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CHAPTER 9 Abdominal wall
342
Umbilical and epigastric hernias
Key facts
These hernias are sometimes referred to collectively as ventral hernias.
• Umbilical hernias can be divided into:
True umbilical hernias• . Occur through the umbilical cicatrix and
are almost always congenital in origin; those present at birth may
close spontaneously before the age of 3; more common in AfroCaribbean races.
Paraumbilical hernias• . Occur through the periumbilical tissues and
are always acquired; common in obese and parous women.
• Epigastric hernias are defects in the linea alba somewhere between the
xiphisternum and umbilicus at sites of penetration of the linea alba by
nerves and vessels; they may be small or extensive.
Clinical features
Umbilical hernia
• Small, centrally placed within the umbilicus.
• Often contains pre-peritoneal fat and rarely contains bowel/omentum.
• May be painful, but rarely strangulates.
Paraumbilical hernia
• Variable in size, up to moderate.
• Paced eccentrically and distorts the shape of the umbilicus.
• May contain bowel or omentum.
• Often painful and occasionally strangulate.
Epigastric hernia
• Variable, up to large defects.
• Always placed in the midline although when large, may lie to one side.
• Most frequently contains only pre-peritoneal fat.
• Moderate risk of strangulation.
Diagnosis and investigations The diagnosis is rarely in doubt. If there
is concern that a palpable lump may be a lipoma or subcutaneous tissue
growth, then a CT scan can usually confi rm the diagnosis.
Treatment
• Congenital umbilical hernias should only be repaired if they persist
beyond the age of 2–3y.
• Surgical repair is offered for symptomatic hernias or those with a high
risk of complications.
Principles of repair
• Identify edges of hernial sac and reduce hernia.
• Small defects are usually repaired by an overlapping sutured repair
using non-absorbable suture, e.g. 0 Prolene, without reinforcements;
larger defects or recurrent hernias may be repaired with mesh (usually
polypropylene-based, e.g. Prolene).
• Laparoscopic repair is increasingly being used.
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CHAPTER 9 Abdominal wall
344
Incisional hernias
Key facts
• Incisional hernias are very uncommon outside the abdomen.
• Up to 10% of midline laparotomy wounds suffer herniation to some
degree. Factors that predispose to incisional herniation include:
Wound infection.•
Steroid use, anaemia, or malnutrition at the time of original surgery.•
Incisional hernias are probably slightly less common after muscle •
splitting or transverse incisions, compared to midline laparotomies.
Poor surgical techniques in abdominal closure increase the risk.•
• The peak time of presentation is up to 5y after surgery.
Pathological features
The hernia occurs through the tissues in which the incision is made.
Typically, the sac is made up of peritoneum, eventrated scar tissue, and
subcutaneous scar tissue.
Clinical features
• The hernia may vary from a few cm to a near complete defect in the
anterior abdominal wall through which all the mobile viscera regularly
protrude.
• The risk of strangulation is maximal in small- to medium-sized defects.
In large and very large defects, the viscera are often permanently herniated and if this has been the case for a long period, they ‘lose the right of
abode’ within the true abdominal cavity. This means that the remaining
lateral abdominal wall tissues chronically retract and there may be insuffi cient room for all the viscera within the revised abdominal cavity when
the tissues are re-approximated.
Diagnosis and investigations
When assessing incisional hernias, ask yourself the following.
• What is the risk of complications/strangulation?
• Is it likely that the contents of the hernia can be reduced fully?
• Is the patient able to undergo the anaesthesia necessary for the
surgery required?
• Is there a risk of compromise to respiratory function if a very large
incisional hernia is reduced and repaired?
Treatment
• Small defects (<4cm). Simple sutured repair.
• Medium and large defects (>4cm). A mesh is placed between the
posterior rectus sheath and the rectus muscle fi bres. If below the
umbilicus, the mesh is placed in the pre-peritoneal space. After the
mesh is fi xated, the anterior rectus sheath is closed.
• Laparoscopic repair is increasingly being used. The use of an
‘underlay’ intraperitoneal mesh enhances the repair, but also
creates the potential for bowel adhesions or fi stula formation.
INCISIONAL HERNIAS
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Polytetrafl uoroethylene (PTEF) mesh is recommended to reduce
adhesive complications.
• Unfi t patients or patients unwilling to have surgery. A custom-made
support corset is often useful.
345
CHAPTER 9 Abdominal wall
346
Other types of hernia
These types are rare, but clinically signifi cant.
Spigelian
• Occurs under the lower edge of the linea semilunaris and protrudes
along the lateral border of the rectus sheath.
• Typically diffi cult to diagnose in the supine position.
• Ultrasound and CT scan may help to confi rm the diagnosis.
• Has a high risk of complications.
• Repair is via direct sutured repair of the rectus sheath.
Obturator
• Occurs through the obturator canal from the lateral wall of the pelvis
with the sac protruding into the medial upper thigh.
• Symptoms include pain or abnormal sensations in the distribution of
the obturator nerve in the skin of the inner medial thigh.
• Diagnosis is often very diffi cult and is usually made by CT scan.
• A high proportion present with complications of bowel obstruction
due to the sac being hidden within the adductor muscles
compartment.
• The neck is narrow and prone to strangulation.
• Repair can be via exposure of the sac in the medial thigh or, more
commonly, at laparotomy for complications.
Lumbar
• Occurs through either the inferior or superior lumbar triangles
(bounded by the lumbar muscles, lumbosacral fascia, and bony features
of the posterior abdominal wall) or, rarely, through lumbar incisions.
• Usually contain retroperitoneal fat and rarely bowel.
• May be repaired by direct suture or mesh repair for larger defects.
Perineal
• Spontaneous perineal hernias occur through the greater or lesser
sciatic foramina and are exceptionally rare.
• Present with acute complications and are diagnosed only at surgery.
• Post-operative perineal hernias occur through the pelvic fl oor muscles
and do so usually as a result of surgical procedures (particularly after
abdominoperineal resection of the rectum).
• Repair may be via sutured closure of the defect or, more commonly,
fi lling of the defect with prosthetic material (mesh) or biological tissue
(muscle fl ap).
Sliding
• The sac is formed partly by a retroperitoneal structure.
• It is thought that the structure slides down the canal pulling its
overlying peritoneum with it hence the name ‘hernia-en-glissade’.
Littre’s hernia The hernia sac contains a Meckel’s diverticulum.
Richter’s hernia Only part of the circumference of the bowel is
strangulated.
RECTUS SHEATH HAEMATOMA
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Rectus sheath haematoma
Key facts
Result from haemorrhage from any of the vascular network within the
rectus sheath that is formed by terminal branches of the superior and
inferior epigastric arteries.
Clinical features
• Presents with a sudden localized abdominal pain ± a tender mass.
• A history of major or minor blunt trauma may be elicited.
• Some patients report events that cause sudden contraction of the
rectus muscle, such as coughing, sneezing, or any vigorous physical
activity; it may also develop spontaneously in anticoagulated patients.
• Pain typically increases with contraction of the rectus muscles and a
tender mass may be palpated and remains unchanged when the rectus
muscle is contracted.
Diagnosis and investigations
• Can be confused with conditions that present with unilateral
abdominal pain like appendicitis.
• Hb level and coagulation profi le should be checked.
• Ultrasonography may help in the diagnosis; CT is diagnostic.
Treatment
• Small and stable haematomas may be observed without patient
hospitalization.
• Bilateral or large haematomas need hospitalization; blood transfusion
and reversal of coagulation may be needed.
• Angiographic embolization is required infrequently, but may be
necessary in case of haematoma enlargement, free bleeding, or clinical
deterioration.
• Surgical ligation of bleeding vessels is indicated if angiographic
treatment fails or the patient becomes haemodynamic unstable.
347
CHAPTER 9 Abdominal wall
348
Groin disruption
Key facts
• Also called ‘Gilmore’s groin’ or ‘sports hernia’ (although hernia is
rarely present).
• An overuse syndrome that results in muscular imbalances of the pelvis
and abdominal wall muscles.
• Common in male athletes, especially in sports that require repetitive
twisting and turning at high speeds (e.g. soccer, tennis, ice hockey).
Pathological features
It has distinctive features that include a torn external oblique aponeurosis,
a torn conjoined tendon, a dilated superfi cial inguinal ring, and a dehiscence between inguinal ligament and conjoined tendon.
Clinical features
• Unilateral groin pain that is often insidious and gradually worsens and
is felt ‘deep’ in the groin area.
• Some patients may identify a distinct provocative event like kicking or
a sudden change in direction while playing.
• Pain is almost always absent at rest.
• Physical fi ndings are non-specifi c. The external inguinal ring may be
dilated and tender. Valsalva manoeuvres and resisted adduction may
elicit pain and are useful provocative tests.
Diagnosis and investigations
• The differential diagnosis includes osteitis pubis, adductor
tendinopathy, and pubic instability or fracture.
• Radiographic fi ndings are usually normal, but helpful in ruling out other
conditions. Therefore, it is a clinical diagnosis that is confi rmed intraoperatively.
Treatment
• These patients are managed conservatively initially due to the diffi culty
in making a diagnosis.
• If symptoms persist, surgical repair is indicated and should be carried
out by a surgeon who is experienced in managing groin disruption.
• Mesh reinforcement is often utilized during the repair.
• This is followed by 2–4-week rehabilitation programme.
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CHAPTER 9 Abdominal wall
350350
Acute groin swelling
Causes of chronic testicular swelling are discussed on b p. 366.
Causes and features
• Incarcerated groin hernia (inguinal or femoral). May or may not be
associated with intestinal obstruction; often red, hot, and tender.
• Acute epididymo-orchitis (in males). Tenderness is particularly over the
spermatic cord and the epididymis.
• Torsion of the testis. May present with pain in the groin, but unless the
testicle is undescended, the tenderness is primarily over the scrotum
(and testis). Testicle is tender, swollen, and high riding. Elevation of the
scrotum, unlike epididymitis, makes the pain worse.
• Iliopsoas abscess. Tenderness primarily below the inguinal ligament;
may be fl uctuant, associated tenderness in the RIF due to underlying
pathology.
• Acute iliofemoral lymphadenopathy (e.g. from infected toenail). Tender
diffuse swelling; often multiple palpable lumps (nodes).
• Acute saphena varix. Compressible, cough thrill.
• Acute complications of femoral artery aneurysm.
Emergency management
Resuscitation
• Establish IV access; consider giving crystalloid fl uid if there is a
suspicion of a complicated hernia or an iliopsoas abscess.
• Catheterize and place on a fl uid balance chart if hypotensive.
• Send blood for FBC (Hb, WCC), U&E (Na, K).
• Group and save and clotting if arterial disease or abscess formation is
suspected.
Establish a diagnosis
2 Torsion of the testis is a true surgical emergency and should not wait
for a diagnosis short of exploration.
Colour fl ow Doppler assessment may be able to confi rm the presence
of a hyperaemic testis, but unless it is immediately available, it should not
delay operation.
2 If there is a strong clinical history in a young male, immediate operation
remains the diagnostic investigation of choice.
• If an iliopsoas abscess is suspected, abdominopelvic CT scanning is the
investigation of choice.
• Rigid sigmoidoscopy and biopsy only if not unstable.
• Flexible endoscopy may be indicated, but carries a risk of perforation.
Defi nitive management
Incarcerated groin hernia
• Repair is indicated for all patients except those considered unfi t for
any surgical procedure or those declining treatment.
• It may not be possible to establish if the hernia is inguinal or femoral
preoperatively; if so, it is safest to approach as if for an inguinal hernia.
ACUTE GROIN SWELLING
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• Femoral hernias may be approached via an infrainguinal or transinguinal
dissection (see b p. 342).
Infrainguinal approaches may be limited in exposure if there is •
necrotic bowel within the hernia requiring resection.
A transinguinal approach will involve repair of the inguinal canal as •
well, but offers an almost unlimited exposure of the femoral canal
from above and allows plenty of exposure for bowel resection.
• Inguinal hernias should be approached through a conventional incision.
Repair may require a mesh although there is an increased risk of
infection if there is an associated bowel resection.
• Anaesthesia may be general or local with sedation.
Psoas abscess The underlying cause should be identifi ed as a matter or
priority. Incision and drainage of the groin collection may be indicated, but
only as part of the overall treatment.
Torsion of the testis
• Once identifi ed, the affected testis should assessed; if non-viable, a
simple orchidectomy is performed and if viable, an orchidopexy.
• If the diagnosis is confi rmed, the contralateral testicle should be fi xed
by orchidopexy to prevent subsequent torsion.
Epididymo-orchitis Antibiotics PO (e.g. ciprofl oxacin 500mg od) for 14 days
or IV if severe.
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