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HERNIA (FEMORAL & UMBILICAL)

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hanisahwarrior
hanisahwarrior

This document discusses femoral and umbilical hernias. It describes the anatomy of the femoral canal and ring, then covers the causes, clinical features, diagnosis, and treatment approaches for femoral hernias. It notes femoral hernias are more common in females and the right side is more affected. For treatment, it describes the low, inguinal, and high surgical approaches. It also briefly discusses umbilical hernias, noting they are more common in infants and adults with repeated pregnancies or obesity. Treatment involves surgery to repair the defect with sutures or mesh.

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FEMORAL & UMBILICAL HERNIA NUR HANISAH BINTI ZAINOREN
CONTENTS Anatomy Introduction Causes Clinical features Diagnosis Treatment
SHEATH . CANAL . RING FEMORAL
FEMORAL SHEATH
FEMORAL SHEATH
FEMORAL SHEATH
FEMORAL SHEATH
FEMORAL SHEATH
FEMORAL SHEATH
FEMORAL SHEATH
FEMORAL SHEATH
FEMORAL CANAL
FEMORAL CANAL
FEMORAL RING
FEMORAL RING BOUNDARIES ANTERIORLY
FEMORAL RING BOUNDARIES POSTERIORLY
FEMORAL RING BOUNDARIES MEDIALLY
FEMORAL RING BOUNDARIES LATERALLY
FEMORAL RING
HERNIA (FEMORAL & UMBILICAL)
HERNIA (FEMORAL & UMBILICAL)
FEMORAL RING Lymphatics Areolar tissue
HERNIA (FEMORAL & UMBILICAL)
Boundaries of femoral ring : •Superoanteriorly inguinal lig. •Inferoposteriorly  iliopectineal lig. •Medially  lacunar ligament (Gimbernat’s ligament) •Laterally  thin septum which separates femoral canal & femoral vein(silver fascia)
INTRODUCTION Protrusion of extra peritoneal tissue, peritoneum & sometimes abdominal content through the femoral canal Female: Male = 2:1 Commonly unilateral, right side are more affected Bilateral, in 15-20 %
RISK FACTORS 1. Female 2. Old ages 3. Low weight, elderly females 4. Previous h/o sutured inguinal hernia repair
CLINICAL FEATURES •Gaur sign : dilatation of superficial epigastric/ circumflex iliac veins due to compression •Right side is more commonly affected •Small swelling below the inguinal lig.  very often unnoticed •Expansile impulse is often not present  due to narrow canal •Swelling is below and lateral to pubic tubercle •Strangulation  30-80%
INGUINAL VS FEMORAL HERNIA INGUINAL FEMORAL Above and medial to the pubic tubercle Below and lateral to the pubic tubercle Above the crease of the groin Below the crease of the groin Can be reduced completely Cannot be reduced completely Cough impulse usually present Many do not have cough impulse
INVESTIGATION •No specific investigations are required •Ultrasound & CT scan •Emergency patient , small bowel obstruction usually occurs  plain X-ray
TREATMENT 3 classical approach : i. Low approach (Lockwood) below the inguinal ligament ii. Inguinal approach (Lotheissen) through inguinal canal iii. High approach (McEvedy) mainly above the inguinal canal *some cases can be managed laparoscopically
TREATMENT 1. Low approach (Lockwood) •An incision is made over 1cm below and parallel to the inguinal lig. •The sac is opened and the contents are reduced •Non-absorbable sutures are placed between inguinal ligament & iliopectineal ligament
TREATMENT 2. Inguinal approach (Lotheissen) •Transversalis fascia is opened from deep inguinal ring to pubic tubercle. •Hernia is reduced by combination of pulling from above and pushing from below. •Once reduced, neck of hernia is closed with sutures/ mesh plugs
TREATMENT 3. High Approach (McEvedy) •Horizontal incision is made in lower abdominal centered at lateral edge of rectus muscle. •Ant. Rectus sheath is incised and rectus muscle displaced medially. •Hernia is reduced and sac is opened for careful inspection of bowel. •Femoral defect then is closed with sutures/ mesh
TREATMENT 4. Laparoscopic approach •TEP andTAPP approach can be used •A standard mesh is inserted •Ideal for reducible femoral hernias, not in emergency cases nor for irreducible hernia
DIFFERENTIAL DIAGNOSIS • Direct inguinal hernia • Lymph node • Saphena varix • Lipoma • Femoral artery aneurysm • Psoas abscess • Rupture of adductor longus with haematoma
UMBILICAL HERNIA
UMBILICAL HERNIA The umbilical defect is present at birth but closes as the stump of the umbilical cord heals, usually within a week of birth This process may be delayed, leading to the development of herniation in the neonatal period The umbilical ring may also stretch and reopen in adult life
UMBILICAL HERNIA IN CHILDREN • 10% of infants, higher incidence in premature babies • Hernia appears within a few weeks of birth • Symptomless • Increases in size on crying • Classical conical shape Incidence: • Boys = Girls • Black infants (8x) >White Obstruction/strangulation are extremely uncommon in <3 years of age
TREATMENT • Conservative treatment : < 2 years, symptomless, parental reassurance • 95% will resolve spontaneously • Surgical repair : if the hernia persists > 2 years (unlikely to resolve) OPERATION • Small curved incision is made immediately below the umbilicus • Neck of the sac is defined, opened and any contents are returned to the peritoneal cavity • Sac is closed and redundant sac is excised • The defect in linea alba is closed with interrupted sutures.
UMBILICAL HERNIA IN ADULT Reopening of umbilical defect caused by conditions that cause thinning and stretching of midline raphe (linea alba) Repeated pregnancies  weaken abdominal wall  Obesity  flabby abdominal muscle  Ascites, especially in cirrhotic patients Defect in median raphe is immediately adjacent to true umbilicus (usually above)  PARAUMBILICAL HERNIA
UMBILICAL HERNIA IN ADULT •Round with well defined fibrous margin. •Contents Small umbilical hernia often contain extraperitoneal fat or omentum Larger hernia contain small or large bowel Very large hernia have narrow neck of the sac  prone to become irreducible, obstructed and strangulated.
UMBILICAL HERNIA IN ADULT Clinical features • Swelling in the umbilical region - increase on coughing/straining • Cough impulse  expansile impulse is present • Patient may also have inguinal hernia • Reducibility can be present • Crescent-shaped appearance of the umbilicus • Patient complaint of pain due to tissue tension, and symptom of intermittent bowel obstruction • Dermatitis in case of large hernia (due to thinned & stretched of overlying skin)
UMBILICAL HERNIA IN ADULT Treatment • Operation  hernia that contain bowel (higher risk of strangulation) • Small hernia is left alone if it is asymptomatic (but may enlarge and require surgery at a later date) • Reduction of weight *Surgery may be performed open or laparoscopically
OPEN UMBILICAL HERNIA REPAIR Very small defects < 1 cm • Closed with a simple figure-of-eight suture • Repaired by darn technique where a non-absorbable, monofilament suture is criss-crossed across the defect and anchored firmly to the fascia all around
OPEN UMBILICAL HERNIA REPAIR Defects up to 2 cm • Sutured primarily with minimal tension • Classical repair by Mayo : • A transverse incision is made and the hernia sac is dissected, opened and its content reduced • Any non viable tissue is removed • The peritoneum is closed • The defect in the anterior rectus sheath is extended laterally on both sides and elevated to create an upper and lower flap (double breasted)
OPEN UMBILICAL HERNIA REPAIR Defects > 2 cm • Mesh repair; mesh is placed in one of the several anatomical planes • Within the peritoneal cavity • In the retromuscular space • In the extraperitoneal space • In the subcutaneous plane
LAPAROSCOPIC UMBILICAL HERNIA REPAIR • 3 ports are placed laterally on the abdominal wall • The contents of the hernia are reduced by traction and external pressure • A disc of non-adherent mesh, is introduced and positioned on the under surface of the abdominal wall, centered on the defect • It is then fixed to the peritoneum and posterior rectus sheaths using staples, tacks or sutures
REFERENCES • Short Practice of Surgery, Bailey & Love’s, 26th Edition • Manipal Manual of Surgery,K Rajagopal Shenoy, 4th edition • https://www.youtube.com/watch?v=NMXdU4UIu9Y
THANKYOU

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HERNIA (FEMORAL & UMBILICAL)

  • 1. FEMORAL & UMBILICAL HERNIA NUR HANISAH BINTI ZAINOREN
  • 3. SHEATH . CANAL . RING FEMORAL
  • 24. Boundaries of femoral ring : •Superoanteriorly inguinal lig. •Inferoposteriorly  iliopectineal lig. •Medially  lacunar ligament (Gimbernat’s ligament) •Laterally  thin septum which separates femoral canal & femoral vein(silver fascia)
  • 25. INTRODUCTION Protrusion of extra peritoneal tissue, peritoneum & sometimes abdominal content through the femoral canal Female: Male = 2:1 Commonly unilateral, right side are more affected Bilateral, in 15-20 %
  • 26. RISK FACTORS 1. Female 2. Old ages 3. Low weight, elderly females 4. Previous h/o sutured inguinal hernia repair
  • 27. CLINICAL FEATURES •Gaur sign : dilatation of superficial epigastric/ circumflex iliac veins due to compression •Right side is more commonly affected •Small swelling below the inguinal lig.  very often unnoticed •Expansile impulse is often not present  due to narrow canal •Swelling is below and lateral to pubic tubercle •Strangulation  30-80%
  • 28. INGUINAL VS FEMORAL HERNIA INGUINAL FEMORAL Above and medial to the pubic tubercle Below and lateral to the pubic tubercle Above the crease of the groin Below the crease of the groin Can be reduced completely Cannot be reduced completely Cough impulse usually present Many do not have cough impulse
  • 29. INVESTIGATION •No specific investigations are required •Ultrasound & CT scan •Emergency patient , small bowel obstruction usually occurs  plain X-ray
  • 30. TREATMENT 3 classical approach : i. Low approach (Lockwood) below the inguinal ligament ii. Inguinal approach (Lotheissen) through inguinal canal iii. High approach (McEvedy) mainly above the inguinal canal *some cases can be managed laparoscopically
  • 31. TREATMENT 1. Low approach (Lockwood) •An incision is made over 1cm below and parallel to the inguinal lig. •The sac is opened and the contents are reduced •Non-absorbable sutures are placed between inguinal ligament & iliopectineal ligament
  • 32. TREATMENT 2. Inguinal approach (Lotheissen) •Transversalis fascia is opened from deep inguinal ring to pubic tubercle. •Hernia is reduced by combination of pulling from above and pushing from below. •Once reduced, neck of hernia is closed with sutures/ mesh plugs
  • 33. TREATMENT 3. High Approach (McEvedy) •Horizontal incision is made in lower abdominal centered at lateral edge of rectus muscle. •Ant. Rectus sheath is incised and rectus muscle displaced medially. •Hernia is reduced and sac is opened for careful inspection of bowel. •Femoral defect then is closed with sutures/ mesh
  • 34. TREATMENT 4. Laparoscopic approach •TEP andTAPP approach can be used •A standard mesh is inserted •Ideal for reducible femoral hernias, not in emergency cases nor for irreducible hernia
  • 35. DIFFERENTIAL DIAGNOSIS • Direct inguinal hernia • Lymph node • Saphena varix • Lipoma • Femoral artery aneurysm • Psoas abscess • Rupture of adductor longus with haematoma
  • 37. UMBILICAL HERNIA The umbilical defect is present at birth but closes as the stump of the umbilical cord heals, usually within a week of birth This process may be delayed, leading to the development of herniation in the neonatal period The umbilical ring may also stretch and reopen in adult life
  • 38. UMBILICAL HERNIA IN CHILDREN • 10% of infants, higher incidence in premature babies • Hernia appears within a few weeks of birth • Symptomless • Increases in size on crying • Classical conical shape Incidence: • Boys = Girls • Black infants (8x) >White Obstruction/strangulation are extremely uncommon in <3 years of age
  • 39. TREATMENT • Conservative treatment : < 2 years, symptomless, parental reassurance • 95% will resolve spontaneously • Surgical repair : if the hernia persists > 2 years (unlikely to resolve) OPERATION • Small curved incision is made immediately below the umbilicus • Neck of the sac is defined, opened and any contents are returned to the peritoneal cavity • Sac is closed and redundant sac is excised • The defect in linea alba is closed with interrupted sutures.
  • 40. UMBILICAL HERNIA IN ADULT Reopening of umbilical defect caused by conditions that cause thinning and stretching of midline raphe (linea alba) Repeated pregnancies  weaken abdominal wall  Obesity  flabby abdominal muscle  Ascites, especially in cirrhotic patients Defect in median raphe is immediately adjacent to true umbilicus (usually above)  PARAUMBILICAL HERNIA
  • 41. UMBILICAL HERNIA IN ADULT •Round with well defined fibrous margin. •Contents Small umbilical hernia often contain extraperitoneal fat or omentum Larger hernia contain small or large bowel Very large hernia have narrow neck of the sac  prone to become irreducible, obstructed and strangulated.
  • 42. UMBILICAL HERNIA IN ADULT Clinical features • Swelling in the umbilical region - increase on coughing/straining • Cough impulse  expansile impulse is present • Patient may also have inguinal hernia • Reducibility can be present • Crescent-shaped appearance of the umbilicus • Patient complaint of pain due to tissue tension, and symptom of intermittent bowel obstruction • Dermatitis in case of large hernia (due to thinned & stretched of overlying skin)
  • 43. UMBILICAL HERNIA IN ADULT Treatment • Operation  hernia that contain bowel (higher risk of strangulation) • Small hernia is left alone if it is asymptomatic (but may enlarge and require surgery at a later date) • Reduction of weight *Surgery may be performed open or laparoscopically
  • 44. OPEN UMBILICAL HERNIA REPAIR Very small defects < 1 cm • Closed with a simple figure-of-eight suture • Repaired by darn technique where a non-absorbable, monofilament suture is criss-crossed across the defect and anchored firmly to the fascia all around
  • 45. OPEN UMBILICAL HERNIA REPAIR Defects up to 2 cm • Sutured primarily with minimal tension • Classical repair by Mayo : • A transverse incision is made and the hernia sac is dissected, opened and its content reduced • Any non viable tissue is removed • The peritoneum is closed • The defect in the anterior rectus sheath is extended laterally on both sides and elevated to create an upper and lower flap (double breasted)
  • 46. OPEN UMBILICAL HERNIA REPAIR Defects > 2 cm • Mesh repair; mesh is placed in one of the several anatomical planes • Within the peritoneal cavity • In the retromuscular space • In the extraperitoneal space • In the subcutaneous plane
  • 47. LAPAROSCOPIC UMBILICAL HERNIA REPAIR • 3 ports are placed laterally on the abdominal wall • The contents of the hernia are reduced by traction and external pressure • A disc of non-adherent mesh, is introduced and positioned on the under surface of the abdominal wall, centered on the defect • It is then fixed to the peritoneum and posterior rectus sheaths using staples, tacks or sutures
  • 48. REFERENCES • Short Practice of Surgery, Bailey & Love’s, 26th Edition • Manipal Manual of Surgery,K Rajagopal Shenoy, 4th edition • https://www.youtube.com/watch?v=NMXdU4UIu9Y

Editor's Notes

  • #15: Base or Upper end of the femoral canal is also known as femoral ring
  • #24: Femoral canal extends from femoral ring to the saphenous ring It is 1 ½ inches below & lateral to pubic tubercle
  • #26: Female has larger pelvis  larger femoral canal  risk of hernia
  • #28: Female has larger pelvis  larger femoral canal  risk of hernia Old ages  femoral defect increases
  • #44: Crescent-shaped appearance of the umbilicus due to bulging of hernia slightly to one side of umbilical depression