Topography of anterolateral abdominal wall

1. Topography of anterolateral abdominal wall.

2. borders

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4. Organs’ projection

P243-fig.4.23

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7. Superficial veins

lateral thoracic
thoracoepigastric
paraumbilical
S epigastric
S circumflex iliac
subclavian
portal
femoral

8. Porto-caval anastomoses

Portocaval
anasto
moses

9. Caput Medusae

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15. Fascia superficialis

Camper’s fascia
Scarpa's fascia
P245-fig.4.25~4.26

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A hernia is a protrusion of a tissue,
structure, or part of an organ through the
muscular tissue or the membrane by
which it is normally contained.
A hernia may be likened to a failure in the
sidewall of a tire. The tire’s inner tube
behaves like the organ and the side wall
like the body cavity wall providing the
restraint. A weakness in the sidewall
allows a bulge to develop allowing the
inner tube to protrude leading to the
eventual failure of the tire.

26. Parts of hernia

27. Types of hernias

Inguinal hernia occurs when part of bowel
(part of digestive system) pokes through
lower abdomen into groin (the area at the
front of the body where your thighs meet
your abdomen).
Femoral hernia occurs when fatty tissue or
a part of bowel pokes through into your
groin, at the top of your inner thigh.
Incisional hernia occurs when tissue pokes
through a surgical wound in your abdomen
that has not fully healed.

28. Hernia types

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Umbilical hernia occurs when fatty tissue or a part of the
bowel pokes through abdomen near navel (belly button).
Hiatus hernia occurs when part of stomach pushes up
into chest by squeezing through an opening in the
diaphragm (a large, thin sheet of muscle that separates
your chest from your abdomen).
Epigastric hernia occurs when fatty tissue pokes through
abdomen, between navel and the lower part of your
sternum (breastbone).
Spigelian hernia occurs when part of bowel pokes
through abdomen at the side of stomach muscle, below
your navel.
Muscle hernia occurs when part of muscle pokes
through abdomen and can also occur in the muscles in
leg, often as the result of a sports injury.

31. Reducible Hernias

When the hernia is reducible it has the
ability to be pushed back inside of the
abdominal cavity. This allows people to
remove the lump that is showing through
and to help control it for a little while.
It is important that you remember that
although it is able to be pushed back in
this does not repair it. Any straining,
coughing, or other movement like this will
push the mass right back out. Many
people with this type of hernia will wear a
special hernia belt to keep it in at all times.

32. Irreducible Hernias

When a hernia is irreducible it means that you
do not have the ability to push the mass back
inside of the abdominal cavity. This is probably
because the mass is lodged into place and is too
large or blocked in by other intestines. Although
these might not cause any pain they are
uncomfortable. Many people prefer to treat the
through surgery as soon as possible to avoid it
becoming a strangulated hernia.

33. Strangulated Hernias

When the hernia is strangulated there is nothing
left for you to do except operate. This is when
the hernia has become twisted with an intestine
and is cutting off its blood supply. This will cause
gangrene and the intestine will die within a few
hours if surgery is not performed. This is a very
serious condition that can cause an infection
and much worse things. Most people will
operate before the hernia is able to get to this
point.

34. Inguinal Hernia Types

Direct Inguinal Hernias – protrudes through the
inguinal ring and is ultimately the result of the
failure of embryonic closure of the internal
inguinal ring after the testicle passes through it
Indirect Inguinal Hernias – enters through a
weak point in the fascia of the abdominal wall.
An inguinal hernia may also become a
strangulated or incarcerated inguinal
hernia which is a more serious situation which
may involve emergency surgery.

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Clinical presentation
contributing factors
obesity, chronic cough, pregnancy, constipation,straining on urination,
ascites, activities which increase intra-abdominal pressure
previous hernia repair
groin mass of variable size
develops insidiously in most cases
occasionally precipitated by single forceful muscular event
associated discomfort
worse at end of day
relieved at night when patient reclines and hernia reduces
relieved with manual reduction
+/- obstruction
+/- local tenderness

38.

must examine patient in both supine and standing positions
hernial sac and contents enlarge and transmit palpable impulse
when patient coughs or strains
may auscultate bowel sounds
unable to “get above” groin mass with palpation
mass does not transilluminate
strangulation results in
intense pain followed by tenderness
intestinal obstruction
gangrenous bowelsepsis
a surgical emergency
small, new hernias more likely to strangulate
do not attempt to manually reduce hernia if sepsis present or
contents of hernial sac thought to be gangrenous

39. Treatment

surgical: goals are to prevent strangulation,
eviscerations
and for cosmetics
indirect hernias - principle of repair is high
ligation of sac and tightening of the internal ring
direct hernias - principle of repair is to rebuild
Hesselbach's triangle: need good fascia or a
prosthesis
femoral hernias - principle of repair is to remove
sac of fat and close the femoral canal with
sutures

40. Postoperative complications

scrotal hematoma
deep bleeding - may enter retroperitoneal space
and not be initially apparent
difficulty voiding
painful scrotal swelling from compromised
venous return of testes
neuroma/neuritis
stenosis/occlusion of femoral vein when treating
femoral hernias causing acute leg swelling

41. Prognosis (inguinal hernia repair)

indirect: < 1% risk of recurrence
direct: 3-4% risk of recurrence

42. Intusscusption