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HERNIORRHAPHY— This means repair of the posterior wall of the inguinal canal in addition to a herniotomy operation.
The steps of operation are same as herniotomy up to the excision of the sac.
Before proceeding for repair of the posterior wall, it is often advised to plicate the fascia transversalis to narrow the deep inguinal ring which often becomes stretched due to presence of indirect hernia. Three vertical interrupted sutures are applied on the fascia transversalis picking up two points giving a gap of V, inch in between. The most lateral colour and peristalsis also indicate returning of viability.
When the involved bowel is viable, it should be pushed into the peritoneal cavity. The sac is ligated at the neck and excised and the operation is concluded as hemiorrhaphy as described above. No form ofhemioplasty should be tried.
If the bowel is non-viable.— (i) A linear patch of gangrene at the constriction ring is best treated by invaginating it by means of Lembert's sutures, (ii) When the whole loop of the small intestine is gangrenous, further procedure will depend upon the general condition of the patient; If the condition of the patient permits and if the bowel above the strangulation is not much distended, resection and end to-end anastomosis should be performed then and there. If on the contrary the general condition of the patient is poor and the anaesthetist is disagreeable and the bowel above the strangulation is grossly distended, it is better to exteriorize the bowel. Restoration of continuity should be attempted as soon as the patient becomes fit. (iii) If the non-viable bowel is the large intestine, the best procedure will be exteriorization to be followed by resection (Paul-Mikulicz's operation), (iv) When the omentum is strangulated, the healthy portion above should be transfixed and the affected part is excised.
FEMORAL HERNIA
In this type of hernia abdominal contents pass through the femoral ring, traverses the femoral canal and comes out through the saphenous opening.
Femoral hernia is the 3rd according to frequency, after inguinal and incisional hernia. It is more common in females and accounts for 20% of cases of hernia. Only 5% of cases of hernia in males are femoral hernia. Femoral hernia is most liable to get strangulated____________!!!!
SURGICAL ANATOMY— :
Femoral ring is an oval opening V; inch in diameter (larger in women than in men). It is normally closed by the femoral septum, which is nothing but thickened extraperiloneal tissue. It is bounded — In front by the inguinal ligament.
Behind by the pectineus muscle covered by its fascia and the peciineal ligament of Cooper, a thickened band running along the iliopectineal line.
Medially by the free margin of Gimbemat's ligament (Lacunar ligament). Sometimes the pubic branch of the inferior epigastric artery takes the place of the obturator artery and is known as abnormal obturator artery. This artery often curves round the medial margin of the femoral ring and is liable to be injured while cutting the medial margin of the lacunar ligament to relieve the strangulated femoral hernia. Laterally by a septum which separates it from the femoral vein.
Femoral canal is the innermost compartment of the 3 compartments of the femoral sheath, It is about2 cm in length and is funnel shaped. The middle compartmentof this sheath carries the femoral vein, while the outer compartment carries the femoral artery. The femoral canal contains areolar tissue, fat, lymphatic vessels and the lymph node ofCloquet. It is closed above by the femoral septum at the femoral ring. The femoral sheath is formed by two fascial layers. The anterior layer is the prolongation downwards of the fascia transversalis behind the inguinal ligament and in front of the femoral vessels. The posterior layer is the downward prolongation of the fascia iliaca behind the femoral vessels. Posteriorly, the femoral sheath rests on the peclincus and adductor longus muscles medially and thcpsoas major and iliacus muscles laterally. Thus the femoral canal lies in front of the pectineus muscle.
closed downwards by the cribriform fascia which covers the saphenous opening.
The saphenous opening (or fossa ovalis) is an opening in the fascia lata situated 4 cm below and lateral to the pubic tubercle. The upper and outer margins of the saphenous opening are thickened and sharp — known as falciform process. This process turns the femoral hernia upwards once it has come out of the saphenous opening. The saphenous opening is covered by loose areolar tissue called a cribriform fascia. This opening is traversed by the long saphenous vein and lymphatic vessels. The fascia of scarpa, the membranous layer of the superficial fascia of the abdomen is attached to the fascia lata just below the saphenous opening.
Course of a femoral hernia.— Femoral hernia comes out through the femoral ring, passes through the femoral canal and comes out through the saphenous opening. After this it progresses upwards in the subcutaneous tissue of the thigh and may even reach above the inguinal ligament. A fully distended femoral hernia assumes the shape of a retort with its bulbous extremity looking upwards. The tendency of the femoral hernia to.move upwards after it has come out of the saphenous opening is attributed to the following factors :
(a) Firm unyielding falciform process turns the hernia upwards.
(b) Attachment of fascia of scarpa to the fascia lata just below the saphenous opening gives it no chance for the femoral hernia to move downwards, so it has to move upwards.
(c) Repeated flexion of the thigh may to certain extent help to push the hernia up.
Coverings of the sac of the femoral hernia.— From outside inwards these are — (i) The skin. (ii) The superficial fascia. (iii) The cribriform fascia. (iv) The anterior layer of the femoral sheath.
(v) The fatty content of the femoral canal. (vi) The femoral septum. (vii) The peritoneum.
Rare types of femoral herniae.— Though majority of the femoral hemiae pass through the femoral canal, a few rare types may be seen as below :
- Prevascular hernia.— In this case hernia passes in front of the femoral artery and behind the inguinal ligament and is sometimes associated with congenital dislocation of the hip when there is lack of posterior support to the femoral hernia (Narath's hernia).
- 2. Pectineal hernia.— In this case hernia passes behind the femoral vessels between the pecuneusTOusele and its fascia (Cloquet's hernia).
3. External femoral hernia.— In this casehemia passes lateral to the femoral artery (Hesselbach s hernia).
- Lacunar hernia.— In this case hernia passes through the lacunar ligament (Lingier's hernia).
- Clinical features.—
- HISTORY—
(i) Age— Femoral hemia is uncommon in children. It is rarely seen before late middle age i.e. below 50 years. Majority are seen between 60 to 80 years
(ii) Sex.— Femoral hernia is much more common in females than males. Remember that even in females the commonest hernia in the groin is the inguinal hernia. MuMparous women are often affected.
(iii) Side.— The right side is affected twice as often as the left. In 20% of cases it is bilateral..
SYMPTOMS—Symptoms can be divided into two groups — local symptoms and general symptoms.
Local symptoms.—
(i) Pain.— Femoral hernia gives rise to less complaint than inguinal hernia. In fact a small femoral hemia may be unnoticed by the patients for years till it get strangulated. Adherence of the greater omentum sometimes leads to a dragging pain.
(ii) Swelling.— This is the usual presenting symptom. It is usually a small globular swelling situated below and lateral to the pubic tubercle. S uch a swelling is more apparent on standing and on straining. It may disappear on lying down.
General symptoms.— If femoral hemia causes obstruction — abdominal colic, vomiting, abdominal distension and constipation may be complained of. Femoral hemia is notorious due to its ability to strangulate quite often. Even a part of the circumference of the bowel may be strangulated — Richter's hemia.
In case of strangulation patient suddenly gets pain at the local site which immediately spreads allover the abdomen with vomiting.
LOCAL EXAMINATIONS—
1. Position.— Femoral hemia is seen below and lateral to the pubic tubercle, and below the inguinal ligament, whereas inguinal hemia is positioned above the inguinal ligament and medial to the pubic tubercle. In obese patients it is difficult to feel the pubic tubercle. In this case one may follow the tendon of adductor longus upwards to reach the pubic tubercle.
2. Size and shape.— It is mostly a globular swelling. Majority of the femoral hemiae are small. If they become large thery adopt a size of a retort in which the bulbous portion looks upwards and may reach above the inguinal ligament.
3. Two important signs of a hemia are (a) impulse on coughing and (b) reducibility. But these signs are relatively less reliable in case of femoral hemia due to (i) adherence of the contents and (ii) narrowness of the neck of the sac. This makes the differential diagnosis very difficult.
4. Consistency.— Majority of the femoral hemiae feel firm and dull to percussion, as the contents are mostly omentum or some amount of extraperitoneal fatty tissue surrounding the sac. Rarely the content may be the urinary bladder.
5. To differentiate from inguinal hernia.—
(a) Impulse on coughing by Zieman's technique the index finger is put over the deep inguinal ring, the middle finger over the superficial inguinal ring and the ring finger over the saphenous opening. The patient is asked to hold the nose and blow or to cough. When impulse is felt on the index finger it is the indirect inguinal hemia, when on the middle finger it is direct inguinal hemia and when on the ring finger it is the femoral hemia.
(b) By imagination test one can detect that the inguinal canal is empty.
(c) Ring occlusion test.— When the hemia is reduced, pressure is exerted over the femoral canal and the patient is asked to cough, the hemia does not come out.
(d) Position.— This is by far the most important point. The neck of the hemial sac lies below the inguinal ligament and lateral to the pubic tubercle, whereas an inguinal hemia is always above the inguinal ligament and medial to the pubic tubercle.
DIFFERENTIAL DIAGNOSIS
This has been discussed above under the heading of 'Differential Diagnosis of Groin Swellings'.
TREATMENT—
There is no place for conservative treatment and surgery should be performed in all cases of femoral hemia. The reasons are mainly two: (i) there is always a risk of strangulation, (ii) no truss can be fitted to control femoral hemia as it becomes displaced with the flexion of the thigh.
Three types of operation are performed in case of femoral hernia and basically these operations are herniorrhaphy, but the approaches are different.
1. High operation of McEvedy's operation — approach is made mainly above the inguinal canal but also below it.
2. Lotheissen's operation — the approach is through the inguinal canal.
3. Lockwood operation — the approach is below the inguinal ligament via a groin-crease incision.
DESCRIPTION OF OPERATIONS
High operation of
McEvedy.—This operation gives a much better access than the 'low' operation. This operation is considered to be the best in strangulated hernia. It allows the sac to be dealt at the fundus as well as at the neck. It is a more time consuming operation than its 'low' counterpart.
A vertical incision is made over the femoral canal extending upwards above the inguinal ligament for about 3 inches. The upper pan of the incision lies '/д inch medial to the linea semilunaris. This part of the incision is deepened, the anterior rectos sheath is incised and the rectus muscle is retracted medially. The fascia transversalis is divided and by working downwards the sac entering the femoral canal is identified. In most cases the sac remains empty and is drawn upwards. The neck of the sac is ligatured and the sac is excised. In irreducible or strangulated hernia, the lower part of the incision is deepened first till the fundus of the sac is reached. The sac is then opened, its contents are dealt with, after which the upper part of the incision is deepened in the similar way as has been described earlier and the neck of the sac is drawn upwards through the canal and ligatured. The repair is now effected by suturing the conjoined tendon with the ligament of Cooper.
Inguinal Operation (LotheiSSen *s).— This operation is widely practised, the advantage being that the sac can be removed flush with the parietal peritoneum.
The incision is made similar to that used for inguinal hernia, except for the fact that it is placed nearer to the inguinal ligament. The external aponeurosis is incised and the inguinal canal is opened. The spermatic cord or the round ligament is retracted upwards. The conjoined muscles arc also drawn upwards. The fascia transversalis is divided more or less in the same plane of incision. This incision should not be extended laterally up to the midinguinal point to avoid injury to the inferior epigastric vessels. The inferior margin of the wound is also retracted downwards and the extra-peritoneal fat is pushed aside by gauze to expose the hcrnial sac entering the femoral canal. If the sac is empty and is not adherent to the surrounding structures, it should be drawn up, the neck is ligatured and the rest of the sac is excised. Sometimes the sac remains adherent and the urinary bladder may adhere to the medial side of the sac. These have to be carefully dissected off. To clear the fundus of the sac properly, the lower margm of the wound has to be retracted downwards.
The femoral ring is now obliterated by stitching the conjoined tendon or the inguinal ligament down to the pectineal ligament. This suturing is done by three sutures of the non-absorbable suture material.While the sutures are being applied, care must be taken to protect the femoral vein by pushing it laterally with a finger. When the femoral ring is very much widened and flabby, one can even use a fascial strip from external oblique aponeurosis to 'dam' the opening. Now the weakness in the posterior wall of the inguinal canal has to be repaired. The cord or the round ligament of the uterus ate placed in their positions and the external oblique aponeurosis is sutured as usual. Finally the skin is sutured.
Low operation of Lockwood.— This operation is less time consuming. But the main problem of this operation is that the neck of the sac cannot be л ached properly, so proper repair of the femoral ring is not possible and this may well
The incision is made along the groin-crease about1/, inch below the inguinal ligament. The various fatty layers are incised including the thinned-cut cribriform fascia to expose the fundus of the sac. It is freed by gauze dissection as high up as to its neck, if possible. The fundus of the sac is opened and any contents therein, are pushed into the abdominal cavity. If greater omentum remains attached to the sac, this portion has to be excised. After holding the opened sac by 2 or 3 pairs of artery forceps, a transfixation ligature is applied to the sac as high as possible. The sac is now resected a little below the ligature. The stump will automatically retract and will disappear.
The closure is made by 2 or 3 stitches which pick up the fasciae forming the floor and the lateral margin of saphenous opening. Care must be taken not to injure the femoral vein which is protected by a finger placed on it.
Strangulated femoral hernia.— The high operation of McEvedy is always preferable. At first, the sac is cleared and the fundus is opened. The contents are inspected. The femoral ring is now exposed above the inguinal ligament and the constriction is investigated. This may be due to narrowness of the sac itself or from the tough boundaries of the femoral ring. In the latter case, first the lacu.iar ligament should be incised. Even if an abnormal obturator artery be present, it will be seen from above and can be avoided. Sometimes the inguinal ligament has to be cut to relieve the constriction. No harm is done by cutting the inguinal ligament as it can be sutured afterwards. The neck of the sac is divided against a grooved director. The contents are now drawn above the inguinal ligament and are dealt with accordingly. The hernia is of Richter's type, when a portion of the circumference of the bowel hemiates through the femoral ring and may be strangulated. After the contents of the sac have been dealt with properly, me closure is done as has been described in non-strangulated type of operation.
UMBILICAL HERNIA
Three types of umbilical hernia are seen in surgical practice:
1. Exomphalos—is a developmental anomaly due to failure of all or part of the midgut to return to the abdominal cavity during early foetal life. So the abdominal organs remain protruded being covered by a membrane — which consists of an outer layer of amniolic membrane, a middle layer of Wharton's Jelly and an inner layer of peritoneum. Two types of exomphalos can be seen —
(a) EXOMPHALOS MINOR — where the sac is relatively small and to its summit is attached the umbilical cord.
Treatment.— Sometimes jusia twist to the cord may reduce the contents of the sac into the peritoneal cavity and this is retained by strapping' applied firmly. Under no circumstances must this strapping be removed within fortnight.
(Ь) EXOMPHALOS MAJOR — in which the umbilical cord is attached to the inferior aspect of a large swelling containing small and large intestine and a portion of the liver.
Treatment.— Operation should be done as an emergency, otherwise the sac may burst. The infant should not be fed and an intravenous blood transfusion and fluid therapy is advisable. Broad spectrum antibiotic should be administered immediately.
Flaps of skin are created on both sides of the swelling by undermining the subcutaneous tissue. The flaps are attempted to bring over the sac of the swelling. If necessary, relaxing incision may be made on the flanks. Postoperatively, gastric suction is continued to prevent distension. A second operation may be required to bring the muscles over the peritoneal sac for closure in layers.
2. Umbilical hernia in infants and children.— This is a hernia through a weak umbilical scar may be following neonatal sepsis. The hernia is usually symptomless and increases in size during crying. This hernia occurs more often in males than in females at the ration of 2:1. Small hemiae are spherical in size but when they increase in size they tend to assume a conical shape.
Strangulation is extremely rare in this type of hernia.
TREATMENT.— As 90% of cases are spontaneously cured within 12 to 18 months, reassurance to the parents is all that is required.
To hasten disappearance of the hernia conservative treatment may be tried. The protrusion is kept reduced continuously by a pad or a big coin or a round piece of metal on the umbilicus and this is kept in position by apad of adhesive plaster which is applied by pulling the skin and abdominal musculature together. This prevents the hernia to come out and will obliterate the sac by adhesion.
Operation is only justified when the hernia fails to disappear after 18 months or so.
Operation.— It is desirable that the umbilicus should be preserved, so that the child may not be psychologically handicapped. A small curved incision is made immediately below the umbilicus. The incision is deepened till the neck of the sac is approached. After making sure that the sac is empty of its contents, the neck of the sac is incised and closed by ligature. The gap in the linea alba is closed with non-absorbable sutures. The skin flap is replaced in position and sutured.
3. Paraumbilical hernia of adults.— In adults the hernia does not protrude through the umbilical cicatrix. It is a protrusion through the linea alba just above the umbilicus (supraumbilical) or occasionally below the umbilicus (infraumbilical). That is why it is called paraumbilical.
The'contents of the hernia are usually greater omentum often accompanied by small intesine or by a portion of the transverse colon. In majority of cases the sac becomes loculated due to adherence of the omentum to its fundus. That is why paraumbilical hernia is seldom reducible.
CLINICAL FEATURES.— Women are by far the major victims and are affected 5 times more frequently than men. Obese patients are mainly involved and they are usually above 40 years of age. Obesity, flabbiness of the abdominal muscles and repeated pregnancy are the predisposing factors.
Symptoms.— Pain and swelling are the main symptoms.
Some sort of discomfort or pain is often complained of when the hernia is quite small. S uch pair gets worse by prolonged standing or heavy exercise. Pull on the omentum often gives rise to gastrointestinal symptoms. Transient attacks of intestinal colic may be present as there may be subacute intestinal obstruction.
Swelling obviously attracts patient's notice when there is not much pain. Gradually the swelling increases and often attains a big size.
On examination.—
(i) Position.— The main bulge of the hernia is mostly just above the umbilicus through the linea alba and occasionally below the umbilicus through the midline.
(ii) Consistency.— The lump is firm as it contains mostly omentum. On percussion it is dull. If it contains small bowel, it may be resonant.
(iii) When the contents are not adherent this hernia becomes reducible and expansile cough impulse becomes also evident but unfortunately in many hemiae the contents are adherent so the hemiae become irreducible and impulse on coughing is absent.
TREATMENT.— Operation is the treatment of choice. Gradually, as the time goes on, the hernia becomes irreducible and eventually strangulation may occur. So no attempt should be made for conservative treatment. If the hernia is symptomless and the patient is obese, it is advisable to reduce the weight and the operation can be postponed for sometime till the weight has been reduced to a respectable order.
Mayo's operation is usually practised. A practical point to be remembered in connection with this type of hernia is that there are adhesions between the sac and the contents (coils of intestine or omentum) mostly at the fundus. The neck of the sac remains free from adhesions. This makes the principle of the operation that the hernial sac is reached at the neck first.
MAYO'S OPERATION.— A transverse elliptical incision is made around the umbilicus. The subcutaneous tissues are dissected off the rectus sheath to expose the neck of the sac. The sac is opened at its neck as adhesions are least here. The contents are freed from adhesions at the fundus of the sac and returned to the abdomen. Sometimes adherent omentum cannot be freed from the fundus of the sac. In that case the omentum is ligated and removed with the sac. The whole circumference of the neck is gradually incised. The fundus of the sac alongwith the redundant skin is removed. The peritoneum of the neck of the sac is closed with catgut stitches. The gap in the linea alba is extended laterally for one inch or more for sufficient overlapping. Now a row of mattress sutures are tied so that the lower margin is lifted up deep to the upper margin for about 2 inches and the upper margin of the linea alba is made to lie over the lower margin of the linea alba. The upper margin of the linea alba is now sutured over the lower flap by interrupted silk sutures. In fat patients, who ooze blood and liquid fat, a drain may be provided with at the end of the wound. The subcutaneous tissue and the skin are approximated as usual.
Postoperatively one must care to relieve the patient of cough or from other causes of incresed intra-abdominal pressure.
EPIGASTRIC HERNIA (SYN. FATTY HERNIA OF THE LINEA ALBA)
When a hernia protrudes in the midline through the interlacing fibres of the linea alba between umbilicus and xiphistemum it is called an epigastric hernia. Majority of cases occur midway between umbilicus and xiphisternum. It occurs through the same opening where the linea alba is pierced by small blood vessel. Such type of hernia begins as a protrusion of extraperitoneal fat and that is why it is also called 'fatty hernia of the linea alba'.
As the hernia grows bigger, it drags a pouch of peritoneum after it and it becomes a true epigastric hernia. The mouth of the hernial sac is usually quite narrow and it does not permit any viscus to enter the hernial sac, only a small portion of greater omentum may enter it.
Aetiology.— It seems sudden strain helps to bring out such hernia. Such strain will lead to tearing of the interlacing fibres of the linea alba. That is why this hernia is mostly restricted to young muscular men majority of whom are manual workers.
Clinical features.— Epigastric hernia usually presents itself in one of the three clinical types. (i) Symptomless.— Epigastric hernia is often symptomless and may be discovered by the patient only as a swelling during washing his own body.
(ii) Painful swelling.— Sometimes patient with epigastric hemia complains of a localised pain exactly at the site of the hernia. Pain often gets worse on the physical exertion. Occasionally the fatty content may be pressed upon by the tight margins of the gap in the linea alba to produce partial strangulation. In these cases the swelling will be tender and patients will feel pain on wearing tight clothings.
(iii) Referred dyspepsia.— Patients with epigastric hernia may give symptoms which mimic peptic ulcer, though there is actually no such ulcer. Patient might not have noticed the swelling even. Peptic ulcer may be present in cases of epigastric hernia and such ulcer must be excluded. Patient may complain of pain after eating possibly due to epigastric distension. Such dyspepsia is also due to epigastric hernia.
PHYSICAL EXAMINATION.— Epigastric hernia feels firm and does not usually have a cough impulse and cannot be reduced. For this, it becomes difficult to distinguish epigastric hernia from lipoma. Only occasionally when a sac is present expansile impulse and reducibility may be noticed.
Treatment.— Operation is only justified if the hernia is giving rise to symptoms.
OPERATION.— A long midline vertical or transverse incision is made over the swelling. The incision must be adequate as the gap in the linea alba must be viewed properly. Theincision is deepened till the fatty protrusion of hernia is detected.
The protruding extraperitoneal fat is dissected clear from the hernial orifice by gauze dissection. The pedicle is ligated and the fat distal to the Jigalion is excised. The gap in the linea alba is repaired by non-absorbable sutures.
If a small peritoneal sac is present, it is opened to see if there is any content or not. If a small portion of omentum is the content, it is dragged out and examined to exclude partial strangulation. If partial strangulation is there the portion of omentum is excised after ligation. If the portion of omentum is healthy it is pushed back into the peritoneal cavity. The sac is ligated and excised. The gap in the linea alba is repaired with non-absorbable sutures.
If the gap in the linea alba is big, it should be repaired by overlapping transversally (as Mayo's operation) or longitudinally. Skin is closed as usual.
INCISIONAL HERNIA (SYN. VENTRAL HERNIA OR POSTOPERATIVE HERNIA)
An incisional hemia is one which occurs through an acquired scar in the abdominal wall caused by a previous surgical operation or an accidental trauma. Scar tissue is inelastic and can be stretched easily if subjected to constant strain. Aetiology.— 1. Defect with the patient.— (i) Obese individuals with lax muscles.
(ii) Patients suffering from chronic cough, which may continue in the early postoperative period and will lead to incisional hernia.
(iii) Undue abdominal distension in the early postoperative period.
(iv) Malnutrition — patients with severe anaemia, hypoproteinaemia or Vitamin С deficiency may predispose to incisional hernia.
2. Fault during operation.—
(i) Injury to the motor nerves supplying the area. Certain incisions are vulnerable to cause nerve injury e.g. Kocher's subcostal incision for cholecystectomy often inflicts injury to the 8th, 9th and loth intercostal nerves; Battle's pararectal incision for appendicectomy; McBurney's incision for appendicectomy may injure the subcostal or ilioinguinal nerve.
(ii) Particular care> infection was the result.
(iv) Tube drainage through the laparotomy wound.
(v) Certain incisions are more liable to cause incisional hernia e.g. midline infraumbilical incision for caesarean section.
3. Postoperative causes.—
(i) Infection.— This seems to be the commonest cause. (ii) Postoperative cough and distension.
(iii) Postoperative peritonitis due to more chance of wound infection. (iv) Too early removal of sutures. (v) Steroid therapy in the postoperative period.
becomes also evident but unfortunately in many hemiae the contents are adherent so the hemiae become irreducible and impulse on coughing is absent.
TREATMENT.— Operation is the treatment of choice. Gradually, as the time goes on, the hernia becomes irreducible and eventually strangulation may occur. So no attempt should be made for conservative treatment. If the hernia is symptomless and the patient is obese, it is advisable to reduce the weight and the operation can be postponed for sometime till the weight has been reduced to a respectable order.
Mayo's operation is usually practised. A practical point to be remembered in connection with this type of hernia is that there are adhesions between the sac and the contents (coils of intestine or omentum) mostly at the fundus. The neck of the sac remains free from adhesions. This makes the principle of the operation that the hemial sac is reached at the neck first.
Pathology.—
- Often the incisional hernia starts unnoticed and symptomless with partial disruption of the deeper layers of a laparotomy wound during immediate of early postoperative period. So careful closure of the wound is extremely important to prevent incisional hernia. There may be some oozing of serosanguineous discharge through the laparotomy wound, but this is more of a signal of wound dehiscence or burst abdomen rather than incisional hernia.
- Wound infection often causes disruption of sutures thus the muscles are separated by weak scar tissue. A portion of the muscles may also be destroyed by infection which are resolved afterwards by fibrosis. This also causes weak scar. Through this weak scar tissue incisional hernia occurs.
Clinical features.—
HISTORY—
A previous operation or a trauma is often noticed. Patient may give a history of wound infection.
Age.— Incisional hernia may occur at any age, but more common in fatty elderly females.
SYMPTOMS—
The commonest symptoms are the swelling and the pain. Sometimes attacks of subacute intestinal obstruction may occur leading to abdominal colic, vomiting, constipation and distension of the abdomen. Strangulation, though uncommon, is liable to occur at the neck of a small sac or in a locule of a large hernia.
ON EXAMINATION—
The old scar is seen with the swelling. The hernia may occur through a small portion of the scar, often the lower end. Usually the diffuse bulging may occur involving the whole of the scar. Usually the swelling is reducible and an expansile cough impulse is present. The defect in the abdominal wall is often palpable.
It may so happen that the hernia is irreducible. Such cases become difficult to diagnose. These cases must be differentiated with (differential diagnosis):
(i) A deposit of tumour.
(ii) An old abscess.
(iii) A haematoma.
(iv) A foreign body granuloma.
Types of incisional hernia.— Two distinct types ofincisionafhernia should be recognized, as the principles of treatment are different in these two cases.
(a) IN TYPE I, this hernia is situated in the upper abdomen or in the midline of the lower abdomen. There is a wide gap in the musculature which is easily recognized and whose margin is smooth and regular. This hemia reduces spontaneously as soon as the patients lies down. So mostly it is a reducible hernia. This type of hernia takes the form of a diffuse bulge. Risk of strangulation is almost negligible. These herniae can be treated by simple abdominal corsets.
(b) IN TYPE II, this hernia is situated in the lateral part of the abdomen. The defect in the musculature is relatively small and irregular. The contents are normally bowel and omentum both. These are usually matted together and are adherent to loculated peritoneal sac. There are usually multiple loculi. So this hemia is partially or wholly irreducible. As the muscular defect is small, risk. of strangulation is high.
Treatment.—
1. PREVENTIVE TREATMENT.— A few preoperative measures should carefully adopted to lessen the chance of incisional hemia. These are :
(a) If the patient is obese, weight should be reduced by dieting if an elective operation has to be performed.
(b) If the patient has a tendency of chronic bronchitis, it should be treated first.
(c) During operation one must be very careful during closure of the abdomen. Deeper layers must be sutured with due respect.
(d) All precautions should be adopted to prevent immediate postoperative wound infection.
2. CONSERVATIVE TREATMENT.— There is hardly any scope for conservative treatment in cases of incisional hernia. Conservative method may be only tried in type I cases if they are reducible. This method cannot be adopted if the hernia is irreducible. After reducing the hemia a belt is fitted with a suitable pad so that the hernia does not get an opportunity to come out If such treatment is continued for a long time without giving chance of hernia to come out, there is a possibility of cure. Moreover this treatment may be applied to those Type I cases where operation is contraindicated due to the general condition of the patient.
3. OPERATIVE TREATMENT.— This is always indicated in type II cases and irreducible type I cases. Operative treatment is also justified when conservative method has failed. In fact majority of the cases of incisional hemia need operation sometime or the other.
OPERATION.— An elliptical incision is made enclosing the area of unhealthy skin. The outer edges are undermined. Now the incision is deepened to the aponeurosis. The unhealthy skin is now gradually dissected off the sac, which is nothing but a redundancy of peritoneum. The sac is not opened. If the sac is loculated and very adherent it is better to open the sac around its neck. The contents are freed. Adherent omentum may be ligated and removed along with the sac. Any adhesions involving the bowel should be separated as far as practicable before the hernial contents are returned to the abdomen.
Repair of the hernia depends on the type of hemia and its size. Followings are the different methods one of which may be applied:—
1. ANATOMICAL RESTORATION.— This is suited for small hemiae with minimal scar. The edges of the defect are carefully dissected and each layer e.g. the peritoneum, the muscle layers or the aponeurosis is freed sufficiently. These layers are sutured individually without tension with non-absorbable sutures.
2. APPROXIMATION OF THE RECTUS SHEATH— This is only performed in case of midline herniae, particularly below the umbilicus. Here also each layer is separated individually. The peritoneum is first sutured. The anterior rectus sheaths are now freed from the underlying rectus muscles. The rectus muscles of both sides are sutured in the midline. Some overlapping may be done. Now the anterior rectus sheath is sutured in the midline if possible by overlapping. To reduce tension one may have to make release incision vertically on the lateral part of the rectos sheath.
3. KEEL OPERATION.— In this operation the hernial sac is not opened but is pushed back into the abdomen. With non-absorbable sutures it is pleated so that it deeps into the abdominal cavity. A few layers of sutures are applied one after the other till the healthy margins of the muscles and aponeurosis are brought close. Now the margins of the healthy muscles and aponeurosis are sutured to each other. As in this operation the hernial sac is pushed into the peritoneal cavity in a pattern which on cross-section looks like the 'keel' of a ship, this operation is called 'keel operation'.
4. CATTELL'S OPERATION.— In this operation the hernial sac is dissected out with equal care as has been described in the earlier operations. But the sac is opened. The viscera are reduced after freeing the contents from the sac. The peritoneum is repaired. The edges of the abdominal wall are now approximated and are sutured with thick chromic catgut or better with non-absorbable suture material layer by layer. After the surrounding aponeurosis has been sutured, an incision is made half inch away from the suture line. The medial edges of this incision are sutured over the previous line of suture and the lateral margins are now sutured over this medial layer of suture. This is continued till the edges of the healthy aponeurosis are brought together firmly.
5. REPAIR BY FASCIAL SUTURES OR SKIN RIBBON— This operation is more or less similar to hemioplasty. This type of repair is necessary when the muscular defect is considerable and cannot be closed without tension. The peritoneum is freed and is sutured. The other layers in the margin are separated particular the muscle layers. The defect is closed with the fascial sutures in an interlacing manner from muscles of one side to the muscles of the other side. The interlacing suture is made in the form of Lattice work or 'dam'.
6. MESH CLOSURES.—These are becoming increasingly popular. The inision and the sac are dealt with similarly as done in the previous operations. The deficiency in the abdominal wall is easily made good without tension by laying and stitching a sheet of Tantalum gauze or a Mesh made of Dacron or marlex or polypropylene to the surrounding aponeurosis. Repair with synthetic mesh is only advised when the defect is very large and cannot be closed effectively by autogenous tissue. It cannot be used routinely as there is increased chance of infection. Collection of oozing fluid inside the wound acts as a good nidus of infection. The following points should be considered whenever a synthetic mesh is used :
(i) Asepsis should be maintained at all costs.
(ii) Too much handling of the tissues should be minimised.
(iii) Haemostasis must be carefully maintained.
(iv) Even the pre-sterilized mesh should be handled as little as possible.
(v) The extra mesh may be used in another patient only after autoclaving. Not more than two autoclavings should -be advised.
(vi) Themesh should be placed as deeply as possible. It should be used as an onlay on the sutured peritoneum. Under no circumstances the intestine should be allowed to come in contact with the mesh lest dense adhesions should form. The
MAYO'S OPERATION.— A transverse elliptical incision is made around the umbilicus. The subcutaneous tissues are dissected off the rectus sheath to expose the neck of the sac. The sac is opened at its neck as adhesions are least here. The contents are freed from adhesions at the fundus of the sac and returned to the abdomen. Sometimes adherent omentum cannot be freed from the fundus of the sac. In that case the omentum is ligated and removed with the sac. The whole circumference of the neck is gradually incised. The fundus of the sac alongwith the redundant skin is removed. The peritoneum of the neck of the sac is closed with catgut stitches. The gap in the linea alba is extended laterally for one inch or more for sufficient overlapping. Now a row of mattress sutures are tied so that the lower margin is lifted up deep to the upper margin for about 2 inches and the upper margin of the linea alba is made to lie over the lower margin of the linea alba. The upper margin of the linea alba is now sutured over the lower flap by interrupted silk sutures. In fat patients, who ooze blood and liquid fat, a drain may be provided with at the end of the wound. The subcutaneous tissue and the skin are approximated as usual.
Postoperatively one must care to relieve the patient of cough or from other causes of incresed intra-abdominal pressure.
The Small and Large Intestines