Abdominal Wall Hernias

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Abdominal Wall Hernias

• John Morton, M.D.
• University of North Carolina

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Objectives

• General principles
• Discuss pertinent history and exam
• Review anatomy
• Discuss common hernia repairs

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Hernia

• Abdominal Wall Defect
• Congenital or acquired
• Potential for bowel obstruction
• Incarceration
• Strangulation
• May suggest underlying pathology
• Hepatic disease, BPH, COPD, obstructing colon
  mass

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Common Hernia

• Umbilical
• Incisional
• Inguinal
• Direct and indirect
• Femoral

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Pertinent History

• Duration/onset
• Symptoms
• Local
• Obstructive
• Nausea, emesis, pain, distension, obstipation
• Prior Incarceration
• Related comorbidity
• Cough/Urinary flow/Constipation
• Operative risk

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Pertinent exam

• Distension
• Bowel obstruction
• Scars
• Incisional hernias
• Recurrence
• Contraindications for certain approaches
• Rectal--blood/masses

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Pertinent Exam

• Location
• Reducible?
• Tender?
• Skin changes?
• Palpable edges
• Genitalia
• Rectal

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Umbilical Hernia

• Congenital
• Most close by age 3
• May remain small and asymptomatic
• Can increase with obesity, pregnancy, ascites,
  peritoneal dialysis
• Typical umbilicus

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Umbilical Hernia Repair
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Ventral Hernia

• Usually incisional
• May be associated with adhesions

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Laparoscopic Ventral Hernia
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Groin Anatomy--Anterior

• Inguinal ligament
• Layers
• External ring
• Internal ring
• Spermatic cord
• Inferior epigastrics
• Hesselbachs triangle
• Femoral vessels

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Groin Anatomy--Posterior
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Groin Anatomy--Nerves
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Groin Hernia

• Indirect Inguinal
• Congenital
• Patent processus vaginalis
• Direct Inguinal
• Acquired
• Inguinal floor defect
• Femoral
• Below inguinal ligament

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Femoral Hernia Repair
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Bassini Repair

• Conjoined tendon (internal oblique, transverse
  abdominal, transversalis fascia)
• Shelving edge Inguinal ligament

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McVay (Coopers Ligament)

• Like Bassini but medial approximation to Coopers
  ligament
• Inguinal and Femoral hernia repair
• Femoral Vessels

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Shouldice Repair

• Imbricated, running repair

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Mesh repair

• Tension free
• Less painful
• Foreign body

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Open Preperitoneal RepairGiant prosthetic
reinforcement of visceral sac

• Stoppa
• Bilateral hernia
• Recurrent hernia
• Precursor laparoscopic repairs

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Unilateral Preperitoneal repair
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Transperitoneal Anatomy
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Groin Anatomy--Posterior
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