Chapter 34_ Abdominal Wall Hernias.pdf

EUROPEAN UNIVERSITY CYPRUS Access Provided by: Current Diagnosis & Treatment: Surgery, 15e Chapter 34: Abdominal Wall Hernias Sean B. Orenstein; Karen E. Deveney I. HERNIAS INTRODUCTION AND DEFINITIONS Abdominal wall integrity relies on organized anatomic layering of muscle and fascia to contain the intraabdominal contents. A defect in one or more layers of fasciae can result in a hernia, which represents an abnormal protrusion of intraabdominal contents through the fascial defect. Groin hernias represent the most common type of abdominal wall hernias (∼75%), whereas ventral, umbilical, and other types of hernias compose the rest. Of the various types of ventral hernias, incisional hernias represent the majority of these, stemming from a failure of appropriate healing following a surgical incision. In general, a hernia is composed of covering tissues (eg, skin, subcutaneous tissues), a peritoneal sac (hernia sac), and various contents including preperitoneal fat, omental fat, and/or any visceral organs. In particular, if the neck of the hernia defect is narrow where it emerges from the abdomen, bowel protruding into the hernia may become compromised (obstruction or strangulation). If the hernia is not repaired early, the defect may enlarge, and operative repair may become more complicated. Although some hernias can be observed over time, the definitive treatment of hernias is operative repair. A reducible hernia is one in which the contents of the sac return to the abdomen spontaneously or with manual pressure when the patient is recumbent. An incarcerated (irreducible) hernia is one whose contents cannot be returned to the abdomen, usually because they are trapped by a narrow neck. The term incarceration does not imply obstruction, inflammation, or ischemia of the herniated organs, although incarceration is typically a requisite for obstruction or strangulation to occur. Compromise of bowel or other viscera can occur with incarcerated hernias. Bowel obstruction results from kinking or twisting of bowel within the hernia, which in turn leads to dilation of the proximal bowel due to blockage of the bowel lumen. However, obstruction does not imply any compromise to the blood supply. Compromise to the blood supply of the hernia contents (eg, omentum or intestine) results in a strangulated hernia, in which gangrene of the viscera has occurred. The incidence of strangulation is higher in femoral than in inguinal hernias, but strangulation may occur in any hernia. An uncommon and dangerous type of hernia, a Richter hernia, occurs when only part of the circumference of the bowel becomes incarcerated or strangulated in the fascial defect. Because the bowel is not obstructed, and because only a portion of the bowel wall becomes strangulated, a Richter hernia commonly presents late in the clinical course after focal perforation and resultant peritonitis. HERNIAS OF THE GROIN Anatomy All groin hernias protrude through the myopectineal orifice of Fruchaud, a weakness or defect in the transversalis fascia, an aponeurosis located just outside the peritoneum. External to the transversalis fascia are found the transversus abdominis, internal oblique, and external oblique muscles, which are fleshy laterally and aponeurotic medially. Their aponeuroses form investing layers of the strong rectus abdominis muscles superior to the arcuate line (linea semicircularis or line of Douglas). Inferior to this line, the aponeurosis lies entirely in front of the muscle, leaving only the transversalis fascia and peritoneum as posterior layers. Between the two vertical rectus muscles, the aponeuroses meet again in the midline to form the linea alba, which is well defined above the umbilicus. The subcutaneous fat contains the Scarpa fascia, which is a misnomer, since it is only a condensation of connective tissue with no substantial strength. In the groin, an indirect inguinal hernia results when obliteration of the processus vaginalis, the peritoneal extension accompanying the testis in its descent into the scrotum, fails to occur. The resultant hernia sac passes through the internal inguinal ring, a defect in the transversalis fascia Downloaded 2024131 5:57 iliac A Your is 82.116.202.56 halfway between the anterior spineIPand the pubic tubercle. The sac is located anteromedially within the spermatic cord and may extend partway Page 1 / 21 Chapter 34: Abdominal Wall Hernias, Sean Orenstein; Karen Deveney (external) inguinal ring. The sac and the spermatic cord are along the inguinal canal or accompany the B. cord out through theE. subcutaneous invested ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility by cremaster muscles, an extension of fibers of the internal oblique muscle. The Hesselbach triangle is bounded by the inguinal ligament, the inferior epigastric vessels, and the lateral border of the rectus muscle. A weakness the transversalis fascia and peritoneum as posterior layers. Between the two vertical rectus muscles, the aponeuroses meet again in the midline to EUROPEAN UNIVERSITY CYPRUS form the linea alba, which is well defined above the umbilicus. The subcutaneous fat contains the Scarpa fascia, which is a misnomer, since it is only a condensation of connective tissue with no substantial strength. Access Provided by: In the groin, an indirect inguinal hernia results when obliteration of the processus vaginalis, the peritoneal extension accompanying the testis in its descent into the scrotum, fails to occur. The resultant hernia sac passes through the internal inguinal ring, a defect in the transversalis fascia halfway between the anterior iliac spine and the pubic tubercle. The sac is located anteromedially within the spermatic cord and may extend partway along the inguinal canal or accompany the cord out through the subcutaneous (external) inguinal ring. The sac and the spermatic cord are invested by cremaster muscles, an extension of fibers of the internal oblique muscle. The Hesselbach triangle is bounded by the inguinal ligament, the inferior epigastric vessels, and the lateral border of the rectus muscle. A weakness or defect in the transversalis fascia, which forms the floor of this triangle, results in a direct inguinal hernia. In most direct hernias, the transversalis fascia is diffusely attenuated, although a discrete defect in the fascia may occasionally occur. Whereas direct inguinal hernias run through the Hesselbach triangle and are located medial to the inferior epigastric vessels, indirect inguinal hernias are located lateral to the inferior epigastric vessels. The peritoneum may protrude on both sides of the inferior epigastric vessels, giving rise to a combined direct and indirect hernia, called a pantaloon hernia. Other anatomic structures of the groin that are important in understanding the formation of hernias and types of hernia repairs include the conjoint tendon, a fusion of the medial aponeurotic transversus abdominis and internal oblique muscles that passes along the inferolateral edge of the rectus abdominis muscle and attaches to the pubic tubercle. Between the pubic tubercle and the anterior iliac spine passes the inguinal (Poupart) ligament, formed by the lowermost border of the external oblique aponeurosis as it rolls on itself and thickens into a cord. Just deep and parallel to the inguinal ligament runs the iliopubic tract, a band of connective tissue that extends from the iliopsoas fascia, crosses below the deep inguinal ring, forms the superior border of the femoral sheath, and inserts into the superior pubic ramus to form the lacunar (Gimbernat) ligament. The lacunar ligament is about 1.25 cm long and triangular in shape. The sharp, crescentic lateral border of this ligament is the unyielding noose for the strangulation of a femoral hernia. Cooper ligaments are strong, fibrous bands that extend laterally for about 2.5 cm along the iliopectineal line on the superior aspect of the superior pubic ramus, starting at the lateral base of the lacunar ligament. These ligaments overlie the pubic bone and are useful for securing mesh during inguinal or lower abdominal wall hernias with tacks or sutures. A femoral hernia passes beneath the iliopubic tract and inguinal ligament into the upper thigh. The predisposing anatomic feature for femoral hernias is a small empty space between the lacunar ligament medially and the femoral vein laterally—the femoral canal. Because its borders are distinct and unyielding, a femoral hernia carries one of the highest risks of incarceration and strangulation of groin hernias. Surgeons must be familiar with the pathways of the nerves and blood vessels of the inguinal region to avoid injuring them when repairing groin hernias. The iliohypogastric nerve (T12, L1) emerges from the lateral edge of the psoas muscle and travels inside the external oblique muscle, emerging medial to the external inguinal ring to innervate the suprapubic skin. The ilioinguinal nerve (L1) parallels the iliohypogastric nerve and travels on the surface of the spermatic cord to innervate the base of the penis (or mons pubis), the scrotum (or labia majora), and the medial thigh. This nerve is the most frequently injured in anterior open inguinal hernia repairs. The genitofemoral (L1, L2) and lateral femoral cutaneous nerves (L2, L3) travel on and lateral to the psoas muscle and provide sensation to the scrotum and anteromedial thigh and to the lateral thigh, respectively. These nerves are subject to injury during laparoscopic hernia repairs. The femoral nerve (L2L4) travels from the lateral edge of the psoas and extends lateral to the femoral vessels. It can be injured during laparoscopic or femoral hernia repairs. The external iliac artery travels along the medial aspect of the psoas muscle and beneath the inguinal ligament, giving off the inferior epigastric artery, which borders the medial aspect of the internal inguinal ring. The corresponding veins accompany the arteries. These vessels can be injured during hernia repairs of all types. Etiology Nearly all inguinal hernias in infants, children, and young adults are indirect inguinal hernias. Although these “congenital” hernias are often present during the first year of life, the first clinical evidence of hernia may not appear until middle or old age, when increased intraabdominal pressure and dilation of the internal inguinal ring allow abdominal contents to enter the previously empty peritoneal diverticulum. An untreated indirect hernia will inevitably dilate the internal ring and displace or attenuate the inguinal floor. In contrast, direct inguinal hernias are acquired as the result of a developed weakness of the transversalis fascia in the Hesselbach area. There is some evidence that direct inguinal hernias may be related to hereditary or acquired defects in collagen synthesis or turnover. Femoral hernias involve an acquired protrusion of a peritoneal sac through the femoral ring. In women, the ring may become dilated by physical and biochemical Downloaded 2024131 5:57 A Your IP is 82.116.202.56 changes during pregnancy. Page 2 / 21 Chapter 34: Abdominal Wall Hernias, Sean B. Orenstein; Karen E. Deveney ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Any condition that chronically increases intraabdominal pressure may contribute to the appearance and progression of a hernia. Marked obesity, abdominal strain from heavy exercise or lifting, cough, constipation with straining at stool, and prostatism with straining on micturition are often implicated. Cirrhosis with ascites, pregnancy, chronic ambulatory peritoneal dialysis, and chronically enlarged pelvic organs or pelvic tumors may also pressure and dilation of the internal inguinal ring allow abdominal contents to enter the previously empty peritoneal diverticulum. An untreated EUROPEAN UNIVERSITY CYPRUS indirect hernia will inevitably dilate the internal ring and displace or attenuate the inguinal floor. Access Provided by: In contrast, direct inguinal hernias are acquired as the result of a developed weakness of the transversalis fascia in the Hesselbach area. There is some evidence that direct inguinal hernias may be related to hereditary or acquired defects in collagen synthesis or turnover. Femoral hernias involve an acquired protrusion of a peritoneal sac through the femoral ring. In women, the ring may become dilated by physical and biochemical changes during pregnancy. Any condition that chronically increases intraabdominal pressure may contribute to the appearance and progression of a hernia. Marked obesity, abdominal strain from heavy exercise or lifting, cough, constipation with straining at stool, and prostatism with straining on micturition are often implicated. Cirrhosis with ascites, pregnancy, chronic ambulatory peritoneal dialysis, and chronically enlarged pelvic organs or pelvic tumors may also contribute. Loss of tissue turgor in the Hesselbach area, associated with a weakening of the transversalis fascia, occurs with advancing age and in chronic debilitating disease. INDIRECT & DIRECT INGUINAL HERNIAS Clinical Findings A. Symptoms Most hernias produce no symptoms until the patient notices a lump or swelling in the groin, although some patients may describe a sudden pain and bulge that occurred while lifting or straining. Frequently, hernias are detected in the course of routine physical examinations such as preemployment examinations. Some patients complain of a dragging sensation and, particularly with indirect inguinal hernias, radiation of pain into the scrotum. As a hernia enlarges, it is likely to produce a sense of discomfort or aching pain in the groin region, with relief if the patient is able to manually reduce the hernia contents. B. Signs Examination of the groin reveals a mass that may or may not be reducible. The patient should be examined both supine and standing and also with Valsalva (coughing and straining), since small hernias may be difficult to demonstrate. The external ring can be identified by invaginating the scrotum and palpating with the index finger just above and lateral to the pubic tubercle (Figure 34–1). If the external ring is very small, the examiner’s finger may not enter the inguinal canal, and it may be difficult to be sure that a pulsation felt on coughing is truly a hernia. At the other extreme, a widely patent external ring does not by itself constitute hernia. Tissue must be felt protruding into the inguinal canal during coughing in order for a hernia to be diagnosed. Figure 34–1. Insertion of finger through upper scrotum into the external inguinal ring. Differentiating between direct and indirect inguinal hernia on examination is difficult, with identification typically taking place during the operative Downloaded 2024131 5:57 A Your IP is 82.116.202.56 procedure. Nevertheless, each type of inguinal hernia has specific features more common to it. A hernia that descends into the scrotum is commonly Page 3 / 21 Chapter 34: Abdominal Wall Hernias, Sean B. Orenstein; Karen E. Deveney associated with an indirect defect. On inspection with the patient erect and straining, direct hernia more commonly appears as a symmetric, circular ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice aAccessibility swelling, whereas an indirect hernia appears as an elliptic swelling given its path though the inguinal canal. EUROPEAN UNIVERSITY CYPRUS Access Provided by: Differentiating between direct and indirect inguinal hernia on examination is difficult, with identification typically taking place during the operative procedure. Nevertheless, each type of inguinal hernia has specific features more common to it. A hernia that descends into the scrotum is commonly associated with an indirect defect. On inspection with the patient erect and straining, a direct hernia more commonly appears as a symmetric, circular swelling, whereas an indirect hernia appears as an elliptic swelling given its path though the inguinal canal. On palpation, the posterior wall of the inguinal canal is firm and resistant in an indirect hernia but relaxed or absent in a direct hernia. If the patient is asked to Valsalva while the examining finger is directed laterally and upward into the inguinal canal, an indirect hernia will lead to an impulse felt at the tip of the finger. In a direct hernia, the impulse is felt more medially, on the side of the finger. The fascial edges of a direct hernia defect may also be palpable medially. Many inguinal hernias result in a vague impulse with Valsalva, without knowing the exact type of hernia until time of repair. Compression over the internal ring when the patient strains may also help to differentiate between indirect and direct hernias. A direct hernia bulges forward through the Hesselbach triangle, but the opposite hand can maintain reduction of an indirect hernia at the internal ring. These distinctions are obscured as a hernia enlarges and distorts the anatomic relationships of the inguinal rings and canal. In many patients, the type of inguinal hernia cannot be established accurately before surgery. Differential Diagnosis Groin pain of musculoskeletal or obscure origin that occurs primarily with vigorous physical exertion is called athletic pubalgia (ie, “sports hernia”) and may be difficult to distinguish from a true hernia, even with thorough physical examination. Magnetic resonance imaging (MRI) may be helpful in identifying the problem, shown as inflammation, edema, or a muscle or tendon tear or strain. Herniation of preperitoneal fat through the inguinal ring into the spermatic cord (“cord lipoma”) is commonly misinterpreted as a hernia. Its true nature may only be confirmed at operation. Cord lipomas are extremely common, and efforts should be made during inguinal hernia repair to find and remove them, since they may cause discomfort if left in place. Occasionally, a femoral hernia that has extended above the inguinal ligament after passing through the fossa ovalis femoris may be confused with an inguinal hernia. If the examining finger is placed on the pubic tubercle, the neck of the sac of a femoral hernia lies lateral and below, whereas that of an inguinal hernia lies above. Inguinal hernia must be differentiated from hydrocele of the spermatic cord, lymphadenopathy or abscesses of the groin, varicocele, and residual hematoma following trauma or spontaneous hemorrhage in patients taking anticoagulants. An undescended testis in the inguinal canal must also be considered when the testis cannot be felt in the scrotum. The presence of an impulse in the mass with coughing, bowel sounds in the mass, and failure to transilluminate are features that indicate that an irreducible mass in the groin is a hernia. Treatment of Inguinal Hernias Although inguinal hernias have traditionally been repaired electively to avoid the risks of incarceration, obstruction, and strangulation, asymptomatic or mildly symptomatic hernias may be safely observed in elderly, sedentary patients or those with high morbidity for operation. The annual risk of bowel compromise from an incarcerated hernia is not precisely known but has been estimated at fewer than 2 per 1000 patients per year. However, a high percentage of patients become symptomatic while being observed expectantly. All symptomatic groin hernias should be repaired if the patient can tolerate surgery. Even elderly patients tolerate elective repair of a groin hernia very well when other medical problems are optimally controlled and local anesthetic is used. Emergency operation carries a much greater risk for the elderly than carefully planned elective operation. If the patient has significant prostatic hyperplasia, it is prudent to solve this problem first, since the risks of postoperative urinary retention are high following hernia repair in patients with significant prostatic obstruction. Because of the possibility of strangulation, an acutely incarcerated, severely painful, and tender hernia may require an urgent or emergent operation. Nonoperative reduction of an incarcerated hernia may first be attempted. The patient is placed with hips elevated and given analgesics and sedation sufficient to promote muscle relaxation. Repair of the hernia may be deferred if the hernia mass reduces with gentle manipulation and if there is no clinical evidence of strangulated bowel. Although strangulation is usually clinically evident, gangrenous tissue can occasionally be reduced into the Downloaded 2024131 5:57 A Your IP is 82.116.202.56 abdomen by manual or spontaneous reduction. It is therefore safest to repair the reduced hernia at the earliest opportunity. At surgery, one must Page 4 / 21 Chapter 34: Abdominal Wall Hernias, Sean B. Orenstein; Karen E. Deveney decide whether to explore the abdomen to make certain that the intestine is viable. If the patient has leukocytosis or clinical signs of peritonitis or if the ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility hernia sac contains dark or bloody fluid, the abdomen should be explored, ideally with laparoscopy. following hernia repair in patients with significant prostatic obstruction. EUROPEAN UNIVERSITY CYPRUS Access Because of the possibility of strangulation, an acutely incarcerated, severely painful, and tender hernia may require an Provided urgentby:or emergent operation. Nonoperative reduction of an incarcerated hernia may first be attempted. The patient is placed with hips elevated and given analgesics and sedation sufficient to promote muscle relaxation. Repair of the hernia may be deferred if the hernia mass reduces with gentle manipulation and if there is no clinical evidence of strangulated bowel. Although strangulation is usually clinically evident, gangrenous tissue can occasionally be reduced into the abdomen by manual or spontaneous reduction. It is therefore safest to repair the reduced hernia at the earliest opportunity. At surgery, one must decide whether to explore the abdomen to make certain that the intestine is viable. If the patient has leukocytosis or clinical signs of peritonitis or if the hernia sac contains dark or bloody fluid, the abdomen should be explored, ideally with laparoscopy. A. Principles of Operative Treatment of Inguinal Hernia 1. Durable repair requires that any correctable aggravating factors be identified and treated (eg, chronic cough, prostatic obstruction, colonic tumor, ascites) and that the defect be repaired without tension. 2. An indirect hernia sac should be anatomically isolated, dissected to its origin from the peritoneum, and ligated (Figure 34–2). In infants and young adults in whom the inguinal anatomy is normal, repair can usually be limited to high ligation, removal of the sac, and reduction of the internal ring to an appropriate size. For most adult hernias, the inguinal floor should also be reconstructed. The internal ring should be reduced to a size just adequate to allow egress of the cord structures. In women, the internal ring can be totally closed to prevent recurrence through that site. 3. In direct inguinal hernias (Figure 34–3), the inguinal floor is usually so weak that a primary repair using the patient’s own tissues would be under tension. Although a vertical relaxing incision in the anterior rectus abdominis sheath was traditionally used, most hernia repairs are now performed using mesh so that a tensionfree repair can be accomplished. 4. Even though a direct hernia is found, the cord should always be carefully searched for a possible indirect hernia as well. Exploration should include evaluation for cord lipomas. 5. In patients with large hernias, bilateral repair has traditionally been discouraged under the assumption that greater tension on the repair would result and therefore would increase the recurrence rate and surgical complications. If open mesh repair or laparoscopic methods are used, however, bilateral repairs can be done with low risk of recurrence. In children and young adults with small hernias, bilateral hernia repair is usually recommended because it spares the patient a second anesthetic. 6. Hernia recurrence within a few months or a year of operation usually indicates an inadequate repair, such as overlooking a femoral or direct hernia, failing to identify an indirect hernia sac, inadequate mesh fixation, insufficient dissection of the myopectineal orifice, or mesh folding, among other causes. Any repair completed under tension is subject to early recurrence. Recurrences 2 or more years after repair are more likely to be caused by progressive weakening of the patient’s fascia. Repeated recurrence after careful repair by an experienced surgeon suggests a defect in collagen synthesis. Because the fascial defect is often small, firm, and unyielding, recurrent hernias are much more likely than unoperated inguinal hernias to develop incarceration or strangulation, and they should nearly always be repaired again. Figure 34–2. Indirect inguinal hernia. Inguinal canal opened, showing spermatic cord retracted medially and indirect hernia peritoneal sac dissected free to above the level of the internal inguinal ring. Downloaded 2024131 5:57 A Your IP is 82.116.202.56 Chapter 34: Abdominal Wall Hernias, Sean B. Orenstein; Karen E. Deveney ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Page 5 / 21 Figure 34–2. EUROPEAN UNIVERSITY CYPRUS Access Provided by: Indirect inguinal hernia. Inguinal canal opened, showing spermatic cord retracted medially and indirect hernia peritoneal sac dissected free to above the level of the internal inguinal ring. Figure 34–3. Direct inguinal hernia. Inguinal canal opened and spermatic cord retracted inferiorly and laterally to reveal the hernia bulging through the floor of the Hesselbach triangle. B. Types of Operations for Inguinal Downloaded 2024131 5:57 Hernia A Your IP is 82.116.202.56 Page 6 / 21 Chapter 34: Abdominal Wall Hernias, Sean B. Orenstein; Karen E. Deveney ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility The goal of all hernia repairs is to reduce the contents of the hernia into the abdomen and reinforce the fascial defect and/or inguinal floor. Traditional tissueonly based repairs use native tissues and suture to repair the defect. However, synthetic mesh has supplanted tissue repairs because multiple prospective, randomized studies have shown lower recurrence with tensionfree mesh repairs versus traditional primary tissue repair, with the EUROPEAN UNIVERSITY CYPRUS Access Provided by: B. Types of Operations for Inguinal Hernia The goal of all hernia repairs is to reduce the contents of the hernia into the abdomen and reinforce the fascial defect and/or inguinal floor. Traditional tissueonly based repairs use native tissues and suture to repair the defect. However, synthetic mesh has supplanted tissue repairs because multiple prospective, randomized studies have shown lower recurrence with tensionfree mesh repairs versus traditional primary tissue repair, with the exception of specialty surgery centers that focus on tissuebased repairs. Over the past 20 years, increased experience has been gained with minimally invasive techniques for hernia repair. Laparoscopic and roboticassisted approaches offer less pain and more rapid return to work or normal activities. Multiple randomized trials have compared open and laparoscopic hernia repairs. Although details of specific studies vary, longterm recurrence rates of open and laparoscopic repairs are similar. The success of laparoscopic approaches is dependent on the experience of the surgeon, as is also true for open repair. Although repairs today overwhelmingly employ prosthetic material, the presence of infection or need to resect gangrenous bowel may make use of permanent mesh unwise. In these situations, primary tissue repairs may still be a preferable option. For this reason, surgeons need to know the traditional techniques even though they are rarely used today. Among the traditional autologous tissue repairs, the Bassini repair is one of the most widely used methods. In this repair, the conjoined tendon is approximated to the Poupart ligament, and the spermatic cord remains in its normal anatomic position under the external oblique aponeurosis. The Halsted repair places the external oblique beneath the cord but otherwise resembles the Bassini repair. Cooper ligament (LotheissenMcVay) repair brings the conjoined tendon farther posteriorly and inferiorly to the Cooper ligament. Unlike the Bassini and Halsted methods, the McVay repair is also effective for femoral hernias but always requires a relaxing incision to relieve tension. Recurrence rates after these open nonmesh repairs vary widely according to skill and experience of the surgeon, but population studies show them to range from as low as 5%10% to as high as 33%. Although the Shouldice repair has a lower reported recurrence rate, it is not widely used aside from specialty surgery centers, perhaps because of the more extensive dissection required. In the Shouldice repair, the transversalis fascia is first divided and then imbricated to the Poupart ligament. Finally, the conjoined tendon and internal oblique muscle are also approximated in layers to the inguinal ligament. A desire to decrease the recurrence rate of hernias prompted the increased use of prosthetic materials in repair of both recurrent and firsttime hernias. The most widely used technique is that of Lichtenstein, an open mesh tensionfree repair that allows an early return to normal activities and a low complication and recurrence rate. In a Lichtenstein repair, a flat piece of mesh is sewn to the inguinal ligament and secured medially to the conjoint tendon, lying in the plane between the external and internal oblique muscle layers. This procedure is sometimes accompanied by a mesh plug that is inserted into the internal ring, the socalled “plug and patch” repair. The open preperitoneal approach exposes the groin from between the transversalis fascia and peritoneum via a lower abdominal incision to effect closure of the fascial defect. Because it requires more initial dissection and is associated with higher morbidity and recurrence rates in less experienced hands, it has not been widely used. For recurrent or large bilateral hernias, a preperitoneal approach using a large piece of mesh to span all areas of potential herniation has been described by Stoppa. Minimally invasive surgery (MIS) approaches using laparoscopic and roboticassisted technology have been developed to reduce wound complications and shorten recovery. The vast majority of MIS approaches use mesh in the repair, with the mesh placed in a posterior (preperitoneal) compartment. The visualization and dissection using MIS techniques allow wide overlap of the entire myopectineal orifice and can be used to repair most groin hernias, including indirect and direct defects, femoral hernias, and obturator hernias. Several methods have been explored, with two methods having emerged as most frequently employed: the transabdominal preperitoneal mesh (TAPP) technique and total extraperitoneal (TEP) technique. The high incidence of complications that occurred in early studies prompted revisions in the operative technique to avoid injury to lateral nerves. Several prospective randomized trials have subsequently been conducted comparing open with minimally invasive techniques as well as TAPP versus TEP. These studies have reported decreased pain and faster return to work with the minimally invasive techniques but increased operative time and cost. Laparoscopic procedures also require general anesthesia and therefore are not appropriate for all patients. Longterm hernia recurrence is equivalent with open and laparoscopic mesh repairs, at approximately 4%. TAPP and TEP techniques have demonstrated equivalency with regard to outcomes, with surgeonspecific training as the likely cause of adoption of one technique over another. Specific situations in which laparoscopic procedures often lower recurrence include the repair of recurrent hernias after previous anterior open repairs (eg, previous Lichtenstein repair), repair of bilateral hernias simultaneously, and repair in patients who must return to work particularly quickly. Although the percentage of hernias repaired laparoscopically has increased, the use of this technique varies considerably across different locales and still represents a minority of groin hernia repairs. Even with the widespread adoption of laparoscopic equipment and training, only about a third of inguinal hernias are repaired in an MIS Downloaded 2024131 5:57 A Your IP is 82.116.202.56 fashion. However, there has been an increase in MIS inguinal hernia repairs being performed with the increased adoption of roboticassisted repairs. Page 7 / 21 Chapter 34: Abdominal Wall Hernias, Sean B. Orenstein; Karen E. Deveney As with many procedures, the success of both open and MIS repairs of groin hernias is highly dependent on the surgeon’s skill and experience with the ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility technique. with open and laparoscopic mesh repairs, at approximately 4%. TAPP and TEP techniques have demonstrated equivalency with regard to outcomes, UNIVERSITY CYPRUS with surgeonspecific training as the likely cause of adoption of one technique over another. Specific situations inEUROPEAN which laparoscopic procedures Access Provided by: often lower recurrence include the repair of recurrent hernias after previous anterior open repairs (eg, previous Lichtenstein repair), repair of bilateral hernias simultaneously, and repair in patients who must return to work particularly quickly. Although the percentage of hernias repaired laparoscopically has increased, the use of this technique varies considerably across different locales and still represents a minority of groin hernia repairs. Even with the widespread adoption of laparoscopic equipment and training, only about a third of inguinal hernias are repaired in an MIS fashion. However, there has been an increase in MIS inguinal hernia repairs being performed with the increased adoption of roboticassisted repairs. As with many procedures, the success of both open and MIS repairs of groin hernias is highly dependent on the surgeon’s skill and experience with the technique. Preoperative & Postoperative Course Although groin hernia repair is usually an outpatient procedure, a thorough preoperative evaluation should be completed before the day of surgery. The anesthetic may be general, spinal, or local. Local anesthetic is effective for most patients, and the incidence of urinary retention and pulmonary complications is lowest with local anesthesia. Recurrent hernias are more easily repaired with the patient under spinal or general anesthesia, since local anesthetic does not readily diffuse through scar tissue. A sedentary worker may return to work within a few days; heavy manual labor has traditionally not been performed for up to 46 weeks after hernia repair, although recent studies document no increase in recurrence when full activity is resumed as early as 2 weeks after surgery, particularly when mesh has been used in the repair. Prognosis In addition to chronic cough, prostatism, and constipation, poor tissue quality and poor operative technique may contribute to recurrence of inguinal hernia. Because tissue is often more attenuated in direct hernias, recurrence rates are slightly higher than for indirect hernias. Placing the repair under tension leads to recurrence. Failure to find an indirect hernia, to dissect the sac high enough, or to adequately cover the internal ring may lead to recurrence of indirect hernia. Postoperative wound infection is associated with increased recurrence. The recurrence rate is considerably increased in patients receiving chronic peritoneal dialysis, cirrhotics with ascites, smokers, and patients on steroids or who are malnourished. The current recurrence rate after hernia repair in adults is reported at best to be 4%. Reasons for recurrence include failure to identify a femoral or indirect hernia. An underappreciated sequela of groin hernia repair is chronic groin pain, the incidence of which varies in published series, but is commonly reported at 5%6%. Causes include recurrent hernia, irritation or inflammation from mesh, or nerve entrapment or neuroma. Laparoscopic repair or prophylactic division of the ilioinguinal nerve in open repairs has been shown to decrease the incidence of chronic groin pain. A discussion of the risk and treatment of chronic groin pain should be a part of the informed consent for repair of groin hernias. Nonsurgical Management (Use of a Truss) The surgeon is occasionally called upon to prescribe a truss when a patient declines operative repair or when there are absolute contraindications to operation. A truss should be fitted to provide adequate external compression over the defect in the abdominal wall. It should be taken off at night and put on in the morning before the patient arises. The use of a truss does not preclude later repair of a hernia, although it may cause fibrosis of the anatomic structures, so that subsequent repair may be more difficult. Alfieri S, et al: International guidelines for prevention and management of postoperative chronic pain following inguinal hernia surgery. Hernia. 2011;15:39–49. Dedemadi G, et al: Laparoscopic versus open mesh repair for recurrent inguinal hernia: a metaanalysis of outcomes. Am J Surg. 2010;200:291–297. [PubMed: 20678621] Eker H, et al: Randomized clinical trial of total extraperitoneal inguinal hernioplasty vs Lichtenstein repair. Arch Surg. 2012;147: 256–260. [PubMed: 22430907] Franz M: The biology of hernia formation. Surg Clin N Am. 2008;88:1–15. Gass M, et al: Bilateral total extraperitoneal inguinal hernia repair (TEP) has outcomes similar to those for unilateral TEP: populationbased analysis of prospective data of 6,505 patients. Surg Endosc. 2012;26:1364–1368. [PubMed: 22113423] Hallén M, et al: Laparoscopic extraperitoneal inguinal hernia repair versus open mesh repair: longterm followup of a randomized controlled trial. Surgery. 2008;143:313–317. 18291251] Downloaded 2024131 5:57[PubMed: A Your IP is 82.116.202.56 Chapter 34: Abdominal Wall Hernias, Sean B. Orenstein; Karen E. Deveney ©2024 Hill. All Rights Reserved. Terms of UseJ Am Privacy Policy2009;209:653–658. Notice Accessibility Itani K,McGraw et al: Management of recurrent inguinal hernias. Coll Surg. [PubMed: 19854408] Mizrahi H, et al: Management of asymptomatic inguinal hernia. Arch Surg. 2012;147:277–281. [PubMed: 22430913] Page 8 / 21 EUROPEAN UNIVERSITY CYPRUS Gass M, et al: Bilateral total extraperitoneal inguinal hernia repair (TEP) has outcomes similar to those for unilateral TEP: populationbased analysis of prospective data of 6,505 patients. Surg Endosc. 2012;26:1364–1368. [PubMed: 22113423] Access Provided by: Hallén M, et al: Laparoscopic extraperitoneal inguinal hernia repair versus open mesh repair: longterm followup of a randomized controlled trial. Surgery. 2008;143:313–317. [PubMed: 18291251] Itani K, et al: Management of recurrent inguinal hernias. J Am Coll Surg. 2009;209:653–658. [PubMed: 19854408] Mizrahi H, et al: Management of asymptomatic inguinal hernia. Arch Surg. 2012;147:277–281. [PubMed: 22430913] Nam A, et al: Management and therapy for sports hernia. J Am Coll Surg. 2008;206:154–164. [PubMed: 18155582] O’Reilly E, et al: A metaanalysis of surgical morbidity and recurrence after laparoscopic and open repair of primary unilateral inguinal hernia. Ann Surg. 2012;255:846–853. [PubMed: 22470068] Stylianidis G, et al: Management of the hernia sac in inguinal hernia repair. Br J Surg. 2010;97:415–419. [PubMed: 20104504] Zendejas B, et al: Simulationbased mastery learning improves patient outcomes in laparoscopic inguinal hernia repair. Ann Surg. 2011;254:502–511. [PubMed: 21865947] Sliding Inguinal Hernia A sliding inguinal hernia (Figure 34–4) is an indirect inguinal hernia in which the wall of a viscus forms a portion of the wall of the hernia sac. On the right side, the cecum is most commonly involved, and on the left side, the sigmoid colon is most common. The development of a sliding hernia is related to the variable degree of posterior fixation of the large bowel or other sliding components (eg, bladder, ovary) and their proximity to the internal inguinal ring. Figure 34–4. Rightsided sliding hernia seen in sagittal section. At arrow, the wall of the cecum forms a portion of the hernia sac. Clinical Findings Downloaded 2024131 5:57 A Your IP is 82.116.202.56 Page 9 / 21 Chapter Abdominal Sean Orenstein; Karen E. from Deveney Although34: sliding hernias Wall haveHernias, no special signsB.that distinguish them other inguinal hernias, they should be suspected in any large hernia that ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility cannot be completely reduced. Finding a segment of colon in the scrotum on contrast radiograph strongly suggests a sliding hernia. Recognition of this variation is of great importance at operation, since failure to recognize it may result in inadvertent entry into the lumen of the bowel or bladder. EUROPEAN UNIVERSITY CYPRUS Access Provided by: Clinical Findings Although sliding hernias have no special signs that distinguish them from other inguinal hernias, they should be suspected in any large hernia that cannot be completely reduced. Finding a segment of colon in the scrotum on contrast radiograph strongly suggests a sliding hernia. Recognition of this variation is of great importance at operation, since failure to recognize it may result in inadvertent entry into the lumen of the bowel or bladder. Treatment Surgical treatment is nearly identical to the aforementioned surgical repair of inguinal hernias; however, it is essential to recognize the entity at an early stage of operation to reduce injury to the viscera. As is true of all indirect inguinal hernias, the sac will lie anteriorly, but the posterior wall of the sac will be formed by colon, bladder, or retroperitoneal ileum. After the cord has been dissected free from the hernia sac, most sliding hernias can be reduced by a series of inverting sutures (Bevan technique) and one of the standard types of inguinal repair performed. Very large sliding hernias may have to be reduced by entering the peritoneal cavity through a separate incision (La Roque technique), pulling the bowel back into the abdomen, and fixing it to the posterior abdominal wall. The hernia is then repaired in the usual fashion. Sliding hernias can also be repaired successfully by laparoscopic (TAPP or TEP) techniques in experienced hands. Prognosis Sliding hernias have a higher recurrence rate than uncomplicated indirect hernias. The surgical complication most often feared during repair of a sliding hernia is entry into the bowel or bladder, usually due to failure to recognize that the hernia is a sliding hernia. Adams R, et al: Outcome of sliding inguinal hernia repair. Hernia. 2010;14:47–49. [PubMed: 19760478] Freundlich R, et al: Laparoscopic repair of an incarcerated right indirect sliding inguinal hernia involving a retroperitoneal ileum. Hernia. 2011;15:225–227. [PubMed: 20165969] FEMORAL HERNIA A femoral hernia descends through the femoral canal beneath the inguinal ligament. Because of its narrow neck, it is prone to incarceration and strangulation. Femoral hernias are much more common in women than in men, but in both sexes, femoral hernia is less common than inguinal hernia. Femoral hernias compose about onethird of groin hernias in women and about 2% of groin hernias in men. Clinical Findings A. Symptoms Femoral hernias are notoriously asymptomatic until incarceration or strangulation occurs. Even with obstruction or strangulation, the patient may feel discomfort more in the abdomen than in the femoral area. Thus, colicky abdominal pain and signs of intestinal obstruction frequently are the presenting manifestations of a strangulated femoral hernia, without discomfort, pain, or tenderness in the femoral region. The patient often has a history of previous repair of an inguinal hernia, lending credence to the concept that a femoral hernia may be overlooked if a thorough search for a femoral hernia is not conducted during an operation for an inguinal hernia. One must have high clinical suspicion for an incarcerated obstructed femoral hernia, especially in a clinically obstructed patient without any history of prior abdominal surgeries. B. Signs A femoral hernia may present in a variety of ways. If it is small and uncomplicated, it usually appears as a small bulge in the upper medial thigh just below the level of the inguinal ligament. Because it may be deflected anteriorly through the fossa ovalis femoris to present as a visible or palpable mass at or above the inguinal ligament, it can be confused with an inguinal hernia. Downloaded 2024131 5:57 A Your IP is 82.116.202.56 Differential Diagnosis Page 10 / 21 Chapter 34: Abdominal Wall Hernias, Sean B. Orenstein; Karen E. Deveney ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Femoral hernia must be distinguished from an inguinal hernia, a saphenous varix, and femoral adenopathy. A saphenous varix transmits a distinct thrill when a patient coughs, and it appears and disappears instantly when the patient stands or lies down—in contrast to femoral hernias, which are either irreducible or reduce gradually on pressure. B. Signs EUROPEAN UNIVERSITY CYPRUS A femoral hernia may present in a variety of ways. If it is small and uncomplicated, it usually appears as a small bulge in Provided the upper Access by: medial thigh just below the level of the inguinal ligament. Because it may be deflected anteriorly through the fossa ovalis femoris to present as a visible or palpable mass at or above the inguinal ligament, it can be confused with an inguinal hernia. Differential Diagnosis Femoral hernia must be distinguished from an inguinal hernia, a saphenous varix, and femoral adenopathy. A saphenous varix transmits a distinct thrill when a patient coughs, and it appears and disappears instantly when the patient stands or lies down—in contrast to femoral hernias, which are either irreducible or reduce gradually on pressure. Treatment A femoral hernia can be repaired through an open or laparoscopic approach, with mesh or primary tissue repair. The traditional primary repair was the McVay (Cooper ligament) repair that employed a relaxing incision in the anterior rectus sheath. More recently, open repair with mesh or laparoscopic preperitoneal repairs with mesh have been used. No matter what the approach, the hernia is often difficult to reduce. Reduction may be facilitated by carefully incising the iliopubic tract, Gimbernat ligament, or even the inguinal ligament. Occasionally, a counterincision in the thigh is required to free attachments below the inguinal ligament. Irrespective of the approach used, successful femoral hernia repair must close the femoral canal. If the hernia sac and mass reduce when the patient is given opiates or anesthesia and if bloody fluid appears in the hernia sac when it is exposed and opened, one must strongly suspect the possibility of nonviable bowel in the peritoneal cavity. In such cases, it is mandatory to explore the abdomen, an advantage of the laparoscopic approach. Prognosis Recurrence rates are equivalent to those of inguinal hernias, at 4%5%. Chan G: Longterm results of a prospective study of 225 femoral hernia repairs: indications for tissue and mesh repair. J Am Coll Surg. 2008;207:360– 367. [PubMed: 18722941] Putnis S: Synchronous femoral hernias diagnosed during endoscopic inguinal hernia repair. Surg Endosc. 2011;25:3752–3754. [PubMed: 21638171] VENTRAL/ABDOMINAL WALL HERNIAS UMBILICAL HERNIAS Umbilical hernias occur quite commonly and result from failure of the umbilical fascial ring to properly fuse. This area begins as a natural orifice in utero, through which the umbilical vessels traverse the abdominal wall at the umbilical ring. After the umbilical cord has sloughed off following childbirth, this area of fascial weakness eventually fuses to close the umbilical ring. This process takes place over the first few years of life. Therefore, most umbilical hernias seen in young children are left alone until at least the age of 4 in order to allow time for natural umbilical fascial closure. However, the fascial fusion process can be incomplete or weakened over a patient’s lifetime, resulting in herniation at the umbilicus. Predisposing factors include (1) multiple pregnancies with prolonged labor, (2) ascites, (3) obesity, and (4) large intraabdominal tumors. Clinical Findings In adults, umbilical hernia does not usually obliterate spontaneously, as in children, but instead increases steadily in size. The hernia sac is commonly in the form of a single spherical entity, but it may have multiple loculations. Umbilical hernias can contain various tissues, with preperitoneal fat or omentum being the most common incarcerated contents. However, small and large bowel may be present if the defect is large enough. Although most umbilical repairs can take place electively, incarcerated bowel often necessitates emergent repair for obstruction and/or strangulation given the typical narrow neck of the hernia defect compared to the size of the herniated mass. Umbilical hernias with tight rings are often associated with sharp pain on coughing or straining, even if only fatty tissue (preperitoneal fat or omentum) is present without any bowel. Very large umbilical hernias more commonly produce a dragging or aching sensation. Treatment Downloaded 2024131 5:57 A Your IP is 82.116.202.56 Umbilical34: hernia in an adult be repaired if onlyKaren containing fatty tissue contents, or more expeditiously if bowel is involved in Page order11 to / 21 Chapter Abdominal Wallcan Hernias, Seanelectively B. Orenstein; E. Deveney ©2024incarceration McGraw Hill.and All resultant Rights Reserved. Terms of Use Privacy Policythere Notice Accessibility avoid obstruction or strangulation. Although is debate as to which defect size requires mesh reinforcement, repairs using mesh result in the lowest recurrence rate. Smaller hernias may be amenable to sutureonly repairs, whereas patients with larger hernias or patients who are obese, perform manual labor, are bodybuilders, or take steroids should be considered for a meshbased repair to reduce the risk of typical narrow neck of the hernia defect compared to the size of the herniated mass. EUROPEAN UNIVERSITY CYPRUS Umbilical hernias with tight rings are often associated with sharp pain on coughing or straining, even if only fatty tissue (preperitoneal fat or omentum) Access Provided by: is present without any bowel. Very large umbilical hernias more commonly produce a dragging or aching sensation. Treatment Umbilical hernia in an adult can be repaired electively if only containing fatty tissue contents, or more expeditiously if bowel is involved in order to avoid incarceration and resultant obstruction or strangulation. Although there is debate as to which defect size requires mesh reinforcement, repairs using mesh result in the lowest recurrence rate. Smaller hernias may be amenable to sutureonly repairs, whereas patients with larger hernias or patients who are obese, perform manual labor, are bodybuilders, or take steroids should be considered for a meshbased repair to reduce the risk of hernia recurrence. Minimally invasive approaches are typically associated with less postoperative pain and faster recovery than open techniques. The presence of cirrhosis and ascites does not contraindicate repair of an umbilical hernia, since incarceration, strangulation, and rupture are particularly dangerous in patients with these disorders. If significant ascites exists, however, it should first be controlled medically or by a transjugular intrahepatic portosystemic shunt, if necessary, because mortality, morbidity, and recurrence are higher after hernia repair in patients with ascites when the procedure must be performed as an emergency. Preoperative correction of fluid and electrolyte imbalance and improvement of nutrition also improve the outcome in these patients. Prognosis Factors that lead to a high rate of complications and recurrence after surgical repair include large size of the hernia, old age or debility of the patient, obesity, immunosuppression, and the presence of other intraabdominal disease. In healthy individuals, surgical repair of the umbilical defects gives good results with a low rate of recurrence. Aslani N, et al: Does mesh offer an advantage over tissue in the open repair of umbilical hernias? A systematic review and metaanalysis. Hernia. 2010;14:455–462. [PubMed: 20635190] Farrow B, et al: More than 150 consecutive open umbilical hernia repairs in a major Veterans Administration Medical Center. Am J Surg. 2008;196:647–651. [PubMed: 18954598] Gray S, et al: Umbilical herniorrhapy in cirrhosis: improved outcomes with elective repair. J Gastrointest Surg. 2008;12:675–681. [PubMed: 18270782] McKay A, et al: Umbilical hernia repair in the presence of cirrhosis and ascites: results of a survey and review of the literature. Hernia. 2009;13:461– 468. [PubMed: 19652907] EPIGASTRIC HERNIAS An epigastric hernia (Figure 34–5) protrudes through the linea alba above the level of the umbilicus. The hernia may develop through one of the foramina of egress of the small paramidline nerves and vessels or through an area of congenital weakness in the linea alba. Figure 34–5. Epigastric hernia. Note closeness to midline and presence in upper abdomen. The herniation is through the linea alba. Downloaded 2024131 5:57 A Your IP is 82.116.202.56 Chapter 34: Abdominal Wall Hernias, Sean B. Orenstein; Karen E. Deveney ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Page 12 / 21 foramina of egress of the small paramidline nerves and vessels or through an area of congenital weakness in the linea alba. EUROPEAN UNIVERSITY CYPRUS Figure 34–5. Access Provided by: Epigastric hernia. Note closeness to midline and presence in upper abdomen. The herniation is through the linea alba. About 3%5% of the population have epigastric hernias. They are more common in men than in women and most common between the ages of 20 and 50. About 20% of epigastric hernias are multiple, and about 80% occur just off the midline. Patients can have both epigastric and umbilical hernias in close proximity. Clinical Findings Most epigastric hernias are painless, and many are found on routine abdominal examination. If symptomatic, their presentation ranges from mild epigastric pain and tenderness to deep, burning epigastric pain with radiation to the back or the lower abdominal quadrants. The pain may be accompanied by abdominal bloating, nausea, or vomiting. The symptoms often occur after a large meal and, on occasion, may be relieved by reclining, probably because the supine position causes the herniated mass to reduce back into the abdominal cavity. The smaller masses most frequently contain only preperitoneal fat and are especially prone to incarceration and strangulation. These smaller hernias are often tender. Larger hernias seldom strangulate and may contain, in addition to preperitoneal fat, a portion of the nearby omentum and, occasionally, a loop of small or large bowel. If a mass is palpable, the diagnosis can often be confirmed by any maneuver that will increase intraabdominal pressure and thereby cause the mass to bulge anteriorly. While epigastric hernias can be present anywhere along the upper midline, they are most commonly located in the lower epigastrium, just above the umbilicus. The diagnosis is difficult to make when the patient is obese, since a mass is hard to palpate; ultrasound or computed tomography (CT) radiographs may be needed in the very obese patient. Differential Diagnosis Differential diagnosis for pain/tenderness in the epigastric region includes peptic ulcer, gallbladder disease, hiatal hernia, pancreatitis, and upper small bowel obstruction. On occasion, it may be impossible to distinguish the hernia mass from a subcutaneous lipoma, fibroma, or neurofibroma. Another condition that must be distinguished from an epigastric hernia is diastasis recti, a diffuse widening and attenuation of the linea alba without a fascial defect. On examination, this condition appears as a fusiform, linear bulge between the two rectus abdominis muscles without a discrete fascial defect with Valsalva. Although this condition may be unsightly, repair is commonly avoided since there is no risk of incarceration, the fascial layer is weak, and the recurrence rate is high. Highly symptomatic diastasis can be repaired with open or laparoscopic plication techniques. Treatment Downloaded 2024131 5:57 A Your IP is 82.116.202.56 Page 13 / 21 Chapter 34: Abdominal Wall Hernias, Sean B. Orenstein; Karen E. Deveney Many symptomatic therefore, be repaired. Treatment is very similar to that of umbilical hernias. Small defects can ©2024epigastric McGrawhernias Hill. All are Rights Reserved.and, Terms of Useshould Privacy Policy Notice Accessibility usually be closed primarily with sutures alone, with mesh placed for large hernias or for patients with risk factors for recurrence. Herniated fat contents are usually dissected free and removed. Another condition that must be distinguished from an epigastric hernia is diastasis recti, a diffuse widening and attenuation of the linea alba without EUROPEAN UNIVERSITY CYPRUS a fascial defect. On examination, this condition appears as a fusiform, linear bulge between the two rectus abdominis muscles without a discrete Access Provided by: fascial defect with Valsalva. Although this condition may be unsightly, repair is commonly avoided since there is no risk of incarceration, the fascial layer is weak, and the recurrence rate is high. Highly symptomatic diastasis can be repaired with open or laparoscopic plication techniques. Treatment Many epigastric hernias are symptomatic and, therefore, should be repaired. Treatment is very similar to that of umbilical hernias. Small defects can usually be closed primarily with sutures alone, with mesh placed for large hernias or for patients with risk factors for recurrence. Herniated fat contents are usually dissected free and removed. Palanivelu C, et al: Laparoscopic repair of diastasis recti using the “Venetian blinds” technique of plication with prosthetic reinforcement: a retrospective study. Hernia. 2009;13:287–292. [PubMed: 19214651] VENTRAL & INCISIONAL HERNIAS Incisional hernias are quite common, with up to 10%30% of all abdominal operations resulting in an incisional hernia. The incidence of this iatrogenic type of hernia is not diminishing despite an awareness of the many causative factors, especially with the obesity epidemic. There is an increasing need to repair large or complex ventral hernias, and risk factors that impede wound healing such as smoking and diabetes contribute to wound complications as well as hernia recurrence, which makes subsequent repair more difficult. Etiology The factors most often responsible for incisional hernia are listed below. When more than one factor coexists in the same patient, the likelihood of postoperative wound failure is greatly increased. 1. Poor surgical technique. Inadequate fascial bites, tension on the fascial edges, and too tight a closure are most often responsible for incisional failure. Additionally, studies have shown that closing fascia with smaller bites (∼0.5 cm) instead of traditional large (∼1 cm) bites reduces the rate of incisional hernia. 2. Postoperative wound infection. An infection in the wound increases the risk of hernia formation to as high as 80%. Wound infection is one of the single greatest risk factors for hernia formation or hernia recurrence. 3. Age. Wound healing is usually slower and the closure less solid in older patients. 4. General debility. Cirrhosis, carcinoma, and chronic wasting diseases are factors that adversely affect wound healing. Any condition that compromises nutrition increases the likelihood of fascial and wound breakdown. 5. Obesity. Obese patients frequently have increased intraabdominal pressure. The presence of excessive visceral fat within the abdominal cavity increases intraabdominal pressure, which puts stress and strain on a closed wound. Additionally, adipose tissue within the abdominal wound masks tissue layers and increases the incidence of seromas and hematomas in wounds. 6. Diabetes. Uncontrolled diabetes reduces microvasculature. With a diminished blood flow to areas of need (eg, surgical or traumatic wounds), the tissues fail to receive efficient flow of oxygen and nutrients required to support proper wound healing. 7. Smoking. Like diabetes, smoking negatively impacts microvasculature and the tissues that require support. While nicotine is a common culprit cited, it is likely the other components within tobacco that inhibit proper wound healing. 8. Postoperative pulmonary complications that stress the repair as a result of vigorous coughing. Smokers and patients with chronic pulmonary disease are at increased risk of fascial disruption. 9. Intraoperative blood loss greater than 1000 mL. 10. Failure to close the fascia of laparoscopic trocar sites over 10 mm in size. 11. Defects in collagen or matrix metalloprotease. Treatment Downloaded 2024131 5:57 A Your IP is 82.116.202.56 There are numerous options for repairing ventral hernias, including primary sutureonly repairs, mesh reinforcement, minimally invasivePage techniques 14 / 21 Chapter 34: Abdominal Wall Hernias, Sean B. Orenstein; Karen E. Deveney using laparoscopy or robotic technology, open techniques, or a combination of these techniques. Each technique has its own pros and cons, and ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility surgeons should be familiar with multiple techniques in order to tailor the approach to a particular hernia. There are many factors that help determine the proper repair technique, including the size of the hernia(s), location in the abdominal wall, history of previous repairs, patient comorbidities, and 10. Failure to close the fascia of laparoscopic trocar sites over 10 mm in size. 11. Defects in collagen or matrix metalloprotease. EUROPEAN UNIVERSITY CYPRUS Access Provided by: Treatment There are numerous options for repairing ventral hernias, including primary sutureonly repairs, mesh reinforcement, minimally invasive techniques using laparoscopy or robotic technology, open techniques, or a combination of these techniques. Each technique has its own pros and cons, and surgeons should be familiar with multiple techniques in order to tailor the approach to a particular hernia. There are many factors that help determine the proper repair technique, including the size of the hernia(s), location in the abdominal wall, history of previous repairs, patient comorbidities, and the skill set of the surgeon. Hernias should be addressed if they become symptomatic (eg, pain) or if bowel is involved within the hernia sac. Incarcerated bowel can lead to obstruction and/or strangulation, which can be life threatening if not addressed in a timely fashion. Concerning clinical features for strangulation include a very firm incarcerated hernia, severe tenderness on exam, and redness or other discoloration of the overlying skin. Additionally, obstruction leads to abdominal distention. If the patient does not require urgent or emergent surgery, is unwilling to undergo surgery, or is a poor surgical risk, symptoms may be controlled by an abdominal binder or other type of elastic undergarment for compression. Small incisional hernias may be amenable to primary suture repair. However, mesh reinforcement greatly reduces the risk of hernia recurrence. Therefore, the vast majority of ventral and incisional hernia repairs are performed with some form of mesh reinforcement. Mesh used in hernia repairs is manufactured from different materials, such as polypropylene, polyester, or expanded polytetrafluoroethylene (ePTFE), and is produced in varying configurations, including composite meshes with antiadhesion barriers and selfadhering meshes. Biologic and bioresorbable meshes are an alternative to permanent synthetic mesh when there is high concern for infection, because such meshes tend to be more resilient in the setting of contamination. Mesh should not be used when there is active infection or gross contamination present. Biologic meshes are manufactured from various tissues and animal sources, with porcine dermis representing the most commonly used biologically derived collagenbased matrix. Mesh can be placed inside the abdominal cavity directly underneath the abdominal wall as an underlay, as long as there is some form of antiadhesion barrier on the mesh to prevent the intestine from adhering to it. Uncoated mesh can be placed within various tissue planes, including the preperitoneal space, retromuscular space (eg, retrorectus), or on top of the fascia in an onlay position after creating skin flaps. Studies have shown that a minimum overlap of 5 cm past the edge of the defect is ideal to reduce the risk of hernia recurrence. Although surgeons strive to achieve fascial closure with most hernia repairs, some hernia defects are too large for closure of the native fascia. Excessive tension on fascial tissue can lead to fascial dehiscence and subsequent hernia recurrence. Such large hernia defects are commonly repaired using component separation techniques to achieve fascial closure (Figure 34–6). It is important to understand the anatomy of the entire abdominal wall, because these complex hernia repairs use cutting of specific myofascial layers (eg, external oblique release, transversus abdominis release) for medial advancement of the fascial layers and hernia defect closure. Even when the fascia can be closed, these repairs should be reinforced by mesh to support the tissue over the long term. Figure 34–6. Component separation technique to allow primary closure in the midline, usually over a mesh underlay. (A) Division of the external oblique aponeurosis. (B) Release of the rectus from the posterior rectus sheath. (C) Closure of the rectus in the midline. (D) Mesh underlay. Downloaded 2024131 5:57 A Your IP is 82.116.202.56 Chapter 34: Abdominal Wall Hernias, Sean B. Orenstein; Karen E. Deveney ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Page 15 / 21 Figure 34–6. EUROPEAN UNIVERSITY CYPRUS Access Provided by: Component separation technique to allow primary closure in the midline, usually over a mesh underlay. (A) Division of the external oblique aponeurosis. (B) Release of the rectus from the posterior rectus sheath. (C) Closure of the rectus in the midline. (D) Mesh underlay. MIS techniques using laparoscopic and roboticassisted technology are increasingly being used to repair ventral hernias and perform adhesiolysis and other intraabdominal procedures. MIS procedures have been shown to greatly reduce the risk of wound complications such as infection, as well as shorten hospitalization and recovery. For many MIS ventral hernia repairs, after closing the hernia defect, a coated sheet of synthetic mesh is secured to the abdominal wall as an underlay mesh; the intraperitoneal placement of the graft greatly enhances the durability of the repair, although it also increases the risk of bowel adhesions or fistula formation. Prognosis Results of randomized clinical trials show that mesh repair is superior to primary suture repair, even for small incisional hernias. Despite the increasing use of both open and laparoscopic mesh repairs, however, populationbased studies show that incisional hernias continue to recur at a high rate after repair, and the recurrence rate increases with each subsequent reoperation for recurrence, reaching almost 40% on average after the third recurrence. Factors shown to increase risk of hernia recurrence include those listed earlier in the “Etiology” section, with obesity, diabetes, and smoking being the three most influential factors. Hernia recurrence and wound complication rates are so high in smokers that many surgeons require patients to stop smoking for a minimum of 1 month prior to the planned hernia repair. Hernia recurrence rates for commonly used procedures range from approximately 4% up to 30% or more and are highly dependent on the repair technique, type of mesh used, amount of mesh overlap, as well as the patient factors listed earlier. These various factors also determine other patient outcomes related to hernia repair, including surgical site infection, seroma, hematoma, fistula formation, and wound dehiscence. To reduce the risks of hernia recurrence and other complications, effort is devoted in the preoperative setting to optimize the patient (eg, weight loss, diabetes management, smoking cessation). Such preoperative optimization greatly improves outcomes and reduces risks, especially in highrisk patients. Albright E, et al: The component separation technique for hernia repair: a comparison of open and endoscopic techniques. Am Surg. 2011;77:839– 843. [PubMed: 21944344] Breuing K, et al: Incisional ventral hernias: review of the literature and recommendations regarding the grading and technique of repair. Surgery. 2010;148:544–558. [PubMed: 20304452] Burger JW, et al: Longterm followup of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg. 2004;240:578–585. [PubMed: 15383785] Downloaded 2024131 5:57 A Your IP is 82.116.202.56 Page 16 / 21 Chapter 34: Abdominal Wall Hernias, Sean B. Orenstein; Karen E. Deveney Deerenberg EB, Hill. et al:All Small bites versus large bitesoffor closure of abdominal midline Accessibility incisions (STITCH): a doubleblind, multicentre, randomised ©2024 McGraw Rights Reserved. Terms Use Privacy Policy Notice controlled trial. Lancet. 2015;386:1254–1260. [PubMed: 26188742] EUROPEAN CYPRUS Breuing K, et al: Incisional ventral hernias: review of the literature and recommendations regarding the grading and techniqueUNIVERSITY of repair. Surgery. Access Provided by: 2010;148:544–558. [PubMed: 20304452] Burger JW, et al: Longterm followup of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg. 2004;240:578–585. [PubMed: 15383785] Deerenberg EB, et al: Small bites versus large bites for closure of abdominal midline incisions (STITCH): a doubleblind, multicentre, randomised controlled trial. Lancet. 2015;386:1254–1260. [PubMed: 26188742] den Hartog D, et al: Open surgical procedures for incisional hernias. Cochrane Database Syst Rev. 2008;3:CD006438. Itani KMF, et al: Comparison of laparoscopic and open repair with mesh for the treatment of ventral incisional hernia. Arch Surg. 2010;145:322–328. [PubMed: 20404280] Jin J, et al: Laparoscopic versus open ventral hernia repair. Surg Clin N Am. 2008;88:1083–1100. Lindström D, et al: Effects of a perioperative smoking cessation intervention on postoperative complications. Ann Surg. 2008;248:739–745. [PubMed: 18948800] Melvin WS, et al: Laparoscopic ventral hernia repair. World J Surg. 2011;35:1496–1499. [PubMed: 21424876] Pauli EM, et al: Open ventral hernia repair with component separation. Surg Clin N Am. 2013;93:1111–1133. Poulose BK, et al: Epidemiology and cost of ventral hernia repair: making the case for hernia research. Hernia. 2012;16:179–183. [PubMed: 21904861] Sauerland S, et al: Laparoscopic versus open surgical techniques for ventral or incisional hernia repair. Cochrane Database Syst Rev. 2011;3:CD007781. PARASTOMAL HERNIAS A parastomal hernia is a particularly troublesome hernia to repair successfully, since the stoma’s course through the abdominal wall is, by its very nature, a hernia. Studies cite an incidence of up to 50% for this type of hernia. Traditional teaching advises that a stoma be placed through the middle of the rectus muscle rather than more laterally to reduce the risk of herniation. However, even perfect stoma placement can result in hernia formation when the fascial opening stretches and allows additional loops of bowel or omentum to herniate adjacent to the stoma. The etiology of parastomal hernias mirrors that of other ventral hernias and includes collagen defects, immunosuppressant therapy, and anything that greatly increases intra abdominal pressure such as straining, heavy lifting, or obesity. Parastomal hernias should be repaired if they interfere with stoma function or are difficult to reduce, as they can obstruct and/or strangulate. If the hernia is asymptomatic, repair is not mandatory, although large hernias can diminish the individual’s quality of life. Many options for repair of parastomal hernias have been described, with poor results given the need to maintain a fascial defect for the stoma itself. The best way to repair a parastomal hernia is to reverse the ostomy, thus avoiding the need for a fascial defect; however, ostomy takedown might not be possible. Primary suture repair has particularly poor results, with recurrence rates close to 100%. As with other hernia repairs, mesh reinforcement reduces the rate of hernia recurrence. Multiple open and MIS techniques have been described, including the Sugarbaker technique (mesh draped underneath a lateralized bowel, with stoma kept in situ), cruciate technique (mesh is slit and bowel delivered through mesh), keyhole technique (mesh is cut around a stoma kept in situ), and retromuscular techniques. Due to the significant risk of parastomal hernias, prophylactic mesh can be placed at the time of (permanent) stoma creation to reduce the risk of parastomal hernia formation. Although studies have demonstrated a significant reduction of hernia formation with the placement of prophylactic mesh, this practice has not gained widespread adoption outside of Europe. Brandsma HT, et al: Prophylactic mesh placement during end colostomy reduces the rate of parastomal hernia. Ann Surg. 2017;265(4):663–669. [PubMed: 27471840] Hansson BM, et al: Surgical techniques for parastomal hernia repair: a systematic review. Ann Surg. 2012;255(4):685–695. [PubMed: 22418006] Downloaded 5:57 A Your IP is 82.116.202.56 Jones HG, et2024131 al: Prosthetic mesh placement for the prevention of parastomal herniation. Cochrane Database Syst Rev. 2018;7:CD008905. [PubMed: Page 17 / 21 Chapter 34: Abdominal Wall Hernias, Sean B. Orenstein; Karen E. Deveney 30027652] ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Tam KW: Systematic review of the use of a mesh to prevent parastomal hernia. World J Surg. 2010;34:2723–2729. [PubMed: 20661562] EUROPEAN UNIVERSITY CYPRUS Brandsma HT, et al: Prophylactic mesh placement during end colostomy reduces the rate of parastomal hernia. Ann Surg. 2017;265(4):663–669. Access Provided by: [PubMed: 27471840] Hansson BM, et al: Surgical techniques for parastomal hernia repair: a systematic review. Ann Surg. 2012;255(4):685–695. [PubMed: 22418006] Jones HG, et al: Prosthetic mesh placement for the prevention of parastomal herniation. Cochrane Database Syst Rev. 2018;7:CD008905. [PubMed: 30027652] Tam KW: Systematic review of the use of a mesh to prevent parastomal hernia. World J Surg. 2010;34:2723–2729. [PubMed: 20661562] Van Dijk SM, et al: Parastomal hernia: impact on quality of life? World J Surg. 2015;39:2595–2601. [PubMed: 26216640] VARIOUS RARE HERNIATIONS THROUGH THE ABDOMINAL WALL Interparietal Hernia Interparietal hernias are hernias in which the sac insinuates itself between the layers of the abdominal wall. Although interparietal hernias are rare, it is essential to recognize them because obstruction and/or strangulation is common and the mass can easily be mistaken for other pathology (eg, tumor or abscess). The lesion usually can be suspected on the basis of the physical examination provided it is kept in mind. In most cases, extensive studies for intraabdominal tumors have preceded diagnosis. A lateral film of the abdomen will usually show bowel within the layers of the abdominal wall in cases with intestinal incarceration or strangulation, and an ultrasound or CT scan may be diagnostic. Given the potential threat to bowel, most postoperative interparietal hernias are repaired as soon as the diagnosis is established. For longstanding ventral hernias with an interparietal component, one can plan out the repair and optimize the patient prior to repair. Spigelian Hernia A Spigelian hernia is an abdominal wall hernia through the linea semilunaris, which is the lateral border of rectus sheath. Spigelian hernias are nearly always found above the level of the inferior epigastric vessels. They most commonly occur where the semicircular (arcuate) line (fold of Douglas) crosses the linea semilunaris. The presenting symptom is pain that is usually localized to the hernia site and may be aggravated by any maneuver that increases intraabdominal pressure. With time, the pain may become more dull, constant, and diffuse, making diagnosis more difficult. If an incarcerated mass can be demonstrated, the diagnosis presents little difficulty. However, physical exam diagnosis is typically difficult given the occult nature of many Spigelian hernias. Because the hernia defect may lie beneath an intact external oblique layer, representing an interparietal hernia, defects might not be palpable. The hernia often dissects within the layers of the abdominal wall and may not present a distinct mass, or the mass may be located at a distance from the linea semilunaris. Physical exam can be aided with a Valsalva maneuver or by increasing abdominal pressure, such as by coughing or performing a situp, to help protrusion of the area of concern. Because of the occult nature of many Spigelian hernias, ultrasound and CT imaging are helpful in confirming. Spigelian hernias have a high incidence of incarceration and should be repaired. Small hernias may be repaired by primary aponeurotic closure, although fascial defects larger than 23 cm should be repaired using mesh, preferable in an underlay, preperitoneal technique. Open or laparoscopic approach may be used according to the surgeon’s experience, with laparoscopy affording an advantage in allowing the evaluation and treatment of bilateral hernia. Bittner J, et al: Meshfree laparoscopic Spigelian hernia repair. Am Surg. 2008;74:713–720. [PubMed: 18705572] Saber A, et al: Laparoscopic spigelian hernia repair: the scroll technique. Am Surg. 2008;74:108–112. [PubMed: 18306858] Littre Hernia A Littre hernia is a hernia that contains a Meckel diverticulum within the hernia sac. Although Littre first described the condition in relation to a femoral hernia, the relative distribution of Littre hernias is as follows: inguinal, 50%; femoral, 20%; umbilical, 20%; and miscellaneous, 10%. Littre hernias of the groin are more common in men and on the right side. The clinical findings are similar to those of Richter hernia; when strangulation is present, pain, fever, and manifestations of small bowel obstruction occur late. Downloaded 2024131 5:57 A Your IP is 82.116.202.56 Page 18 / 21 Chapter 34: Abdominal Wall Hernias, Sean B. Orenstein; Karen E. Deveney Treatment consists of repair of the hernia plus, if possible, excision of the diverticulum. If acute Meckel diverticulitis is present, the acute inflammatory ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility mass may have to be treated through a separate abdominal incision. Littre Hernia EUROPEAN UNIVERSITY CYPRUS Provided by: in relation to a femoral A Littre hernia is a hernia that contains a Meckel diverticulum within the hernia sac. Although Littre first describedAccess the condition hernia, the relative distribution of Littre hernias is as follows: inguinal, 50%; femoral, 20%; umbilical, 20%; and miscellaneous, 10%. Littre hernias of the groin are more common in men and on the right side. The clinical findings are similar to those of Richter hernia; when strangulation is present, pain, fever, and manifestations of small bowel obstruction occur late. Treatment consists of repair of the hernia plus, if possible, excision of the diverticulum. If acute Meckel diverticulitis is present, the acute inflammatory mass may have to be treated through a separate abdominal incision. Amyand Hernia An Amyand hernia is a groin hernia that contains the appendix. If the appendix is inflamed, it should be removed and the hernia repaired using native tissues or biologic mesh, because the risk of infection to permanent mesh is too great. If the appendix is normal and only an incidental finding in the hernia, it should be returned to the abdomen and a mesh repair employed. Sharma H, et al: Amyand’s hernia: a report of 18 consecutive patients over a 15year period. Hernia. 2007;11:31–35. [PubMed: 17001453] Lumbar or Dorsal Hernia Lumbar or dorsal hernias (Figure 34–7) are hernias through the posterior abdominal wall at some level in the lumbar region. The most common sites (95%) are the superior (Grynfeltt) and inferior (Petit) lumbar triangles. A “lump in the flank” is the common complaint, associated with a dull, heavy, pulling feeling. With the patient erect, the presence of a reducible, often tympanitic mass in the flank usually makes the diagnosis. Incarceration and strangulation occur in about 10% of cases. Hernias in the inferior lumbar triangle are most often small and occur in young, athletic women. They present as tender masses producing backache and usually contain fat. Lumbar hernia must be differentiated from abscesses, hematomas, soft tissue tumors, renal tumors, and muscle strain. Figure 34–7. Anatomic relationships of lumbar or dorsal hernia. On the left, lumbar or dorsal hernia into space of Grynfeltt. On the right, hernia into the Petit triangle (inferior lumbar space). These acquired hernias may be traumatic or nontraumatic. Severe direct trauma, penetrating wounds, abscesses, and poor healing of flank incisions are the usual causes. However, incisional hernias from extended flank procedures can lead to fascial disruption and herniation posterolaterally. Congenital hernias occur in infants and are usually isolated unilateral congenital defects. Lumbar hernias increase in size and should be repaired when found. The approach can be by open or, increasingly, by MIS technique. Repair is by mobilization of the nearby fascia and obliteration of the hernia defect by precise fasciatofascia closure for small defects and mesh repair for most Downloaded 2024131 5:57 A Your IP is 82.116.202.56 defects. Page 19 / 21 Chapter 34: Abdominal Wall Hernias, Sean B. Orenstein; Karen E. Deveney ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Stamatiou D, et al: Lumbar hernia: surgical anatomy, embryology, and technique of repair. Am Surg. 2009;75:202–207. [PubMed: 19350853] These acquired hernias may be traumatic or nontraumatic. Severe direct trauma, penetrating wounds, abscesses, and poor healing of flank incisions EUROPEAN UNIVERSITY CYPRUS are the usual causes. However, incisional hernias from extended flank procedures can lead to fascial disruption and herniation posterolaterally. Access Provided by: Congenital hernias occur in infants and are usually isolated unilateral congenital defects. Lumbar hernias increase in size and should be repaired when found. The approach can be by open or, increasingly, by MIS technique. Repair is by mobilization of the nearby fascia and obliteration of the hernia defect by precise fasciatofascia closure for small defects and mesh repair for most defects. Stamatiou D, et al: Lumbar hernia: surgical anatomy, embryology, and technique of repair. Am Surg. 2009;75:202–207. [PubMed: 19350853] Obturator Hernia Herniation through the obturator canal is more frequent in elderly women and is difficult to diagnose preoperatively. Because of the occult nature and difficulty with diagnosis of obturator hernias, the mortality rate (13%40%) of these hernias makes them one of the most lethal of all abdominal hernias. These hernias most commonly present as small bowel obstruction, with symptoms of abdominal distention, crampy abdominal pain, and vomiting. The hernia is rarely palpable in the groin, although a mass may be felt on pelvic or rectal examination. The most specific finding is a positive HowshipRomberg sign, in which pain extends down the medial aspect of the thigh with abduction, extension, or internal rotation of the knee. Because this sign is present in fewer than half of cases, diagnosis should be suspected in any elderly debilitated woman without previous abdominal operations who presents with a small bowel obstruction. Although diagnosis can be confirmed by CT scan, operation should not be unduly delayed if complete bowel obstruction is present. Open or laparoscopic transabdominal approach allows the best exposure for repair. Because of the deep inner pelvic location of these hernias, a thigh approach should be avoided. When performed laparoscopically, the repair emulates that of typical MIS inguinal hernia repairs, with wide mesh overlap including deep posterior overlap of the obturator canal. The CheatleHenry approach (retropubic) may also be used. Simple repair is most often possible, although bladder wall, pectineal muscle, peritoneum, or mesh has been used when the defect cannot be approximated primarily. Petrie A, et al: Obturator hernia: anatomy, embryology, diagnosis, and treatment. Clin Anat. 2011;24:562–569. [PubMed: 21322061] Stamatiou D, et al: Obturator hernia revisited: surgical anatomy, embryology, diagnosis, and technique of repair. Am Surg. 2011;77:1147–1157. [PubMed: 21944623] Perineal Hernia A perineal hernia protrudes through the muscles and fascia of the perineal floor. It may be primary but is usually acquired following pelvic procedures such as perineal prostatectomy, abdominoperineal resection of the rectum, or pelvic exenteration. These hernias present as easily reducible perineal bulges and usually are asymptomatic but may present with pain, dysuria, bowel obstruction, or perineal skin breakdown. Repair is usually done by an abdominal approach, with an adequate fascial and muscular perineal repair. Occasionally, polypropylene mesh or tissue flaps using the gracilis, rectus abdominis, or gluteus may be necessary, when the available tissues are too attenuated for adequate primary repair. Sciatic Hernia Sciatic hernias are one of the rarest of abdominal hernias and consist of an outpouching of intraabdominal contents through the greater sciatic foramen. The diagnosis is typically made after incarceration or strangulation of the bowel occurs, but usually requires CT or MRI for the diagnosis to be made preoperatively. The repair is usually made through the abdominal approach. The hernia sac and contents are reduced, and the weak area is closed by making a fascial flap from the superficial fascia of the piriformis muscle. Reinforcement of the closure with prosthetic mesh provides the most durable repair. Losanoff JE, et al: Sciatic hernia: a comprehensive review of the world literature (19002008). Am J Surg. 2010;199:52–59. [PubMed: 20103066] TRAUMATIC HERNIAS Abdominal wall hernias occur rarely as a direct consequence of direct blunt abdominal injury. The patient presents with abdominal pain. On examination, ecchymosis of the and a bulge are usually present. The existence of a hernia may not be obvious, however, and the Downloaded 2024131 5:57 A abdominal Your IP is wall 82.116.202.56 Page for 20 / 21 Chapter 34: Abdominal Wall Hernias, Sean B. Orenstein; Karen E. Deveney patient may require CT scan to confirm it. Because of the high incidence of associated intraabdominal injuries, laparotomy is usually required ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility further exploration. The defect should be repaired primarily, if possible, at the time of initial exploration, saving more definitive (meshbased) repair until the patient has fully healed and recovered from the traumatic event. EUROPEAN UNIVERSITY CYPRUS Access Provided by: TRAUMATIC HERNIAS Abdominal wall hernias occur rarely as a direct consequence of direct blunt abdominal injury. The patient presents with abdominal pain. On examination, ecchymosis of the abdominal wall and a bulge are usually present. The existence of a hernia may not be obvious, however, and the patient may require CT scan to confirm it. Because of the high incidence of associated intraabdominal injuries, laparotomy is usually required for further exploration. The defect should be repaired primarily, if possible, at the time of initial exploration, saving more definitive (meshbased) repair until the patient has fully healed and recovered from the traumatic event. II. OTHER LESIONS OF THE ABDOMINAL WALL CONGENITAL DEFECTS Congenital defects of the abdominal wall other than hernias or lesions of the urachus and umbilicus are rare. The important ones involving the urachus and umbilicus are discussed in Chapter 45. TRAUMA TO THE ABDOMINAL WALL Rectus Sheath Hematoma This is a rare but important entity that may follow mild trauma to the abdominal wall or may occur spontaneously in patients with disorders of coagulation, blood dyscrasia, or degenerative vascular diseases. Abdominal pain localized to the rectus muscle is the presenting symptom. The pain may be sudden and severe in onset or slowly progressive. The key to diagnosis is the physical examination. Careful palpation will reveal a tender mass within the abdominal wall. When the patient tenses the rectus muscles by raising the head or body, the swelling becomes more tender and distinct on palpation, in contrast to an intraabdominal mass or tenderness that disappears when the rectus muscles are contracted (Fothergill sign). In addition, there may be detectable discoloration or ecchymosis. If the physical signs are not diagnostic, ultrasound or CT scan will demonstrate the hematoma in the abdominal wall. The condition does not commonly require an operation. Coagulation abnormalities should be corrected if possible. The acute pain and discomfort usually disappear within 2 or 3 days, although a residual mass and ecchymosis may persist for several weeks. Rarely bleeding persists, requiring embolization by interventional radiology. PAIN IN THE ABDOMINAL WALL A number of conditions are characterized by pain in the abdominal wall without a demonstrable organic lesion. Pain from a diaphragmatic, supradiaphragmatic, or spinal cord lesion may be referred to the abdomen. Herpes zoster (shingles) may present as abdominal pain, in which case it will follow a dermatomal distribution. Scars may be sensitive or painful, particularly in the first 6 months after surgery. Entrapment of a nerve by a nonabsorbable suture may cause persistent incisional pain, sometimes quite severe. Hyperesthesia of the skin over the involved dermatome may provide a clue to the cause. If local anesthetic nerve block relieves the pain, nerve block with alcohol or nerve excision may be performed. In all cases of localized pain in the abdominal wall, careful search should be made for a small hernia: MRI or CT scan may be helpful to rule out a hernia. ABDOMINAL WALL TUMORS Tumors of the abdominal wall are not unusual, but most are benign, eg, lipomas, hemangiomas, and fibromas. Musculoaponeurotic fibromatoses (desmoid tumors), which often occur in abdominal wall scars or after parturition in women, are discussed in more detail in Chapter 47. Endometriomas may also occur in the abdominal wall, particularly in the scars from gynecologic procedures and cesarean sections. Most malignant tumors of the abdominal wall are metastatic. Metastases may appear by direct invasion from intraabdominal lesions or by vascular dissemination. The sudden appearance of a sensitive nodule anywhere in the abdominal wall that is clearly not a hernia should arouse suspicion of an occult cancer, with the lung and pancreas being the more likely primary sites. Downloaded 2024131 5:57 A Your IP is 82.116.202.56 Chapter 34: Abdominal Wall Hernias, Sean B. Orenstein; Karen E. Deveney ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Page 21 / 21

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