ANATOMIC DEFECTS OF THE

ABDOMINAL WALL
AND PELVIC FLOOR
Abdominal wall hernias

Layers of the abdominal wall

1. Skin
2. Subcutaneous connective tissue
3. External oblique
4. Transversus abdominis muscle with
their investing fascia
5. Parietal peritoneum

Internal Inguinal ring

o Medial margin inferior epigastric
artery
1. Inguinal hernia
o A bulge in the peritoneum through the
internal inguinal ring and into the
inguinal canal
o Less common in the female than in the
male
o Frequently identified after stretching
of the abdominal wall during or after
pregnancy
o Related to congenital weakness of the
area
Def:
Reducible contents can be returned to
the abdominal cavity
Incarcerated= contents cannot be reduced,
acute and accompanied by pain or may be
long standing and asymptomatic
Strangulated=contents are incarcerated and
whose blood supply to the contents structure
is compromised
Sliding hernia= portion of the hernia sac is
composed of an organ such as the sigmoid
colon or the cecum
2. Femoral hernia
o Defect in the transversalis fascia occur
in the hesselbachs triangle
o Lateral boundary: inferior epigastric
artery
Inferiorly: inguinal ligament
Medially: lateral margin of the
rectus sheet
o More common in female
o Hernia sac passes under the inguinal
ligament into the femoral triangle
rather than coursing through the
inguinal canal
3. Ventral hernias
o Occurs in the abdominal wall away
from the groin(umbilical hernia,

incisional hernia, epigastric hernia,

and spigelian hernia)
a. Umbilical hernia
Hernia producing through the
umbilicus
Caused by congenital relaxation of
the umbilical ring
b.Incisional hernias
Involve separation of the fascia of
the abdominal wall
Hernia sac palpated beneath the
skin and subcutaneous tissue
Sac wall is composed of
peritoneum
c. Epigastric hernia
Occurs in a defect in the linea alba
above the umbilicus
d. Spigelian hernia
Herniation at a point where the
vertical linea semilunaris joins the
lateral border of the rectus muscle
Etiology
o Congenital malformation(umbilical
hernia)
o Trauma and injury
o Chronic cough(sec to smoking or
chronic respiratory disease)
o Poor healing of the fascia (eg.
Incisional hernia)
Symptoms and signs:
o Bulges in the abdominal wall
asymptomatic noted during increase
intraabdominal pressure (pregnancy
ascites)
o Aching or discomfort(larger hernias)
o Acute pain or discomfort
(strangulation)
Physical exam:
o Weakening at the site of the hernia
o Palpation of the ring of the hernia
o Accentuation of the hernia during
straining
o Fever, leukocytosis
o Acute abdomen (strangulated hernia)
Management:
A. Non-operative:
Ventral and groin hernia
Umbilical hernia(close by 3or 4 yo)
Small incisional hernia(corset)
Unincarcerated groin hernia
B. Operative:
Principles= Reduce the sac
Repair the fascial defect

Lysis of adhesions
Larger hernias
Incarcerated hernia
Strangulated hernia
Continuous discomfort

1. Umbilical hernia repair:

sac dissected
fascial edges closed by direct
approximation or vest over
pants manner
2. Incisional hernia repair
Hernia sac reduced
Fascial edges mobilized
completely and closed side to side
with interrupted non-absorbable
suture
3. Inguinal hernia
Sac identified, intraabdominal
contents reduced
Sac neck ligated and transfixed
away from the ring often to the
coopers ligament
Transversalis fascia approximated
4. Femoral hernia repair
Incise the inguinal ligament to free
the sac neck
Sac neck sutured to the coopers
ligament beneath the inguinal
ligament

Complications of operative repair

o Lateral thigh paresthesia
o Inferior epigastric artery injury
o Enterotomy from adhesiolysis
o Bowel obstruction
Disorders of Pelvic Support
Pelvic support structures are often
weakened by
1. Childbirth
2. Pelvic trauma
3. Stress and strain
4. Aging process
Results in abnormalities
1. urethrocele
2. cystocele
3. rectocele
4. enterocele
5. uterine prolapse
6. prolapse of the vagina(post
hysterectomy)
1. Urethrocele and cystocele

Due to attenuation or rupture of the

pubovesicle cervical fascia
o Descent of the urethra bladder neck
or bladder into the vaginal canal
o Urethrocele more common in
gynecoid type pelvis
Symptoms and signs
o Sensation of fullness or pressure
o Feeling that organs are falling out
o Stress incontinence
o Urgency
o Feeling of incomplete emptying
with voiding
Diagnosis
o Bladder partially filled
o Dorsal lithotomy position
o Retractor or graves speculum
depress the posterior vaginal wall
o Patient asked to strain
o Palpate the bladder neck
o Palpate soft,pliable, non-tender
mass
Differential diagnosis
o Enlarged skenes glands =tender
express pus
o Bladder tumor
o Bladder diverticula
= reducible, sensation of a mass
=pus may be expressed (test for
Gn and Chlamydia)
Management:
A. Nonoperative
1. Smith Hodge or inflatable pessary
2. Intermittent use of a large tampon
3. Kegel exercises
4. Estrogen (cream/systemic)
= younger woman with large cystocele
should be encouraged to avoid operative
repair until she has completed her family
= if repaired performed, cs considered
for subsequent pregnancies
B.Operative
= anterior and posterior colporrhaphy
=Kelly plication suture at bladder neck
=postoperative bladder drainage for 3to
5 days
=heavy lifting, prolonged periods of
standing should be avoided for 3 months
2. Rectocele
Symptoms and Signs
1. Heavy or falling out feeling in the
vagina
2. Constipation
o

3. Splinting of the vagina with fingers to

effect bowel movement
4. Incomplete emptying of the rectum at
the time of bowel movement
Diagnosis
1. Retract the anterior vaginal wall
upward and have the patient strain
a. Rectum will bulge into the
vagina
b. Bulge will protrude through the
introitus
c. Rectovaginal exam: palpate the
hernia
Management
1. Non-operative:
a. Pesaries
b. Kegel exercises
c. Estrogen
2. Operative
a. Posterior colporrhaphy and
perineorrhaphy
3. ENTEROCELE
o True hernia of the peritoneal cavity
emanating from the pouch of
Douglas between the uterosacral
ligaments and into the vaginal
septum
o Frequently occur after an
abdominal or vaginal hysterectomy
o Result of a weakened support for
the pouch of Douglas
o Prevention: Incorporation of the
cardinal and uterosacral ligaments
into the vault repair during
hysterectomy
Diagnosis
o Noticed as a separate bulge above
the rectocele
o Prolapse through the vagina (large)
o Transillumination: small bowel
shadows within the sac
o RVE: contents small bowel and
usually reducible
Management
1. Primary procedure: sac reduced
upward and uterosacral ligaments
brought together in the midline
2. Post-hysterectomy: obliteration of
the cul de sac by CONCENTRIC PURSE
STRING SUTURES in the endopelvic
fascias using PERMANENT sutures
3. At the time of posterior
colporrhaphy:
a. Visualize sac as the vagina is
separated from the rectum

b. Sac dissected and isolated at its

neck
c. Neck of the hernia sutures with
a PURSE STRING O-ligature
d. Sac is excised
4. Mc Call Stitch
a. Fix the UTEROSACRAL
LIGAMENTS to the PERITONEUM
of the sac and the vaginal vault
using O-polyglycol suture
beginning on one side of the
vagina and continuing through
the uterosacral ligaments of
that side, peritoneum of the sac
and the uterosacral ligament
and vagina of the opposite side
b. Effectively SHORTENS the cul de
sac
c. Provides SUPPORT of the NECK
of the enterocele sac
Correctly repaired enteroceles usually
will not recur
Recurrence: Repair enterocele and
OBLITERATE cul de sac with
imbricating suture through an
ABDOMINAL INCISION.
5.
UTERINE PROLAPSE (DECENSUS,
PROCIDENTIA)
Associated with injuries of the:
o Endopelvic fascia
o Cardinal ligament
o Uterosacral ligament
o Levator ani muscles
Result of increased
intraabdominal pressure such as:
o Ascites
o Large pelvic tumors
o Large intraabdominal tumors
Diabetic nephropathy
Sacral nerve disorders (S1 to S4)
Anatomic predisposition:
o Large TRANSVERSE INLET
diameter
Chronic respiratory disease:
o Chronic BRONCHITIS
o Asthma
o Bronchiectasis
o Severe obesity
Congenital , damaged or relaxed
pelvic floor supports (young,
nulliparous)
Almost always associated with
RECTOCELE and CYSTOCELE
Classification:

First Degree: prolapse into the

BARREL OF THE VAGINA
o Second Degree: Prolapse
through the vaginal barrel to
the region of the INTROITUS
o Third Degree: Cervix and
uterus prolapsed OUT through
the INTROITUS; vagina is
everted around the uterus and
cervix, and COMPLETELY
EXTERIORIZED
Dryness, thickening, and
chronic inflammation of
the vaginal epithelium
Stasis ulcers result
Symptoms and signs of Uterine
Prolapse
1. Feeling of heaviness, fullness or
falling out in the perineum
2. Tumor bulging out of the vagina
(cervix protrudes from the introitus)
3. Pain and vaginal bleeding
4. Discharge from the cervix and
vagina (secondary infection)
o

o
o

Management
o Minimum prolapse: NO TREATMENT
unless patient is very uncomfortable
1. MEDICAL Management:
o Pessary (Smith-Hodge donut,
cube, inflatable(
o Estrogen-replacement for
30days (POSTMENOPAUSAL)
in the form of CREAM or
SYSTEMIC estrogen
2. OPERATIVE MANAGEMENT
o Vaginal hysterectomy
with anterior and
posterior colporrhaphy
Isolate the uterosacral
and cardinal ligaments
to be used in the
support of the vaginal
vault
Uterosacral ligament
should be sutured
together so that the cul
de sac is shortened

Abdominal hysterectomy
plus AP repair
Previous
intraabdominal
operation for an
inflammatory process
PID
Endometriosis
Laparoscopically-assisted
vaginal hysterectomy
Manchester Fothergill
Operation
Combines AP repair
with AMPUTATION of
the CERVIX and
The use of the
CARDINAL LIGAMENTS
to support the anterior
vaginal wall and
bladder
Hypertrophied,
elongated cervix with
good support for the
uterus itself
For older women,
technically easier
LE FORT COLPOCLEISIS
Older women who are
NOT SEXUALLY active

Removal of a strip of
anterior and posterior
wall with CLOSURE of
the margins of the
anterior and posterior
wall to each other
A small vaginal canal
exists on either side of
the septum which is
produced by suturing
the lateral margins of
the excision
GOODAL POWER
PROCEDURE
Modification of Le Fort
allows removal of a
TRIANGULAR PIECE of
the VAGINAL WALL
Works well for SMALL
prolapses
When colpocleisis is
performed, if an enterocele is
found, sac must be identified
and ligated and the
peritoneum of the sac is

excised to prevent
recurrence of the enterocele
behind the colpocleisis
o PERINEORRHAPHY is
performed with a colpoclesis
to REINFORCE the introitus
o PROGNOSIS for a colpocleisis
procedure to reduce the
prolapsed and prevent
recurrence is generally
EXCELLENT
6. VAGINAL STUMP PROLAPSE
Incidence: 1-18.2%
May be TOTAL and may be
accompanied by a CYSTOCELE,
RECTOCELE, ENTEROCELE, or
combination
Causes:
1. Continuing pelvic support
weakness
2. Failure of the cardinal and
uterosacral ligaments to
maintain their tone or
attachment to the vagina
Symptoms and signs:
1. Pelvic heaviness
2. Backache
3. Mass protruding through the
introitus
4. Stress incontinence, dribbling,
urgency, frequency
5. Vaginal bleeding or discharge
6. Difficulty with sitting or walking
Diagnosis:
1. Examine contents of herniation
2. Rectovaginal examination
helpful in delineating an
ENTEROCELE from a
RECTOCELE
Management Principles:
1. Normal position of the vagina in
the standing position is
AGAINST the RECTUM and NO
MORE than 30deg from the
horizontal
2. PELVIC RELAXATION is a part of
the problem and dictates that
an existing cystocele, rectocele,
or enterocele
3. Perineal body is almost always
weakened and must be
constructed as well

Management:
1. NON-SURGICAL
Pessaries
Estrogen
2. SURGICAL
Abdominal approach:
fixation of the vaginal
vault to the
Anterior abdominal
wall
Lumbar spine
Sacral promontory
Various tendinous
lines
Sacrospinous
ligament (MOST
SUCCESSFUL)
Vaginal approach
Unilateral or
bilateral vaginal
sacrospinal fixation
procedure
combined with
repair of cystocele,
rectocele, and
enterocele
Fixation of the
vault to the sacrum
Le Fort Colpocleisis
(women who are no
longer sexually active,
and with medical
complications)
PERINEORRHAPHY should ALWAYS be
performed

FECAL INCONTINENCE
Most devastating of all physical
disabilities
Definition: Inability to defer
elimination of stool or gas until there
is a socially acceptable time and place
to do so
Requires a persons ability to perceive
the type of fecal bolus, store or retain
when necessary and to excrete when
desirable
PHYSIOLOGY OF FECAL CONTINENCE
Fecal continence requires:

1. Normal stool consistency and

volume
2. Normal colonic transit time
3. A compliant rectum
4. Innervation of the pelvic floor and
anal sphincter
5. Interplay between the puborectalis
muscle, rectum and anal sphincters
Anal pressure is dependent on
function IAS and EAS
The IAS is under AUTONOMIC
CONTROL maintaining HIGH pressure
zone or CONTINENCE ZONE and along
with the EAS, keeps the anal canal
closed
The EAS provides the VOLUNTARY
SQUEEZE PRESSURE that prevents
incontinence with increasing rectal or
abdominal pressure
o Innervated by the
HEMORRHOIDAL BRANCH of the
PUDENDAL NERVE from S2-S4
roots
The PUBORECTALIS
o maintains a CONSTANT TONE
that is DIRECTLY proportional to
the VOLUME OF RECTAL
CONTENT and PRESSURE
o relaxes at the time of defecation
o The puborectalis is innervated
by direct branches from S3-S4
and to a lesser degree, the
pudendal nerve

ETIOLOGY AND PATHOPHYSIOLOGY OF

FECAL INCONTINENCE
Common causes of fecal incontinence:
1. Obstetric injury
2. Trauma
3. Diarrheal states
4. Rectal neoplasia
5. Overflow
6. Neurologic disease
7. Rectal prolapsed
8. Congenital abnormalities of
anorectum/pelvis
Detection of fecal incontinence
How often do you leak gas, liquid or
solid stool?
Evaluation:
o History
o Review of systems
o Past medical history

o Physical examination
o Testing
Diagnostic procedures:
o Trans anal UTS
o Anal manometry
o Electromyography
o Pudendal nerve terminal motor
latencies (PNTML)
o Defecography
o MRI
o Transit Study
Treatment:
o Biofeedback
o Electrical stimulation
o Surgery
Repair of rectal prolapsed
Anal sphincteroplasty
Anal sphincter
neomuscular flaps
Implantation of artificial
sphincters

RECTOVAGINAL FISTULA
Common complication of vaginal birth
and gynecologic surgeries
Complaint fecal or flatal incontinence
Etiology:
obstetric
Foreign bodies
Iatrogenic
Inflammatory
Neoplastic
1% of vaginal births will result in a RVF
Fistulas that occur more than 3cm
above the anal verge are true
rectovaginal fistulas
Most RVF secondary to OB injury occur
in the lower 3rd of the vagina
Fistulas secondarty to surgical trauma,
malignancy or inflammatory process
may occur anywhere along the vaginal
wall including apex

Signs and Symptoms

Depends on size and location of
fistula
1. Asymptomatic
2. Small amount of flatus
passing into the vagina
(low, small fistula)
3. Formed stool coming out
of the vagina (large
fistula)

Evaluation
1. History
2. PE
3. Colonoscopy (IBD)
4. Rectal Exam
5. Anoscopy or Proctoscopy
6. Examination under anesthesia

Surgical management:
o Opening of fistula tract
o Curetting the tract
o Leave the tract to heal
secondarily