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Abdominal Herniae ETIOLOGY (1) High intra-abdominal pressure from; (a) Powerful muscular effort or strain occasioned by lift-ij(| a heavy weight. (b) Chronic cough, constipation. (c) Straining on micturition, or on defecation. (d) Obesity. (e) Pregnancy. (2) (3) (4) (a) (b) (c) (5) (6) (7)

Intra-abdominal malignancy. An acquired weakness following trauma. An anatomical weakness where; Structures pass thru abdominal wall. Muscles fail to develop, No muscles, only scar tissue eg umbilicus. Smoking (causing acquired cbllagen deficie'ncy). Peritoneal dialysis. Old age.

COMPOSITlON OF A HERNIA (1) Sac It is a diverticulum of. Peritoneum consisting of mouth, neck, body, & fundus. Neck (a) Usually well defined. (b) In some direct inguinal herniae & in many incisional herniae there is no actual neck. (c) In femoral &umbilical herniae it is narrow, thus pre disposing to Strangulation; Body : It vanes greatly in size, & is not necessarily occupied. (2) Coverings of sac Derived from the layers of abdominal wall thru which sac passes. (3) Contents of sac Most commonly are: (a) Fluid->Derived from peritoneal exudate. (b) Omentum (omentocere, epiplocele) (c) Intestine (enterocele)-> Usually small intestine but in some cases large intestine or vermiform appendix. (d) A portion of circumference of intestine (Richter s hernia). (e) A portion of bladder, or a diverticulum of bladder. (f) Ovary with or without the corresponding fallopian tube. (g) A Meckel's diverticulum (Littre's hemia).

CLINICAL CLASSIFICATION (1) Reducible hernia (a) Hernia either reduces itself when the patient lies down, or can be reduced by the patient or surgeon; (i) Intestine gurgles on reduction, & first portion is more difficult to reduce than last, (ii) Omentum is doughy, & last portion is more difficult to reduce than first. (b) It imparts an expansile impulse on coughing. (2) Irreducible (incarcerated) hernia Contents cannot be returned to abdomen, & there is no evidence of other complications. Etiology (a) Adhesion of its contents to each other. (b) Adhesion of its contents with sac. (c) Adhesion of one part of sac to other part. (d) Sliding hernia. (e) Very large scrotal hernia. (3) Obstructed hernia This is an irreducible hernia containing intestine which is obstructed from without or from within; & there is no interference to blood supply of bowel. (4) Strangulated hernia A hernia is said to be strangulated when the contents are so constricted as to interfere with their blopd supply. On examination (a) Hernia is tense, & extremely tender. (b) It is irreducible. (c) There is no expansile impulse on coughing. (5) Inflamed hernia Inflamation can occur from irritation or sepsis of contents within sac, eg acute appendicitis or Salpingitis, & also from external causes, eg from a sore caused by an ill fitting truss. I On examination (a) Hernia is tender but not tense. (b) Overtying skin becomes red & edematous.

INGUINAL HERNIA SURGICAL ANATOMY (1) Superficial inguinal ring It is a triangul채r aperture in the aponeurosis of external oblique, & lies l .25 cm above the pubic tubercle.

(2) Deep Inguinal ring It is an U-shaped opening in tr채nsversalis fascia l .25 cm above the midpoint of inguinal ligament. (3) Inguinal canal (a) In infants, superficial & deep inguinal rings are almost superimposed, & obliquity of canal is slight. (b) In adults. it is about 3.75 cm long, & is directed down-. wards & medially frorn deep to superficial inguinal ring. Contents of inguinal canal (a) In male, inguinal canal transmits spermatic cord. ilioinguinal nerve, & genital branch of genitofemo-ral nerve. (b) In female. round ligament replaces spermatic cord. Boundaries of inguinal canal (a) Anteriorly (i) External oblique aponeurosis. (ii) Conjoined muscle, laterally. (b) Posteriorly (i) Inferior epigastric artery. (ii) Fascia transversalis. (iii) Conjoined tendon, medially. (c) Superiorly Conjoined muscles.(Transverse abdominalis and internal oblique). (d) Inferiorly Inguinal ligament. UN-STRANGULATED INGUINAL HERNIA Types (1) Indirect (oblique) inguinal hernia It comes out of abdominal cavity thru deep inguinal ring, traverses all along.inguinal canal & ultimately becomes superficial thru superficial inguinal ring. (a) Bubonocele Hernia is limited to inguinal canal. (b) Funicular Processus vaginalis (preformed sac) is closed just above the epididymis, & contents of sac can be feit separately from testis, which lies below the hernia. (c) Comptete (scrotal). Hernia reaches the bottom of scrotum, & testis appears lo lie within the lower part of hernia. (2) Direct inguinal hernia It enters the inguinal canal thru a weakness or defect of transversalis fascia in posterior wall. & becomes superficial thru the same superficial inguinal ring. (a) Incomplete Hernia comes out thru superficial inguinal ring, but fails to reach the bottom of scrotum.

(b) Complete Hernia reaches the bottom of scrotum t.rare). (c) Funicular direct inguinal hernia It is a narrow-neckcd hernia with pre-vesical fat & a portion of bladder that occurs thru a small oval defect in medial part of conjoined tendon just above the pubic tubercle. (d) Dual (Saddle bag, pantaloon hernia) Here there are 2 sacs which straddle the inferior epigastric artery, one sac being medial & other lateral to this vessel. Clinical Features . (1) Age-> Indirect hernia is most common in young, whereas a direct hernia is most common in middle life or after. (2) Sex -> Males are 20 time more commonly affected than females. Symptoms (1) Pain (a) Site -> In groin, or referred to testicle. (b) Time -> While performing heavy work or taking strenuous exercise. (c) Character-> Dragging & aching type. (d) Progress -> Continues so long as the hernia is progressing, but ceases when it is fully formed. (2) Lump (a) Site -> In the groin, & extending into scrotum. (b) Size->Initially small, becoming more obvious when the patient cough, but as time goes on it gradually increases in size to reach the bottom of scrotum. (c) Reducibility -> Direct hernia may disappear automatically as soon as the patient lies down, while indirect hernia has to be reduced. (3) Systemic Symptoms (a) In obstructed hernia, cardinal Symptoms of intestinal obstruetion are present -> Colicky abdominal pain. vomiting, abdominal distension, & absolute constipation. (b) Peisistent coughing (of chronic bronchitis). (c) Constipation. (d) Frequency of micturition or urgency (of benign. prostatic enlargement). Signs (A) Locol signs —Lump (1) Position (a) Initially, it is just above & medial to pubic tubercle, (b) As time goes on, it spreads out over the whole pubis into neck of scrotum. & may descend to fill the scrotum. (2) Shape Pear-shaped. with slalk at Ihc superficial inguinal ring. (3) Sixe Vary from 1-2 cm in diameter to large masses extending down to knee Joint. (4) Color (a) Skin may be reddened in cases of inflamed hernia. (b) It may be white & scarrcd if patient has worn a truss for many years.

(5) Temperature Raised in cascs of inflamed hernia. (6) Cough Impulse An expansile cough impulse is present. (7) Composition (a) Hernia that contains gut have: (i) Consistency -> Soft. (ii) Percussion note -> Resonant. (iii) Gut sounds-> Audible. (b) Hernia that contains Omentum have; (i) Consistency -> Rubbery or doughy. (ii) Percussion note-> Dull. (iii) Gut sounds -> Nil. (8) Reducibility It may be possible to return the Contents of hernia to the abdominal cavity. (B) General signs (1) There may be the signs. which reveals a cause of hernia. eg chronic bronchitis. ascites, intra-abdominal masses. & enlargcd prostate. (2) Signs of intestinal obstruetion in cases of obstructed hernia -> Distension. increased bowel sounds. visible peristalsis. Treatment (I) Surgical treatment (A) Inguinal herniotomy (1) Anesthesia Local. epidural or spinal.'as well as general anesthesia can be used. (2) Incision (a) Incision is made in skin & subcutaneous tissues 1.25 cm above & parallel to medial 2/3rd of inguinal ligament. (b) In large irreducible herniae incision is extendcd into upper part of scrotum. (c) External oblique aponeurosis is incised in the line of its fibres & structures beneath it are carefully separated, before completing the incision thru superficial, inguinal ring. (d) External oblique aponeurosis is separated by blunt dissection from internal oblique. (e) Cremasteric muscle fibres are divided longiludinally to open up subcremasteric space & display- spermatic cord which is then lifted out. (3) Dissection, & opening of hermal sac (a) If the sac is small -> It can be freed in two. & then opened between hemostats. (b) If it is of long funicular or scrotal type -> Fundus need not be sought & the sac is freed & divided in inguinal cahal. (4) Reduction of Contents (a) Intestine or Omentum is returned to peritoneal cavity.

(b) In cases of adherent Omentum - If to the neck, it is freed & if to the fundus of a large sac. it may by transfixed ligated & cut across at a suilable site (& the distal part is left in situ with sac). (5) Transfmng the neck of sac, & removing the remainder (a) Neck is freed by blunt & gauze dissection,until parietal Peritoneum can be Seen on all sides. (b) Finger is passed thru the mouth of. sac, to make Sure that no bowel or omentum is adherent. (c) Neck is transfixed & ligated as high as possible & sac is excised 1.25 cm below the ligature. (d) Wound is closed in layers. (B) Herniorrhaphy (1) Inguinal herniotomy See above. (2) Repair of transversalis fascia & internal inguinal ring (a) Lytle method -> Consists of repairing and narrowing the ring, with lateral displacement of cord. (b) Shouldice method -> Ring & fascia are incised & carefully separated from deep inferior epigastric vessels & extraperitoneal fat before an overlapping repair (double breasting) of lower flap behind the upper flap is effected. (3) Reinforcement of posterior inguinal wall (a) Bassini repair->This is achieved by approximating without tension the tendinous and aponeurotic part of conjoined muscle to the pubic tubercle & inguinal ligament, using 5 or 6 irtterrupted sutures (of prolene, dexon, nylon or tantalum wire). (b) Darning repair -> This is also achieved by approximating without tension the tendinous & aponeurotic part of conjoined muscle to the pubic tubercle & inguinal ligament but here the repair consists of 2 layers of continuous sutures without any tension. (c) Lichtenstein tension-freehernioplasty->lnvolves placement of a mesh (eg polypropylene mesh) as an extra lamina, anterior to the posterior wall & overlapping it generously in all directions, including medially over the pubic tubercle. (4) Completion of Operation (a) External oblique is directly sutured or over-lapped leaving a new external ring which should accommodate the tip of a finger. (b) Skin incision is closed. (II) Non-surgical treatment (Truss) A truss is used when surgery is contrairidicated or refused: (A) It controls a small or moderate-sized inguinal hernia. (B) It must be applied before the patient gets up & while the hernia is reduced. (C) It must be worn continuously during working hours, kept clean & in proper repair, & renewed when it shows signs of wear.

STRANGULATED INGUINAL HERNIA Predisposing Factors (1) Oblique inguinal hemia. (2) Truss, worn for a long time. (3) Partially reducible or irreducible hernia. (4) Large hernia in elderly patients. Constricting Agents (1) Neck of sac. (2) Superficial inguinal ring in children. (3) Adhesions within sac. Contents (1) Small intestine (usually). (2) Omentum. (3) Both small intestine & Omentum (sometimes). (4) Large intestine (rarely). Pathology (1) Intestine is obstructed (except in Richter's hernia) & its blood supply is constricted. (2) At first only venous return is impeded-> Wall of intestine become congested & bright red, & serous fluid is poured out into sac. (3) As congestion increases, strangulated loop becomes distended & purple, & the arterial supply becomes more & more impaired. (4) Blood is extravasated under serosa & is effused into lumen., (5) Shining serosa becomes dull, & the intestine flabby & very friable. (6) Lowered vitality of intestine favors migration of bacteria thru the wall into sac. (7) Gangrene appears first at rings of constriction. & then it appears in antimesenteric border & spreads upwards. (8) If Strangulation is unrelieved, Perforation of intestinal wall occurs, & Peritonitis spreads from the sac to peritoneal cavity. Clinical Features Symptoms (1) Pain (a) Onset ->Sudden. (b) Site-> At first over the hernia, followed by generalized abdominal pain. (c) Character -> Paroxysmal. (2) Vomiting Forcible, & usually oft-repeated. (3) Lump Recent increase in the size of lump.

Signs (1) Local signs — Lump (a) Position, shape & size Same as in un-strangulated hernia (see above). (b) Color Skin is reddened. (c) Tcmperature Raised. (d) Tenderness Hernia is tense & extremely tender. In Maydl's hernia (hernia-en-W, the strangulated loop of the W lies within the abdomen, thus local tendemess over tht hernia is not marked). (e) Cough impulse Absent. (f) Reducibility Hernia is irreducible. (2) General signs (a) As mentioned above, in case of unstrangulated hernia. (b) Features of paralytic ileus, Peritonitis, &. Endotoxic shock, in late cases. D/D OF INGUINAL HERNIA In Male 1)Femoral hernia 2)Vaginal hydrocele 3)Encysted hydrocele of the cord 4)Spermatocele 5)Undescended testis 6)Lipoma of cord In Female 1)Femoral hernia 2)Hydrocele of canal of nuck

Treatment (A) Preoperative treatment (1) Intravenous fluid replacement, if dehydration & collapse are present.

(2) Gastric aspiration for l-3 hours, to make sure that the stomach is emptied just before commencing anesthetic. (3) Bladder must also be emptied. (4) Suitable broad-spectrum antimicrobials, IV. Operation — inguinal herniotomy (1) Incision This is made over the most prominent part of swelling. (2) Delivering, & opening up ofsac (a) Extemal oblique aponeurosis is exposed, & the sac is seen issuing from superficial inguinal ring. (b) Deliver the body & fundus of sac together with its coverings & testis onto surface. (c) Coverings of the sac are incised. (d) Sac is then incised, & the fluid herein is mopped up or aspirated very thoroughly. (3) Division of constricting agent (a) External oblique aponeurosis &. superficial inguinal ring are divided. (b) A finger or a grooved director is passed into the opening of sac, & the sac is slit along its length. (4) Excision of strangulated content (a) Devitalized Omentum is excised after being securely ligated. (b) Viable intestine is returned to peritoneal cavity, while gangrenous intestine is excised & end-to-end anastomosis is done to restore the continuity of bowel. (5) Excision of sac (a) A moderate-sized hernial sac can be excised, & closed by a purse-string suture. (b) When the sac is large & adherent, it is cut across, & the neck of sac is tied or sutured. (c) Wound is closed. Miscllenious Richters Hernia : Occurs when only part of circumference of the bowl becomes incarcerated or strangulated in the fascial defect.A strangulated Richters hernia may spontaneously reduce and the gangrenous piece of intestine be overlooked at operation. The bowel may subsequently perforate, with resultant peritonitis. Conjoined Tendon or Flax inguinalis:a fusion of the medial aponeurotic transverses abdominis and internal oblique muscles that passes along the inferolateral edge of the rectus abdominis muscle and attaches to th pubic tubercle. Inguinal ligament=Poupart Ligament. Lacunar ligament=Gimbernat ligament.

Coopers Ligament: a thick, strong fibrous band that passes laterally from the lacunar ligament along the pectineal line of the pubis. This fibrous tissue on the bony surface allows the purchase of sutures in various procedures to repair inguinal herniae. aponeurosis of external oblique muscle. Syn: Cooper ligaments(2), ligamentum pectineale . Hesselbach Triangle: the triangular area in the lower abdominal wall bounded inferiorly by the inguinal ligament (externally) or iliopubic tract (internally), the border of the rectus abdominis medially and the inferior epigastric vessels (lateral umbilical fold) laterally. It is the site of direct inguinal hernia. Syn: Hesselbach triangle, inguinal triangle, trigonum inguinale. Bassini Repair:The conjoined tendon is approximated to Pouparts ligament and the spermatic cord remains in its normal anatomic position under the external oblique aponeurosis. Halsted Repair: Places the external oblique beneath the cord but otherwise resembles the bassini repair. Coopers ligament repair (Lotheissen-McVay repair):Brings the conjoined tendon farther posteriorly and inferiorly to coopers ligament. and spigelian hernia: abdominal hernia through the semilunar line,the line where the sheats of the lateral abdominal muscles fuse to form the layers of rectus sheath.They are almost always found above the level of Inf. epigastric vessel. Syn: lateral ventral hernia. Litters Hernia: Is a hernia that contains Meckel diverticulum in the hernia sac. In shouldice repair the transversalis fascia is first divided and then imbricated to poparts ligament.Finally the conjoined tendon and internal oblique muscle are also approximated in layers to the inguinal ligament. FEMORAL HERNIA SURGICAL ANATOMY Femoral canal (1) Position It occupies the most medial compartmeht of femoral sheath, & extends from femoral ring above to saphenous opening below. (2) Dimensions (a) 1.25 cm long. (b) 1.25 cm widc at its base. (3)Contents (a) Fat. (b) Lymphatics.

(c) Lymph nodc of Cloquei. (4) Boundaries (a) Anteriorly Inguinal ligamcnt. (b) Posteriorly  lliopectineal ligament, pubic bone, & pectineal fascia. . . (c) Medially  Lacunar ligament. (d) Laterally  Thin septum separating it from femoral vein. PATHOLOGY (1) Hernia passing down the femoral canal descends vertically as far as saphenous opening. (2) Once escapes thru saphenous opening it expands, sometimes considerably. (3) A fully distended hernia assumes the ähape of a retort, & its bulbous extremity may be above the inguinal ligament. (4) By the time the Contents have pursued so tortuous a path, they are usually irreducible & apt to strangulate. CLINICAL FEATURES (1) Sex incidence  Female to male ratio is 2:1. (2) Age incidence  Rare before puberty; prevalence increases between 20 & 40 years, & continues to old age. Symptoms (A) Locol (1) Lumpingroin. (2) Pain & discomfort. (B) General If causing obstruction + Colic, distension, vomiting, & constipation. Signs (A) Local signs — Lump (1) Position (a) Initially. it is below & lateral to pubic tubercle. (b) Once itescape thru saphenous opening, itspreads in any direction; usually points dbwhwards & laterally, but it can pass medially & may bulge up & over the inguinal ligament. (2) Shape & size (a) Usually spherical & small. (b) When enlarges, it tend to Halten & spread in the fold of groin. (3) Color Skin may become red & edematous if the hernia is obstrueted or strangulated. (4) Temperature Raised in strangulated. hernia. (5) Tenderness Present in strangulated hernia. . (6) Cough impulse May be absent (because of adherence of Contents & a narrow neck of sac). (7) Composition (a) Usually contain Omentum, or the sac is empty surrounded by a lot of extraperitoneal fat:

(i) CunsislencyFirm, (ii) Pereussion note  Dull. (b) A large hernia may contain bowel: (i) Consistency Soft, (ii) Pereussion note  Resonant. (8) Reducibility Size can be reduced by firm pressure, but hernia often cannot be completcly reduced (because Contents are often adherent to peritoneal sac). D/D OF FEMORAL HERNIA 1)Inguinal hernia 2)Saphena hernia 3)Enlarged lymph node 4)Lipoma 5)Femoral aneurysm 6)Psoas abscess 7)Distended psoas bursa 8)Rupture of adductor longus with hematoma

(B) Systemic signs Same as mentioned above in inguinal hernia. TREATMENT Preoperative preparation (1) Stomach & bladder must be emptied. (2) Broad-spectrum antibiotics (in strangulated hernia). Operative choiees (1) Low (Lockwood) Operation (a) Sac is dissected out below inguinal ligament via a groin-crease incision. (b) All the änatomical layers of sac are peeled off. (c) After dealing with Contents (eg freeing adherent Omentum), the neck of sac is pulled down & ligated as high as possible. (d) Canal is closed by suturing inguinal ligament to iliopectineal line using unabsorbable sutures. Note: Abnormal obturator artery can be damaged during this procedure. (2) High (McEvedy) Operation (a) Vertical incision is made over the femoral canal & continued upwards above the inguinal ligament. (b) Thru the lower part of incision, sac is dissected out. (c) Thru the Upper part of incision, extraperitoneal Space above the femoral canal is' reached, & if the sac is empty & small, it ein be drawn upwards. (d) If it is large, fundus is opened below, & its Contents dealt with appropriately before delivering the sac upwards from its canal. (e) Sac is then freed from extra-peritoneal tissue, & its neck is ligated. Note: This technique protects the origin of an abnormal artery, & also strangulated hernia is dealt with. (3) Lotheissen 's Operation (a) Inguinal canal is opened as for inguinal herniotomy.

(b) Transversalis fascia is incised medial to epigastru vessels, & opening is enlargcd. (c) Peritoneum is picked up & incised, to ascertain il any intraperitoneal strueture is enterihg the femoral sac. (d) If the sac is empty, it is withdrawn from femoral canal by gauze dissection. (e) If the sac is oecupied, it is dealt with the technique given below for Strangulation. (f) Conjoined tendon is sutured to ilio-pectineal line to form a shutter. Note: This technique allows easy control of an abnormal artery that is damaged at surgery. (4) Modified Lotheissen Operation (for strangulated femoral hernia) (a) Coverings ofsac are incised & peeled off. (b) Sac is incised, & the fluid that escapes is mopped up with great care. (c) Should the obstruction lie in a narrow neck of sac, the beak of hemostat is insinuated, & the neck is stxetched. (d) Contents ofsac are delivered,& dealt with.

UMBLICAL HERNIA EXOMPHALOS (OMPHALOCELE) Abdominal Contents are protruded thru a defect in all layers of abdominal wall at the centre of abdomen, being covered by a thin transparent membrane. Etiology Failure of all or part of midgut to return to coelom during early fetal life. Types (1) Exomphalos minor Fascial defect is less than 4 cm; the sac is relatively small, contains a loop of small intestine or a Meckel's diverticu-lum, & to its summit is attached the umbilical cord. (2) Exomphalos major Fascial defect. is greater than 4 cm. Umbilical eord is attached to the inferior aspect of swelling, which contains small & large intestine, & nearly always a portion of liver; spieen, stomach, pancreas, or bladder mayalso be Seen thru the membrane. Note: Here the sac may rupture, & Peritonitis supervene. Treatment (A) In exomphalos minor Twist the cord, so as to reduce the contents of sac thru narrow umbilical opening into peritoneal cavity, & retain them by firm strapping. 3) In exomphalos major (1) Nonoperative therapy lnlact sac is painted daily with a desiccating antiseptic Solution &, if suocessful, an eschar forms over the sac. Evcntualty granulations grows in from the periphery & the subsequcnt ventral hernia can be re-paired laier. (2) Skinflap closure

(a) Sac is genily trimmed enabling inspection of the abdominal contents, & the skin is frecd from the fascial cdges & undcrmined laterally. (b) Umbilical vessels are ligaied or one artery is canulated for monitoring. (c) Skin flaps are approximatcd in the midline wiih simple sutures & the ventral hernia is then closed at a later date (months to years later). (3) Staged closure (a) Sac is gently trimmed away from the skin edge & the skin further freed from the fascial attachments. (b) Prosthetic material eg polypropylene mesh or expanded poly tetrafluoroethylene (PTFE) is sutured with interrupted nonabsorbable sutures circumferemially to the full thickness of the musculo-fascial abdominal wall to form a silo. (c) Top of the silo is gathered & tied with umbilical tape. (d) Silo is opened daily under strict aseptic conditions; (i) Contents are examined for infection or dehiscence. (ii) Viscera are pushed gently back in to the abdominal cavity & the infant is observed for signs of raised intra-abdominal pressure, (iii) Silo is then tied at areduced leve & the cycle repeated until the sac is flush with the abdominal wall, (e) At this stage, the fascia may be closed with inter rupted sutures & skin closed over the top. (4) Primary closure (a) Sac is gently dissected away from the skin edge & the underlying fascia. (b) Intestine is evacuated completely of meconium & fluid distally & proximally. (c) Abdominal wall is stretched gradually & repeat-edly in quaÜrants, usually achieving a doubling of volume. (d) Viscera are then replaced & the fascial layer is closed primarily, usually under moderate tension. CONGENITAL UMBILICAL HERNIA This is a hernia thru a weak umbilical scar. usually the resuit of neonatal sepsis. About 90% hcrniac disappears spontaneously during ftrst 5 years of life as the umbilical scar ihickcns & contracts. Clinical Features (A) Symptoms (1) Swelling at umbilical scar, which increases in size on crying. (2) Aching abdominal pain (occasionally). (B) Signs — lump (1) Position In the centre of umbilicus. (2) Shape Small hernia is spherical, while a large one assume a conical shape. (3) Size 0.5 cm - 10 cm in diamcier. (4) Cough impulse Expansile cough (cry) impulse is present. (5) Composition Usually contain bowel, so these herniae are soft, com-pressible, & resonant to percussion.

(6) Reducibility Reduce spontaneously when the child lies down. Treatment (1) Conservative treatment (a) Masterly inactivity. (b) Pulling the skin & abdominal musculature together by adhesive strapping placed across the abdorrten. (2) Herniorrhaphy (a) A small curved incision is made immediately below the umbilicus. (b) Sac is emptied of contents, & then ft is either inverted in» abdomen or ligated by transfixion & excised. (c) Defect in linea alba is closed with 2 unabsorbable sutures. ACQUIRED UMBILICAL HERNIA This hernia occurs in adult life & protrudes thru the umbilical scar, & is usually secondary to a raised intra-abdominal pressure. PARAUMBILICAL HERNIA (SUPRAUMBLICAL OR INFRAUMBILICAL HERNIA) It is a Protrusion thru the linea alba just above or sometimes just below the umbilicus. Owing to the narrow neck of sac & fibrous edge of linea alba, Strangulation is likely to occur. Clinical Features (1) AgeMiddle & old age (2) Sex  Five times more common in women than in men esp. in obese & muitiparous women. Symptoms (1) A swelling, just above or below the umbilicus. (2) Dragging pain, in caseof large hernia. (3) Gastrointestinal Symptoms (due to traction on stomach or transverse Colon): (4) Transient attack of intestinal colic (due to subacute intestinal obstruction). (5) Intertrigo (superficial dermatitrs)of adjacent surfacesof skin, in long-standing cases. Signs — lump (1) Position Above or below the umbilicus in midline. (2) Shape (a) Spherical when small; (b) As it enlarges, it becomes oval with a tendency to . sag downwards.i (3) Size 1 cm -15 cm in diameter. (4) Skin Superficial dermatitis of adjacent surfaces of skin in long-standing cases.; (5) Cough impulse Expansile cough impulse is usuaüy present. (6) Composition (a) Omentum  Feel firm, & is dull to percussion. (b) Bowel  Fee! sjit, & is resonant to percussion.

(7) Reducibility May be reducible. Treatment (1) Herniorrhaphy (a) In small hernia Deficiency can be closed by a simple repair using interrupted unabsorbable sutures. (b) For larger hernia — Mayo's repair (i) A transverse elliptical incision is made around the umbilicus. (ii) Neck of the sacis exposed, which is then incised to expöse the contents. (iii) Intestine is retumed to abdomen, & any adherent Omentum is freed. (iv) Excess adherent Omentum can be removed with sac, if necessary (v) Sac is then removed & neck is closed with catgut. (vi) Aponeurosis on both sides of umbilical ring is incised transversely for 2.5 cm or more, to allow an overlap of 5 or 7.5 cm. (vii) 3-5 mattress sutures are inserted into aponeurosis, & the overlapping Upper margin is stitched to rectus sheath & midline aponeurosis. (viii) Additional lipectomy can be done in pts with pendulous, fat-laden abdominal wall. 2) Hernioplasty In very large para-umbilical hernias (fascial defect 4 cm) or for recurrent paraumbilicai hernias, the use of prosthetic material (polypropylene mesh) is recomrucnded. (3) For strangulated hernia (a) In early cases  Mayo's technique. (b) Devitalized OmentumExcision. (c) Gangrenous small intestine  Excision & end-to-end .anastomosis. (d) Gangrenous transverse colon  It should be exteriorized by Paul-Mikulicz method, & the-gangrenous portion is excised.

EPIGASTRIC HERNIA It occurs thru the linea alba anywhere between xiphoid pro-cess & umbilicus, usuaflymidway between thes & jitruclures. It commences as a Protrusion of extraperitoneal fat, & when enlarges, it drags a pouch of Peritoneum after it. Clinical Features (1) Symptomless Hernia discovered during routine abdominal palpation.

(2) Lump In the midline between xiphoid process & umbilicus, firm, unreducible, & with no cough impulse. (3) Pain Attacks of local pain, which is worse on physical exertion & after eating, & tenderncss to touch & tight clothing. Treatment Operation (1) Vertical or transverse incision is made over swelling, exposing the'linea alba. (2) Protruding extraperitoneal fat is cleared from hernial ori-fice by gauze dissectioh, pedicle is ligated, & opening in linea alba is closed by nonabsorbable sutures. (3) When a hernial sac is present it is opened & any contents reduced, after which the sac is excised before repairing linea alba. (4) If the hernia is large (defect greater than 4 cm in diameter), the repair should be reinforced with polypropylene mesh positioned in the retromuscular plane. This is a hernia thru an acquired scar in abdominal wall, usually caused by previous surgical operaüon or accidental trauma. INCISIONAL POSTOPERATIVE HERNIA Predisposing Factors (1) Persistent postoperative cough. (2) Postoperative abdominal distension. (3) Obesity. (4) Operation for Peritonitis without drainage tubes. Clinical Features Symptoms (1) Lump (a) Site  Thru a small portion of scar, often the lower end, or a diffuse bulge of whole length of incision. (b) Size  Increases steadily, & more of its Contents be-come irreducible. (2) Pain (3) Symptoms of intestinal obstruction Distension, colic, vomiting, & constipation. Signs (1) Lump (a) Site  Thru a small portion of scar, often the lower end, or a diffuse bulge of whole length of incision. (b) Skin  May be so thin & atrophic that normal peri-stalsis can be seen in the underlying coils of intestine. (c) Cough impulse  Expansile. (d) Reducibility  Usually reducible. (2) Abdominal distension Treatment

(A) Palliative treatment An abdominal belt esp. in cases of a hernia thru an upper abdominal incision. (B) Surglcal treatment Preoperative measures Reduction of weight by dieting. Operation choices (1) Anatomical repair (a) Hernial sac is dissected, opened & Contents are reduced. (b) Adherent Omentum & bowel have to be freed by dissection before the mouth of sac can be de-fined. (c) Layers arg repaired usually with non-absorbable sutures. (2) Plastic flbre mesh or riet closures Method of choice for defects > 4 cm; (a) Sac is dealt with as above. (b) Layers of the fascia aredissected out; (i) If defect is above the umbilicus, the posterior rectus sheath edges apposed. A sheet of polypropylene mesh is then inserted between the posterior rectus sheath & the muscle fibres & anchored in place. (ii) If below the umbilicus, the mesh is placed in the preperitoneal Space. Anterior rectus sheath is then apposed as above. (端i) If the defect is too large to close by apposi-tion of the rectus sheath, the deficiency in the abdominal wall can be bridged by sewing the mesh to the fascia on either side of the defect, ensuring at least a 4-cm overlap of the fascial edges. (c) Careful hemostasis & meticulous asepsis are es-sential during these Operations, (d) Postoperative collections of serum can be removed by suction drainage, eg Redivac drain. Postoperative treatment (1) Gastric decompression & intravenous fluids. (2) Nothing by mouth allowed until the bowels have functioned. (3) Early ambula端on & gentle physical exercise are to be encouraged. (4) Patient should not resume strenuous exercise for several weeks. BURST ABDOMEN (ABDOMINAL DEHISCENCE) In 1-2 % of cases, mostly between the 6th &. 8th day postop-eratively, an abdominal wound bursts open & viscera are ex-truded. , Factors Related to Burst Abdomen (1) Technique of wound closure (a) Choice of suture material Catgut leads to a higher incidence of bursts than non-absorbable monofilament eg polypropylene. (b) Method of closure (i) Interrupted suturing has a low incidence (ii) A one-layer closure has a low incidence, but it is higher than that f ollowing a two-layered closure. (iii) Interrupted 'far & near' sutures are a recom-mended technique for single-layer mass closures.

(iv) When continuous suturing of layers (one or two) is performed a particular fault is the use of a short length of material, pulled tightly, for in an anesthetized patient the incision is shortened thereby,& made taut so that the material will act as if it were a cheese wire cutter when the patient is con-scious & coughing. (c) Drainage Drainage directly thru a wound leads to a higher incidence of bursts' than employing drainageThru a separate (stab) incision. ' (2) Factors relating to incisions Midline & vertical incisions have a higher tendency to burst than transverse incisions. (3) Reasons for Operation (a) Infected cases. (b) Operations on the pancreas, with leakage of enzymes. (c) Obstructed cases, (4) Coughing,fvomiĂźng, distension (a) Violent coughing set off by the removal of an endotracheal tube & suction of the laryngopharynx strains the sutures.. (b) Cough, vomiting & distension (eg due to ileus) in the early postoperative period. (c) Over-vigorous postoperative Ventilation in sedated patients. (5) General condition of the patient Obesity, jaundice, malignant disease, hypoproteinemia & anemia are all factors conducive to disruption of a laparo-tomy wound. Clinical Features (1) A serosanguinous (pink) discharge from the wound is a forerunner; it signifies that intraperitoneal Contents are lying extraperitoneally. (2) Patients give the history that they 'felt something give way'. (3) If skin sutures have been removed ďƒ  Omentum or coils of intestine will be found lying on the skin. (4) Symptoms & signs of intestinal obstruction. Treatment (1) Preoperative measures (a) Reassure the patient & cover the wound with a sterile towel. (b) Stomach should be emptied using a nasogastric tube. (c) Intravenous fluid therapy commenced. (2) Operation (a) Protruding coil of intestine is washed gently with saline Solution & returned to the abdominal cavity. (b) Then protruding greater Omentum is treated similarly & spread over the intestine. (c) Abdominal wall having been" cleaned, all layers are approximated by thru & thru sutures of monofilament nylon, each passed thru a soft rubber or plastic tuber collar (tension suturing).

(d) Abdominal wall may be supported by Strips of adhe-sive plaster enctrcling the anterior 2/3rds of the circumference of the trunk.

Abdominal Herniae