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Abdominal Wall Hernias

Abdominal Wall Hernias. John Morton, M.D. University of North Carolina. Objectives. General principles Discuss pertinent history and exam Review anatomy Discuss common hernia repairs. Hernia. Abdominal Wall Defect Congenital or acquired Potential for bowel obstruction Incarceration

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Abdominal Wall Hernias

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  1. Abdominal Wall Hernias John Morton, M.D. University of North Carolina

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

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

  4. Common Hernia • Umbilical • Incisional • Inguinal • Direct and indirect • Femoral

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

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

  7. Pertinent Exam • Location • Reducible? • Tender? • Skin changes? • Palpable edges • Genitalia • Rectal

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

  9. Umbilical Hernia Repair

  10. Ventral Hernia • Usually incisional • May be associated with adhesions

  11. Laparoscopic Ventral Hernia

  12. Groin Anatomy--Anterior • Inguinal ligament • Layers • External ring • Internal ring • Spermatic cord • Inferior epigastrics • Hesselbach’s triangle • Femoral vessels

  13. Groin Anatomy--Posterior

  14. Groin Anatomy--Nerves

  15. Groin Hernia • Indirect Inguinal • Congenital • Patent processus vaginalis • Direct Inguinal • Acquired • Inguinal floor defect • Femoral • Below inguinal ligament

  16. Femoral Hernia Repair

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

  18. McVay (Cooper’s Ligament) • Like Bassini but medial approximation to Cooper’s ligament • Inguinal and Femoral hernia repair • Femoral Vessels

  19. Shouldice Repair • Imbricated, running repair

  20. Mesh repair • Tension free • Less painful • Foreign body

  21. Open Preperitoneal RepairGiant prosthetic reinforcement of visceral sac • Stoppa • Bilateral hernia • Recurrent hernia • Precursor laparoscopic repairs

  22. Unilateral Preperitoneal repair

  23. Transperitoneal Anatomy

  24. Groin Anatomy--Posterior

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