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Hernia- Abdominal wall

Abnormal protrusion of a viscus or part of a viscus through an opening in the cavity in which it is normally contained A hernia has three parts – the sac , the coverings of the sac and the contents Incarceration →lumen of that portion of the colon occupying a hernial sac is blocked with faeces Reducible → can be pushed back into its original anatomical location Irreducible → contents cannot be returned to abdomen but no evidence of other complications 
( usually due to adhesions ) Obstructed →irreducible hernia containing intestine that is obstructed from without or within , but there is no interference with blood supply to the bowel Strangulation → hernia gets stuck passing through the defect and structures loose their blood supply

risk factors-History of previous abdominal wall hernia or prior abdominal surgery Abdominal trauma Age Chronic cough ↑ Intra-abdominal pressure eg BPH , constipation Connective tissue disorders eg Ehlers-Danlos / Marfans Smoking ( acquired collagen deficiency ) Family history of abdominal hernia

Types –Anatomical – Epigastric , Para-umblical /Umblical , Spigelian , Inguinal , Femoral Abdominal hernias can also be classified as Internal , External and Diaphragmatic Reducible , Incarcerated or Strangulated Congenital or Acquired Contents of sac ( Indirect hernia )
▬ Enterocele -sac contains intestine
▬ Omentocele – sac contains omentum
▬ Entero-omentocele-both intestine and omentum
▬ Cystocele -part of urinary bladder inside the sac

Inguinal hernia is most common ( 75 % ) followed by umblical (15 % ) and then femoral (8.5 % )

Examination –Standing and lying Start with patient standing
○ Expose umblicus to knees
○ Check for cough impulse
○ Palpate- soft , fluctuant pulsatile etc
○ Check for other side as well Examine the abdomen ( r/o any cause of ↑ intra-abdominal pressure )
○ Check for cough impulse
○ Position of hernia ( for eg if the neck of hernia is above and medial to pubic tubercles : inguinal , if below and lateral to pubic tubercle : Femoral )
○ Relation of swelling to inguinal ligament
○ Is it reducible
○ Skin erythema over the hernia ? Consider examining the scrotum and testis

Obstruction –Obstruction Colicky abdominal pain Tenderness over hernia site Abdominal distension and vomiting Onset ↑ gradual than in strangulated hernia Obstruction can culminate in strangulation

 Irreducible hernia ( ie no expansile cough impulse ) Tender and red Pain initially over hernia is followed by generalised abdominal pain colicky in nature Systemic signs- nause and vomiting

Inguinal hernias –Most common abdominal hernia Eight times more often in males- abdominal wall deficiency caused by testicular descent.

More common in young Most common type of hernia in men and women Predominantly in boys and more common on the rt hand side Inguinal hernia in babies are the result of a persistent processus vaginalis Peritoneal sac protrudes through the deep inguinal ring – passes down the inguinal canal and may extend as far as the upper pole of testis In infants often an associated hydrocele and undescended testis ↑ risk of incarceration and possible strangulation

Always acquired Women practically never develop a direct inguinal hernia The sac passes through a weakness or defect of the transversalis fascia in the posterior wall of the inguinal canal Often bilateral Occurs in older patients and may be associated with obesity , cough , constipation , prostatism Do not often attain a large size or descend into scrotum Do not often strangulate ( neck of sac is wide )

Umbilical hernia results from congenital weakness due to persistence of an abdominal wall defect at the site of ulbilicus.In children due to incomplete closure of umblical orifice ↑ in ♂ Spontaneous resolution in majority of cases by 2 yrs Consider surgical referral if it has not disappeared by age 3 and the fascial defect is > 1.5 cm in diametre

Periumbilical hernia –Just above or just below the umblicus- are acquired ↑ common in females , multiparous , obese , ascites , CAPD ( peritoneal dialysis ) Can present with intestinal colic as the hernia can obstruct intermittently Narrow neck of sac – high risk of strangulation

Femoral hernia-Common in older females Rare in men Protrusion of peritonium into the potential space of the femoral canal ( sac may contain abdominal viscera ) Narrow neck of the femoral canal opening leads to ↑ ed risk of incarceration Can be small unimpressive -size of a grape A cough impulse can rarely be detected Usually irreducible Up to 40 % of femoral hernias present as an emergency with signs of strangulation or distal small bowel obstruction

References –References ; Further reading Essentials of Clinical surgery E-Book Ian J Franklin , Peter M Dawson , Alexander D. Rodway Churchill’s Pocketbook of Surgery- Andrew T Raftery , Michael S Delbridge , Marcus J D Wagstaff ASGBI Commissioning Guide Groin hernia accessed via Hospital Surgery- Edited by Omer Aziz , Sanjay Purkayastha , Paraskevas Paraskeva ; Forward by Ara Darzi E Medicine Abdominal Hernias Author: Assar A Rather, MBBS, MD, FACS; Chief Editor: John Geibel, MD, DSc, MSc, MA Abdominal Wall Hernias Classic and Unusual Arash Bedayat MD , Hemang Kotecha DO , Matthew L Hoimes MD , Byron Y Chen MD ,Hao S Lo MD , Adib Karam MD UMASS Medical School Essential Surgery- Clive R.G.Quick , Joanna B. Reed , Simon J F Harper , Kourosh Saeb-Parsy Bailey and Love’s Short Practice of surgery 25th edition- Edited by Normal S Williams , Christopher J K , Bulstrode P Ronan O’Connell Hernias Dr Ben Stubbs Mr Zargham Hyder InnovAit Vol 2 Issue 11 November 2009

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