abdominal wall

ABDOMINAL WALL ABDOMINAL WALL DEFECTSDEFECTS

Celso M. Fidel, MD, FPCS,FPSGSCelso M. Fidel, MD, FPCS,FPSGSDiplomate Philippine Board of SurgeryDiplomate Philippine Board of Surgery

IntroductionIntroduction

ABDOMINAL WALL ABDOMINAL WALL

Complex musculo-aponeurotic structure Complex musculo-aponeurotic structure

Attached to the :Attached to the :

Vertebral column posteriorly Vertebral column posteriorly

Ribs superiorly Ribs superiorly

Bones of the pelvis inferiorlyBones of the pelvis inferiorly

Derived embryonically in a segmental, Derived embryonically in a segmental,

metameric manner, and is reflected metameric manner, and is reflected

in blood supply and innervation.in blood supply and innervation.


ABDOMINAL WALLABDOMINAL WALL

Protects and restrains the abdominal Protects and restrains the abdominal viscera, viscera,

and its musculatureand its musculature

Acts indirectly to flex the vertebral Acts indirectly to flex the vertebral column.column.

Integrity is essential to the prevention of Integrity is essential to the prevention of

hernias, whether they be:hernias, whether they be:

CongenitalCongenital

Acquired Acquired

IatrogenicIatrogenic



It is the repository of the panniculus It is the repository of the panniculus adiposus adiposus

May reach considerable proportions May reach considerable proportions in some members of the species in some members of the species afflicted with morbid obesityafflicted with morbid obesity..



Variety of pathology difficult to assess on Variety of pathology difficult to assess on

physical examination.physical examination.

Computed tomography (CT) often delineates Computed tomography (CT) often delineates

these abnormalitiesthese abnormalities

GENERAL CONSIDERATIONSGENERAL CONSIDERATIONS

VENTRAL HERNIAVENTRAL HERNIA

UMBILICAL HERNIASUMBILICAL HERNIAS

EPIGASTRIC HERNIAEPIGASTRIC HERNIA

INCISIONAL HERNIAINCISIONAL HERNIA

TROCAR HERNIATROCAR HERNIA

Emergency Abdominal wall DefectsEmergency Abdominal wall Defects

Difficult Abdominal Wall ClosureDifficult Abdominal Wall Closure

ABDOMINAL WALL HERNIASABDOMINAL WALL HERNIAS

UMBILICAL HERNIASUMBILICAL HERNIAS

UMBILICAL HERNIAUMBILICAL HERNIA


Other Abdominal Wall HerniaOther Abdominal Wall Hernia Spigelian HerniaSpigelian Hernia Lumbar HerniaLumbar Hernia 1. Petit’s or inferior triangle hernia1. Petit’s or inferior triangle hernia 2. Grynfelt’s or sup. Triangle hernia2. Grynfelt’s or sup. Triangle hernia

Pelvic Floor HerniaPelvic Floor Hernia 1. Obturator Hernia1. Obturator Hernia 2. Perineal Hernia2. Perineal Hernia 3. Sciatic Hernia3. Sciatic Hernia


Other Abdominal Wall HerniaOther Abdominal Wall Hernia

4. Parastomal Hernia4. Parastomal Hernia

5. Internal hernia 5. Internal hernia

(a) Normal Orifice(a) Normal Orifice

(b) Abnormal Orifice(b) Abnormal Orifice

(c) Iatrogenic ( post-operative)(c) Iatrogenic ( post-operative)



6. Co6. Congenital Abdominalngenital Abdominal Wall defect Wall defect

(a) Gastroschisis(a) Gastroschisis

(b) Omphalocele(b) Omphalocele

7. C7. Congenitalongenital Diaphragmatic Hernia Diaphragmatic Hernia

(a) Bochdalek(a) Bochdalek

(b) Morgagni(b) Morgagni

Abdominal Wall DefectsAbdominal Wall Defects Ventral HerniaVentral Hernia

Defect in the abdominal wall with Defect in the abdominal wall with intestines intestines or preperitoneal fat thru fascial or preperitoneal fat thru fascial defectdefect

On PE fascial defect usually palpable in On PE fascial defect usually palpable in obese patients obese patients

Ultrasound or CT scan for the diagnosisUltrasound or CT scan for the diagnosis Same principle of management as Same principle of management as groingroin herniahernia

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

Ventral HERNIAVentral HERNIA Umbilical HerniaUmbilical Hernia

MAYO HERNIOPLASTYMAYO HERNIOPLASTY

Vest over pants imbrication of the superior Vest over pants imbrication of the superior

& inferior aponeurotic fascia layer& inferior aponeurotic fascia layer

EPIGASTRIC HERNIAEPIGASTRIC HERNIA

Protrusion of properitoneal fat & peritoneum Protrusion of properitoneal fat & peritoneum

through the dicussating fibers of the through the dicussating fibers of the rectus rectus

sheath in the midline (linea alba) between sheath in the midline (linea alba) between

the xiphoid.the xiphoid.

Ventral HERNIAVentral HERNIA Epigastric HerniaEpigastric Hernia Diastasis RectiDiastasis Recti Wide gap between the medial borders Wide gap between the medial borders

of theof the rectus sheath rectus sheath Diffuse bulge at upper midline of Diffuse bulge at upper midline of

abdomenabdomen Not a fascial defect, hence repaired forNot a fascial defect, hence repaired for cosmetic purposescosmetic purposes Incisional HerniaIncisional Hernia

Patient Rogelia TacubanPatient Rogelia Tacuban

INCISIONAL HERNIOPLASTYINCISIONAL HERNIOPLASTY

Anatomic reconstruction of the abdominal Anatomic reconstruction of the abdominal

wall and Includes;wall and Includes;

Closure of the parietal defectClosure of the parietal defect Restoration of normal intra-abdominal Restoration of normal intra-abdominal

pressurepressure Tendinous reinforcement of the lateralTendinous reinforcement of the lateral

abdominal muscles.abdominal muscles.

Clear View of External O AponeurosisClear View of External O Aponeurosis

Separation of the SacSeparation of the Sac

CATTELL REPAIR

Ventral HERNIAVentral HERNIA

Incisional HerniaIncisional Hernia 2-11% of abdominal wall closure2-11% of abdominal wall closure 56% in the first year postoperative56% in the first year postoperative 17% incarcerate17% incarcerate 20-46% repeat recurrence20-46% repeat recurrence Causes:Causes: 1. Obesity1. Obesity 2. post-op pulmonary complications2. post-op pulmonary complications 3. Wound infection3. Wound infection

Visceral HERNIAVisceral HERNIA

Incisional HerniaIncisional Hernia

4. Jaundice4. Jaundice

5. Advanced age5. Advanced age

6. Abdominal Distention6. Abdominal Distention

7. Re-use of previous incision7. Re-use of previous incision

8. Emergency operation8. Emergency operation

9. Pregnancy9. Pregnancy

10. Chemotherapy post-op10. Chemotherapy post-op

Ventral HERNIAVentral HERNIA Incisional HerniaIncisional Hernia

11. Steroids11. Steroids

12. Malnutrition12. Malnutrition

13. Ascites13. Ascites

14. Peritoneal dialysis14. Peritoneal dialysis

Trocar HerniasTrocar Hernias

< 1% after laparoscopic procedure< 1% after laparoscopic procedure

Fascial defects > 5mm should be closedFascial defects > 5mm should be closed

Ventral HERNIAVentral HERNIA Repair TechniquesRepair Techniques

1. P1. Primary repair w/rimary repair w/ non-absorbablenon-absorbable monofilamentmonofilament

sutures; 49-58% failure ratesutures; 49-58% failure rate

Mayo repair (fascial imbrication) 54% Mayo repair (fascial imbrication) 54% recurrecur

in 5-7 years follow upin 5-7 years follow up

“ “Far and Near” suturing by Shukla= 0%Far and Near” suturing by Shukla= 0%

Internal retention suturing-2% recur forInternal retention suturing-2% recur for

large ventral hernialarge ventral hernia

Ventral HERNIAVentral HERNIA Repair TechniquesRepair Techniques

2. Mesh onlay- 6% recur2. Mesh onlay- 6% recur

3. Mesh onlay and patch repair= Mesh placed3. Mesh onlay and patch repair= Mesh placed

deep to the rectus sheathdeep to the rectus sheath

4. Sandwich and cuffed mesh repair 4. Sandwich and cuffed mesh repair combinedcombined

onlay + inlayonlay + inlay

5. Stoppa- Giant mesh prosthesis for large 5. Stoppa- Giant mesh prosthesis for large >10>10

cm incisional herniacm incisional hernia

6. Laparoscopic repair6. Laparoscopic repair

Emergency Abdominal Wall Emergency Abdominal Wall DefectDefect

Difficult abdominal wall closure in:Difficult abdominal wall closure in:

Massive bowel edemaMassive bowel edema

Tissue loss due to TraumaTissue loss due to Trauma

Debridement for necrotizing lesionsDebridement for necrotizing lesions

Resection of tumorsResection of tumors

Repair with prosthetics w/ absorbable Repair with prosthetics w/ absorbable meshmesh

followed by skin grafting then followed by skin grafting then plannedplanned

ventral hernia repairventral hernia repair

Other Abdominal Wall Other Abdominal Wall HerniaHernia

SPIGELIAN HERNIASPIGELIAN HERNIA Ventral Ventral hernia occurringhernia occurring along the subumbilical along the subumbilical

portion of the Spieghel’s Semilunar line & portion of the Spieghel’s Semilunar line &

through Spieghel’s Fascia.through Spieghel’s Fascia.

Vague pain, mass usually not palpableVague pain, mass usually not palpable, , intraintra

mural mural mass located 0-6 cranialmass located 0-6 cranial to interspinous to interspinous

line (horizontal line between 2 ASIS)line (horizontal line between 2 ASIS)

Usual location- just below semicircular line ofUsual location- just below semicircular line of

Douglas; Defect in Transversus AbdominisDouglas; Defect in Transversus Abdominis


LUMBAR HERNIALUMBAR HERNIA CongenitalCongenital spontaneous spontaneous & traumatic herniation & traumatic herniation

occur through Grynfelts superior & petits occur through Grynfelts superior & petits

inferior lumbar triangleinferior lumbar triangle..

Defect in transversalis fascia & TranversusDefect in transversalis fascia & Tranversus

Abdominis AponeurosisAbdominis Aponeurosis

Contains retroperitoneal sac or peritoneumContains retroperitoneal sac or peritoneum

lined saclined sac

Lumbar HerniaLumbar Hernia

PETIT’S TRIANGLE PETIT’S TRIANGLE is bounded by:is bounded by:

Medial= Latissimus dorsi muscleMedial= Latissimus dorsi muscle

Lateral= External oblique muscleLateral= External oblique muscle

Inferior= Iliac crestInferior= Iliac crest

Covered by superficial fasciaCovered by superficial fascia

GRYNFELT’S TRIANGLE GRYNFELT’S TRIANGLE is bounded by:is bounded by:

Superior= 12Superior= 12thth rib rib

Lateral= Internal oblique abdominal muscleLateral= Internal oblique abdominal muscle

Medial=Sacrospinalis muscleMedial=Sacrospinalis muscle

Covered by latissimus dorsiCovered by latissimus dorsi

PELVIC HERNIA- PELVIC HERNIA- occurs in cachetic, elderlyoccurs in cachetic, elderly

patients in the, Obturator fossa, Perineum &patients in the, Obturator fossa, Perineum &

Greater and lesser sciatic foraminaGreater and lesser sciatic foramina

1. Obturator Hernia1. Obturator Hernia

50% with Howship-Romberg Sign50% with Howship-Romberg Sign

Pain in the region of the hip, and of the knee Pain in the region of the hip, and of the knee

and on the inner aspect of the thigh because and on the inner aspect of the thigh because

of pressure on the obturator nerve by an of pressure on the obturator nerve by an

obturator hernia.obturator hernia.


Usually in emaciated females in late 70’s onUsually in emaciated females in late 70’s on

the right sidethe right side

Often with either large or small bowel Often with either large or small bowel

incarceration or strangulationincarceration or strangulation

Rarely with a mass at the anteromedial thighRarely with a mass at the anteromedial thigh

or a bulge on rectal or pelvic examinationor a bulge on rectal or pelvic examination

Diagnosis by CT scanDiagnosis by CT scan

Repair by midline approach to take care ofRepair by midline approach to take care of

bowel problem too.bowel problem too.


2. Perineal Hernia2. Perineal Hernia

Occur spontaneously or after APR orOccur spontaneously or after APR or

pelvic exenterationpelvic exenteration

1. Anterior- defect in urogenital 1. Anterior- defect in urogenital diaphragm;diaphragm;

mass in labia majoramass in labia majora

2. Po2. Posterior-sterior- defect in the levatordefect in the levator ani between ani between

the urinary bladder and rectumthe urinary bladder and rectum

Repair= Transperineal or transabdominal Repair= Transperineal or transabdominal

primary repair or with meshprimary repair or with mesh


3. Sciatic Hernia3. Sciatic Hernia

Rarest of all hernias; Rarest of all hernias;

Occurs in the greater or lesser sciatic Occurs in the greater or lesser sciatic

foramen or thru a defect in the foramen or thru a defect in the pyriformispyriformis

musclemuscle

Presents as sciatic nerve palsy and a Presents as sciatic nerve palsy and a massmass

or simply intestinal obstructionor simply intestinal obstruction

Repair= GRepair= Glutealluteal or Transabdominalor Transabdominal approachapproach


PARASTOMAL HERNIAPARASTOMAL HERNIA Occurs thru defects adjacent to ostomy Occurs thru defects adjacent to ostomy

sitesite Incidence: 12-32% paracolostomyIncidence: 12-32% paracolostomy < 10% paraileostomy< 10% paraileostomy Prevention: Small fascial incision, avoidPrevention: Small fascial incision, avoid maturing thru the abdominal incisionmaturing thru the abdominal incision Complications: Complications: 1. Obstruction;1. Obstruction; 2. Incarceration2. Incarceration 3. Poor Appliance fit3. Poor Appliance fit 4. Local pain4. Local pain


PARASTOMAL HERNIAPARASTOMAL HERNIA

Repair: Primary fascial or prosthetic Repair: Primary fascial or prosthetic repairrepair

or relocation of stomaor relocation of stoma

Symptoms generally well toleratedSymptoms generally well tolerated

All repairs associatedAll repairs associated with: with:

1. 1. significant morbiditysignificant morbidity

2. high recurrence 2. high recurrence


INTERNAL HERNIAINTERNAL HERNIA Abdominal contents protrude thru Abdominal contents protrude thru normal or abnormal intra-abdominal normal or abnormal intra-abdominal orificeorifice 3. Iatrogenic (Post operative)3. Iatrogenic (Post operative) (a) Defect in Mesentery or Omentum(a) Defect in Mesentery or Omentum Peterson Hernia=thru Roux limbPeterson Hernia=thru Roux limb CONGENITAL ABDOMINAL WALL DEFECTSCONGENITAL ABDOMINAL WALL DEFECTS GastroschisisGastroschisis 1. Herniation of abdominal viscera without 1. Herniation of abdominal viscera without

aa sac, intact umbilical cordsac, intact umbilical cord


CONGENITAL ABDOMINAL WALL DEFECTSCONGENITAL ABDOMINAL WALL DEFECTS OmphaloceleOmphalocele 1. Herniation of abdominal viscera into 1. Herniation of abdominal viscera into

thethe umbilical cord, hence lined by umbilical cord, hence lined by

internallyinternally by peritoneal sac and externally byby peritoneal sac and externally by amnionamnion 2. Associated anomalies:2. Associated anomalies: (a) Cloacal exstrophy(a) Cloacal exstrophy (b) Chromosomal abnormality in 50%(b) Chromosomal abnormality in 50%


CONGENITAL ABDOMINAL WALL DEFECTSCONGENITAL ABDOMINAL WALL DEFECTS GastroschisisGastroschisis 2. Two times (2X) more common than2. Two times (2X) more common than omphaloceleomphalocele 3. Associated anomalies: Intestinal 3. Associated anomalies: Intestinal

Atresia Atresia 10%10% 4. Eviscerated Bowels are:4. Eviscerated Bowels are: (a) Edematous(a) Edematous (b) Shortened with fibrinous adhesions(b) Shortened with fibrinous adhesions 5. < 10% mortality5. < 10% mortality


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


CONGENITAL DIAPHRAGMATIC HERNIACONGENITAL DIAPHRAGMATIC HERNIA

Bochdalek HerniaBochdalek Hernia

(e) Better repaired after a few days to(e) Better repaired after a few days to

weeks when the child stabilizes;weeks when the child stabilizes;

higher mortality if repaired at birthhigher mortality if repaired at birth

(f) Repair: Transabdominal with the Ladd(f) Repair: Transabdominal with the Ladd

procedure for the malrotationprocedure for the malrotation

Morgagni Morgagni

(a) Between sternal & costal (a) Between sternal & costal diaphragmaticdiaphragmatic

mmargin either retrosternalargin either retrosternal or parasternal or parasternal


abdominal wall

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