FAISAL GHANI SIDDIQUI PROFESSOR OF SURGERY J I N N A H S I N D H M E D I C A L U N I V E R S I T Y VENTRAL HERNIA
FAISAL GHANI SIDDIQUIPROFESSOR OF SURGERY
J I N N A H S I N D H M E D I C A L U N I V E R S I T Y
VENTRAL HERNIA
INTRODUCTION
WHAT ARE VENTRAL HERNIA?HERNIAS OF THE ANTERIOR ABDOMINAL WALL
EUROPEAN HERNIA SOCIETY CLASSIFICATION (2009)
EPIGASTRICUMBILICAL – PARAUMBILICAL INCISIONALSPIGELIANLUMBAR
EPIGASTRIC HERNIA
EPIGASTRIC HERNIA Occur through the linea alba, anywhere between the xiphoid process and umbilicus
Split in the linea alba at a site of entry of a blood vessel
Protrusion of extra-peritoneal fat through the split into the s/c tissue
Peritoneal sac follows
EPIGASTRIC HERNIA–CLINICAL FEATURES
Fit, healthy men between 25 –40 years of age Severe pain (partial
strangulation of fat by narrow neck) Small, soft, pea-size, tender
midline swelling Irreducible due to narrow neck
Two separate epigastric hernias. The smaller one contains pre-peritoneal fat, and the larger one contains omentum
EPIGASTRIC HERNIA - TREATMENT Very small hernia disappear spontaneously
Small to moderate-sized hernia without peritoneal sac are not dangerous and operated, only if symptomatic
EPIGASTRIC HERNIA - TREATMENT Open
Laparoscopic
UMBILICAL / PARAUMBILICAL HERNIA
UMBILICAL / PERIUMBILICAL HERNIA -CAUSES
In neonates: delay in closure of the umbilical defect
In adults: stretching and thinning of linea alba and reopening of the umbilical defect due to raised intra-abdominal pressure:
• pregnancy• ascites• obesity
UMBILICAL HERNIA INCHILDREN
UMBILICAL HERNIA IN CHILDREN-FEATURES
Appears few weeks after birth
Higher incidence in premature / black babies
Symptomless
Increase in size when baby cries
Appear as a conical mass
UMBILICAL HERNIA IN CHILDREN TREATMENT Conservative: under the age two years
Surgical: if hernia persists beyond two years
a. Curved incision below the umbilicus given
b. Neck of sac identified; opened and contents reduced
c. Redundant sac excised and sac closed; defect in linea alba closed
d. Skin sutured
UMBILICAL HERNIA INADULTS
UMBILICAL HERNIA IN ADULTS
Bulge is typically to one side of the umbilicus
Crescent-shaped depression created
UMBILICAL HERNIA INADULTS …cont.
Pain In large hernia, overlying skin may
be stretched, thinned-out and ulcerated
Umbilical and paraumbilical hernia
Umbilical and paraumbilical hernia
UMBILICAL HERNIA IN ADULTS-TREATMENT
Surgery advised due to high risk of strangulation
UMBILICAL HERNIA IN ADULTS –TREATMENT OPTIONS
Defect less than 1 cm Simple closure
Defects up to 2 cm Mayo’s repair
Defect > 2 cm Mesh repair
INCISIONAL HERNIA
INCISIONAL HERNIAHerniadeveloping through a postoperative scar
INCISIONAL HERNIA -ETIOLOGY
PATIENT FACTORS • Poor wound healing• Obesity• Early return to work• Postop. cough
WOUND FACTORS • Wound infection
SURGICAL FACTORS
• Inappropriate suture material• Improper suture technique
INCISIONAL HERNIA -TREATMENT No treatment, if asymptomatic Abdominal binder may be advised
INCISIONAL HERNIA -TREATMENT Mesh repair Open Laparoscopic
POSITIONING OF THE MESH ONLAY INLAY SUBLAY INTRAPERITONEAL
• Very large incisional hernia
• > 25 % of the volume of the abdominal cavity
VERY LARGE INCISIONAL HERNIA
• Will not fit back into the abdomen; wound breakdown
• Cause increase in the intra-abdominal pressure
• Visceral compression• Pulmonary complications
TECHNIQUES
Progressive preoperative pneumoperitoneum for several weeks
Resection of omentum and/or colon to create extra space
Mesh to span the uncloseable defect
Ramirez component separation technique
REDUCING THE RISK OF INCISIONAL HERNIA
• Improving patient’s general condition• Weight loss for obesity• Correction of malnutrition
• Proper suturing• Proper gauge• Proper distance• Proper suture length to wound length (4:1) –Jenkins’ rule
• Prophylactic mesh placement in patients at high risk for incisional hernia (e.g. bariatric surgery)