia in their lifetimeinguinal hernia in their lifetime

CLINICAL PRESENTATIONCLINICAL PRESENTATION


42/66

CLINICAL PRESENTATIONCLINICAL PRESENTATION

can vary from vague pain to large bulgecan vary from vague pain to large bulge

right side in 60% of casesright side in 60% of cases left side in 30%left side in 30%

bilateral in 10%.bilateral in 10%.

Bilateral inguinal hernias are moreBilateral inguinal hernias are morecommon in preterm infants.common in preterm infants.

The major risk factor in cases ofThe major risk factor in cases of inguinalinguinalherniahernia is the occurrence of bowelis the occurrence of bowelincarceration and possible strangulation.incarceration and possible strangulation.


43/66

SURGICAL REPAIR INCLUDESSURGICAL REPAIR INCLUDES


44/66

SURGICAL REPAIR INCLUDES

HIGH LIGATION OF HERNIA SACHIGH LIGATION OF HERNIA SAC


45/66


46/66

Direct Inguinal HerniaDirect Inguinal Hernia


47/66

Direct Inguinal HerniaDirect Inguinal Hernia

A direct hernia occurs when aA direct hernia occurs when a hernialhernial

sac is pushed through the conjointsac is pushed through the conjointtendon directly towards thetendon directly towards the

superficial ring.superficial ring.

Direct hernias occur medial to theDirect hernias occur medial to the

inferiorinferior epigastricepigastric vessels invessels in

HasselbachHasselbach’ ’ ss Triangle through theTriangle through thefloor of the inguinal canalfloor of the inguinal canal


48/66

Boundaries ofBoundaries of Hasselbach'sHasselbach'sTriangleTriangle


49/66

TriangleTriangle

Medial boundary: RectusMedial boundary: Rectus abdominisabdominis

Lateral boundary: InferiorLateral boundary: Inferior epigastricepigastricvesselsvessels

Inferior boundary: Inguinal ligamentInferior boundary: Inguinal ligament

MARKS THE AREA FOR DIRECTMARKS THE AREA FOR DIRECTHERNIASHERNIAS


50/66

SURGICAL REPAIR INCLUDES RESURGICAL REPAIR INCLUDES RE--


51/66

SURGICAL REPAIR INCLUDES RESURGICAL REPAIR INCLUDES RE

ENFORCEMENT OF FLOOR WITH MESHENFORCEMENT OF FLOOR WITH MESH““LICHTENSTEIN REPAIRLICHTENSTEIN REPAIR””


52/66

Open Lichtenstein RepairOpen Lichtenstein Repair


53/66

Open Lichtenstein Repair Open Lichtenstein Repair

Laparoscopic repairLaparoscopic repair


54/66

Laparoscopic repair Laparoscopic repair

NONOPERATIVE MANAGEMENTNONOPERATIVE MANAGEMENT


55/66

NONOPERATIVE MANAGEMENTNONOPERATIVE MANAGEMENT

Femoral HerniaFemoral Hernia


56/66

Femoral HerniaFemoral Hernia

In a femoral hernia the hernia sac isIn a femoral hernia the hernia sac ispushed into the femoral canal, below thepushed into the femoral canal, below the

inguinal ligament and between theinguinal ligament and between the lacunarlacunar

ligament and the femoral vein.ligament and the femoral vein. The hernia sac thus lies inferior and lateralThe hernia sac thus lies inferior and lateral

to the pubic tubercle and anterior to theto the pubic tubercle and anterior to the

superiorsuperior pubicramuspubicramus periosteumperiosteum(COOPER(COOPER’ ’ S LIGAMENT)S LIGAMENT)


57/66

FEMORAL HERNIAFEMORAL HERNIA


58/66

FEMORAL HERNIAFEMORAL HERNIA

3030 –– 40% of femoral hernias become40% of femoral hernias become

incarcerated or strangulatedincarcerated or strangulated Femoral hernias are more common inFemoral hernias are more common in

women than menwomen than men…………

McVayMcVay RepairRepair –– TF and ConjoinedTF and Conjoined

tendon to Coopertendon to Cooper’ ’ s Ligaments Ligament

Umbilical HerniaUmbilical Hernia


59/66

Umbilical HerniaUmbilical Hernia

At the umbilicus hernias can developAt the umbilicus hernias can developdue to developmental deficiencies,due to developmental deficiencies,congenital umbilical hernia, or maycongenital umbilical hernia, or may

occur due to a weakness in theoccur due to a weakness in the linealineaalba in the area of the umbilicus, analba in the area of the umbilicus, anacquired umbilical hernia.acquired umbilical hernia.


60/66

UMBILICAL HERNIAUMBILICAL HERNIA


61/66

UMBILICAL HERNIAUMBILICAL HERNIA

10 times more common in women10 times more common in women

Common in children but usuallyCommon in children but usuallycloses by age 2, fix at age 5closes by age 2, fix at age 5

Fewer than 5% of umbilical herniasFewer than 5% of umbilical hernias

persist into later childhood and adultpersist into later childhood and adult

lifelife


62/66

VENTRAL HERNIAVENTRAL HERNIA


63/66

VENTRAL HERNIA

Ventral HerniaVentral Hernia-- generic term given togeneric term given tohernias in areas other than the inguinalhernias in areas other than the inguinal

regionregion

IncisionalIncisional HerniaHernia –– most common typemost common typeof ventral hernia, results from poor woundof ventral hernia, results from poor woundhealing in a previous surgical incisionhealing in a previous surgical incision

(infection, tension,(infection, tension,

malnutrition,intramalnutrition,intra

--

abdominal pressure, etc) and occurs inabdominal pressure, etc) and occurs in55 –– 10 % of abdominal incisions10 % of abdominal incisions


64/66

Problems and PresentationProblems and Presentation


65/66

Bowel obstruction (N/V, pain,Bowel obstruction (N/V, pain,

Distention,Distention, ObstipationObstipation)) PERFORATION after strangulationPERFORATION after strangulation

HOW TO FIXHOW TO FIX


66/66

LaparotomyLaparotomy :primary:primary vsvs meshmesh

closureclosure

Laparoscopy with meshLaparoscopy with mesh

Abdominal binderAbdominal binder

Abdominal Wall and Abdominal Wall Hernias

Documents

Transcript of Abdominal Wall and Abdominal Wall Hernias