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Abdominalwallhernias❑generalconsideration❑inguinalhernias❑femoralhernia❑incisionalhernia❑umbilialhernia❑herniaoflineaalbageneral

consideration⚫DefinitionHerniameansasprout,andprotrusion.Externalabdominalwallherniaisanabnormalprotrusionofintra-abdomi

naltissueorthewholeorpartofaviscerathroughanopeningorfascialdefectintheabdominalwall.mostoccurinthegrion❖Etiology1.inte

nsityofabdominalwalldecreasedcommonfactors:1)sitethatsometissuespassthroughtheabdominalwall,eg.Spermaticcord,roundligamentofuterus2)baddevelopmen

tofabdominalwhiteline3)incision,trauma,infectionetal.defectincollagensynthesisorturnover2.anyconditionwhichinc

reasesintra-abdominalpressurechroniccough,chronicconstipation,dysuria,ascites,pregnancy,cry❖Pathologicalana

tomycomposedof:coveringtissue:skin,subcutanoustissuehernialsac:protrusionofperitonum,neckofthesac:isnarrowwherethesacemergesfromtheabdom

enbodyofthesachernialcontents:smallintestine,majoromentum❖Clinicaltypes1.reducibleherniaisoneinwhichthe

contentsofthesacreturntotheabdomenspontaneouslyorwithmanualpressurewhenthepatientisrecumbent.2.irreducibleherniaisonewhoseconte

ntsorpartofcontentscannotbereturnedtotheabdomen,withoutserioussymptoms.herniasaretrappedbythenarrowneckSlidingherniaisoneinwhichthewallofaviscusfo

rmsaportionofthewalloftheherniasac.Itismaybecolon(ontheleft),caccum(ontheright)orbladder(oneitherside).Belongstoirred

uciblehernia3.incarceratedhernia:isonewhosecontentscannotbereturnedtotheabdomen,withseveresymptoms.4.strangulatedhernia:denotesco

mpromisetothebloodsupplyofthecontentsofthesac.incarceratedherniaandstrangulatedherniaarethetwostagesofapathologicc

ourseRichter’shernia(intestinalwallhernia)aherniathathasstrangulatedorincarceratedapartoftheintestinalwallwithoutcomprom

isingthelumen.Littrehernia:aherniathathasincarceratedtheintestinaldiverticulum(usuallyMeckeldiverticu

lum).Reductiveincarceratedhernia:reductionofthehernialcontents(intestine)intoabdominalcavity.Inguinalhernias→→→⚫Anatomy1.Anatomiclayers1)skin,

subcutaneoustissue2)externalobliquemuscle,aponeurosis⚫Subcutaneous(external)inguinalring:Triangularopening,intheaponeu

rosisoftheexternalobliquejustsuperiorandlateraltothepubictubercle.Inguinalligament:itisformedasthelateraledgeoftheaponeurosisofexternalo

bliquerollsuponitselfandthickensintoacord,extendingfromtheanteriorsuperioriliacspinetothepubictubercle.

LacunarligamentCooper’sligament(pectinealligament)Sensorynerves:iliohypogastricnerve,ilioinguinalnerve3)intern

alobliquemuscleandtranverseabdominalmuscleConjoinedtendon(flaxinguinalis):thelowerfibersoftheinternalobliquemusclefusewiththelowermostarchingfib

ersofthetransversemuscleoftheabdomenandinsertwiththemintothepubictubercle,formingtheconjoinedtendon.4)TransversalisfasciaInternalinguinalrin

g:isthepointatwhichthespermaticcordorroundligamentpassesthroughthetransversalisfasciatoentertheinguinalcanal.surfacemarking:2cmsuperiort

othepointmidwaybetweentheanteriorsuperioriliacspineandthepubictubercle.Iliopubictract:itisthethickestportionofthetran

sversalisfasciaintheinguinalregion.Itparallelsandliesjustmedialtotheinguinalligament.5)extraperitonealfatandperitoneu

m2.AnatomyofinguinalcanalContents:spermaticcord,roundligament,ilioinguinalnerveWalls:anterior:skin,superficialfascia,andexternalabliqueaponeuros

isposterior:transversalisfasciasuperior:conjoinedtendeninferior:inguinalligament3Hesselbach’striangleBoundedbytheinguinalligament,theinferiorepigas

tricvessels,andthelateraledgeofrectusmuscle.❖Causesofindirectinguinalhernia1.congenitalabnormalityofanatomyduetofailureoffusionoftheprocessusva

ginalisperitoneiafterthetestishasdescendedintothescrotum.2.acquiredweaknessordefectofabdominalwall❖Clinical

manifestationanddiagnosisSymptoms:pain,discomfort,draggingsensationSign:reducibleorirreduciblelump,expansilecoughimpulseReducing

theherniafully,compresstheinternalring:becontrolled–indirectnotcontrolled--directDifferencesbetweenindirectanddirecthe

rniafeatureindirectdirectagechildren,youngpeopleagedpeoplepathwayofprotrusioncomingdowntheinguinalcanal,mayenterthescrotumpassthroughH

esselbach’striangle,rarelyenterthescrotumcontoursofsacelliptic,pear-shapedsemispheric,widebasecompresstheinternalringafterreducedcontrolle

dcontrolledRelationshipofspermaticcordwithsacPosteriortothesacAnteriorandlateraltothesacRelationshipofsacneckw

ithinferiorepigastricarterySacneckislateraltoitSacneckismedialtoitIncarceratedincidencehighlow1.Differentialdiagnosis2.1dydroceleoftestistranslucentt

est(+)3.2communicatedhydrocele4.3hydroceleofcord:notreducible5.4undescendedtestis6.5acuteintestinalobstruction7.Treatment1.nonoperativetherapyIndicat

ions:<1yearoldelderlypatientsorwithseveresystemicdisease--truss2.operationsforinguinalherniaconventionalre

pairsPrinciples:excisionorreductionofthehernialsac,highligationofthesac,andrepairthewallsoftheinguinal

canalA:highligationofherniasacUsedininfants,andpatientswithseverelocalinfectionB:repairofwallsoftheingui

nalcancalIrepairoftheanteriorwalloftheinguinalcanalFergusonrepairIIRepairoftheposteriorwallBassinirepairHalstedre

pair:placingthelatterinasubcutanouspositionMcVayrepair:loweredgeofinternalobliquemuscleandtheconjoined

tendonareapproximatedtoCooper’sligamentontheiliopectineallineofthepubis.Shouldicerepair:theposteriorwal

loftheinguinalcanalisrepairedbydividingthetransversalisfasciafromthepubistoadjacenttotheinferiorepigastricvessel,thenimbricatesutures.Inte

rnalring:passafingertip2)tension-freehernioplastyinsertionofaprostheticmesh3)laparoscopicrepairofinguinalhernia3.managementruleofincarcerated

andstrangulatedherniaIndicationsformanualreduction:1)duration<3-4hours,nolocaltenderness,noabdominalten

derness,norigidityofabdominalmuscle2)elderlypatientsorwithotherseverediseases,andtheintestinalloopisstillaliveUsuallyrequiresemergencyoperation4.Mana

gementruleofrecurrentinguinalhernia1)truerecurrenthernia2)concomitanthernia3)newoccurringherniaFemoralhernia⚫introductionFemora

lherniaisaprotrusionofperitoneumthroughthefemoralcanal.Usuallyinwomen>40yearsCauses:laxityofgrointissue

elevatedintra-abdominalcanal⚫AnatomyoffemoralcanalFemoralring–fossaovalisAnterior:inguinalligamentPosterior:pectinealligamentMedial:lacunarligamen

tLateral:femoralvein❖Pathologicanatomy❖ClinicalfindingsanddiagnosisReduciblefemoralhernia:asymptomaticlump,lo

calizedintermittentdiscomfortIrreduciblefemoralhernia:constantlumpandlocalizeddiscomfortStrangulatedfemoralhernia❖Differentialdiagnos

is1.indirectinguinalhernia2.lipoma3.groinlymphnodes4.longsaphenousvarix5.iliolumbartuberculousabscess❖TreatmentNotbetreatedconservati

velyRuleoperation:excisionorreductionofthehernialsac,andnarrowingofthestretchedfemoralopeningmethods:McVa

yrepairtension-freehernioplastylaparoscopicrepairofinguinalherniaOtherabdominalexternalherniaIncision

alherniaIncisionalhernia:anabnormalprotrusionofaviscusthroughthemusculoaponeuroticlayersofasurgicalscar.Wounddehiscence⚫Eti

ologyPreoperativefactorsOperativefactors:typesofincision:verticalincision,transrectusincision,midlineincision,standar

dparmedianincisiontechniqueofclosuresuturemateriaPostoperativefactors:increasedintra-abdominalpressure,etal.❖Clinicalfeatures

anddiagnosisSwellingandmassintheincisionHernialringRarelyincarcerate❖TreatmentOperativerepair:thesamewayasalaparotomywoundisrepaired,orusemeshU

mbilicalhernia1infantileumbilicalhernia1)failureoffusionofumbilicalring,orweakenedumbilicaltissue2)sym

ptomless,reduciblelump3)usuallydisappearbytheageof2years4)rarelyincarcerate5)surgicalrepair>2years2Adultumbilicalhernia1)acquiredhernia

2)morecommoninfemales3)incarcerationiscommon4)surgicalrepair:excisionofthesac,suturetheherniaringHerniaoflineaalbaEpigastricherniaItisapr

otrusionofpreperitonealfatand/orperitonealsacthroughagapinthedecussatingfibersofthelineaalba,usuallythesupraumbilicalportiono

fthelineaalba.Mostareasymptomatic,orvagueupperabdominalpainandnauseamaybepresent.Surgicalrepair