Abdominal wall and hernias
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- Site - left or right
- Direct or indirect
- Reducible or non reducible
- Complete or incomplete
Length of incision
- Chole - 5cm standard, increased upto 10 cm
- Appen - about 5cm
Difference between direct and indirect hernia?
- Indirect hernia // Direct hernia
- Cord is attached to hernia // Cord is not attached to hernia contents
- Inferior epigastric artery is lateral // Medial
Classify hernia according to extent
- • Incomplete:
- – Bubonocele: Here sac is confined to the inguinalcanal.
- – Funicular: Here sac crosses the superficialinguinal ring, but does not reach the bottom of the scrotum.
• Complete: Here sac descends to the bottom of the scrotum.
What is pantaloon hernia?
Pantaloon hernia (Saddle Bag hernia): a combined direct and indirect hernia, when the hernial sac protrudes on either side of the inferior epigastric vessels
What are the complications of hernia?
In which layer is the mesh placed?
Placed in .... layer
Complications of mesh repair
Factors that lead to incisional hernia
- Preoperative factors
- - Nutrition of the patient
- - Comorbidities
- - Smoking
- - Obesity
- - Type of suture material - absorbable or non absorbable
- - Type of incision - transverse is better than longitudinal
- - Intermittant suture is better, single layer suturing is better
- - Cough raises the intrabdominal pressure - burst
Difference between direct and indirect inguinal hernia
- A direct inguinal hernia protrudes directly forwards when the patient stands up whereas the indirect hernia shows a more oblique route downwards towards the scrotum.
- A hernia which goes into the scrotum is always indirect.
- The direct hernia appears as a symmetric, circular swelling at the external ring, i.e. medial to the femoral artery, whereas the indirect hernia is seen as an elliptical swelling.
- From the superficial ring, an indirect hernia reduces superiorly then superolaterally. A direct hernia reduces superiorly then posteriorly.
- The reduced indirect hernia can be controlled by pressure over the internal ring, classically with a single finger, but a reducible, direct hernia cannot.
- On standing, the direct hernias appears immediately whilst the indirect hernia takes time to reach its full size. Similarly, on lying down, direct hernias disappear immediately whilst there is a delay before the reducible indirect retracts fully. This is due to the relatively large orifice of the direct hernia compared to that of the indirect one. This also explains the greater propensity of the indirect hernia to strangulate and that its defect is not always palpable. For a direct hernia, the defect may be palpable superior to the pubic tubercle.
Incision for inguinal hernias
In emergency setting, go for inguino-scrotal incision to release constriction ring
If preoperative periotonitis is present, go fro midline incision
Approach for femoral hernias
- Low operation (Lockwood),
- High operation (McEvedy) and
- Inguinal operation (Lotheissen).
In all cases, the bladder must be emptied by catheterisation immediately before commencing surgery.
Various mesh placement options for abdominal wall reconstruction.
- 1. Onlay - defect closed and mesh placed in anterior rectus sheath.
- 2. Overlay - defect not closed, mesh placed over anterior rectus sheath
- 3. Inlay - mesh placed in the margin of defect
- 4. Sublay
- - Retrorectus
- - Intramuscular
- - Preperitoneal
- 5. Underlay (intraperitoneal)
Laparoscopic repair of hernias
The most common laparoscopic techniques for inguinal hernia repair are transabdominal preperitoneal (TAPP) repair and totally extraperitoneal (TEP) repair.
- In TAPP the surgeon goes into the peritoneal cavity and places a mesh through a peritoneal incision over possible hernia sites.
- TEP is different in that the peritoneal cavity is not entered and mesh is used to seal the hernia from outside the peritoneum (the thin membrane covering the organs in the abdomen). This approach is considered to be more difficult than TAPP but may have fewer complications. Laparoscopic repair is technically more difficult than open repair.
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