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