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Hernia

Hernia. Tulane University Department of Surgery. What is a Hernia? . Congenital or Acquired defect in the abdominal wall Herniorrhaphy is one of the most commonly performed operations in all of surgery Incidence ~ 1-5%. Physical Exam Characteristics .

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Hernia

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  1. Hernia Tulane University Department of Surgery

  2. What is a Hernia? • Congenital or Acquired defect in the abdominal wall • Herniorrhaphy is one of the most commonly performed operations in all of surgery • Incidence ~ 1-5%

  3. Physical Exam Characteristics • Reducible: hernia returns to anatomical location • Incarcerated: fixed hernia +/- intestinal obstruction • Strangulated: s/s of ischemia and obstruction

  4. Abdominal Wall Anatomy • 9 Layers • Skin • Subcutaneous fat • Camper’s fascia • Scarpa’s fascia • External Oblique • Internal Oblique • Transversus Abdominus • Transversalis fascia • Peritoneum

  5. Types 1. Inguinal 2. Femoral 3. Umbilical 4. Epigastric 5. Sliding 6. Littre’s 7. Internal 8. Obturator 9. Petit’s 10. Gryngelt’s 11. Coopers 12. Pantaloon 13. Richters 14. Incisional 15. Ventral 16. Hiatal 17. Parastomal 18. Etc. What is the most common Type?

  6. Types 1. Inguinal 2. Femoral 3. Umbilical 4. Epigastric 5. Sliding 6. Littre’s 7. Internal 8. Obturator 9. Petit’s 10. Gryngelt’s 11. Lumbar 12. Pantaloon 13. Richters 14. Incisional 15. Ventral 16. Hiatal 17. Parastomal 18. Etc. What is the most common Type?

  7. Differential Diagnosis (Inguinal Hernias) • Lymphadenopathy • Varicocele • Undescended testicle • Hematoma/Pseudoaneursym • Sarcoma • Lipoma

  8. Contents of Spermatic Cord • Vas deferans • Spermatic vessels • Genital branch of gentiofemoral nerve • Cremasteric vessels

  9. Inguinal Repairs • Marcy • Bassini • McVay • Shouldice • LICHTENSTEIN – Tension Free

  10. Acquired Causes • Increased abdominal pressure • Obesity • Chronic cough • Ascites • Pregnancy

  11. Hesselbach’s Triangle Indirect (50%) >> Direct (25%)

  12. Indirect Hernia

  13. Operative Repair—Mesh, Mesh, Mesh

  14. Incisional Hernias • Up to 11% of pts with previous laparotomy will develop hernia • Previous hernia is a risk for development of future hernia • Chances of successful closure decrease with each successive repair attempt

  15. Incisional Hernia Repairs

  16. Abdominal Wall Reconstruction

  17. Paradigm for Repairs 1900- Silver Filigree Mesh Stainless Steel Cloth 1940- Tantalum Mesh (metal) Shift 1 1944- Nylon Mesh 1958- Marlex (Polyethylene) 1962- Prolene (Polypropylene) 1984- Mersilene (Polyester) Shift 2 1985- Component Separation Shift 3 - Bioprosthetics

  18. Component Separation • Defined anatomic planes and range of advancement of rectus-internal/transversus muscle block

  19. Alloderm • Acellular Human Dermis • Epidermis and all cellular compenents are removed • Initially used in burn patients as a scaffolding for STSG • Minimal inflammatory response

  20. Conclusion • Hernias REQUIRESURGERYto prevent further complications (intestinal obstruction and infarction) • If reducible----elective • If incacerated----semi-elective • If strangulated----emergent

  21. Questions? According to the National Center for Health Statistics, approximately five million Americans have an abdominal hernia, but only a fraction of those seek treatment. Hernias do not go away and, if left untreated, may worsen over time, causing complications.

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