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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

Umbilical hernia

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

incisional hernia

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

CT scan of incisional hernia

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

Mesh repair of incisional hernia

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.

 

 
 

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