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FIGURE 11.11. Rectal traumatic injury. (A) Plain film of the pelvis of an elderly patient in a nursing
home after traumatic insertion of a rectal thermometer shows the unusual location of multiple air collections (arrows) suggestive of rectal perforation. (B) Water-soluble contrast material is instilled
through a soft rubber catheter to define the site of rupture. The radiograph shows contrast material
in the rectum (R) and sigmoid (S), and extravasation into the perirectal area (arrowheads). (Courtesy of
Henry I. Goldberg, MD.)
M anagement of Specific I ntraabdominal Organ I njuries.................................................................... 349
FIGURE 11.12. Classification of retroperitoneal hematoma. Zone 1 hematoma is associated with pancreaticoduodenal and vascular trauma and must always be explored. Zone 2 hematoma is associated
with injury to the kidney and ascending colon and is explored selectively when either colon injury is
suspected or the hematoma is expanding. Zone 3 hematoma is usually associated with pelvic fracture
and is generally not opened. When low abdominal hematoma is not associated with pelvic fracture,
the hematoma must be explored.
vascular control should be obtained by controlling the
renal artery, or, if this is not possible, by obtaining aortic
control below the diaphragm.
3. Zone 3 retroperitoneal hematomas are often associated with pelvic fracture and, as a general rule, are not
explored. If they are expanding, angiogram is performed
to identify the site of bleeding and to obtain angiographic
control of bleeding. Retroperitoneal hematomas not associated with pelvic fracture, as seen in penetrating trauma,
however, are explored to exclude and, if present, repair
major retroperitoneal vessel injury.
REFERENCE
1. Nance FC, Wennar MH, Johnson LW, et al. Surgical judgment
in the management of penetrating wounds of the abdomen:
experience with 2212 patients. Ann Surg 1974;179:639–646.
SELECTED READINGS
Stomach and Duodenum
Harrison CR, Debas HT. Injuries of the stomach and duodenum.
Surg Clin North Am 1972;52:635–648.
Levison MA, Peterson SR,Sheldon GF, et al. Duodenal trauma: expe-
rience of a trauma center. J Trauma 1984;24:475–480.
Pancreas
Cogbill TH, Moore EE, Morris JA Jr, et al. Distal pancreatectomy for
trauma: a multicenter experience. J Trauma 1991;31:1600–1606.
Feliciano DV, Martin T, Cruse PA, et al. Management of combined
pancreaticoduodenal injuries. Ann Surg 1987;205:673–680.
Lucas CE. Diagnosis and treatment of pancreatic and duodenal
injury. Surg Clin North Am 1977;57:49–65.
Wisner DH, Wold RL, Frey CF. Diagnosis and treatment of pancre-
atic injuries. An analysis of management principles. Arch Surg
1990;125:1109–1113.
Liver
Carrillo EH, Wohltmann C, Richardson JD, et al. Evolution of the
treatment of complex blunt liver injuries. Curr Probl Surg
2001;38:1–60.
Knudson MM, Lim RC Jr, Oakes DD, et al. Nonoperative manage-
ment of blunt liver injuries in adults: the need for continued
surveillance. J Trauma 1990;30:1494–1500.
Pachter HL, Spencer FC, Hofstetter SR, et al. Significant trends in
the treatment of hepatic trauma: an experience with 411
injuries. Ann Surg 1992;215:492–502.
Yellin AE, Chaffee CB, Donovan AJ. Vascular isolation in treatment
of juxtahepatic venous injuries. Arch Surg 1971;102:566–573.
Colon and Rectum
Burch JM, Martin RR, Richardson RJ, et al. Evolution of the
treatment of injured colon in the 1980s. Arch Surg 1991;126:
979–984.
Chappuis CW, Frey DJ, Dietzen CD, et al. Management of colon
injuries: a prospective randomized trial. Ann Surg 1991;
213:492–498.
Ivatury RR, Licata J, Gunduz Y, et al. Management options in pene-
trating rectal injuries. Am Surg 1991;57:50–55.
Thomas DD, Levison MA, Dykstra BJ, et al. Management of rectal
injuries: dogma versus practice. Am Surg 1990;56:507–510.
350 ............................................................................................................................ Abdominal T rauma
........................................................................................................................................................... 351
The primary clinical significance of the abdominal wall is
herniation, which constitutes a typical surgical problem.
Peritonitis and intraabdominal abscesses also require
surgical intervention. While secondary malignancies are
common, primary tumors of the peritoneum are rare. Disorders of the retroperitoneum are far less common.
ANATOMY AND EMBRYOLOGY
The abdominal wall consists of skin, subcutaneous fascia,
and Scarpa’s fascia overlying the musculature. From superficial to deep, the muscular wall layers include the external
oblique, the internal oblique, and the transversus. The
muscles are fleshy laterally and become aponeurotic medially, where the aponeurosis fuses before separating to the
anterior and posterior fascia that invest the rectus muscles.
The anterior and posterior rectus fascia fuse in the midline
to form the linea alba (Figure 12.1). The transversus
muscle ends at the semilunar line, where the transversalis
fascia begins. The transversalis fascia extends down to the
groin.
The innermost layer of the abdomen, the peritoneum,
invests continuously all the abdominal viscera. In the male
embryo, peritoneum may project as a sac through the
processus vaginalis at the internal inguinal ring if, following testicular descent, the processus vaginalis fails to obliterate completely. An oval defect exists in the external
oblique aponeurosis just above and lateral to the pubic
tubercle—the external inguinal ring. The internal ring is a
defect in the transversalis fascia about 1 inch above the
midinguinal point, midway between the anterior superior
iliac crest and the public tubercle. The oblique space
extending from the internal ring superiorly and laterally,
and to the external ring inferiorly and medially,constitutes
the inguinal canal. The spermatic cord in men and the
round ligament in women course through the inguinal
canal, which is bounded anteriorly by the external oblique
aponeurosis, superiorly by the internal oblique and trans-
12
Abdominal Wall, Peritoneum,
and Retroperitoneum
versus abdominis aponeurosis, and inferiorly by the
inguinal and lacunar ligaments. The transversalis fascia
forms the floor (posterior wall) of the inguinal canal.
Hernias commonly form because of weaknesses in the
inguinal canal floor or in the femoral ring. The boundaries
of the femoral ring are, anteriorly, the inguinal ligament;
laterally, the femoral vein; posteriorly, the pectinius fascia,
which condenses to create Cooper’s ligament; and medially, the lacunar ligament, also known as Gimbernat’s ligament. The anatomy of inguinal hernia is summarized in
Table 12.1.
INGUINAL OR GROIN HERNIAS
Three types of inguinal or groin hernia are common: the
indirect inguinal hernia, the direct inguinal hernia and the
femoral hernia. An indirect inguinal hernia is associated
with a peritoneal sac that protrudes through the internal
ring into the inguinal canal and lies anteromedial to
the spermatic cord or round ligament. The sac and its
contents, which may include omentum or small intestine,
may protrude so extensively in men that they reach
the scrotum (scrotal hernia). Direct inguinal hernias
do not often have well-developed sacs. They are protrusions through Hesselbach’s triangle as a result of weakness
of the posterior wall of the inguinal canal. Femoral hernias
occur when a segment of the peritoneum protrudes
through the femoral ring. The sac is usually small and
has a narrow neck, allowing only a small piece of omentum
or part of the wall of the small intestine to herniate.
The sites of the three main groin hernias are shown in
Figure 12.2.
Pathogenesis
The development of a hernia requires an abdominal wall
defect and an increase in abdominal pressure.
ABDOMINAL WALL
FIGURE 12.1. (A and B) Muscles and fascia of the abdominal wall showing fusion of anterior and posterior rectus fascia in midline to form the linea alba. (Adapted from Norton, JA, ed. Basic Science and
Clinical Evidence. New York: Springer, 2001:788.)
Defect in the Abdominal Wall
A key anomaly in indirect inguinal hernia is the presence
of a hernial sac in the inguinal canal. The sac is a vestige
of the processus vaginalis, a structure important in boys
for descent of the testes from the retroperitoneum to the
scrotum. It is likely, however, that an indirect hernial sac
may develop de novo in the adult. With time, enlargement
of an indirect inguinal hernia is associated with weakness
of the posterior wall of the inguinal canal and thinning
and bulging of the transversalis fascia.
In direct inguinal hernia, the primary abnormality is
weakness of the posterior wall of the inguinal canal,
leading to a bulge through Hesselbach’s triangle. Direct
inguinal hernias typically occur in elderly men. The sac
may not be prominent, although a well-developed sac may
sometimes be encountered. Such sacs are rarely large
enough to merit excision and may be managed by pushing
TABLE 12.1. Essentials: Inguinal Hernia Anatomy
External inguinal ring: Defect in external oblique aponeurosis
Internal ring: Defect in transversalis fascia
Hesselbach’s triangle: Site of direct hernia
Boundaries
䊏
Medially: Rectus fascia
䊏
Superiorly: Inferior epigastric vessels
䊏
Inferiorly: Inguinal ligament
Relation of neck of hernia sac
䊏
Direct hernia: Medial to inferior epigastric vessels
䊏
Indirect hernia: Lateral to inferior epigastric vessels
them into the abdomen and applying a few sutures to hold
them in place.
Femoral hernia involves not only weakness of the posterior inguinal wall but also widening of the femoral ring.
A hernial sac is formed as part of the peritoneum descends
through the ring.
Increased Abdominal Pressure
Increased abdominal pressure is sometimes an acute precipitating event. The construction worker who attempts to
lift a heavy object and suddenly experiences tearing pain
in the groin is an example. More commonly, however,
increased abdominal pressure is caused by chronic cough,
constipation, or straining to urinate as a result of prostatic hypertrophy. Occasionally, constipation may be associated with development of colonic cancer.
Whenever possible, the condition of increased abdominal pressure should be improved or eliminated before
herniorrhaphy. The correction of abdominal pressure is
particularly important in prostatic hypertrophy, where
prostatectomy (transurethral or otherwise) should be performed before hernia repair.
Progression of Disease
In the early stages, the hernia bulge develops intermittently,
often associated with activities that generate sudden elevation in intraabdominal pressure. The patient experiences a
dull pain in the groin and can feel the bulge. The bulge may
either reduce spontaneously or can easily be pushed back
by the patient—the stage of reducible inguinal hernia. As
352 ........................................................................ Abdominal W all, P eritoneum, and R etroperitoneum
FIGURE 12.2. Anatomical sites of groin hernias.
time passes, the herniation may become permanent, and
the patient may be unable to reduce it—the stage of
incarcerated (irreducible) inguinal hernia. An irreducible
inguinal hernia may exist as a chronic abnormality without
serious symptoms or complications. At times, an incarcerated inguinal hernia is associated with small bowel obstruction within the hernia. In some cases, the blood supply of
the herniated structures (omentum or bowel) may become
compromised, causing an acute clinical problem—the
stage of irreducible, strangulated hernia. The wall of a
viscus may descend to form part of the hernial sac. This
type of hernia is known as sliding hernia.
Bowel obstruction or strangulation is uncommon in
direct inguinal hernia but much more common in indirect
inguinal and femoral hernias, which have a narrow neck.
The swelling in an irreducible femoral hernia is in the
groin below the inguinal ligament, just lateral to the pubis
and medial to the femoral vessels. When strangulation
develops, the swelling becomes tender. Because the
femoral ring is narrow, only a portion (usually the antimesenteric aspect) of the small intestine may become incarcerated and, when strangulated, only part of the small
intestine may become gangrenous. This type of hernia,
called Richter’s hernia, presents with a tender groin lump
below the inguinal ligament and is associated with small
bowel obstruction. The essentials of femoral hernia are
summarized in Table 12.2.
Management
Techniques Common to All Types of
Inguinal Hernia Repair
ANESTHESIA Most inguinal hernia repair is performed
on an outpatient basis, admission to hospital being
TABLE 12.2. Essentials: Femoral Hernia
Boundaries of femoral ring
䊏
Anteriorly: Inguinal ligament
䊏
Laterally: Femoral vein
䊏
Posteriorly: Pectineus fascia
䊏
Medially: Lacunar ligament
Femoral hernia
䊏
More common in women
䊏
Causes small bowel obstruction in 20%
䊏
Richter’s hernia: Strangulated femoral hernia involving
infarction of part of the small intestine wall
Treatment: McVay repair
A bdominal W all .................................................................................................................................. 353
FIGURE 12.3. Technique for administering local anesthesia in preparation for hernia repair. Effective
local anesthesia can be provided by directing the local anesthetic to points A, B, C, and D to desensitize the iliohypogastric, the genitofemoral, the ilioinguinal, and hypogastric branches of the iliohypogastric nerves, respectively. (Adapted from Flanagan L, Bascom JU. Repair of the groin hernia:
outpatient approach with local anesthesia. Surg Clin North Am, 1984;64:257–267.)
reserved only for patients who have other confounding
medical problems. Anesthesia may be general, epidural
(spinal), or local. Increasingly, hernia repair is being done
either under epidural or local anesthesia with parenteral
sedation (Figure 12.3).
NCISION The midpoint of the incision should be over
I
the internal ring, the surface marking for which is 0.5 inch
above the midinguinal point. An oblique or transverse skin
incision (6–8cm) is made and deepened to the external
oblique aponeurosis after dividing Scarpa’s fascia and
superficial veins.
PENING THE INGUINAL CANAL The external ring, a
O
defect superior and lateral to the pubic tubercle, is first
identified. The genitofemoral nerve is seen issuing from it.
The anterior wall of the inguinal canal is opened along the
fibers of the external oblique aponeurosis, taking care to
preserve the nerve. The spermatic cord is mobilized at the
pubic tubercle, encircled, and then retracted using a .25inch Penrose drain.
DENTIFYING THE HERNIA SAC An indirect hernia sac
I
is found on the anteromedial aspect of the spermatic cord.
Its apex is picked with clamps and the sac is dissected proximally to the internal ring. Its neck lies lateral to the inferior epigastric vessels. A direct hernia sac, on the other
hand, is found in Hesselbach’s triangle. The direct hernia
sac is usually not prominent but can be at times. When dissected proximally, its neck is found medial to the inferior
epigastric vessels.
XCISION OR INVERSION OF THE HERNIAL SAC All indi-
E
rect hernia sacs are opened at their apex; any omental or
bowel content is reduced into the abdomen. The neck of
the sac is closed using suture ligature flush with the peritoneum. The sac is then excised distal to the ligature.
Most direct hernia sacs are inverted, but large sacs are
excised.
Open Surgical Approaches to Hernia Repair
The major surgical approaches to inquinal hernia repair
are summarized in Table 12.3.
ASSINI REPAIR The Bassini repair, introduced in
B
1890, is a simple and effective repair. The essential element
is approximation of transversalis fascia and the internal
oblique muscle to the inguinal ligament using interrupted
sutures (Figure 12.4). Some believe that this procedure predisposes to future development of femoral hernia, although
the evidence is anecdotal.
CVAY (COOPER LIGAMENT) REPAIR The McVay
M
repair has two important components: the repair itself and
a relaxing incision. The repair is accomplished by approx-
354 ........................................................................ Abdominal W all, P eritoneum, and R etroperitoneum
TABLE 12.3. Essentials: Surgical Approaches to Inguinal
Hernia Repair
Bassini
Approximation of internal oblique, transversus abdominus and
transversalis fascia to inguinal ligament
Shouldice (modified Bassini)
䊏
Division of posterior inguinal canal and imbrication of lateral
and medial edges
䊏
Suturing of free edge of medial flap to shelving edge of
inguinal ligament
䊏
Approximation of internal oblique to inguinal ligament
McVay
Approximation of transversalis fascia to Cooper’s ligament
Lichtenstein
Tension-free repair suturing synthetic mesh to transversalis
fascia superiorly and inguinal ligament inferiorly
Preperitoneal
Approximation of transversalis fascia to inguinal ligament
imating the transversalis fascia to Cooper’s ligament
(Figure 12.5). Interrupted nonabsorbable sutures, either
2.0 or 0, are used, beginning at the public tubercle and
moving laterally. The first suture to the pubic tubercle is
important because this is a frequent site of recurrence. A
sturdy needle is used so that the fascial insertion and the
periosteum of the pubis can be incorporated.
As approximation of the transversalis fascia to
Cooper’s ligament proceeds laterally, the femoral vein is
reached. At this point, a transition stitch is required incorporating Cooper’s ligament, the femoral sheath covering
the vein and the inguinal ligament. Lateral to this point,
the transversalis fascia is approximated to the inguinal ligament. As the repair proceeds laterally, a new internal ring
is formed when the spermatic cord is reached. The new
ring should be snug but should permit introduction of the
small finger next to the cord to avoid compression of the
spermatic veins and subsequent scrotal swelling.
The second step in the McVay repair is to perform a
relaxing incision by vertical division of the anterior rectus
sheath (Figure 12.5B).
HOULDICE REPAIR The Shouldice herniorrhaphy,
S
popularized in Canada, is a modified Bassini repair (Figure
12.6) and is typically performed under local anesthesia.
ENSION-FREE HERNIORRHAPHY OF LICHTENSTEIN
T
The major concept of this repair, performed under local
anesthesia is to avoid tension at the suture line by the use
of prosthetic mesh (Figure 12.7).
REPERITONEAL (CHEATLE–HENRY) REPAIR The pre-
P
peritoneal approach was not frequently used until the
advent of laparoscopic herniorrhaphy. The preperitoneal
repair, most often indicated in bilateral hernias in which
bilateral herniorrhaphy is accomplished through a single
incision, is also an excellent technique for repair of recurrent inguinal hernia. A transverse skin incision is made
about 3cm above the inguinal ligament, and transverse
incisions are made in the rectus sheath, the external and
internal obliques, and the transversus abdominus aponeurosis. The rectus muscle is retracted medially, the transversalis fascia is incised, and the preperitoneal space is entered.
With blunt dissection, the pelvic peritoneum is separated
from the pelvic floor. Femoral and direct hernial sacs are
easily visualized and reduced. An indirect hernia sac can
also be dissected and excised using this approach.A McVaytype repair can then be performed from the back of the
transversalis fascia.
FIGURE 12.4. Bassini repair. (Adapted from Wartz GE. The operation of Bassini as described by Attilo
Catterina. Surg Gynecol Obstet 1989;168:67–80.)
A bdominal W all .................................................................................................................................. 355
A
FIGURE 12.5. McVay or Cooper repair. (A) After dissection and excision of the hernial sac, the transversalis fascia is approximated to Cooper’s ligament, beginning at the pubic tubercle and extending
laterally to the femoral vein, beyond which the transversalis fascia is approximated to the inguinal ligament. (B) Tension at the repair is avoided by making a relaxing incision, 3 to 4 inches long, in the
fusion of the external oblique and rectus fascia starting just above the pubic tubercle. (Adapted from
Wartz GE. Atlas of Hernia Surgery. Philadelphia: Lippincott Williams & Wilkins, 1991:76.)
B
COMPLICATIONS OF INGUINAL HERNIA REPAIR Com-
plications specific to inguinal herniorrhaphy may occur
early or late following the operation. Early local complications include wound infection or hematoma (1% to 2%),
scrotal and testicular swelling (7%), compression of the
femoral vein (1%), and urinary retention (up to 30%).
Scrotal swelling usually occurs when the internal ring is too
tightly closed. Acute ischemic orchitis occurs when the
spermatic cord or spermatic vessels are severed. Compression of the femoral vein is most likely to occur after McVay
(Cooper ligament) repair. The resulting complications may
include femoral thrombophlebitis or even pulmonary
embolism.
Late complications include hydrocele formation, testicular atrophy, neuroma formation, nerve entrapment of
the genitofemoral or ilioinguinal nerves, and recurrence.
A late-developing hydrocele is usually due to incomplete
excisions of the distal extension of the sac. Testicular
atrophy occurs in fewer than 2% of cases and may represent partial interruption of the blood supply during
surgery or may follow early acute testicular swelling.
Neural complications are most distressing and are not
always successfully treated. Local anesthetic blocks directly
in the region of the neuroma or nerve entrapment or
blocks of L1 and L2 (genitofemoral nerve) are sometimes
used. Some surgeons have reported success after excising
the entrapped nerve or after separating the genitofemoral
nerve proximal to the entrapment.
Laparoscopic Hernia Repair Techniques
Several randomized clinical trials have shown that
laparoscopic hernia repairs are safe and effective. The
cost is higher than for open repair, but laparoscopic
procedures are associated with less postoperative pain
and shorter recovery time for the patient. Definitive
statements comparing laparoscopic to open hernia
repair await the conclusion of a large ongoing randomized
U.S. Department of Veterans Affairs Medical Center
trial. Most surgeons agree, however, that the laparoscopic approach is preferred only in bilateral and recurrent hernias.
Three techniques have emerged as the most popular
laparoscopic procedures for inguinal hernia repair: transabdominal preperitoneal (TAPP), intraperitoneal onlay
mesh (IPOM), and totally extraperitoneal (TEP). Laparoscopic hernia repair techniques that violate the peritoneum pose risks of trocar injury to viscera and an
increased risk of adhesion formation. In the TAPP
356 ........................................................................ Abdominal W all, P eritoneum, and R etroperitoneum
A
B
FIGURE 12.6. Shouldice repair. (A) The procedure begins with complete division of the cremaster
muscle, the external spermatic artery and vein, and the inguinal branch of the genitofemoral nerve.
Then the posterior wall of the inguinal canal, including the transversalis fascia, is divided about 1 cm
above the inguinal ligament. The internal ring is destroyed, leaving the spermatic cord mobile. The
medial edge of the flap is elevated to the rectus sheath. (B) Repair is accomplished by imbricating the
lateral and medial edges in a “vest-over-pants” fashion using continuous sutures (usually 34-gauge
stainless steel), and the free edge of the medial flap is sutured to the shelving edge of the inguinal
ligament. (C) With a second suture, the aponeurosis of the internal oblique muscle is approximated to
the inguinal ligament. (Adapted from Wartz GE. Atlas of Hernia Surgery. Philadelphia: Lippincott
Williams & Wilkins, 1991:67.)
C
A bdominal W all .................................................................................................................................. 357
A
B
C
FIGURE 12.7. Lichtenstein repair. (A and B) Under local anesthesia, an appropriate patch of prosthetic
mesh is sutured to the inguinal ligament from the pubic tubercle to the internal ring, using continuous 3.0 Prolene® and Novafil® (U.S. Surgical, Norwalk, CT) sutures. A slot is made in the mesh at the
internal ring to allow emergence of the spermatic cord. (C) The superior edge of mesh is then sutured
to the rectus sheath and conjoined tendon. (Adapted from Arregui ME, Nagan RD, eds. Inguinal
Hernia: Advances or Controversies. Oxford, England: Radcliffe Medical, 1994.)
358 ........................................................................ Abdominal W all, P eritoneum, and R etroperitoneum
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