Abdominal Wall HerniaSharfi Sarker, MDDecember 5, 2006

Abdominal Wall HerniaDefinitionExternalInterparietalInternal

ReducibleNon-reducible (aka incarcerated)Strangulated

Abdominal Wall HerniaRichters herniaLittres hernia

LocationGroinUmbilicusLinea alba (epigastric)Surgical incisionsSemi-lunar lineDiaphragmLumbar trianglesPelvis

Groin herniaIndirect inguinalscrotal Direct inguinal Femoral

Groin HerniaMen > womenRight > left10% of premature babies5% of adult population

Indirect Hernia AnatomyIndirect herniaDilated persistent processus vaginalisWithin spermatic cordFollows indirect courseComplete vs. incomplete sacSliding herniaCord lipoma

Direct Hernia AnatomyHesselbachs triangleInguinal ligament (base), rectus (medial), inferior epigastric vessels (lateral)Sliding hernia

Femoral Hernia AnatomyInferior to inguinal ligamentWomen> menCloquets nodeUsually on medial aspect of femoral sheath

DiagnosisGroin swelling that resolves with supine positionPrecipitating factorsIncreased intra-abdominal pressureDefects in collagen synthesisSmokingExamine erect and supineDoes not transilluminate

Groin Hernia Differential DiagnosisHydroceleVaricoceleEpididymoorchitisTorsion of testisUndescended testisEctopic testisTesticular tumorFemoral artery aneurysmLipomaLymphadenopathy

TreatmentExpectant management Surgical repairMeshOpenLaparoscopicTEP (totally extra-peritoneal)TAPP (transabdominal pre-peritoneal)

ComplicationsRecurrenceNeuralgiaIlioinguinalIliohypogastricGenitofemoralLateral cutaneous Ischemic orchitisInjury to vas deferenceWound infectionBleeding

Umbilical HerniaWomen> menRisk factorsObesityPregnancyMay rupture with ascitesRepair primarily or with mesh

Umbilical HerniaCommon in infantsClose spontaneously if 2 cm or if persists at age 3-4 years

Repair primarily or with mesh

Epigastric HerniaIncidence 1-5%Men> womenPre-peritoneal fat protrusion through decussating fibers at linea albaBetween xiphoid and umbilicus20% multipleRepair primarily

Incisional HerniaRisk factorsTechnicalWound infectionSmokingHypoxia/ ischemiaTensionObesityMalnutritionLaparoscopic vs. open repair

Parastomal HerniaVariant of incisional herniaParacolostomy > paraileostomyLow rate if through rectus muscleTraditionally relocate stoma, repair defectConcern for mesh erosionLaparoscopic repair

Spieghelian HerniaRareHernia through subumbilical portion of semi-lunar lineDifficult to diagnoseClinical suspicion (location)CT scanRepair primarily or with mesh

Lumbar HerniaCongenital, spontaneous or traumaticGrynfeltts triangle12th rib, internal oblique and sacrospinalis muscleCovered by latissimus dorsiPetits triangleLatissimus dorsi, external oblique and iliac crestCovered by superficial fascia

Pelvic HerniaObturator herniaMost commonly in womenHowship-Romberg signSciatic herniaPerineal hernia