Other hernias

Umbilical hernias

Two types of umbilical hernia occur in adults
True umbilical hernias are rare
Occur with abdominal distension (e.g. ascites)
Para-umbilical hernias are more common
Occurs through the superior aspect of the umbilical scar
Female : male ratio is 5:1
Usually contain omentum
Neck is often tight and the hernias are often irreducible

Differential diagnosis

Cyst of the vitello-intestinal duct
Urachal cyst
Metastatic tumour deposit (Sister Joseph's nodule)

Management

Management of true and para-umbilical hernias is similar
Surgery is usually performed through a infra-umbilical incision
Occasionally the umbilicus needs to be excised
Contents of the hernia are reduced
Defect in linea alba can be repaired with:
- An overlapping Mayo repair
- A mesh repair

Epigastric hernia

Arises through a congenital weakness if the linea alba
Hernia usually consists of extra-peritoneal fat from near to falciform ligament
Male : female ratio is 3:1
Many are asymptomatic
Produce local symptoms
Strangulation is rare
Can be repaired with either sutures or a mesh

Incisional hernia

Occurs through the scar from a previous operation
1% of all transparietal abdominal incisions result in a hernia
Account for 10% of all abdominal wall hernias
Partial dehiscence of all deep fascial layers occurs
Skin remains intact
Most develop within a year of surgery
Symptoms are often minimal with cosmetic appearance the main concern
Most are wide necked but strangulation can occur

Picture provided by Eduard Villatoro. Derby City General Hospital. United Kingdom

Aetiological factors

Preoperative
- Increasing age
- Malnutrition
- Sepsis
- Uraemia
- Jaundice
- Obesity
- Diabetes
- Steroids
Operative
- Type of incision
- Technique and materials used
- Type of operations
- Use of abdominal drains
Postoperative
- Wound infection
- Abdominal distension
- Chest infection or cough

Management

CT or ultrasound may clarify muscular defect and hernial sac content

Picture provided by Eduard Villatoro. Derby City General Hospital. United Kingdom

The elderly or infirm may be helped by an abdominal wall support
If surgery is required the following should be considered
- Fascial closure or mayo-type repair using sutures
- A 'keel repair' using sutures
- A mesh repair using polypropylene or PTFE
- Mesh can be placed as a sublay, onlay or inlay
Laparoscopic mesh repair may be considered
The results of surgery for incisional hernias are variable
Re-recurrence rate of 20% have been reported
The results with mesh are superior to suture repairs
Composite meshes may offer reduced risk of complications
A sublay mesh repair may have the lowest recurrence rate

Picture provided by Mr M Maniman, Royal Berkshire County Hospital, Reading, United Kingdom

Spigelian hernia

Occurs at the lateral edge of the rectus sheath
Interparietal hernia in the line of the linea semilunaris
Usually occurs at the level of the arcuate line

Obturator hernia

Occurs in the obturator canal
Usually asymptomatic until strangulation occurs
May complain of pain on the medial aspect of the thigh
Vaginal examination may allow identification of a lump in the region of the obturator foramen

Bibliography

Cassar K, Munro A, Surgical treatment of incisional hernia. Br J Surg 2002; 89: 534-545.

Dumanian G A, Denham W. Comparison of repair techniques for major incisional hernias. Am J Surg 2003; 185: 61-65.

Kingsnorth A. The management of incision hernia. Ann R Coll Surg Engl 2006: 88: 252-260.

Klinge U, Conze J, Krones C J et al. Incisional hernia: open techniques. World J Surg 2005; 29; 1066-72.

LeBlanc K A. Incisional hernia repair: laparoscopic techniques. World J Surg 2005; 29: 1073-1079.

Law N. Incisional hernia. Current Practice in Surgery 1995; 7: 43 - 46.

Luijendijk R W, Hop W C J, Van den Tol P et al. A comparison of suture repair with mesh repair for incisional hernia. N Eng J Med 2000; 343: 392-398.

Millikan K W. Incisional hernia repair. Surg Clin North Am 2003; 83: 1223-1234.