Hernia of the antero-Hernia of the antero-lateral abdominal walllateral abdominal wall

Definition

Progressive protrusion through the abdominal wall of the peritoneum, with tendency to progress, together with an abdominal viscus

SO– An abdominal viscus will HAVE to leave the

abdominal cavity – There must be a peritoneal covering

NOT real hernias by this definition

Embrionic or fetal hernia where there is an anomaly in development

Protrusions of the organs of the retroperitoneum without peritoneal cover.

Common Common manifestations of manifestations of

herniahernia

HERNIA? Pathological aspects

Hernia developmentHernia development – HERNIATION POINT-

First step in develeopment The protrusion of serosa begins like a

small bulge through a small PARIETAL DEFECT

CLINICAL SIGNS:– Pain of variable intensity– Digital examination may be inconclusive,

except for a large defect

Hernia developmentHernia development – Interstitial hernia-

Peritoneal diverticulum increases in size Protrusion within the muscular-fascial

structures of the abdominal wall Peritoneal serosa becomes thick and

becomes a herniation sac CLINICALLY:

– Pain through compression on viscera or traction on mesentery. Possible pain through interstitial compression

– All signs of a hernia can be identified

Hernia developmentHernia development – COMPLETE HERNIA-

Herniation sac = completely passed through the wall

Clinical signs are complete both in uncomplicated and complicated form

PATHOLOGIC CHANGES

Wall defect – the abnormality in the abdominal wall– Fibrous (umbilical hernia)– Fibro-muscular (epigastric hernia)– Fibro-osseous (obturator hernia)– True channel (inghuinal hernia)

Hernia wall or coverings Hernia content

Complete hernia – structures of the wall

Skin and subcutaneous fat

Sac (peritoneum which is stretched + fat and structures migrating from under the peritoneum)– Fundus area– Neck area

Causes

Conflict: pressure inside the abdominal cavity and possibility of the abdominal wall to content that pressure

Fragile balance – if imbalance appears a herniation point and a hernia will develop

CausesCauses

Congenital: the sac preexists at birth or defect of development

Acquired hernia : in areas of minimal resistence of the abdominal wall

CausesCauses-high intraabdominal pressure-

An increase in abdominal pressure acute (muscular rupture) or chronic (long term increase in stress over the abdominal wall) may increase the risk of hernia development– Increase respiratory effort: chronic respiratory diseases

associated with cough; jobs that require increase expiratory effort.

– Tumors or peritoneal effusion in large quantity (pregnancy, ascites, peritoneal dialyses)

– Straining or effort with closed epiglotis– Functional disorders with chronic effort (prostate adenoma,

chronic constipation)– Pathologic causes – colonic tumor!!!!!

CausesCauses-wall defects-

Abdominal structure is not homogenous WEAK POINTS– Natural communications

between abdominal cavity and other cavities

– Passing of nerves or vessels towards superficial structures

– Scars (posttraumatic, postoperative)

– Intersection of fascial structures

CausesCauses-wall defects

Other factors essential in hernia develoment– Loss of tissue elasticity and resistence –

usually associated with agging– Genetic factors – hernias predominant in some

families: defects in synthesis and structure of colagen fibers

– Trauma – tissue distruction + scars. Infection is a major contributor in incisional hernia

– Metabolic abnormalities

Hernia formation

Hernia with preexisting sac: development abnormalities when the peritoneal diverticula is preexistent. There is no wall defect.

Pushing hernia: association of high intraabdominal hernia and weak point

Sliding henria: similar but organs attached to peritoneum slide in the sac.

Hernia with abnormally distended sac –peritoneum fixed at the level of the neck is blown up and loses its characteristics (umbilical hernia)

Clinical signs in uncomplicated hernia

Pseudo-tumoral bulge with variable medical history that is apparent to the patient

Discomfort; difficulties in dressing +/- skin lesion through friction; the patient notices that it can be reduced and may need an orthopedic support.

Pain: traction or compression on nerves or mesentery. Usually it is bothersome but not major. Small hernia with small defects will be more painful.

Incomplete obstruction – when bowel is present in large hernia

Esthetic problem

Clinical examination-uncomplicated hernia-

Positio of the patient :– Standing up : COMPULSORY as an initial

assesment– Laying down - compare the size and dynamic

of tumor when intraabdominal pressure changes

– ALL WEAK ABDOMINAL POINTS should be examined, as more hernias can be present

Protect the patient’s sensibility

Clinical examination-uncomplicated hernia-

Inspection:Inspection:– Tumor, bulging, in an area known

as weak area of the abdominal wall

– “Tumor” is changing volume according to changes in abdominal pressure (standin/laying down, coughing, straining)

– Skin covering is normal – Volume increases while coughing– Progression of hernia follows a

trajectory which is the herniation channel

Clinical examination-uncomplicated hernia-

Superficial palpationSuperficial palpation– Check the sensibility– Tumor has elastic consistency– Pear-like shape with a neck that

continues in the abdominal cavity!!! (very important)

– Content: diferentiate between bowel and non digestive structures

– Reduce the hernia content in the abdominal cavity REDUCTIBLE HERNIA

– Hernia forms back after reduction: COERCIBILE VS NONCOERCIBLE

Clinical examination-uncomplicated hernia-

Palpation of the abdominal Palpation of the abdominal wall after reduction of the wall after reduction of the contentcontent– Evaluation of the well defect

(dimension, structure, position)– The “tumor” follows the finger

to progress during a coughing effort, following the direction of your finger EXPANSSION

– The “tumor” knocks your finger during a coughing effort PULSATE WITH COUGH

Clinical examination-uncomplicated hernia-

PercussionPercussion– Tympanic – presence of air = bowel– Dull = omentum or retroperitoneal fat, but

bowel can also be present but does not contain air.

Clinical examination-uncomplicated hernia-

AuscultationAuscultation– NOT significant but you may hear hydro-aeric

sounds characteristic for bowel content

POSITIV DIAGNOSTIC IN UNCOMPLICATED HERNIA

“Tumor” or bulge + in a weak point Normal skin Volume changes with postural changes Pedicle inside the abdominal cavity Communication through a defect in the

abdominal wall - palpable Reducible + expansion during cough Pulsation during cough

Lab exploration

Barium enema-colon in hernia + colonic tumors

Small bowel follow-up

Ultrasound scan - content

Laparoscopy – “gold standard” for small hernia

Natural history

Hernia of the adult never heal spontaneously!!!

Hernia with a large defect are well tolerated but represent a handicap

Rigid defect: can produce a strangulation at any time

COMPLICATIONS – given enough time all hernias will complicate

Complications Irreducible Incarceration To large to be adapted in the peritoneal cavity “no right

to stay in the abdomen” Strangulation Incomplete intestinal obstruction peritonitis in the sac Complications due to compression (testicular atrophie,

changes in urinary habits, respiratory disfunction) Trauma to the hernia Tumors in the hernia Foreign body in the hernia

Strangulation

The most serious complication: transforms a benign pathology in one potentially lethal

CAUSES that favor strangulation:– Inextensible parietal defect (orifice)– Narrow or sclerotic neck of hernia sac– Adhesions in the sac

Pathogenesis of strangulation Effort with sudden increase in intra-abdominal pressure A larger volume of bowel/viscus is pushed in the hernia Increases the pressure inside hernia sac

– Much more so at the level of the inextensible hernia orificeor neck of hernia

Impediment in the venous retur with consecutive edema. Further increase in intra-sacular pressure and of hernia

volume Pressure inside the hernia becomes bigger then arterial

pressure = ischemia SPEED OF PROGRESSION towards ireversible lesions is greater in tight strangulation.

LesionsSac: same changes edematous – eritematous –

liquid initially serous+/- bloody the puss or fecal Intestinal loop: 3 stages

1. Congestion (venous stasis): congesitve loop, cyanosis, visible strangulation ridge. REVERSIBLE LESION

2. Intermediate bowel becomes purple – black, more rapidly at the strangulation area, the loop wall is destroyed and reduced to serosa 3. Necrosis and perforation the lopp becomes green (necrotic) like a dead leaf. Partial or total rupture of the wall + contamination of the peritoneum of the sac.

Pathology Mesentery in strangulated area

– Edematous, friable with distended veins and trombosis

Omentum– Similar as above, can progress towards

necrosis

Intestinal obstruction

Strangulation = (with few exception) a clinical manifestation of complete obstruction– Loops above hernia are dilated, with active peristalsis– Loops below hernia are emtpy

After perforation – peritonitis (either localized in the hernia sac or generalized peritonitis

Unusual forms

Lateral pinch (Richter)– Strangulation of a segment of circumference on the

anti-mesenteric border– Incomplete clinical manifestations of intestinal

obstruction (lumen is free)– Manual reduction of hernia is possible but ischemic

lesion of the loop may progress in the abdomen – when the necrotic tissue is delimitated and falls of = PERITONITIS

– More frequent in femoral hernia

Unusual forms

Retrograde strangulation “In W”– A large loop is in the hernia but strangulation

involves a segment of loop situated in the abdominal cavity with a part of mesentery in the hernia

– Greatest risk – during the surgical cure in the emergency settings – the intraabdominal loop may not be noticed - PERITONITIS

Clinical signs in strangulation

SHARP PAIN at the level of hernia, continuous – SIGNAL - viability of the loop is threatened

INTESTINAL OBSTRUCTION Colicky abdominal pain (obstruction) Nausea, vomiting (at first food, the bile,

then fecal aspect) No intestinal transit but diarrhea is posible

General signs

Very good at first Tachycardia Anxiety

Clinica examination Patient is known to have a hernia BUT not

always (strangulation as a first symptom) Hernia is large and painful (in particular at the

level of the neck) DISAPPEAR impulsion and expansion with

cough Henria becomes irreducible: TAXISUL (forceful

reduction) is very dangerous – and more so after one hour from onset– En bloc reduction together with peritoneum– Non vital loop being reduced in the peritoneum

Clinical examination Abdomen: classic appearance of intestinal

obstruction – Meteorism– Hyper-peristaltic loops – Borborism

Peritonitis;it is a “normal” evolution of clinical aspect a strangulated hernia neglected for too long

Abscess formation – may open spontaneously producing a digestive fistula

Positive diagnosis

Hernia can not be reduced ANY MORE NO impulsion NO expansion Hernia becomes painful - continuous pain Intestinal obstruction Peritonitis

Treatment of strangulation

URGENT: operated as soon as possible to save the loop

Hemo-dynamic control Gastric aspiration (naso-gastric tube) Surgical treatment using any type of

anesthesia

Hernia SAC

Open but isolate as it may be contaminated Laparotomy – if abdominal contamination is probable!– Treat content– Resection of sac– Close peritoneum– Drain the contaminated area (+/-)

Content

Incise the neck and decompress the strangulation area

Evaluate viability of bowel loop– If viable – reintroduce in the peritoneal cavity– Not viable – resect– In doubt: warm saline + infiltrations in the

mesenter; wait and see

Orifice

Close the orifice and repair the defect Exception:

– Massive contamination. Repair can be put in danger by septic complications

Peritoneal cavity

Non-contaminated (infection limited at the level of the neck) – nothing special but need to be checked intraoperatively

Contaminated– LAPAROTOMY (LAPAROSCOPY) irrigate

and drain– Intestinal resection

Irreducible hernia Henria content can not be reduce anymore

– does not affect viability of the loop– In general it is progressive. The hernia is more

and more difficult to be reduced. BUT sudden henriation of a larger volume can induce this complication.

– Intra-sacular adherences Old hernia with step by step development

of irreducibility Differential diagnosis – strangulation: all

strangulated hernias are ireducible

NO right to stay anymore in the abdomen (not welcome anymore)

Rare complication of very large hernia that recur immediately after reduction

Large volume outside the abdominal cavity for a long time = abdomen is reshaped on a smaller content

Reduction immediately increases the abdominal pressure and the whole volume can not be reduce or recurs immediately

NO right to stay anymore in the abdomen (not welcome anymore)

Consequences :– hernia is incoercible– Forceful reduction and contention is

accompanied by respiratory distress– Treatment is very problematic

• Need to increase the abdominal volume in time

• Organ resections to reduce the pressure

• Large synthetic meshes

Trauma to the hernia

Organs in the hernia are exposed. Much so if traumatized they do not have the liberty to retract in the abdomen. Entraped.

Diagnostic problems – Lesions that can progress in 2 steps– Intra-sacular peritonitis is non specific and

few symptoms may be present. May develop generalized peritonitis.

Peritonitis in the hernia

Unusual complication Secondary to infectious complications of

intra-sacular organs (appendicitis, diverticulitis, etc)

Clinical signs: increase in volume, becomes painful, ireducible, local signs of inflamation