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)