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Hernia of the antero-lateral abdominal wall

Hernia of the antero-lateral abdominal wall. Definition. Progressive protrusion through the abdominal wall of the peritoneum, with tendency to progress, together with an abdominal viscus SO An abdominal viscus will HAVE to leave the abdominal cavity There must be a peritoneal covering.

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Hernia of the antero-lateral abdominal wall

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  1. Hernia of the antero-lateral abdominal wall

  2. Definition • Progressive protrusion through the abdominal wall of the peritoneum, with tendency to progress, together with an abdominal viscus • SO • An abdominal viscus will HAVE to leave the abdominal cavity • There must be a peritoneal covering

  3. NOT real hernias by this definition • Embrionic or fetal hernia where there is an anomaly in development • Protrusions of the organs of the retroperitoneum without peritoneal cover.

  4. Common manifestations of hernia

  5. HERNIA? Pathological aspects

  6. Hernia development– HERNIATION POINT- • First step in develeopment • The protrusion of serosa begins like a small bulge through a small PARIETAL DEFECT • CLINICAL SIGNS: • Pain of variable intensity • Digital examination may be inconclusive, except for a large defect

  7. Hernia development– Interstitial hernia- • Peritoneal diverticulum increases in size • Protrusion within the muscular-fascial structures of the abdominal wall • Peritoneal serosa becomes thick and becomes a herniation sac • CLINICALLY: • Pain through compression on viscera or traction on mesentery. Possible pain through interstitial compression • All signs of a hernia can be identified

  8. Hernia development– COMPLETE HERNIA- • Herniation sac = completely passed through the wall • Clinical signs are complete both in uncomplicated and complicated form

  9. PATHOLOGIC CHANGES • Wall defect – the abnormality in the abdominal wall • Fibrous (umbilical hernia) • Fibro-muscular (epigastric hernia) • Fibro-osseous (obturator hernia) • True channel (inghuinal hernia) • Hernia wall or coverings • Hernia content

  10. Complete hernia – structures of the wall • Skin and subcutaneous fat • Sac (peritoneum which is stretched + fat and structures migrating from under the peritoneum) • Fundus area • Neck area

  11. Causes • Conflict: pressure inside the abdominal cavity and possibility of the abdominal wall to content that pressure • Fragile balance – if imbalance appears a herniation point and a hernia will develop

  12. Causes • Congenital: the sac preexists at birth or defect of development • Acquired hernia : in areas of minimal resistence of the abdominal wall

  13. Causes-high intraabdominal pressure- • An increase in abdominal pressure acute (muscular rupture) or chronic (long term increase in stress over the abdominal wall) may increase the risk of hernia development • Increase respiratory effort: chronic respiratory diseases associated with cough; jobs that require increase expiratory effort. • Tumors or peritoneal effusion in large quantity (pregnancy, ascites, peritoneal dialyses) • Straining or effort with closed epiglotis • Functional disorders with chronic effort (prostate adenoma, chronic constipation) • Pathologic causes – colonic tumor!!!!!

  14. Causes-wall defects- • Abdominal structure is not homogenous WEAK POINTS • Natural communications between abdominal cavity and other cavities • Passing of nerves or vessels towards superficial structures • Scars (posttraumatic, postoperative) • Intersection of fascial structures

  15. Causes-wall defects • Other factors essential in hernia develoment • Loss of tissue elasticity and resistence – usually associated with agging • Genetic factors – hernias predominant in some families: defects in synthesis and structure of colagen fibers • Trauma – tissue distruction + scars. Infection is a major contributor in incisional hernia • Metabolic abnormalities

  16. Hernia formation • Hernia with preexisting sac: development abnormalities when the peritoneal diverticula is preexistent. There is no wall defect. • Pushing hernia: association of high intraabdominal hernia and weak point • Sliding henria: similar but organs attached to peritoneum slide in the sac. • Hernia with abnormally distended sac –peritoneum fixed at the level of the neck is blown up and loses its characteristics (umbilical hernia)

  17. Clinical signs in uncomplicated hernia • Pseudo-tumoral bulge with variable medical history that is apparent to the patient • Discomfort; difficulties in dressing +/- skin lesion through friction; the patient notices that it can be reduced and may need an orthopedic support. • Pain: traction or compression on nerves or mesentery. Usually it is bothersome but not major. Small hernia with small defects will be more painful. • Incomplete obstruction – when bowel is present in large hernia • Esthetic problem

  18. Clinical examination-uncomplicated hernia- • Positio of the patient : • Standing up : COMPULSORY as an initial assesment • Laying down - compare the size and dynamic of tumor when intraabdominal pressure changes • ALL WEAK ABDOMINAL POINTS should be examined, as more hernias can be present • Protect the patient’s sensibility

  19. Clinical examination-uncomplicated hernia- • Inspection: • Tumor, bulging, in an area known as weak area of the abdominal wall • “Tumor” is changing volume according to changes in abdominal pressure (standin/laying down, coughing, straining) • Skin covering is normal • Volume increases while coughing • Progression of hernia follows a trajectory which is the herniation channel

  20. Clinical examination-uncomplicated hernia- • Superficial palpation • Check the sensibility • Tumor has elastic consistency • Pear-like shape with a neck that continues in the abdominal cavity!!! (very important) • Content: diferentiate between bowel and non digestive structures • Reduce the hernia content in the abdominal cavity REDUCTIBLE HERNIA • Hernia forms back after reduction: COERCIBILE VS NONCOERCIBLE

  21. Clinical examination-uncomplicated hernia- • Palpation of the abdominal wall after reduction of the content • Evaluation of the well defect (dimension, structure, position) • The “tumor” follows the finger to progress during a coughing effort, following the direction of your finger EXPANSSION • The “tumor” knocks your finger during a coughing effort PULSATE WITH COUGH

  22. Clinical examination-uncomplicated hernia- • Percussion • Tympanic – presence of air = bowel • Dull = omentum or retroperitoneal fat, but bowel can also be present but does not contain air.

  23. Clinical examination-uncomplicated hernia- • Auscultation • NOT significant but you may hear hydro-aeric sounds characteristic for bowel content

  24. POSITIV DIAGNOSTIC IN UNCOMPLICATED HERNIA • “Tumor” or bulge + in a weak point • Normal skin • Volume changes with postural changes • Pedicle inside the abdominal cavity • Communication through a defect in the abdominal wall - palpable • Reducible + expansion during cough • Pulsation during cough

  25. Lab exploration • Barium enema-colon in hernia + colonic tumors • Small bowel follow-up • Ultrasound scan - content • Laparoscopy – “gold standard” for small hernia

  26. Natural history • Hernia of the adult never heal spontaneously!!! • Hernia with a large defect are well tolerated but represent a handicap • Rigid defect: can produce a strangulation at any time • COMPLICATIONS – given enough time all hernias will complicate

  27. Complications • Irreducible • Incarceration • To large to be adapted in the peritoneal cavity “no right to stay in the abdomen” • Strangulation • Incomplete intestinal obstruction peritonitis in the sac • Complications due to compression (testicular atrophie, changes in urinary habits, respiratory disfunction) • Trauma to the hernia • Tumors in the hernia • Foreign body in the hernia

  28. Strangulation • The most serious complication: transforms a benign pathology in one potentially lethal • CAUSES that favor strangulation: • Inextensible parietal defect (orifice) • Narrow or sclerotic neck of hernia sac • Adhesions in the sac

  29. Pathogenesis of strangulation • Effort with sudden increase in intra-abdominal pressure • A larger volume of bowel/viscus is pushed in the hernia • Increases the pressure inside hernia sac • Much more so at the level of the inextensible hernia orificeor neck of hernia • Impediment in the venous retur with consecutive edema. • Further increase in intra-sacular pressure and of hernia volume • Pressure inside the hernia becomes bigger then arterial pressure = ischemia SPEED OF PROGRESSION towards ireversible lesions is greater in tight strangulation.

  30. Lesions • Sac: same changes edematous – eritematous – liquid initially serous+/- bloody the puss or fecal • Intestinal loop: 3 stages1. Congestion(venous stasis): congesitve loop, cyanosis, visible strangulation ridge. REVERSIBLE LESION • 2. Intermediate bowel becomes purple – black, more rapidly at the strangulation area, the loop wall is destroyed and reduced to serosa 3. Necrosis and perforation the lopp becomes green (necrotic) like a dead leaf. Partial or total rupture of the wall + contamination of the peritoneum of the sac.

  31. Pathology • Mesentery in strangulated area • Edematous, friable with distended veins and trombosis • Omentum • Similar as above, can progress towards necrosis

  32. Intestinal obstruction • Strangulation = (with few exception) a clinical manifestation of complete obstruction • Loops above hernia are dilated, with active peristalsis • Loops below hernia are emtpy • After perforation – peritonitis (either localized in the hernia sac or generalized peritonitis

  33. Unusual forms • Lateral pinch (Richter) • Strangulation of a segment of circumference on the anti-mesenteric border • Incomplete clinical manifestations of intestinal obstruction (lumen is free) • Manual reduction of hernia is possible but ischemic lesion of the loop may progress in the abdomen – when the necrotic tissue is delimitated and falls of = PERITONITIS • More frequent in femoral hernia

  34. Unusual forms • Retrograde strangulation “In W” • A large loop is in the hernia but strangulation involves a segment of loop situated in the abdominal cavity with a part of mesentery in the hernia • Greatest risk – during the surgical cure in the emergency settings – the intraabdominal loop may not be noticed - PERITONITIS

  35. Clinical signs in strangulation • SHARP PAIN at the level of hernia, continuous – SIGNAL - viability of the loop is threatened • INTESTINAL OBSTRUCTION • Colicky abdominal pain (obstruction) • Nausea, vomiting (at first food, the bile, then fecal aspect) • No intestinal transit but diarrhea is posible

  36. General signs • Very good at first • Tachycardia • Anxiety

  37. Clinica examination • Patient is known to have a hernia BUT not always (strangulation as a first symptom) • Hernia is large and painful (in particular at the level of the neck) • DISAPPEARimpulsion and expansion with cough • Henria becomes irreducible: TAXISUL (forceful reduction) is very dangerous – and more so after one hour from onset • En bloc reduction together with peritoneum • Non vital loop being reduced in the peritoneum

  38. Clinical examination • Abdomen: classic appearance of intestinal obstruction • Meteorism • Hyper-peristaltic loops • Borborism • Peritonitis;it is a “normal” evolution of clinical aspect a strangulated hernia neglected for too long • Abscess formation – may open spontaneously producing a digestive fistula

  39. Positive diagnosis • Hernia can not be reduced ANY MORE • NO impulsion NO expansion • Hernia becomes painful - continuous pain • Intestinal obstruction • Peritonitis

  40. Treatment of strangulation • URGENT: operated as soon as possible to save the loop • Hemo-dynamic control • Gastric aspiration (naso-gastric tube) • Surgical treatment using any type of anesthesia

  41. Hernia SAC • Open but isolate as it may be contaminated Laparotomy – if abdominal contamination is probable! • Treat content • Resection of sac • Close peritoneum • Drain the contaminated area (+/-)

  42. Content • Incise the neck and decompress the strangulation area • Evaluate viability of bowel loop • If viable – reintroduce in the peritoneal cavity • Not viable – resect • In doubt: warm saline + infiltrations in the mesenter; wait and see

  43. Orifice • Close the orifice and repair the defect • Exception: • Massive contamination. Repair can be put in danger by septic complications

  44. Peritoneal cavity • Non-contaminated (infection limited at the level of the neck) – nothing special but need to be checked intraoperatively • Contaminated • LAPAROTOMY (LAPAROSCOPY) irrigate and drain • Intestinal resection

  45. Irreducible hernia • Henria content can not be reduce anymore – does not affect viability of the loop • In general it is progressive. The hernia is more and more difficult to be reduced. BUT sudden henriation of a larger volume can induce this complication. • Intra-sacular adherences • Old hernia with step by step development of irreducibility • Differential diagnosis – strangulation: all strangulated hernias are ireducible

  46. NO right to stay anymore in the abdomen (not welcome anymore) • Rare complication of very large hernia that recur immediately after reduction • Large volume outside the abdominal cavity for a long time = abdomen is reshaped on a smaller content • Reduction immediately increases the abdominal pressure and the whole volume can not be reduce or recurs immediately

  47. NO right to stay anymore in the abdomen (not welcome anymore) • Consequences : • hernia is incoercible • Forceful reduction and contention is accompanied by respiratory distress • Treatment is very problematic • Need to increase the abdominal volume in time • Organ resections to reduce the pressure • Large synthetic meshes

  48. Trauma to the hernia • Organs in the hernia are exposed. Much so if traumatized they do not have the liberty to retract in the abdomen. Entraped. • Diagnostic problems • Lesions that can progress in 2 steps • Intra-sacular peritonitis is non specific and few symptoms may be present. May develop generalized peritonitis.

  49. Peritonitis in the hernia • Unusual complication • Secondary to infectious complications of intra-sacular organs (appendicitis, diverticulitis, etc) • Clinical signs: increase in volume, becomes painful, ireducible, local signs of inflamation

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