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III. Femoral hernias occur below the inguinal ligament and go into the
femoral canal. About 75% of all abdominal hernias are inguinal.
IV. Incisional hernias comprise another 10 to 15%. Femoral and
unusual hernias account for the remaining 10 to 15%.
Burst abdomen and incisional hernia:
Burst abdomen, (wound dehiscence) it is disruption of an abdominal
wound and extruding of viscera, usually in the between 6th and 8th
post operative days.
- Incisional hernia: it is partial disruption of the deeper layers of a
laparotomy wound with intact skin wound, usually symptomless,
and can occur in the immediate or early postoperative period.
Huge incisional hernia.
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B. Classification of hernias according reducibility:
Strangulated hernias are ischemic from physical constriction of their
blood supply. Gangrene, perforation, and peritonitis may develop.
Incarcerated and strangulated hernias cannot be reduced manually.
1. Reducible hernia: It is the hernia which reduce spontaneously
when patient lie down or it can be reduced by patient or surgeon,
and it reappear when patient strain or cough or stand, it has
positive expansile cough impulse.
2. Irreducible hernia: The content of the hernia cannot be returned to
the abdomen, but no evidence of intestinal obstruction, it is usually
due to adhesions between sac and its contents (omentocele).
3. Obstructed hernia: It is irreducible hernia containing bowel which
is obstructed from within or without but there is no interference to
the blood supply of the bowel, patient present clinically with
symptoms and signs of intestinal obstruction with tenderness over
the hernia. There is no clear clinical distinction between obstruction
and strangulation, and it is safer to deal with any obstructed hernia
as a strangulated hernia and treat accordingly. Incarcerated hernia:
term used when the part of the colon involved in the hernia sac is
loaded with stool.
4. Strangulated hernia: it is the hernia in which the content of the sac
is ischemic due to impairment of its blood supply, gangrene may
occur 6 hours after the onset of the symptoms. Femoral hernia is
more likely to strangulate because of its narrow neck and rigid
bounders of the femoral canal. Unless the strangulation is relieved
by surgery, gangrene will appear on the ring of constriction (the
neck of the sac), and then on the antimesentric border of the bowel,
perforation of the bowel wall will occur leading to peritonitis which
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will spread from the sac to the peritoneal cavity. Clinically, patient
will present with sudden pain at the site of the hernia followed by
generalized colicky abdominal pain mainly around umbilicus,
followed by nausea and vomiting, locally the hernia will be tense,
enlarged in size, extremely tender, irreducible with negative cough
impulse. Unless the strangulation is relieved the pain will cease
because of ileus and perforation.
Etiological factors:
1- Technique of closure:
a- Material of closure: higher incidence with the use of catgut sutures
b- Method of closure: incidence is less with interrupted sutures,
and less with two layers closure technique
c- Drainage: incidence is more when drain is directly placed through
the wound.
2- Type of incision: midline and vertical incisions have a higher
incidence than the transverse incisions .
3- Indication of operation: incidence is more in operations for
peritonitis, as deep wound infection is strong aetiological factor,
operations of the pancreas because of enzyme leakage.
4- Postoperative factors: vigorous cough during extubation, or because
of postoperative pulmonary complication, postoperative vomiting
due to any cause, abdominal distension due to postoperative ileus
is important aetiological factors.
5- Factors related to the patient general condition: Obesity, anaemia,
hypoproteinaemia due to any reason, malignant disease, steroids,
cytotoxic drug therapy, uraemia, diabetes mellitus.
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Symptoms and Signs
Left side incisional hernia.
Most patients complain only of a visible bulge, which may cause
vague discomfort or be asymptomatic. Most hernias, even large ones,
can be manually reduced with persistent gentle pressure; placing the
patient in the Trendelenburg position may help. An incarcerated hernia
cannot be reduced but has no additional symptoms. A strangulated
hernia causes steady, gradually increasing pain, typically with nausea
and vomiting. The hernia itself is tender, and the overlying skin may
be erythematous; peritonitis may develop depending on location, with
diffuse tenderness, guarding, and rebound.
* Diagnosis
Clinical evaluation
The diagnosis is clinical. Because the hernia may be apparent only when
abdominal pressure is increased, the patient should be examined in a
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standing position. If no hernia is palpable, the patient should cough or
perform a Valsalva maneuver as the examiner palpates the abdominal
wall. Examination focuses on the umbilicus, the inguinal area (with a
finger in the inguinal canal in males), the femoral triangle, and any
incisions that are present. Inguinal masses that resemble hernias may
be the result of adenopathy (infectious or malignant), an ectopic testis,
or lipoma. These masses are solid and are not reducible. A scrotal
mass may be a varicocele, hydrocele, or testicular tumor. Ultrasound
may be done if physical examination is equivocal.
* Prognosis
Congenital umbilical hernias rarely strangulate and are not treated;
most resolve spontaneously within the first or second year. Very large
defects may be repaired electively after age 2 years. Umbilical hernias
in adults cause cosmetic concerns and can be electively repaired;
strangulation and incarceration are unusual but, if happen, usually
contain omentum rather than intestine.
* Treatment
Surgical repair
Groin hernias should be repaired electively because of the risk of
strangulation, which results in higher morbidity (and possible mortality
in elderly patients). Repair may be through a standard incision or
laparoscopically. An incarcerated or strangulated hernia of any kind
requires urgent surgical repair.
Treatment of indirect inguinal hernia;.
Surgical intervention is the treatment of choice, local, epidural, spinal,
or general anasthesia can be used. In infants and adolescents heniotomy
which consist of dissecting out and opening the sac, reducing the
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content, transfixation of the neck then excision of the sac, is sufficient
and there is no need to open the canal, because the superficial and deep
rings are superimposed.
In adults: the operation consists of herniotomy and hernial repair
(herniorrhaphy) which includes in addition to excision of the sac repair
of the stretched deep ring and transversalis facia and reinforcement of
the posterior wall of the canal.
Many techniques are used to achieve better results with minimal rate
of complications especially the recurrence of the hernia:
I. Bassini`s repair
II. Shouldice repair
III. Lichtenstein repair: tension free technique in which synthetic
mesh is implanted to reinforce the posterior wall.
IV. Laparoscopic hernial repair are now standardized, two technique
are used, in which the sac is mobilized and dissected out from the
sac and a prolene mesh is implanted in the extraperitoneal space
posterior to the fascia transversalis to reinforce it:
V. TAPP: Trans Abdominal Pre Peritoneal approach
VI. TEP: Totally Extra Peritoneal approach
- Treatment of direct inguinal hernia: same like the indirect type
except that the sac is not always excised but simple inversion is
enough, otherwise the techniques for the repair are the same.
Complications of inguinal hernia repair:
A. Local:
1. Wound infection
2. Haematoma
3. Wound sinus: especially if a prosthetic mesh is used.
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4. Lymphocele
5. Injury of the spermatic cord (the most important is the vas
difference).
6. Testicular ischemia and subsequent testicular atrophy
7. Hydrocele
8. Parasthesia and pain due to nerve entrapment
9. Recurrence:especially after repair without mesh implant, and wound
infection
B. General:
1.Urine retention: mostly due to postoperative pain
2.Respiratory complications
3.Thromboembolic complications
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Vascular Injury
Vascular injury presents major problems to clinicians when dealing
and looking after trauma patients as an immediate and emergency
management of life-threatening injuries. 90 % 0f vascular injuries
result from penetrating trauma. Vascular injuries from blunt trauma
may result from road traffic accidents or complicated fractures.
Blunt trauma to major vessels could cause life-threatening hemorrhage.
Seatbelt injuries could cause circumferential tears in the intima of the
abdominal aorta. Intimal tears can lead to thrombosis of arteries with
devastating consequences. Iatrogenic causes of vascular injuries
include tight plaster of Paris splints and inadvertent intra-arterial
injections or during injection of varicose veins. Vascular injury requires
prompt diagnosis and treatment to save life or limb.
TYPES OF INJURIES.
Vascular injuries may result from punctures, contusions, lacerations or
transections.
Punctures and lacerations of vessels usually continue to bleed and
therefore must be managed immediately. Transection vessel injury
could stop bleeding because of vessel retraction. Contusions may lead
to occlusion of a vessel due to intimal dissection flaps.
Varicose injuries may result from penetrating trauma or the vein may
be compressed by surrounding haematoma or soft tissue swelling.
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ASSESSMENT OF THE PATIENT.
The essential first steps in the management of vascular trauma are to
avoid delay in diagnosis and to intervene early. This could prevent
problems associated with massive transfusions or prolonged tissue
ischemia. The accurate diagnosis depends on careful history taking
and detailed clinical examination with particular attention to the
pulses in the area of the vascular injury.
The examination of traumatized patients must be meticulous. The
repeated and frequent assessment of peripheral pulses is very important
as well as temperature, colour, capillary and venous return of the injured
limbs.
In the majority of vascular injury cases Doppler ultrasound is very
helpful. Angiography is sometimes needed.
PRINCIPLES OF MANAGEMENT.
1- Control bleeding by direct pressure.
2- Relieve shock by resuscitation measurements.
3- Evaluate the peripheral circulation (Ischemia, impaired circulation).
4- Formally explore puncture wounds with wide exposure of the
vessels proximally and distally. And primary closure of punctures
and clean lacerations.
5- Excision and reconstruction of ragged lacerations and intimal flap
with venous patch or excision and anastomosis.
6- Reduce fractures and dislocations.
INDICATIONS FOR SURGERY.
Surgical intervention is often indicated in cases of vascular traumas.
Immediate surgery is indicated if:
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1- There are signs of vascular insufficiency.
2- There is continuing bleeding.
3- There is an expanding haematoma.
4- There is a vascular bruit.
COMPLICATIONS OF VASCULAR TRAUMAS.
A. Early complications.
1- Haemorrhage.
2- Thrombosis.
3- False aneurysm.
B. Late complications.
1- Secondary haemorrhage.
2- Arterio-venous fistula.
3- False aneurysm.
4- Vascular insufficiency.
5- Ischemic muscle contracture.
I. THE NECK.
The most common vascular problems in the neck are trauma to the
carotid artery or jugular vein, as a result of stab wound injury or
laceration from accidents with broken glass. Adequate local pressure
would usually control the bleeding with parallel resuscitation and
continuous clinical assessment and neurological examination. Patients
with haemorrhage from the neck should never have their wounds
explored under local anaesthesia. General anaesthesia with intubation
and ventilation is essential. Surgically the first priority is to obtain
control of the internal jugular vein and the common carotid artery in
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