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Abdominal Wall Hernias - Coggle Diagram

- - - - Lining of the hernia typically pintoneum
    - - The defect that the hernia proturudes from
        Can be narrow or broad
    - - Eg bowel - Enterocoele
        Omentum - Omentocoele
- - - - Umbilical in neonates
        Diaphragmatic hernias
      - Through pre-formed defect
    - - Through a weakness in the abdominal wall from increased intra-abdominal pressure
  - - - Herniation within the peritoneal cavity - no visible lumb
      - Most common bariatric surgery
    - - Protrusion through the abdominal wall
  - - - Contents spontaneously return or can be returned with presurre
    - - Incarcerated
        
        Irreducible but with safe blood supply
      - Strangulated
        
        Blood supply threatened
        
        Pain
        Tenderness
        Overlying lying skin changes
      - Contents cannot be returned
- - - - Primary suture repair
    - - Mesh repair
- - - - Mx undylering risk
    - - InDX
        
        Incarceratoin / Strangulation
- - - - Superior to medial edge of inguinal ligament
    - - Males
        
        Spermatic cord
      - Female
        
        Round ligament
      - Both
        
        Lymph vessels
        
        Ilioinguinal nerve
    - - Anterior
        
        Aponeurosis of external oblique (interal oblique laterally)
      - Posterior
        
        Transversalis fascia (conjoint tenodon mediallu)
      - Roof
        
        Arching ribres of int oblique and transverse abdominis
      - Floor
        
        Inguinal ligament and lacunar ligament
    - - Rule of 3
      - 3 Arteries
        
        Testicular
        
        Artery to the Vas
        
        Cremasteric
      - 3 Nerves
        
        Genital branch of genitofemoral
        
        Sympathetic
        
        Ilio-inguinal (outside of cord)
      - 3 More
        
        Vas deferens
        
        Pampiniform plexus
        
        Lymphatics
    - - Mid Inguinal Point
        
        Location of femoral artery
        
        Midway between ASIS and pubic symphasis
      - Mid Point of Inguinal Ligament
        
        Location of deep ring
        
        Midway btween ASIS and pubic tubercle
    - - Triangle of direct inguinal hernials
      - Borders
        
        REctus abdominis
        
        Inguinal Ligament
        
        3,. Infeior epigastric
  - - - Does not typically extend to scrotum
      - Wide neck and incarceration uncommon
    - - MEdial to epigastric vessels - In Hesselbach's triangle
  - - - Can extend to scrotum
      - Oftne asymptomatic
      - Dragging sensation
      - Develops over months - years
      - Classically does not recur if redued ans asked to cough while occluding the deep ring
  - - - Reduce hernia, occlude deep ring, ask pt to cough
        
        Recurs - Direct
        
        No recurrence - Indirect
- - - - EPi
        
        No role for watchful waiting
        
        High Risk of strangulation
        
        Likely to need emergency repair
        
        40% present strangulated
      - Approach
        
        Lap
        
        McEvedy
        
        Allows for bowel resectio - more used if bowel felt to be threatened
- - - - Dynamic
      - PT can valsalva to make herni more visible
    - - Good sensitivity
      - Poor for small hernias
- - - - Removal of hernia sac only (children)
    - - HErniotomy and repair of posterior wall with suture
    - - Reinforcement of posterior wall with mesh
        Last two often used interchangeably
  - - - Specialised centres or if contamination in strangulated hernias
      - SHouldice
      - Bassini
      - MCVay
  - - - Preference
    - - Bilateral - beter lap
      - Recurrent - do the other
    - - Surgeon ability
      - Preference availabiltiy
  - - - Reflect down leaflet of laparoscopy
      - Refuce hernia and place mesh
    - - Create pre-peritoneal space
      - Reduce hernia and place mesh
- - - - Allows for bowel resectio - more used if bowel felt to be threatened
- - - - Due to inadequate healing or excessive tension
      - Occur posy op
    - - Obesity
      - Chronic cough
      - Inadequate suture technique
      - Wound infx
      - Steroids
    - - Emergency surgery high risk
      - Chemo - risk factor
    - - Neck typically larhe
      - Incarceration uncommon
      - May be asymptomatic
    - - Asymptomatic
        
        MAy be managed with binder
      - Symptomatac
        
        Complex revision and abdominal wall repair
        
        MEsh repair
  - - - Rare
    - - Linea semilunaris at the level pf the arcuate line
      - Intra-periatal hernia (between layers of abdominal wall
    - - Narrow neck
      - Often incarcerated
      - Difficult to appreciate on exam
  - - - Rare
      - Most common i 50-70 y/o age
    - - Can be asymptomatic
    - - Open or lap
  - - - Rare
      - Older cachexic women
    - - Usually present with obstruction
      - Can compress obturator nerve causing pain in anteromedial thigh (Howship-Romber sign)
  - - - COntaines Meckel's Diverticulum
    - - Inguinal hernia containing appendix
    - - Femoral hernia containing appendix
  - - - Commonly only identified at time of operation
      - ORgan may be damaged in mobilising the sac
  - - - Rare
      - High risk of strangulation and closed loop obstruction