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
- 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.
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. |