ABDOMINAL WALL DEFECTS

Celso M. Fidel, MD, FPCS,FPSGS

Diplomate Philippine Board of Surgery

Introduction
ABDOMINAL WALL Complex musculo-aponeurotic structure Attached to the : Vertebral column posteriorly Ribs superiorly Bones of the pelvis inferiorly Derived embryonically in a segmental, metameric manner, and is reflected in blood supply and innervation.

Introduction ABDOMINAL WALL Protects and restrains the abdominal viscera, and its musculature Acts indirectly to flex the vertebral column. Integrity is essential to the prevention of hernias, whether they be: Congenital Acquired Iatrogenic

Introduction
ABDOMINAL WALL

It is the repository of the panniculus adiposus May reach considerable proportions in some members of the species afflicted with morbid obesity.

Introduction
ABDOMINAL WALL Variety of pathology difficult to assess on physical examination. Computed tomography (CT) often delineates these abnormalities

GENERAL CONSIDERATIONS
VENTRAL HERNIA UMBILICAL HERNIAS EPIGASTRIC HERNIA INCISIONAL HERNIA TROCAR HERNIA Emergency Abdominal wall Defects Difficult Abdominal Wall Closure

ABDOMINAL WALL HERNIAS

UMBILICAL HERNIAS

UMBILICAL HERNIA

GENERAL CONSIDERATIONS
Other Abdominal Wall Hernia Spigelian Hernia Lumbar Hernia 1. Petits or inferior triangle hernia 2. Grynfelts or sup. Triangle hernia Pelvic Floor Hernia 1. Obturator Hernia 2. Perineal Hernia 3. Sciatic Hernia

GENERAL CONSIDERATIONS
Other Abdominal Wall Hernia 4. Parastomal Hernia 5. Internal hernia (a) Normal Orifice (b) Abnormal Orifice (c) Iatrogenic ( post-operative)

GENERAL CONSIDERATIONS
Other Abdominal Wall Hernia 6. Congenital Abdominal Wall defect (a) Gastroschisis (b) Omphalocele 7. Congenital Diaphragmatic Hernia (a) Bochdalek (b) Morgagni

 Ventral Hernia

Abdominal Wall Defects

Defect in the abdominal wall with intestines or preperitoneal fat thru fascial defect On PE fascial defect usually palpable in obese patients Ultrasound or CT scan for the diagnosis Same principle of management as groin hernia

 Umbilical Hernia

Ventral HERNIA

Occur more frequently in females; 10-30% live birth Obesity and repeated pregnancies precludes this problem In infants aponeurotic defect of 1.5 cm or less would close spontaneously Repair for children present by the age of three or four & infants whose defect is 2 cm

Ventral HERNIA
Umbilical Hernia

MAYO HERNIOPLASTY Vest over pants imbrication of the superior & inferior aponeurotic fascia layer EPIGASTRIC HERNIA Protrusion of properitoneal fat & peritoneum through the dicussating fibers of the rectus sheath in the midline (linea alba) between the xiphoid.

Ventral HERNIA
Epigastric Hernia

Diastasis Recti Wide gap between the medial borders of the rectus sheath Diffuse bulge at upper midline of abdomen Not a fascial defect, hence repaired for cosmetic purposes Incisional Hernia

Patient Rogelia Tacuban

INCISIONAL HERNIOPLASTY Anatomic reconstruction of the abdominal wall and Includes; Closure of the parietal defect Restoration of normal intra-abdominal pressure Tendinous reinforcement of the lateral abdominal muscles.

Clear View of External O Aponeurosis

Separation of the Sac

CATTELL REPAIR

Ventral HERNIA
Incisional Hernia 2-11% of abdominal wall closure 56% in the first year postoperative 17% incarcerate 20-46% repeat recurrence Causes: 1. Obesity 2. post-op pulmonary complications 3. Wound infection

Visceral HERNIA
Incisional Hernia 4. Jaundice 5. Advanced age 6. Abdominal Distention 7. Re-use of previous incision 8. Emergency operation 9. Pregnancy 10. Chemotherapy post-op

Ventral HERNIA
Incisional Hernia 11. Steroids 12. Malnutrition 13. Ascites 14. Peritoneal dialysis Trocar Hernias < 1% after laparoscopic procedure Fascial defects > 5mm should be closed

Ventral HERNIA
Repair Techniques 1. Primary repair w/ non-absorbable monofilament sutures; 49-58% failure rate Mayo repair (fascial imbrication) 54% recur in 5-7 years follow up Far and Near suturing by Shukla= 0% Internal retention suturing-2% recur for large ventral hernia

Ventral HERNIA
Repair Techniques 2. Mesh onlay- 6% recur 3. Mesh onlay and patch repair= Mesh placed deep to the rectus sheath 4. Sandwich and cuffed mesh repair combined onlay + inlay 5. Stoppa- Giant mesh prosthesis for large >10 cm incisional hernia 6. Laparoscopic repair

Emergency Abdominal Wall Defect

Difficult abdominal wall closure in: Massive bowel edema Tissue loss due to Trauma Debridement for necrotizing lesions Resection of tumors Repair with prosthetics w/ absorbable mesh followed by skin grafting then planned ventral hernia repair

Other Abdominal Wall Hernia

SPIGELIAN HERNIA
Ventral hernia occurring along the subumbilical portion of the Spieghels Semilunar line & through Spieghels Fascia.

Vague pain, mass usually not palpable, intra mural mass located 0-6 cranial to interspinous line (horizontal line between 2 ASIS) Usual location- just below semicircular line of Douglas; Defect in Transversus Abdominis

Other Abdominal Wall Hernia

LUMBAR HERNIA
Congenital spontaneous & traumatic herniation occur through Grynfelts superior & petits inferior lumbar triangle.

Defect in transversalis fascia & Tranversus Abdominis Aponeurosis Contains retroperitoneal sac or peritoneum lined sac

Lumbar Hernia
PETITS TRIANGLE is bounded by: Medial= Latissimus dorsi muscle Lateral= External oblique muscle Inferior= Iliac crest Covered by superficial fascia GRYNFELTS TRIANGLE is bounded by: Superior= 12th rib Lateral= Internal oblique abdominal muscle Medial=Sacrospinalis muscle Covered by latissimus dorsi

Other Abdominal Wall Hernia

PELVIC HERNIA- occurs in cachetic, elderly patients in the, Obturator fossa, Perineum & Greater and lesser sciatic foramina 1. Obturator Hernia 50% with Howship-Romberg Sign Pain in the region of the hip, and of the knee and on the inner aspect of the thigh because of pressure on the obturator nerve by an obturator hernia.

Other Abdominal Wall Hernia

Usually in emaciated females in late 70s on the right side Often with either large or small bowel incarceration or strangulation Rarely with a mass at the anteromedial thigh or a bulge on rectal or pelvic examination Diagnosis by CT scan Repair by midline approach to take care of bowel problem too.

Other Abdominal Wall Hernia

2. Perineal Hernia Occur spontaneously or after APR or pelvic exenteration 1. Anterior- defect in urogenital diaphragm; mass in labia majora 2. Posterior- defect in the levator ani between the urinary bladder and rectum Repair= Transperineal or transabdominal primary repair or with mesh

Other Abdominal Wall Hernia

3. Sciatic Hernia Rarest of all hernias; Occurs in the greater or lesser sciatic foramen or thru a defect in the pyriformis muscle Presents as sciatic nerve palsy and a mass or simply intestinal obstruction Repair= Gluteal or Transabdominal approach

 PARASTOMAL HERNIA Occurs thru defects adjacent to ostomy site Incidence: 12-32% paracolostomy < 10% paraileostomy Prevention: Small fascial incision, avoid maturing thru the abdominal incision Complications: 1. Obstruction; 2. Incarceration 3. Poor Appliance fit 4. Local pain

Other Abdominal Wall Hernia

Other Abdominal Wall Hernia

PARASTOMAL HERNIA
Repair: Primary fascial or prosthetic repair or relocation of stoma Symptoms generally well tolerated All repairs associated with: 1. significant morbidity 2. high recurrence

Other Abdominal Wall Hernia INTERNAL HERNIA

Abdominal contents protrude thru normal or abnormal intra-abdominal orifice 3. Iatrogenic (Post operative) (a) Defect in Mesentery or Omentum Peterson Hernia=thru Roux limb CONGENITAL ABDOMINAL WALL DEFECTS Gastroschisis 1. Herniation of abdominal viscera without a sac, intact umbilical cord

 CONGENITAL ABDOMINAL WALL DEFECTS Omphalocele 1. Herniation of abdominal viscera into the umbilical cord, hence lined by internally by peritoneal sac and externally by amnion 2. Associated anomalies: (a) Cloacal exstrophy (b) Chromosomal abnormality in 50%

Other Abdominal Wall Hernia

 CONGENITAL ABDOMINAL WALL DEFECTS Gastroschisis 2. Two times (2X) more common than omphalocele 3. Associated anomalies: Intestinal Atresia 10% 4. Eviscerated Bowels are: (a) Edematous (b) Shortened with fibrinous adhesions 5. < 10% mortality

Other Abdominal Wall Hernia

 CONGENITAL DIAPHRAGMATIC HERNIA Bochdalek Hernia (a) Postero-lateral, most common at costal and spinal diaphragmatic attachment (b) Associated with malrotation, pulmonary hypoplasia (c) 4 x more common in the left side (d) Only 10-20% have a sac; 80% mortality by the first year of life

Other Abdominal Wall Hernia

Other Abdominal Wall Hernia

CONGENITAL DIAPHRAGMATIC HERNIA Bochdalek Hernia (e) Better repaired after a few days to weeks when the child stabilizes; higher mortality if repaired at birth (f) Repair: Transabdominal with the Ladd procedure for the malrotation Morgagni (a) Between sternal & costal diaphragmatic margin either retrosternal or parasternal