abdominal wall

download abdominal wall

of 43

  • date post

    15-May-2015
  • Category

    Documents

  • view

    2.155
  • download

    1

Embed Size (px)

Transcript of abdominal wall

  • 1.ABDOMINAL WALL DEFECTS Celso M. Fidel, MD, FPCS,FPSGS Diplomate Philippine Board of Surgery

2. Introduction ABDOMINAL WALL Complex musculo-aponeurotic structure Attached to the : Vertebral column posteriorly Ribs superiorly Bones of the pelvis inferiorly Derived embryonically in asegmental,metameric manner, and is reflectedin blood supply and innervation. 3. 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

4. Introduction ABDOMINAL WALL It is the repository of the panniculus adiposusMay reach considerable proportions in some members of the species afflicted with morbid obesity . 5. Introduction ABDOMINAL WALL Variety of pathologydifficult to assess onphysical examination. Computed tomography (CT) often delineatesthese abnormalities 6. GENERAL CONSIDERATIONS VENTRAL HERNIA UMBILICAL HERNIAS EPIGASTRIC HERNIA INCISIONAL HERNIA TROCAR HERNIA Emergency Abdominal wall Defects Difficult Abdominal Wall Closure 7. ABDOMINAL WALL HERNIAS 8. UMBILICAL HERNIAS 9. UMBILICAL HERNIA 10. 11. 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 12. GENERAL CONSIDERATIONS Other Abdominal Wall Hernia 4. Parastomal Hernia 5. Internal hernia(a) Normal Orifice (b) Abnormal Orifice (c) Iatrogenic ( post-operative) 13. GENERAL CONSIDERATIONS Other Abdominal Wall Hernia 6. Co ngenital AbdominalWall defect (a) Gastroschisis (b) Omphalocele 7. C ongenitalDiaphragmatic Hernia (a) Bochdalek (b) Morgagni 14. Abdominal Wall Defects

  • Ventral Hernia
    • 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

15. Ventral HERNIA

  • Umbilical 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

16. 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 inthe midline (linea alba) between
  • the xiphoid.

17. 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

18. Patient Rogelia Tacuban 19. INCISIONAL HERNIOPLASTY

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

20. Clear View of External O Aponeurosis 21. Separation of the Sac 22. CATTELL REPAIR 23. 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

24. 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

25. 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

26. Ventral HERNIA

  • Repair Techniques
  • 1. P rimary repair w/ non-absorbablemonofilament
  • 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

27. 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

28. 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

29. Other Abdominal Wall Hernia

  • SPIGELIAN HERNIA
  • Ventralhernia occurringalong the subumbilical
  • portion of the Spieghels Semilunar line &
  • throughSpieghels Fascia.
  • Vague pain, mass usually not palpable ,intra
  • muralmass located 0-6 cranialto interspinous
  • line (horizontal line between 2 ASIS)
  • Usual location- just below semicircular line of
  • Douglas; Defect in Transversus Abdominis

30. Other Abdominal Wall Hernia

  • LUMBAR HERNIA
  • Congenitalspontaneous& traumatic herniation
  • occur through Grynfelts superior & petits
  • inferior lumbar triangle .
  • Defect in transversalis fascia & Tranversus
  • Abdominis Aponeurosis
  • Contains retroperitoneal sac or peritoneum
  • lined sac

31. Lumbar Hernia

  • PETITS TRIANGLEis bounded by:
  • Medial= Latissimus dorsi muscle
  • Lateral= External oblique muscle
  • Inferior= Iliac crest
  • Covered by superficial fascia
  • GRYNFELTS TRIANGLEis bounded by:
  • Superior= 12 thrib
  • Lateral= Internal oblique abdominal muscle
  • Medial=Sacrospinalis muscle
  • Covered by latissimus dorsi

32.

  • 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 obturatornerve by an
  • obturator hernia.

Other Abdominal Wall Hernia 33.

  • 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 34.

  • 2. Perineal Hernia
  • Occur spontaneously or after APR or
  • pelvic exenteration
  • 1. Anterior- defect in urogenital diaphragm;
  • mass in labia majora
  • 2. Po sterior- defect in the levatorani bet