Hernias and Intraperitoneal abscess PowerPoint Presentation

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Sheng Yan MD, PhD The First Affiliated Hospital Zhejiang University Hernias, and Intraperitoneal abscess

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General consideration Definition Hernia means a sprout, and protrusion. External abdominal wall hernia is an abnormal protrusion of intra-abdominal tissue or the whole or part of a viscera through an opening or fascial defect in the abdominal wall. most occur in the groin

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Historical Hernias Hernias have been documented throughout history with varying success at either reduction or repair.

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Trusses & Techniques

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Camper’s Scarpa’s Fascia

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Inguinal canal Contents: spermatic cord, round ligament, ilioinguinal nerve anterior: skin, superficial fascia, and external ablique aponeurosis posterior: transversalis fascia superior: conjoined tenden inferior: inguinal ligament Hesselbach’s triangle Bounded by the inguinal ligament, the inferior epigastric vessels, and the lateral edge of rectus muscle.

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scrotum

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Anatomy

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Pathological anatomy The hernia composed of: covering tissue: skin, subcutanous tissue hernial sac: protrusion of peritonum, neck of the sac: is narrow where the sac emerges from the abdomen body of the sac hernial contents: small intestine, major omentum

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Etiology 1. intensity of abdominal wall decreased common factors: 1) site that some tissues pass through the abdominal wall, eg. Spermatic cord, round ligament of uterus 2) bad development of abdominal white line 3) incision, trauma, infection et al. defect in collagen synthesis or turnover 2. any condition which increases intra-abdominal pressure chronic cough, chronic constipation, dysuria, ascites, pregnancy, cry

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Causes of indirect inguinal hernia 1. congenital abnormality of anatomy due to failure of fusion of the processus vaginalis peritonei after the testis has descended into the scrotum. 2. acquired weakness or defect of abdominal wall

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Clinical manifestation and diagnosis Symptoms: pain, discomfort, dragging sensation Sign: reducible or irreducible lump, expansive cough impulse Reducing the hernia fully, compress the internal ring: be controlled – indirect not controlled -- direct

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Hernia Exam

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Differential diagnosis 1 hydrocele of testis translucent test (+) 2 communicated hydrocele 3 hydrocele of cord: not reducible 4 undescended testis 5 acute intestinal obstruction

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Clinical types 1. reducible hernia is one in which the contents of the sac return to the abdomen spontaneously or with manual pressure when the patient is recumbent. 2. irreducible hernia is one whose contents or part of contents cannot be returned to the abdomen, without serious symptoms. hernias are trapped by the narrow neck Sliding hernia is one in which the wall of a viscus forms a portion of the wall of the hernia sac. It is may be colon ( on the left), cecum (on the right) or bladder (on either side). Belongs to irreducible hernia

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3. incarcerated hernia: is one whose contents cannot be returned to the abdomen, with severe symptoms. 4. strangulated hernia: denotes compromise to the blood supply of the contents of the sac. incarcerated hernia and strangulated hernia are the two stages of a pathologic course Richter’s hernia (intestinal wall hernia ) a hernia that has strangulated or incarcerated a part of the intestinal wall without compromising the lumen. Littre hernia: a hernia that has incarcerated the intestinal diverticulum (usually Meckel diverticulum). Reductive incarcerated hernia: reduction of the hernial contents ( intestine ) into abdominal cavity.

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Sliding hernia viscera forms a portion of the wall of the hernia sac

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Richter——intestinal wall Littre ——intestinal diverticulum

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incarcerated hernia: is one whose contents cannot be returned to the abdomen, with severe symptoms incarcerated hernia Reductive incarcerated hernia

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strangulated hernia: denotes compromise to the blood supply of the contents of the sac

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Indirect Hernia Route Note: The hernia sac passes outside the boundaries of Hesselbach's triangle and follows the course of the spermatic cord.

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Direct Hernia Route Note: The hernia sac passes directly through Hesselbach's triangle and may disrupt the floor of the inguinal canal.

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Differences between indirect and direct hernia

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Treatment 1. nonoperative therapy Indications: <1 year old elderly patients or with severe systemic disease--truss

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2, Specific Surgical Procedures Lichenstein (Tension Free) Repair Bassini Repair McVay (Cooper’s Ligament) Repair Shouldice (Canadian) Repair Laproscopic Hernia Repair

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Bassini Repair Is frequently used for indirect inguinal hernias and small direct hernias The conjoined tendon of the transversus abdominis and the internal oblique muscles is sutured to the inguinal ligament

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AKA: Cooper’s ligament Repair Is for the repair of large inguinal hernias, direct inguinal hernias, recurrent hernias and femoral hernias The conjoined tendon is sutured to Cooper’s ligament from the pubic cubicle laterally McVay Repair

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McVay Repair Note: This repair reconstructs the inguinal canal without using a mesh prosthesis.

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Ferguson repair Conjoint tendon Inguinal Lig Spermatic cord Ferguson Repair the anterior wall of the inguinal canal

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Shouldice Repair AKA: Canadian Repair A primary repair of the hernia defect with 4 overlapping layers of tissue. Two continuous back-and-forth sutures of permanent suture material are employed. The closure can be under tension, leading to swelling and patient discomfort.

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Lichtenstein Repair AKA: Tension-Free Repair One of the most commonly performed procedures, using prosthetic materials A mesh patch is sutured over the defect with a slit to allow passage of the spermatic cord

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Lichtenstein Repair Note: Open mesh repair. Mesh is used to reconstruct the inguinal canal. Minimal tension is used to bring tissue together.

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Laparoscopic Hernia Repair Early attempts resulted in exceptionally high reoccurrence rates Current techniques include Transabdominal preperitoneal repair (TAPP) Totally extraperitoneal approach (TEP)

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Types of Laparoscopic Inguinal Hernia Repair IPOM (IntraPeritoneal On-lay Mesh) repair. A mesh is placed intra-abdominally covering the hernia defect and then secured to the abdominal wall. Very popular at the beginning of laparoscopic experience, it has since been abandoned. TAPP  (Trans Abdominal Pre-Peritoneal) repair. With this technique, the pre-peritoneal space is accessed from the abdominal cavity and a mesh is then placed and secured. This is procedure of choice for recurrent inguinal hernias or in case of incarcerated bowel – visualized. TEP (Totally ExtraPeritoneal) repair. The mesh is again placed in the retroperitoneal space, but in this case, the space is accesed without violating the abdominal cavity. This is probably the most physiological repair although technically more demanding. The procedure of choice for bilateral inguinal hernia repairs

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Trochar placement for both TEP & TAPP

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Laparoscopic Mesh Repair Note: Viewed from inside the pelvis toward the direct and indirect sites. A broad portion of mesh is stapled to span both hernia defects. Staples are not used in proximity to neurovascular structures.

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Femoral hernia Inguinal lig. Cooper Lig. Femoral V. Femoral ring

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McVay REPAIR Direct suture OPERATION

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The incision most common for hernia: trans-rectus incision The major reason for incisional hernia : incisional infection 50% Incisional Hernia

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Poor nutritional status

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Incision hernia

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Incision hernia

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Intraperitoneal abscess

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Gross: Supra-mesocolic spaces: falciform lig. Right sub-phrenic space: suprahepatic space / infrahepatic space Left subphrenic space: - space bet. left lobe of liver & stomach - lesser sac

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Gross: Infra-mesocolic spaces: Right lateral paracolic / right medial paracolic gutter Left medial paracolic / left lateral paracolic gutter

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ANATOMY: Microscopic: Mesothelium – 1.8 m2 Mesothelial cells (cuboidal cells/flattened cells) Stomata Basement membrane Connective tissue (collagen, elastic fiber, fibroblast, adipose, endothelial cells, mass cells, machrophage). Gross: Intra-abdominal area: (intraperitoneal / retroperitoneal) Intra-peritoneal Space – defined by mesothelial membrane a. visceral peritoneum b. parietal peritoneum

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Thanks Welcome questions!